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Last day in Kampala

March 23, 2010

Thanks to the UNICEF country office’s internet connection, we are now able to post within minutes of our last meeting.  This is great, as it was a fast-paced and informative conversation with a representative of an organization that has some opinions about the appropriate speed and nature of data collection that are very different from previous meetings. Rather than collecting real-time data using technology, this organization is focused on more traditional cluster sampling. In an effort to keep costs low and make this surveillance system more sustainable, they currently collect data only three times per year. There is also talk of streamlining the system by reducing the number of indicators collected and focusing on seasonablility of data (some argue only two seasons are important in relation to agricultural and weather cycles) rather than arguably arbitrary four-month intervals.

In terms of analyzing specific forms of data (in this case, nutrition data) our interviewee explained that there are a few pieces of data analysis software that are generally agreed on. One notable example is ENA for SMART – Software for Emergency Nutrition Assessment

Another interesting portion of our conversation addressed the question of appropriately incentivizing those who collect data. It seems that, in contrast to the intangible incentives proposed by some organizations, others  feel that it is generally understood that “In Uganda, you can get nothing done without money”. I suspect that this difference of opinion may become important when considering larger surveillance system such as GIVAS.

Because this organization focuses on data that is collected at regular but infrequent intervals, we were curious to get their opinion of less formal, real-time information. They explained that it may be helpful to identify trends, but feel that if it is not both random and representative, it will be quite difficult to draw conclusions based on it.

The last portion of our discussion focused on the question of feedback. While, this is not a current component of this organization’s work, our interviewee did have some interesting thoughts on the matter. She feels that feedback, if used, should be presented in specific streamlined forms appropriate to different actors in the surveillance system. For example, perhaps District Health Officers would only receive information on the four performance indicators most relevant to them. One consideration for this sort of feedback system would be the amount of additional training that would be needed to enable those receiving feedback (especially those at the district level) to appropriately respond to it.

This is our last day in Uganda, and as such, we are working hard to type up our remaining notes and plan to squeeze in at least one more interview before we head to the airport. Each time I have told a Ugandan that I am leaving today, they’ve asked when (never if) I plan to return. I’m not sure when it will be, but I’m already looking forward to my next visit.

-Mark (Uganda Team)


Meeting with the Ministry and UNICEF Country Office

March 23, 2010

Uganda, Kampala, Monday, 03/22/2010

UNICEF Country Office & Ministry of Health Visit

After a weekend spent typing up notes and exploring downtown Kampala, our team set off early Monday morning for the UNICEF Country Office. Today was the big day to be introduced to the UNICEF staff at their Monday Morning Meeting and meet with officials from the Ugandan Ministry of Health. At the meeting we saw a prototype of the “digital drum”, a low-cost UNICEF version of the South African made “digital doorway”, a project to bring indestructible internet stations to rural communities. Impressive! Made out of empty oil drums, it can be produced at a fraction of the cost.

At UNICEF, we had one meeting focused on nutrition and health. We learned more about the proposed new package for the Village Health Teams (VHTs) and the timeline of the current health facilities reporting system.  One hope is that a SMS-based system could reduce the time it takes for data to reach the Ministry. Another way SMS could be used is to supervise and motivate the Village Health Team members. Also, by tracking referrals it would hopefully become easier to see whether the children referred by the Village Health Team member actually reach the nearest health facility to receive treatment. A patient identification system would tremendously help with the tracking efforts, as would higher rates of birth and death registrations.

Our first meeting with the Ministry of Health was focused on information management. What was particularly interesting at this meeting was to hear the high prevalence of improvised mobile phone use for reporting currently. According to the information we heard at the meeting, many health facilities already use SMS to text in their weekly reports to the next higher level. However, this is done manually and there exists no system so far to enter this data directly into a database as it is sent. Rather, each level forwards the reports manually. Nevertheless, this should make the acceptance of a SMS-based system easier. We also learnt that under the current system, the reports from the community based Village Health Teams (VHTs) stay at the district level and do not move up to the Ministry level.

