Basic Information
Like
many developing countries, Tanzania and Kenya suffer from a severe lack of
healthcare professionals. There is one doctor for every 50,000 people in East
Africa compared to one doctor for every 390 people in the United States (1). Provider shortages
are likely to persist, as many countries do not have the means to train
adequate numbers of medical personnel. Access
to care is further limited when large distances must be traveled for basic
medical care, and often times the decision to seek professional help is made
too late. We interviewed over 200 people in the Imbaseni area of northern
Tanzania and found that people travel an average of one hour and spend about 300
TSh (about 25 cents) to reach a doctor. The average income in this area is
about TSh 8,000 (~ 7 USD) per week.
With the expanding youth population of
Tanzania, children are often the victims of poor access to health care. There
are 2.4 million orphans in Tanzania (2), many of whom live
in orphanages with caregiver to child ratios as high as 1:30 (approximate
number at Good Hope orphanage where we have been working every Summer for the
last five years). Children at Good Hope do not see a doctor on a regular basis
because taking a child to the doctor costs a significant amount of time and
money. We have witnessed first-hand a number of cases where a child’s health
was significantly compromised because the decision to see a doctor was made too
late.
The Promise of
Telemedicine
Communications
technologies and telemedicine have the potential to help overcome some of the healthcare
challenges in remote regions. Cell phones are
rapidly transforming the African continent. It is estimated that 97% of the people
in Tanzania have access to a cell phone (3). Computers are slowly making their way into rural Africa. Computers and
cell phones can connect patients in developing communities with doctors around
the world. We surveyed about twenty five U.S. doctors and found that many of
them and their colleagues are interested in performing outreach in developing
communities but cannot make commitments to long-term international assignments,
like those required by Doctors Without Borders (4). Short-term mission
trips are very expensive and not sustainable solutions.
Mashavu:
Networked Health Solutions for the Developing World
Mashavu
enables medical professionals around the world to connect with patients in the
developing world using modern technology and communications infrastructure.
Trained operators at Mashavu stations in developing communities collect essential
medical information including weight, body temperature, lung capacity, blood
pressure, photographs, stethoscope rhythms, and basic hygiene and nutrition
information for each patient on a regular basis. The station operator serves as
a facilitator during check-ups and the patient is encouraged to interact with
the user-friendly software. At each individual check-up, the patient is asked
questions, photographed, and given standard tests to monitor their health and
nutrition.
Web
servers aggregate this information from various Mashavu stations over a
cell-phone GPRS link and provide it on a web-based portal. Medical professionals can view the patient’s
information and respond to the patient and the nearest doctor(s) with their
recommendations. The patients follow up directly with the local doctor, if
necessary. In some cases, the system serves as a link between the patients and
local doctors. The medical professionals can review community health statistics
in order to evaluate any general health trends or possible epidemics in the
area. This anonymous information can then be shared with local community
leaders so that health priorities are addressed effectively.
Other
Telemedicine Initiatives & Competitive Advantage
There
are a number of telemedicine companies in the U.S. serving geriatric needs and
rural communities. These comprehensive systems are fairly expensive and will not meet the diagnosis
and care needs in
developing countries. We studied telemedicine models in India, Cambodia and other
countries and found:
·
Most
models are based on communication between doctors and patients (over
cellphones) and in some cases photographs (Teledoc in India). They do not
include any kind of biomedical devices to provide more information to the doctors.
·
Some
solutions focus on connecting rural and urban clinics (AMREF in Africa) but
very few connected people to clinics.
·
Very
few systems keep records of the patient’s health numbers and history.
·
We
did not come across any systems that embed traditional medicine based on indigenous
knowledge (which is widely practiced).
·
There
is significant literature on successful telemedicine studies. Most of them were
experiments and not ventures - they lacked an entrepreneurial component to
ensure economic sustainability.
Mashavu
combines patient inputs with personal biomedical information (leading to better
diagnosis/judgment), employs a holistic approach, and sustains itself in
low-resource areas. The system uses ruggedized, inexpensive, low cost biomedical
sensors and existing telecommunications infrastructure. We have an entrepreneurial
approach to making Mashavu economically sustainable and excellent
collaborations to implement it and setup an effective process for replication
and scaling up. Mashavu takes a holistic approach and engages community members
in the process of monitoring their own health.
