September 14, 2012

Stories from the Field: Malaria Project in Laos

Lao PDR is a country with a population of around 6 million people.  Most of these people live in hilly terrain and dense forests which makes them particularly vulnerable to Malaria carrying mosquitoes.  It is estimated that more than half of the population is at risk for contracting the disease.

image: WHO World Malaria Report 2011 -
THE GOAL: RAPID INFORMATION SHARING TO LIMIT DAMAGE OF MALARIAWith support from The Global Fund, the iLab Southeast Asia has been working on a project with the Center for Malaria Parasitology and Entomology of Lao PDR (CMPE) to provide technical assistance in developing an SMS system for Malaria reporting.  

The goal of using an SMS-based reporting system is to help the people at the national and/or supervisor level to get critical information and alerts from the field, in real time, so that they can better manage and coordinate their resources to keep people better protected from the potentially devastating effects of Malaria.

The application allows the Malaria workers to send in SMS reports consisting of:

  • critical malaria drug stock information
  • geographic locations, and the
  • number of patient cases from the villages and health centers

Currently, Malaria workers use a slow and burdensome paper based system that takes around one month for the information about the patient to travel up the system. For example, if a patient at the village level is suspected of having Malaria, the information regarding the patient and the stock level of drug supply needs to travel from the Village level up to the National level, as shown below.  This system is done by paper or through an excel file at the Provincial Health Department level.

We knew that we could improve the speed, accuracy and ease of information sharing to help make this process better, so we took a trip to the Saravan province to help us better understand the context.  

We visited villages, health centers and operational districts to learn more about the end users who would eventually use the tool we were developing.  Our trip was accompanied by representatives from the National Level, the head of the Global Fund and the head of the Malaria unit within the Saravan Province.   

We learned about the health worker’s literacy levels, and how they shared knowledge.  We learned about their access to mobile phones and other tools that could help.  We learned that there were a total of 37 villages within the Saravan province, with 35 villages under a single Health Center catchment area.  The remaining 2 villages reporting directly to the Operational District.  These numbers mean that one modest health center could be responsible for up to 10 villages!

In order to conduct some field usability testing, we purchased two phones with SMS capabilities that supported the local language (Lao):
  1. Cell phone (about $22)

  1. Desk phone (about $18)

We prepared instructions on how to send SMS through each of the phones.  We also prepared three different instruction options to test with the health centers and the Malaria village volunteers to see which options were easiest for them to use. Those four options were:

  1. Indicators card: The front of this card explained how to send an SMS report. The back of the card listed of all indicator codes. The idea behind this card was to help users understand how to enter the reporting data into the SMS template and send the information in.

  2. Picture and number: Each card represent one indicator.  The information included was the indicator name (written in Lao) plus a picture and a code number. This picture card helped the user understand the indicators and guided the user on how to input data for reporting into the template message.

  3. Reporting Wheel:  This allowed the user to encode a descriptive message into a number that they could send through SMS.  Our Reporting Wheel system then decoded that number for the people on the receiving end.

(left: Dr.Rattanaxay from the Global Fund, right: head of malaria unit Saravan province)

We traveled to the Saravan Provincial Health Department to meet with the Provincial Director and Malaria unit staff.  We learned that the provincial level emails an Excel spreadsheet to the National level containing their report. While visiting the facility, we also learned that they have a laptop with an internet connection.

Next, we continued on for a 2 hour bumpy ride until we reached the Tomlanh District hospital within the Tomlanh district.

(It was a difficult 2-hour journey to get the the Tomlanh District Hospital)

Once we arrived at the Tomlanh District Hospital, we learned that they had several computers there.  We were told that these computers were rarely used and did not have access to the Internet. It was surprising for us to learn that there was a good 3G connection (through Unitel) within the district hospital compound.  We tested our own 3G modem to load our Resource Map application and found that the speed was quite acceptable.

(left: Tumlanh district hospital, right: Dr.Rattanaxay (in blue shirt) explaining the system to the district staff)

While we were visiting the district hospital, we were fortunate enough to meet two other health center staff who were on site for another meeting that day.  When we spoke with them, they told us that when the village had a shortage of the malaria drugs and needed to treat patients, the malaria workers were only able to conduct the malaria tests there.  That meant that the patient and had to go the way to the health center in order to receive any treatment.  This was a major problem for the patients in having additional travel while they were sick was very burdensome.