The second meeting we had with Ministry officials was more focused on nutrition. The lack of consistent reporting was identified as a major challenge which the proposed system could hopefully help remedy. We also came across an important new consideration. Currently, the UN-proposed Global Impact Vulnerability Alert System (GIVAS) aims to monitor the same vulnerability indicators worldwide. In many of the Ugandan projects we have been researching, the efforts seem to be aimed at harmonizing the indicators nation-wide. However, at today’s meeting it was pointed out to us that the most effective indicators are likely differ from region to region, possibly even within a district, depending on the source of food, etc. For example, the level of rainfall might be more important in terms of food security in one region than in another, depending on whether the local population relies on purchased food, subsistence farming or possibly depends on food aid, as is the case in some parts of Eastern Uganda. It was also suggested that it would be important to work together with other ministries, such as the Ministry of Agriculture or Education, in order to combine efforts.

It will be interesting to bring what we have learned in Uganda back to New York to discuss with the Iraq group and the UNICEF HQ Team. As always, we have learnt a lot today but are left with many new questions and thoughts. Thankfully, we still have another day in Uganda.

Greetings from Kampala,

Karoline (Uganda Team)

Return to Kampala: Battle of Technologies

March 22, 2010

(Blog Entry for Friday, 3/19/2010; Posted on Monday, 3/22/2010 due to lack of connectivity)

Today, we said goodbye to Gulu and traveled back to Kampala.  After a 5 hour drive, it was bittersweet to leave calm Gulu and return back to the hectic city-life of Kampala.  Yet, we were excited to dive back into our meetings with NGOs, motivated with new questions from our field experience.  We met with two representatives from an organization that aims to control malaria in the country.  They currently have one pilot project working with local government using mobile phones for integrated community case management, collecting basic health information including rapid disease testing and mortality reports.

The difference between this project and previously mentioned projects in Uganda is that this one uses Java phones.  Java phones are more sophisticated compared to typical mobile phones that just receive SMS messages because they have a larger, more interactive screen and internet access.  For this organization, the decision to equip 10 members of the Village Health Team (VHTs) with these more advanced phones for the pilot project came from surveys done based on cost evaluation, coverage, and user-friendliness – the larger screen allows easier and more accurate data input as compared to SMS-based string of letters and numbers.  To solve the problem of electricity use, the project chose phones that can also be solar powered.  While the organization is still working out the quirks (what happens if the phone breaks or is stolen?) for equipping VHTs with Java phones, they believe that the benefits (easier training, more data accuracy, possibility of internet access) far outweighs the costs.

Another interesting discussion that came up during our meeting is the possible fragmentation of this sector as more and more projects are using different mobile technologies and systems for data collection.  Our team has heard the perspective that these projects need to find some common ground and agree on a set of standards, so that later systems or data can be more easily integrated or shared.  In the perspective of this organization, while it is important to form working groups and know what others are doing, the representatives felt that at this stage, it is more advantageous for each project to go out and do their own thing. Ultimately, all of these pilot projects are tests to see what works and what does not.  Allowing these early projects to try different things will provide good evidence for what may be best for future projects, if they choose to be more integrated and standardized.

Overall, another great meeting – this time with a more focused discussion on technologies used and possibility of more system compatible projects in the future.  It has been an exciting week of meetings and discussions, but our team is also looking forward to tomorrow when we can do little bit of exploring in the busy city of Kampala!

Signing off from the land of boda-bodas,

Ruby (Uganda Team)

Meeting under the Mango Tree: Field Visit to the Local Community

March 20, 2010

Uganda, Gulu District, Awash Health Center, Thursday, 03/18/2010

Posted on 03/20/2010 due to lack of internet access

Meeting under the Mango Tree: Field Visit to the Local Community

Today we left the provincial capital Gulu to go to the local Health Centre in Awash. After a couple of hours drive on dusty red sand roads, passing children carrying water or walking to school and many, many bicycles, we arrived in Awash, a WHO drugs delivery in the boot of our jeep. Today was to be our day in the field, meeting with members of the Village Health Team (VHT) of different villages and staff of the Health Clinics in the region, some who had already been trained on a SMS-based data gathering system. Some members from UNICEF were also joining us.