Work Done / Validation
Coalition Building
We
have had detailed discussions and sought feedback from our numerous contacts in
East Africa, colleagues familiar with healthcare challenges in Africa, and most
importantly doctors and nurses in the U.S., Kenya and Tanzania. We have developed
a team of students and faculty from Engineering, Health and Human Development,
Business and Medicine to advance the project. Since Spring 2008, about 30
students from these colleges have been engaged in the feasibility study for Mashavu.
The investigators on this proposal have several ongoing projects in Kenya and
Tanzania (for more than five years) and we have built on those relationships
and negotiated specific roles and responsibilities for the various partners.
Proof-of-concept
Development
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Proof of concept prototype in the lab. It gathers user data and
measures Blood Pressure, Temperature, Weight, SpO2(not shown) and transmits
it over cellphone to a web portal.
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A happy customer at the Design Expo
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Mashavu – User Interface
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Mashavu – User Interface: Credits page
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A fully functional proof-of-concept has been developed and undergone numerous
refinements based on feedback from doctors and patients. The prototype consists
of various Commercial-Off-The-Shelf (COTS) biomedical devices (a blood pressure
monitor, pulse oximeter, weighing scale, thermometer) that are interfaced to a
laptop. A cell phone module and a tethered cell phone have been tested for data
transmission. The system collects sensor information, groups it with patient
information and publishes it to a website. Responses from the website are sent
back to the computer. The system built using COTS devices costs about $620,
which is not feasible for developing communities. The technology section
explains our technology innovations that aim to bring the cost down to $150.
On-the-ground Validation
From
similar past projects we have learned that technology-based social
entrepreneurial ventures are challenging, not
so much because the technology is difficult to develop, but because making the
technology work and sustain itself in the social and economic context of the
partnering communities
presents unique design challenges. To address some of the social
challenges, we have recently developed a collaborative program between Engineering
and Women’s Studies. The program brings together engineers, business people and
social scientists and provides them with a compelling context to explore and
appreciate the complexities of social problems and develop, deploy, and assess
innovative and practical technology solutions that create sustainable value for
the partnering communities. Fourteen students participated in the three-credit
professional seminar (Spring 2008) followed by a three-credit three-week
internship in Tanzania (Summer 2008).
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 The UAACC students had to
make pitches about Mashavu in English and Swahili to qualify for working with
the rest of the team. |
Five
of the students from this class worked specifically on the Mashavu project.
They teamed up with 20 students (ages 19 to 30) from the United African
Alliance Community Centre (UAACC) in Imbaseni, Tanzania. For the next three
weeks, the 25 students engaged in various activities related to community
education and concept validation, business model validation, pilot testing of
preliminary user interface and coalition building. Photographs of the
validation activities and selected survey datasets are appended. Some of the
activities that the joint student teams engaged in to validate the concept and
business model for Mashavu include:
Concept
Validation
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Mashavu station operator (Salvatori) checks temperature (and other
vitals) of sick child (Mary) while mother watches
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Salvatori enters info on Mashavu station which is immediately posted
on web portal. An alert is sent to Dr. Milnes who has e-adopted Mary.
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Dr. Milnes (US) gets alert, reviews info and recommends visiting
doctor immediately. He also sends info and recommendations to nearest clinic.
Child is carried to the nearest clinic – an hour’s walk away.
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Tanzanian doctor at local clinic treats Mary and she becomes healthy
again.
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Performing the skit at a secondary school
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One of our champions, Nanyaro addressing the crowd after the skit and
asking questions.
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Mashavu Skit: Health Education for communities
followed by concept validation research for Mashavu. (We developed a three-part skit to engage and educate the audience and
get richer feedback on Mashavu. First ten minutes focused on basics of health
and hygiene. Next ten minutes on health indicators and what happens when they
go out of normal range. The last ten minutes explained the Mashavu concept.
The photos are from the last part. This 30 minute skit was followed by a
question/answer session and surveys.)
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Student teams spent multiple days visiting the local clinics and district
hospital. They spoke to a number of nurses, doctors and patients. At one
clinic, the majority of the patients were children (0 – 4 years old) who were
brought in by their mothers. Some women had traveled for up to three hours to
reach the clinic. We compiled notes of the challenges and costs involved in
accessing healthcare and how the Mashavu system might make their life easier.
Business Plan Validation
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We set up a Mashavu health station at a community festival. Children
could get their weight for free. Adults were charged a small fee for weight
and blood pressure. 300 TSh (25 cents) for weight or blood pressure and 500
TSh for both. A chart tells them whether or not their numbers are normal. We
made about ten dollars in four hours!
