Tag Archive for 'mHealth'

Mosewalelu: Mobile phone as the Moses of today

My best source of information on Malawian culture is a taxi driver named Alex. A year and a half and many rides after meeting him during my first week in Malawi, our initial discussions about how he uses his phone as a business tool have evolved to cover the news of the day and many aspects of Malawian culture. Now he knows a great deal about Medic Mobile and my interest in culture, technology and innovation, and recently he offered me a real gem.

In Chichewa, the dominant indigenous language in Malawi, the phone pictured to the right above is widely referred to as a Mosewalelu or simply Mose for short. Literally this translates to “the Moses of today” or in the shorter version, simply “a Moses.” The notion is that this was the first type of phone available to the common man, and that like Moses this technology is liberating a people from the cruel yoke of poverty and oppression and leading them to the Promised Land. This almost universally Church or Mosque attending population aren’t quite calling a cell phone a modern messiah, but it’s a lot like that.

The back story involves a Malawian musician who wrote a song naming Malawi’s president Dr. Bingu Wa Mutharika as Mosewalelu. Much has changed economically for Malawi in the last few years, some of which President Mutharika has played a direct role in (such as a somewhat controversial but massively popular fertilizer subsidy for small plot subsistence farmers), and other changes which have been led largely by private companies (including explosive growth in mobile telecommunications). It was during Mutharika’s first term that mobile connectivity rapidly scaled up to cover a majority of Malawi’s predominantly rural population, and about the same time that the two telecoms began selling these Hauwei and ZTE phones for as little as $12 USD. I can’t claim to know the whole story, but somehow the public mind shifted the term Mosewalelu away from the president, instead connecting it to these ultra low cost phones. As Alex said “This was was the first phone for every man, before there were phones but it was only big men or organizations, now we can every man have a phone like this (gesturing upwards with hand as if seizing something substantive).” In my experience working with subsistence farmers who volunteer as community health workers, somewhere approaching or exceeding half the population do not yet have phones. They do have almost universal access to a mobile phone, at least for emergencies, via spouses, relatives, or neighbors. To say the least, these ultra low cost phones made mobile telecommunications an industry with mass appeal in Malawi.

Friends and colleagues frequently ask me for a massively abbreviated sketch of the mobile landscape in East Africa so I often use an analogy with the role that cars have played in American culture. Mobile phones and cars both confer a very concrete power through mobility – either mobility of the person or the ability to communicate long distance. The Mosewalelu plays the role of the model T as the first point of mass access and therefore the route to mass appeal. Before mass access, cars and mobile phones largely remained culturally obscure like yachts and other toys of the elite. Many North Americans would call the Nokia 1680 pictured center above a low-end feature phone, but in Malawi this phone has massive sex appeal like a 1960s Masarati Roadster or Shelby Cobra. Such elite versions are only available to an economic elite, but the status they confer interestingly relies on the fact that they are seen as the better version of a Mosewalelu, the elite version of a technology that everyone is already discussing. And of course like the well designed yet economical Volkswagens and Toyotas there are the well made mid-range phones like the Nokia 1208 on the left.

After hearing this fascinating story from Alex I approached a number of other Malawian friends and invariably they recognized the term and laughed. “How does a Zungu (white person) know what you call this?” Too often Malawians find that their foreign colleagues care little about their language and we tend to be sadly apathetic if not antagonistic about social phenomena that reference religious practice (North Americans and Europeans are usually fascinated by traditional ceremonies, religious or otherwise, but we seem to think we already know too much about Christianity and Islam). Learning about this term was really fun and it underscored my frequent perception that you can’t really understand a technology until you understand the social circumstances surrounding its use.

Managing airtime with community health workers

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Throughout Africa the vast majority of phone subscriptions are pre-pay. Usually that means you buy a voucher like the one pictured above and enter the voucher PIN into your phone to redeem units of airtime (rather than using a certain amount of airtime and paying at the end of the month). One of the big challenges in my work is figuring out how we can let our community health workers continue to use their phones in this way, while also reimbursing them for work or hospital related airtime. A week or two ago I posed these questions to the ICT4CHW mailing list:

Option 1: has anyone come across a telecom that offers zero-rated SMS or data lines – analogous to a 1-800 number in the USA – as a standard service? This approach is very appealing but for the fact that usually you need to negotiate this on a special basis with the telecom which can take time, requires clout, etc. Is there any way we could collaborate to make negotiation for this service easier and/or convince more telecoms to offer it as a standard service?