After an initial round of introductions where everybody clapped or stomped their feet after each person had said their name, we split in two groups and talked to the different VHTs. Their role in the community is to give out basic drugs, do community education, write referrals and submit monthly epidemiological reports to the Health Centers. We were particularly interested in the monthly reports and the process of submitting and validating them. What was particularly surprising was the large number of households (100-200) each VHT (village health team worker) is looking after.

After the meeting with the VHTs, we had lunch all together. Rice, goat and really good spinach, called Boo.

For the second meeting we moved under the large mango tree outside the Health Center. Our research team split up, half of us stayed to do an interview with the Health Clinics’ staff and the other half went to visit households in the community. The people we interviewed in the community, sitting in the shade of their huts, children playing all around us, were mainly women living with their families in the huts of the former IDP (internally displaced persons) camp. Many were widows and the main health problem appeared to be malaria, many having lost half their children to Malaria. There was also a high prevalence of mental illnesses in the community and HIV was a problem. As my guide, a VHT who spoke excellent English, explained to me, this camp had been raided several times by LRA (Lord Resistance Army) rebels during the civil war. Now the rebels were gone but the military base remained.

Many insights in one day, we had a lot to discuss over dinner at one of the local restaurants in Gulu, eating rice with a gooey spinach-peanut sauce, a specialty for this region. What was particularly nice was the fact that the staff from the country office in Kampala who joined us on our trip stayed in the same hotel, so we found ourselves discussing the best solutions and new insights related to our project over dinner and breakfast.

What a trip so far, this was only our third day and we have already learnt so much! We are so grateful for the opportunity to come here and gain such an insight. However, so far, each meeting brings up more new questions than answers, a lot to think about once we get back to New York!

Karoline (Uganda Team)

Greetings from Gulu: Meeting with District Health Office

March 20, 2010

(Blog entry for Wednesday, 3/17/2010, posted on Saturday, 3/20/2010 due to lack of internet connectivity)

Today, our team traveled 328 km northwest of Kampala to Gulu.  Our first impression of Gulu is that the weather is much hotter and the climate is much drier compared to the very green and cooler Kampala.  Gulu is the largest town in Northern Uganda with a population of roughly 113,000.  Although the town is quite safe now, it was heavily influenced by civil war and rebel conflicts for decades. Many internally displaced persons (IDPs) flooded to this town from neighboring areas of conflict.  Only in the past few years have they slowly moved back to their villages.  The past presence of IDPs is still noticeable in the many huts, “manyatas”, that scatter the region, not to mention the many IDPs who decided to remain in Gulu instead of returning to their villages.  Another piece of recent history that shaped many of our discussions was the October 2000 outbreak of Ebola in the district, which claimed about 160 lives and sparked the interest of collecting data on epidemic diseases in the region and creating protocol for rapid response.

With this history as a background, our mission in Gulu was to meet with representatives at the District Health Office and discuss the SMS-based pilot project that is currently being implemented there.  The pilot project, as mentioned in previous post, allows health centers (HCs) to submit their reports to the district level via SMS instead of the traditional paper system. We received a warm welcome from three representatives to discuss their experience in switching over to the SMS-based system.  Besides learning more about the structure of data flow from the village to ministry-level, below are some key points to consider from the perspective of Gulu District Health Office:

1. Advantages of SMS system: a) fast, easy, and no transportation costs for sending paper reports; b) no need for paper because keeping constant stock of forms have been a problem; c) paper records take up a lot of space in the office

2. Advantages of paper system: Although slower and requires more resources (forms), the paper system offer advantages in terms of data accuracy and validation.  The traditional paper system allows each level time and opportunity to review the data.  This was a key reason why some hospitals / health centers in this district had refused to participate in the Rapid SMS system. They fear that information may be transmitted and shared too quickly without proper validation through the levels of the traditional chain of data flow.

3. Possibility for best of both worlds: Using the SMS system, find a way to allow different participants in the traditional chain of data flow to validate or make comments on the information via the internet.  However, this will require each level to have internet access and be trained for this new process of validation.

4. Ways for information to flow back to community: a) display submitted reports online for all levels of the data chain to see how they are performing and how they are doing in comparison to others, b) display a summarized version of the reports and distributed via a paper bulletin or SMS message, c) utilize quarterly review meetings to display and discuss summarized reports at the various levels.