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Long Queues at the Mashavu station!
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One Happy customer.
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…and a happy Mashavu station operator
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Market Research
Fifteen
students worked together to develop a 30-minute skit (in English and Swahili) on
basic concepts surrounding health, hygiene, health indicators and implications
of their being out of normal range, and an explanation of the Mashavu system.
The play was performed by the team at various local schools, orphanages and
community centers. At the end of the play, the audience was invited to ask
questions about Mashavu and offer their insights. They were specifically probed
on how much they would be willing to pay to use the system.
The
teams also interviewed more than 200 families on health related issues and on
how much they would pay to use it. The teams also set up a Mashavu Station (no
networking) during a community festival and provided weight and blood pressure
measurements for free to children and a small fee for adults. They made about
ten dollars in four hours. Some individuals did not see the point of getting
their numbers once – they would rather know their blood pressure over time.
Others were hesitant to use the system because they did not want any bad news. These
conversations convinced us of the importance of engaging local grassroots
organizations and developing a holistic approach combining Mashavu with health
education. The summarized tables will be added here later by Julia Wittig.
User Interface Testing
Preliminary User Interface Testing at Good Hope
Orphanage
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A caregiver learning how to use an automatic blood pressure measuring
device.
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An elderly caregiver learning how to use the Mashavu user interface.
She picked it up in 15 minutes and LOVED playing with the computer.
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Students
performed the Mashavu play for one of our partners – Good Hope orphanage. This
was followed by teaching the orphanage caregivers to use a weighing scale,
blood pressure monitor and the user interface for Mashavu (on a laptop computer).
The caregivers (all women: 20 to 60+ years) loved working with the computer and
devices and tested them on the kids. Tanzania is a patriarchal system whereby
women are undoubtedly the caregivers of the family and community in general. We
also realized that training them to be health care operators does not disrupt
traditional gender roles though use of technology (besides a cell phone) is
seen as a masculine thing.Fun Validation
Julia playing hide and seek with kids at the Good Hope orphanage.
The Mashavu team worked very hard but also had a lot of fun!!!
Mashavu Technology
Technology Innovation
The proof-of-concept prototype for the Mashavu system used Commercial-Off-The-Shelf
(COTS) devices connected directly to the computer over USB or Serial protocol.
COTS devices are made by a number of vendors, primarily for western markets.
These devices are expensive and not rugged enough for our context. We are
developing virtual instrumentation-based biomedical devices with an emphasis on modular, rugged, and affordable design. The COTS devices embed the primary sensor, signal
conditioning, user display and networking support on the device itself.
Block Diagram of the Mashavu Station Three-way Mashavu Network
Our devices consist of a sensor and the minimal essential
hardware around it. The sensor output is digitized by a Data Acquisition (DAQ)
Card and the signal conditioning and user display is done on the computer in
software. Hardware is more expensive and repairing the devices is unrealistic.
Computer software is free and easily upgradable (through the cell phone
itself!). Some of the hardware is locally manufacturable with local materials
and only the basic sensors (widely available and mostly inexpensive) have to be
imported.
Mashavu is a
computer-based system set up as a kiosk with an attractive industrial design
and user-friendly interface. Various biomedical sensors capable of recording
images, body temperature, lung capacity, body weight, etc. will be attached to
the kiosk. These biomedical devices are low-cost, rugged, locally manufacturable,
and easily replaceable. Virtual Instrumentation based designs and prototypes
already exist for most basic biomedical diagnostic devices. We will use
existing designs as a starting point and redesign the devices for our context. An
electronic spirometer (lung capacity measurement) costs about $50 in the U.S. We have built a proof-of-concept spirometer with a PVC
pipe (few cents) and a vibration sensor ($5) connected to a DAQ card. The
signal processing and display is done on the computer. Mechanical redesign and thorough
testing will prepare it for user testing in East Africa.
Data
transmission is accomplished by a cell phone connected to the computer using a
USB data cable—a setup known as tethering. Cell phones can connect to the
internet through a mobile gateway using a technology called General Packet
Radio Service (GPRS). This technology allows cell phones to receive e-mail, browse
websites as well as upload data to them. It is widely available across East
Africa by Zain, Vodacom, and SafariCom. The Mashavu web portal features an
intuitive user interface with secure login to verify identity and protect
patient privacy.
