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TulaSalud's m-Health project
CATEGORIA: Qualità della vita (Vedi tutti
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TAGLINE: Using mobile technology to reduce maternal and infant mortality
KEYWORDS: m-Health, ICT4D, Guatemala
WHERE: Guatemala
Innovation in mobile health is not quite as widespread in Latin America as it is in Africa and Asia. Of the m-health programs in Latin America, little sharing of region-specific strategies has taken place.
TulaSalud is an organization based in Guatemala that is leveraging ICT, specifically mobile phones, to improve the delivery of health care services for indigenous communities. Through this case study, we hope to share some of what TulaSalud has learned over the years.
TulaSalud partners with the Ministry of Health and the Cobán School of Nursing and receives support from the Tula Foundation based in Canada. The organization's vision is to use ICT and mobile technology to reduce maternal and infant mortality and to monitor disease outbreaks in the remote highlands of Alta Verapaz. Using mobile phones, TulaSalud has been able to improve the flow of information between health professionals based in hospitals and community health workers (CHWs) in remote villages.
Alta Verapaz has the largest rural and poor indigenous population in the region with limited access to health care services. In an area with one million inhabitants, 93% are indigenous and share the highest burden of maternal mortality.
TulaSalud's community health workers, known as tele-facilitadores, use mobile phones to:
- Seek remote diagnostic and decision-making support from physicians in urban centers
- Receive calls from people in their communities seeking care
- Organize logistics and transportation for emergencies
- Refer patients to hospitals and follow-up with nurses at hospitals to ensure their referred patients received care
Using mobile phones, TulaSalud is able to:
- Monitor disease outbreaks in real-time based on the data aggregated from patient consultations through EpiSurveyor
- Send text message alerts and reminders to tele-facilitadores using FrontlineSMS
- Evaluate the productivity of tele-facilitadores working in the field
- Deliver remote health training via mobile-based audio conferencing
Over five weeks, I observed the different ways ICT and mobile phones have been implemented by TulaSalud at the primary, secondary, and tertiary levels of care. This is a reflection of what I learned from TulaSalud's team of administrators, doctors, technicians, and consultants, including the field monitors and tele-facilitadores themselves.
In 2009, TulaSalud distributed mobile phones to 60 community health workers. With the phones, the CHWs could call a doctor based in the city of Coban for a second opinion if they were unsure about making a diagnosis or referral. The tele-facilitadores also started to collect information about each patient consultation using Datadyne's EpiSurveyor. The aim was to improve coverage of primary health care services in seven rural municipalities and to better serve 175,000 indigenous peoples.
EpiSurveyor surveys were based on mandatory Health Information Management System (Sistema de Informacion Gerencial en Salud or SIGSA) forms required by the Ministry of Health. These are paper-based forms to be completed for every patient consultation and hospital referral. Once the data is collected in the community, it is sent to the district to be digitized. Data from several districts are consolidated and analyzed at the area level. If suspicious disease signs are identified at this stage, directives for risk management need to come from the Ministry of Health in Guatemala City. (That is, if any analysis is conducted at all).
The above process can take up to 40 days, which is often 40 days too late to take preventive steps in the community. Collecting and digitizing the information in the community via EpiSurveyor allows for epidemiologists to assess the data as soon as it comes in. This information has enabled TulaSalud to take action within 3 to 4 days to prevent the spread of disease. For example, when cases of meningitis and measles are identified, the lead doctor can immediately inform higher level health officials. On the flip side, without TulaSalud's support, it is likely that the diagnoses could be made incorrectly in the village, or a correctly identified case may not be managed in a timely way.
In the pilot, tele-facilitadores entered key pieces of data into the EpiSurveyor form including the patient's name, an eight-digit code representing geographic location, sex, age, and a code representing the clinical impression and type of consultation (such as first visit, re-consultation or emergency). For a pregnant patient, the form automatically branches to ask the expected date of delivery. The CHWs can also access a built-in calculator to predict this date based on the women's last menstrual cycle. All health workers need to record which doctor was consulted if they sought remote diagnostic support. And for referrals, the worker must select the health centers and hospitals where the patient was sent to receive further attention.
Meanwhile, physicians and epidemiologists monitor the patient cases as they come through EpiSurveyor's web-based database and watch for descriptions that match, for example, malaria or dengue fever. Data collected by the CHWs was instrumental in the early detection of meningitis, rabies, and H1N1.
Based on the clinical impressions noted by the tele-facilitadores, doctors are also able to identify high-risk pregnancies and alert CHWs to closely monitor these women. Fifteen days before the expected date of delivery, the physician sends a text message using FrontlineSMS (via Clickatell) to remind the workers to make home visits.
By 2010, over 19,000 consultations were made and more than 400 patients were referred to health centers. Of these referrals, 156 cases were identified as being high-risk pregnancies and 83 women were at risk of dying. Currently, TulaSalud's database has over 38,000 patient consultations, and the database is growing.
The 60 tele-facilitadores currently cover 22% of the rural regions of Alta Verapaz. Incrementally, over the next five years, TulaSalud hopes to expand the program to include 330 CHWs equipped with mobile phones. The NGO believes this expansion could have an impact on health outcomes by drastically reducing rates of maternal and infant mortality and improving reaction time for disease outbreaks.
Because supplies, equipment, and personnel are limited, knowing the details of a patient referral in advance can improve hospital preparedness and timeliness. Several tele-medicine modules, staffed by nurses, have been set up by TulaSalud in hospitals around Alta Verapaz. Before sending a patient from the village, CHWs will call the nurses at these modules to explain the patient's condition. A few days later, health workers follow-up by calling the nurses.
The above referral and follow-up process is carried out via a phone call -- it has not yet been systematically automated via text-message nor is it linked to the patient data that is originally collected using EpiSurveyor. Evidently, the referral and follow-up loop needs to be developed and TulaSalud is currently exploring ways to do so.
TulaSalud also hosts capacity-building conferences using the mobile phones. In the local Mayan languages of Pocomchí or Q'eqchi, TulaSalud trains health workers and communities about natural medicines, nutrition, recognition of high-risk pregnancies, post-partum care, respiratory infections, and HIV/AIDS. Each month, tele-facilitadores link the mobile phone provided by TulaSalud to a conferencing unit that is equipped with speakers and a microphone for distance training. Members of the community also gather around to participate by asking questions of the facilitators at the office.
MORE INFORMATION:
Website: www.tulasalud.org/
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