As I listened to Mike McKay, former country director of the Baobab Health Partnership, speak about how his organization is improving patient care with ICT in Malawi, I was struck by four key themes in Baobab's solution:
Mike McKay of Baobab Health- Start with Patient Data
- Keep Technology Easy to Use & Modify
- Always Build Local Capacity
- Project Poverty is an Advantage
Now neither Mike, nor Baobab's founder, Gerry Douglas, made all these points explicitly, but they are the takeaways we can learn the most from.
Start with Patient Data
Knowing a patient's past medical history is critical to continuity of care, particularly for patients with chronic illness. Do you know if the patient in front of you has tuberculosis? Or HIV? Or both plus malaria? Or is on any other medications or has any peculiarities you should know about them before you diagnose or treat their current ailment? If you had their medical records, you may.
And if you could track vital signs like body weight and Mid-Upper Arm Circumference (MUAC) over time, you could map its fluctuations against the patient's ails. Aggregate that data from all patients, and you could track disease and malnutrition across entire populations.
This is the promise of starting with patient data. And capturing the data electronically, at the point where its taken - from initial registration to actual patient-clinician interaction - makes the input process more streamlined and the data more accurate and timely; the approach Baobab took to great success.
Even though Baobab initially started in the pediatric ward of Kamuzu Central Hospital in Lilongwe, by focusing on creating an easy way to record patient data, they've been able to expand into other medical wards, and other clinics, across the country. At the same time, they are able to deliver accurate and timely aggregate data to the Ministry of Health. Baobab has now issued nationally unique patient ID numbers to over 800,000 Malawians, and tracks more than 20,000 HIV patients using their point-of-care approach.
Keep Technology Easy to Use & Modify
Even in Lilongwe, the capital of Malawi, electrical power is intermittent. Yet, if you are using an electronic patient records system, you have to commit to 100% uptime during clinic hours. Technology solution needs to be very energy-efficient so it can be run off backup power as needed. Baobab has introduced a 48VDC approach taken from the telecommunications industry to provide multi-day power backup using locally available solar batteries. You are also working with a user population that is not usually familiar with computers, so your solution needs to be dead simple. In general, the technology used has to be both cheap to buy and cheap to ship to your clinical sites, and also cheap to maintain and customize.
Back in 2001in the hunt for a solution that could be robust yet easy to use and cheap, Baobab stumbled on the Netpliance I-Opener, a low-cost, low power solution for Internet access. This device, with some customization, seemed perfect for running electronic patient records software as a web-based application with a touchscreen interface.
The real innovation came with that touchscreen interface. By eliminating the keyboard and mouse, Baobab was able to make its patient record system easy to use by everyone - from doctor to janitor - eliminating the need for users to have advanced ICT skills. And by using Open Source software, they were able to develop their own solutions, and modify them as needed with local programmers making the changes.
The only drawback is the limited supply of their original touchscreen hardware - its not longer produced and current touchscreen hardware is over $700 per device, relatively expensive for Baobab's saturation model, but still considered to be a viable solution by Baobab.
Always Build Local Capacity
Let's be honest. Expatriates are expensive, often temperamental, and almost always temporary. So for any project to have real staying power, it needs to be designed for handover to local staff from the beginning. But at the same time, its usually hard to find local staff that have a Western work culture. Which means that projects also need to be constantly training local staff, grooming internal candidates for advancement.
Gerry and Mike were both committed to transferring their knowledge and skills to their local staff, often hiring fresh graduates to train them in Western methodologies - especially software development. In fact, once trained, their local programmers were able to get more and better feedback when Gerry and Mark were not involved in requirements definition (so called "mzungu free meetings"), as local clinical staff were more honest and open about software issues with their countrymen than the expatriates.
Baobab Health is now almost entirely locally staffed, only the Country Director is an expatriate, and that's more a function of her skills and leadership than a specific need for an expat.
Project Poverty is an Advantage
It may seem counter-intuitive, but being resource constrained can actually be beneficial to a project's long term success. When there is little money to be spent on extravagance, the organization is very focused on delivering quality on time and on budget. And when low budgets are expected to continue, the project can be designed to have low maintenance costs, making sustainability easier to achieve.
For Baobab Health, its tiny budget kept it lean and focused. It only recently reached $200,000 a year, so everything - salaries to software - was cost-efficient. Baobab was able to reject opportunities for mission creep and helped it achieve acceptance by the Ministry of Health. Its seen as a real Malawian solution, not a donor-driven external organization.
Now that Baobab is looking at scaling up, and has a significantly increased budget, the challenge will be for it to keep that lean, focused organization.