Preliminary Business Plan
The approximate cost
of each Mashavu system will be $200, excluding an appropriate cell phone and
computer. Customers (orphanages, community centers, churches, clinics,
entrepreneurs) will purchase the system with help from micro-finance
organizations like Kiva. They will charge community members a small fee to use
the service. This past summer, our team conducted extensive surveys in Tanzania
to determine the feasibility of this business model. The people overwhelmingly
supported the venture, with most willing to pay about 1000 TSh (80 cents) --
thrice the amount we had originally anticipated. With these numbers, the ROI (Return
On Investment) will be under 6 months.
We are also
considering other models like having doctors around the world e-adopt children
on Mashavu - which makes them responsible for looking over the child’s health statistics regularly. We
believe that the system will be sustainable even if the foreign doctors are
excluded from the system. The system without the networking is also valuable as
an inexpensive basic diagnostic system or to encourage people to “know their
numbers” and take an active interest in their health. We intend to set up a
for-profit or non-profit entity to support the venture in the longer term. The
UN Industrial Development Office (UNIDO) has taken taken an active interest in
this venture, opening up the possibility of the venture being adopted by other
UN agencies and large development organizations.
Collaborators and Implementation Strategy
Our
team has formulated an ambitious two pronged implementation strategy for
Mashavu: a top-down approach by partnering with UNIDO and CYEC in Kenya and a
bottom-up approach with the National Institute of Medical Research and grassroots
organizations in Tanzania. The assessment results and lessons learned during
the execution of the two implementation strategies will help us craft the final
commercialization strategy that takes the best of both approaches. Our
collaborators in East Africa include:
Children and
Youth Empowerment Center (CYEC), Kenya: CYEC is a project of the Street
Families Rehabilitation Trust Fund – an organization established by the
government of Kenya as a public-private sector partnership to oversee the
national program for street dwelling children, youth and families. The CYEC is
located in Nyeri, the capital of the Central Province, about 75 km north of
Nairobi. It currently serves 160
children in residential and non-residential care and a further 40-50 at its
associated drop-in center. The Mashavu team visited CYEC in summer 2008. CYEC has
agreed to pilot the Mashavu system. A large team from Penn State is working
with CYEC on another project involving building eco-villages as an exit
strategy for the street-dwelling youth.
UNIDO, Kenya: The United
Nations Industrial Development Office mission in Kenya is interested in the
Mashavu project because it is an excellent fit with their “Lighting Up Kenya”
initiative. From 2004-2007, the PI led a project in Kenya which attempted to
set up businesses around windmills that can be manufactured locally. One of the PI’s
collaborators was subsequently hired by UNIDO for their rural electrification
and micro-enterprise development initiative. The Mashavu team met with the
UNIDO representative for Kenya and Eritrea in summer 2008 and decided to
synergize on the Mashavu project. UNIDO will be setting up “sustainable energy
kiosks” at CYEC in collaboration with the Government of Kenya. These energy
kiosks will power the Mashavu stations.
UAACC /
Grassroots, Tanzania:
The various validation activities described earlier were carried out in and
around the United African Alliance Community Center (UAACC) in Imbaseni,
Tanzania. Imbaseni is located about 45 minutes by road from the city of Arusha.
Penn State has several ongoing projects in and around Imbaseni since the last
five years. Over this time period, we have forged very close ties with a number
of individuals and entities around UAACC including Good Hope orphanage, Mt.
Meru Peak School, Bega Kwa Bega environmental action group, etc. These
organizations are excited about piloting the Mashavu system and we have identified
champions to smooth the process.
NIMR, University
of Arusha, Tanzania:
The closest clinic to UAACC is operated by the University of Arusha. The
Mashavu team spent considerable time with doctors and patients at the clinic to
understand the context and how the Mashavu system could fit into it. Dr. Josiah
Tayali, head doctor of the clinic is very supportive of the effort and has
pledged support to pilot testing the system at his clinic. Dr. Tayali
researches traditional medicine and is interested in finding ways to embed
traditional medicine in the Mashavu network. He is a businessman himself and a
leader on the Tanzanian Chamber of Commerce – bringing critical business skills
with him. The traditional medicine department at the Tanzanian National Institute
of Medical Research is particularly interested in the community health aspect
of the Mashavu project. We have met with scientists at NIMR and have had
several conversations thereafter on the specifics of implementation.