All in all, it was a very productive meeting, which will greatly prepare us for our meetings to the Awach Health Center III tomorrow with representatives from the HCs, members of the VHTs and some IDP households that are in the nearby area.  We are super excited to learn more about their roles and their perspective on this project.

Signing off from peaceful Gulu,

Ruby (Uganda Team)

Greetings from Kampala, Uganda!

March 20, 2010

Tuesday, March 16th (Posted on the 20th due to lack of connectivity)

Greetings from Kampala, Uganda!

After a series of weather-related delays and an unexpected detour through Kenya, our research team arrived in Uganda today a day a half late and eager to begin work. Despite a bit of jetlag, our team hit the ground running upon arrival and conducted two very fruitful interviews with coordinators of local projects.

The first interview was based on an innovative program here in Uganda to forecast droughts and drought-related challenges. While not currently utilizing new technologies (though this is being considered for future iterations), this program is especially relevant to our research project in that it has focused on coordinating new methods of surveillance and data collection with existing local, district and national efforts.  The program has experienced a number of successes and has also identified a number of areas to consider when scaling up this and similar programs. These include:

  • Seeking a balance between a large number of indicators requested by various partners and a realistic number of indicators that can be assessed in an accurate, timely fashion
  • Developing effective systems to monitor and verify data streams in coordination with relevant government agencies
  • Recruiting and/or electing local and district-level representatives and training them in a quick, cost-effect manner
  • Following up initial trainings with periodic “refresher trainings” or “sharing experience workshops”
  • Utilizing paid officials, such as parish chiefs, in an effort to avoid the need for providing significant monetary incentives (other than lunch allowances, etc.)

Our group was happy to learn that this program has been picking up momentum and has secured an impressive level of government buy-in at all levels. We look forward to learning about its progress and whether technology solutions will be included, as is being considered.

Our second meeting was with an organization with a very different focus but was also quite fruitful. This organization is currently utilizing an SMS based system to monitor a variety of health indicators in two regions of Uganda. The system allows data currently being collected by Health Centers in these regions to be communicated via a series of SMS messages. Indicators being tracked include data that has been tracked since 1997 on paper forms, such as numbers of cases and deaths caused by various epidemic diseases (dysentery, malaria, rabies, cholera, etc.). New indicators that have been added to this SMS-based project deal specifically with confirmations of malaria cases, treatments of malaria cases and drug stock data. This information is then presented in map format via the internet. Participants at higher levels in the system (district officials, not village health teams) can view pertinent information online using passwords provide to them.

Information learned at this meeting that is especially relevant to our research includes:

  • Considering various methods information may be verified as it travels upward
  • Proactively addressing the possibility of catastrophic failures, such as cell outages and power failures in designing a technology-based system
  • Being aware of the importance of appropriate, though simple, feedback to those entering the data via SMS
  • The possibility of creating a mapping system (perhaps using GIS) with universal location tags which various NGO and government entities could possibly use collaboratively
  • The implications of creating a toll-free SMS number (using reverse billing) for participants

After this two meeting, we really look forward to travelling to Gulu tomorrow to learn about this project’s on-the-ground methods of data collection and transmission.  That and a good night’s sleep…

-Mark (Uganda Team)

Academic Collaboration between UNICEF Iraq & Universities in the Middle East?

March 18, 2010

1. UNICEF (MENARO) + Columbia (Public Health)

CUMERC (Columbia University Middle East Research Center) is facilitating collaboration with UNICEF MENARO (Middle East and North Africa Regional Office) and the School of Public Health of Columbia University. Through this collaboration, this center is providing information for training, operation research, and technical assistance for UNICEF’s health programs in the Middle East.

2. UNICEF (Iraq) + Columbia (SIPA, TC)

CUMERC already has a strong partnership with Teachers College and applying the expertise of Teachers College (Columbia University) to education in Jordan. In our research back in NYC, we are planning to utilize some of these resources for our project.

3. UNICEF (Iraq) + Universities in the Middle East?

As the next step, it would be an exciting opportunity if CUMERC could serve as a hub for research and would facilitate academic collaboration between UNICEF, Columbia University, and other universities in Middle East (of course, including universities in Iraq) to make this project sustainable with local ownership.

Maki (Iraq Team)