Leveraging 4,000,000,000 Phones for Development: TRACnet: A Case Study from Rwanda by Pamela Johnson, Voxiva Ruton Hinda, TRACplus Jean Philbert Nsengimana, Voxiva SARL Mobile Innovations for Social and Economic Transformation: From Pilots to Scaled-up Implementation September 16, 2009

Outline Leveraging 4,000,000,000 Phones for Development: TRACnet, A Case Study from Rwanda I.Background II.TRACnet III.Implementing at Scale –ICT Infrastructure –Architecture and Integration –Sustaining Large-Scale Systems IV.Extending the Model –Rwanda eSoko mUbuzima –Other Countries V.Conclusions 2

Nine million people GDP/capita – $ 314/ year Health Statistics –Life expectancy 44, males 47, females –Immunization rate: 90% –Infant mortality rate: 86 –Maternal mortality rate: 750/100,000 live births 517 Health Centers Health Professionals –401 physicians –3593 nurses –30,000 + Community Health Workers * UNICEF, MoH I. BACKGROUND: Rwanda*

Cell Phone PCs/ Internet PDA/ Smartphone A GoR information system that supports the national HIV/AIDS and other health programs. Builds on existing telecommunications infrastructure Allows TRACplus to: Collect real-time information from the field via web, phone, mobile application, paper... Communicate and send alerts and information back out to the field in a timely and systematic way. View Rapid visualization of data – in charts, tables, graphs and dashboards Local Applications Phone II. TRACnet:

COVERAGE 2004: TRACnet launched to support national ART treatment program operating in 16 facilities 2009: operating in all 225 ART treatment facilities in all districts End of 2009: expansion planned to all health facilities nationwide 5 CORE MODULES Patient Registry Longitudinal Patient Record Program Indicators ART, VCT, PMTCT Key Performance Indicators Analytics and management views Inventory Stock-level reporting Stock-out and shortage alerts Laboratories Lab result reporting and access from the field.  Disease Surveillance and Outbreak Alert

As soon as data is in the system, supervisors at multiple-levels view and analyze data in real-time via a web-based dashboard. They can: Track new reports Map and analyze data Track and manage people. They can use communication tools to send alerts and broadcast messages out to the field. Sample dashboards. National Disttrict Facility

TRACKING > 105,000 PATIENTS

TRACnet: Results to Date ACCESS AND USE Widespread access - over 1,000 users at 219 facilities throughout Rwanda > 7500 user sessions in April 2009 = > 85,000 sessions/year Multi-channel access - using a national toll-free phone number, the web, a PC client software, and a mobile phone client 90% facilities reporting by IVR Access to robust and easily navigable dataset of HIV/AIDS program indicators and patient data DATA Aggregate program indicators since 2004 from all ART facilities and patient data > 95% routine reporting Longitudinal data on over 105,000 patients in care and treatment TECHNOLOGY A scaled national infrastructure - secure, access controlled, redundant infrastructure, hosted in Rwanda at a carrier grade data center and managed 24x7 > 99% uptime A robust enterprise architecture – built to support an evolutionary infrastructure, TRACnet leverages a standards based infrastructure and software platform, evolving into an open standards framework for scale and interoperability

III: Implementing at Scale ICT Infrastructure Architecture and Integration Sustaining Large-scale Systems 9

Coverage Super-imposed on Health Facilities a. ICT Infrastructure

Future Directions –Three mobile carriers –Fiber optic to be completed by 2009 (government, MTN initiatives) –Submarine cable connection –Kigali, all district hospitals connected –Site-level investments in infrastructure and data management –Support for connectivity in schools and health facilities Current Reality: Mobile is here Internet is coming You don’t have to wait

b. Sustaining Large-Scale Systems SIMPLE FOR THE END USER BACK-END: NOT QUITE SO SIMPLE

c: Architecture: Status Quo MOH TBMalariaHIV/AIDSMCHEPI Disease Surv. Donor 1 Donor 2 Donor 3 Etc District Health Authority Provincial Health Authority Labs Warehouse/ Distribution Center NGO si986hs X5t77s X5t6hs 3k9dbns 0kb3YY X5t6hs9w 3k9dbns 0kb3YY X5t6hs N7uKK0 X5t6hs9w 3k9dbns In Peru, health workers spend 40% of time on paperwork and admin tasks.

Architecture: Integrated system Rwanda eHealth Strategy Integrated national system of systems Common standards, e.g. facility ID, national ID, SNOMED, etc

IV. Extending the Model: eSoko 15

Community Health Workers Extending the Model: mUbuzima

Other Countries India –Monitoring supply chain of family planning and other commodities to the community level Peru, Tanzania and Panama –National disease surveillance Peru –Monitoring maternal health program –Citizen safety Nigeria –Monitoring and evaluation of national HIV/AIDS program Zambia –Support for patients post-circumcision Kenya –Compliance support for patients on ART –Distribution of agricultural commodities Mexico –Compliance support for patients on ART –Cardiovascular risk assessment and support for behavior change –Support for diabetes patients 17

V. Conclusions Mobile is here. Internet is coming Mobile telecommunication systems can be leveraged into large-scale enterprise information systems Mobile can be used to support health and other development sectors Sustaining any large scale enterprise information system requires investments in human capacity to use and maintain the system Mobile is a tool to reach citizens with services 18