Option 2: Brian of ComCare mentioned bulk buying data for their program and fortunately the CHWs weren’t using data services personally so they didn’t use program airtime for personal use – clever! Has anyone else tried this approach?

Option 3: At one of Medic’s projects in Malawi we set up an automated top-up system where CHWs could text in their ID and have airtime sent automatically to their phone. It was easy to manage and was very infrequently abused, in retrospect this was due to the strong relationship between the hospital we were working with and their CHW program, and because we had explained to the CHWs that their airtime requests were monitored after the fact – if they requested more airtime than they should have needed based on the number of messages they were sending to the hospital, they would be removed from the program.

This approach isn’t foolproof though. Here are some issues:
You may send enough airtime for 10 SMS and find that CHWs only use 1 or 2 SMS for program use and spend the rest on their own stuff, then request more airtime. You could switch to a system where a CHWs is initially given enough airtime for say 10 SMS, and they are automatically credited 10 more SMS (via USSD) as soon as the tenth SMS is received by the system. This does prevent abuse… but it also just halts your program if CHWs spend their initial airtime on personal stuff and it is beyond their means/will to buy more so that they can keep sending SMS to the hospital.

Another option is to send smaller amounts of airtime each time you request a CHW activity that will require them to respond to you, and say they can have for personal use whatever they don’t use in responding to that specific task. This has a high transaction cost though; in places like Malawi where the transaction cost for a USSD airtime transfer is the same as the cost of one SMS, you can basically doubles the cost of your program’s SMS.

Have others encountered similar circumstances? In the long run we should probably invest more time in figuring out Option 1, but we are really trying to develop models that can be replicated by normal health care folks – people who aren’t professional mHealth practitioners like us – and so we’d like to find a solution that doesn’t involve negotiating with a telecom. I feel like a human and work flow solution is may be necessary here, it’s hard to replace basic health worker trust and discipline, but I’d love to hear ideas any others have!

Other mHealth practitioners seem to be dealing with these issues as well – we had a lively discussion over 32 posts to the list. Here’s my summary of a few key points:

    Reverse billing, short codes etc are possible, and usually the best option if your project is large and you have staff who can make a good business pitch to the local telcos.

    Smaller projects, those that need to get up and running quickly, or project that lacks the savvy to pitch to/negotiate with a telecom will usually want to reimburse their health workers manually. The key to success here may be in creating proper incentive structures. For example, allowing some extra airtime for personal use, making airtime a collective resource so that peers in the community enforce prudent airtime use, or modifying salaries (bonuses or salary deductions) according to whether airtime use was appropriate.

    To “reimburse manually” could mean handing out paper scratch-off airtime vouchers, sending airtime directly from facility SIM to CHW SIM, distributing voucher pins via SMS, or having a telco or kiosk vender send out airtime for you. The most appropriate method may depend on your incentive structure.

    There are also technical hacks – for example only buying data bundles among CHWs who don’t use data, getting smart phones that can restrict which numbers may be called/SMSed, or working with a telco to restrict sms/voice/gprs services and outgoing numbers (the reality may not live up to the expectation with some telcos).

    Long term, I’m excited to continue conversations about working with individual telcos and the GSMA ‘union’ to make available the services that will be most useful to us. Based on the broad issues we’re discussing here I think there is a profit incentive for telcos to offer these services. Eduardo offered some useful insight on how to go about making the pitch to various telcos.

The ICT4CHW list has a new discussion about once a week, you are welcome to join us.

FrontlineSMS Update for Malawi’s Ministry of Health Data Standards Meeting

View more presentations from Isaac Holeman.

I have been working in Malawi for about six months now, and though I miss home (Oregon), I am beginning to feel comfortable and increasingly productive here. Malawi is a wonderful place to work. I have met many good people and seen much of the land. I have yet to explore so much more, but I have been very busy and very content with work.

Last Thursday, February 4th, I had the fortunate opportunity to present at a National Data Standards Meeting, convened at the Cresta Hotel in Lilongwe by Chris Moyo of the Central Monitoring and Evaluation Division of Malawi’s Ministry of Health. These slides offer a brief overview of FrontlineSMS:Medic’s evolution in Malawi, the current work that has kept me busy for the last six months, a few lessons learned, and some of our vision and strategy for the future.

If you have questions, ideas, critiques, or general feedback, I’d love to see it in the comments or on Twitter.

Note: If you click through to this presentation on slideshare.net, you can select the Notes tab underneath the presentation to see more or less the full text of this talk.




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