Next, we talked with the health center staff about the overall goal of the SMS reporting system.  It was important for us to connect with them in way that helped them understand that we were there to help support them and make their jobs easier.  We started off by walking them through the materials we had prepared.  We asked them to follow the instructions we had prepared.  While they tested the system, we observed their reactions to see if they really understood the material and if it would be something of value to them.

(left: Dr. Kongxay from the National level of CMPE, a health center staff)

At the first Health Center, there was a young man who recently graduated from medical school. Typical for the younger generation, he knew how to send SMS. The young man told us that he usually sends around 5 SMS per week to his friends. He was able to follow all of the instructions we laid out without any problems.

At the second Health Center we also encountered younger staff members.  At this health center, one of the young staff members had a cell phone, but he had only used it to make calls and was totally unfamiliar with how to send and receive text messages.

(left: A health center staff try the testing material for reporting)

We gave him the instructions on how to send SMS and let him read and practice for a little while. Dr.Rattanaxay and Dr.Kongxay helped explain the directions to him further so that he could follow the instructions to send in the code through the SMS template. The young man learned fast, but as with any new skill, it would take time and practice before he would feel comfortable using the new system.

We went to Tumlanh district again to visit Nadou Health Center and to go visit an additional two villages. Luckily, there was a good Unitel mobile phone signal at this health center as well.  In addition, we noticed there were several young staff at this health center, which made them more likely to adapt to using an SMS based reporting system.

Left: Nadou health center in Tumlanh district, Right: A health center staff do SMS report testing

We watched the young health center staff follow the instructions we laid out for her.  It was exciting to see that she was easily able to send in the indicators as guided using the Reporting Wheel, the image card with instructions and the SMS template report.  She told us that it was easy for her to use both the Reporting Wheel and the Image Cards.  We tested each option to see which option the user felt most comfortable following.  


Afterwards, we continued on to a small village called Done Sat (click here to see this village on the map) which was located in a relatively remote part of the country.  The village was very modest with only 2 water pumps, some electricity, and a very low cell phone signal that seemed to waver on and off even in half meter distance away. This particular village had a health center that was located across a small river.  However, during the 3-month rainy season, the small river would flood, making it nearly impossible to access the health center without a boat to cross the river.

Some people in the village, such as the village chief,  had a Unitel desk phone. The village malaria volunteers we met did not have their own phones, but did know how to make a phone call if needed. Unfortunately in order to make a call, they would need to go to the villager who had a phone and borrow it.

One of the village Malaria volunteers we met could read and write Lao, the local language, but he was unfamiliar with SMS. Dr.Rattanaxy explained to him the value of using SMS and while he was keen to learn, it was a much steeper learning curve than what we experienced at the previous health centers.

left: village volunteer reading phone instruction

According to the village volunteers, one of the main ways that people were contracting malaria was from their trips into the jungle. Part of the reason for this was that while they were in the forest, they usually slept in wide open spaces without a protective net.  When we asked why they did this, we were told that it was easier for them to breath in the open spaces (as opposed to sleeping under trees) and they believed that there were not any mosquitos in the open spaces.  

Solar panel used in the village

After that, we continued on to the next village named Nado(click here the see this village on the  map). While this village also had an unstable phone signal, they had the extra challenge of being off the electrical grid.  In order to have some basic electricity, those who were able to afford the alternative solar panel that cost around $300 were the only ones able to have the sort of electricity you and I are familiar with.

There is no electricity in this village. Villager use regular battery to charge phone.

One of the village malaria volunteers in this village that we met was knew how to read and write Lao, but was completely unfamiliar with how to use a phone.  In fact, he told us that he had never used a phone before in his whole life! We were able to witness this man's very first time touching a phone. As you can imagine, he was very happy when he learned how to make his very first call!

He tried and focus hard to read and and listen to the explanation from Dr.Kongxay and Dr.Rattanaxay. He seemed to be able to follow along, but he had quite a lot to learn since he was starting as such a low level. It would require quite a lot of practice for him to get to a point where he felt comfortable using this this unfamiliar system.  Even in the face of that challenge, he expressed his willingness and commitment to learn how to do SMS reporting and was looking forward to it!

This field trip is an eye opener for everyone involved in the project. It challenged many of the assumptions that we had, such as the type of experience and comfort level with using a phone, as well as their willingness to learn new skills. Due to our assumptions being so challenged, it really exposed us more to the reality of life in the field and with these new experiences we were able to alter our design to make it easier for them to use.  This experience reminded us exactly why all of our tools are born and developed in the field!

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