Limited lifeline: Zuhura Hussein, who does outreach in Nairobi’s Kibera slum, has the names of many TB sufferers and HIV-positive clients on her phone but no technology to track them
Erick Njenga, a 21-year-old college senior wrapping up his business IT degree at Nairobi’s Strathmore University, has a gap-toothed grin and a scraggly goatee. A mild-mannered son of auditors, he didn’t say much as we tucked into a lunch of grilled steak, rice, and fruit juice at an outdoor café amid the din of the city’s awful traffic. But his code had done the talking. Last year Njenga and three classmates developed a program that will let thousands of Kenyan health workers use mobile phones to report and track the spread of diseases in real time—and they’d done it for a tiny fraction of what the government had been on the verge of paying for such an application. Their success—and that of others in the nation’s fast-growing startup scene—demonstrates the emergence of a tech-savvy generation able to address Kenya’s public-health problems in ways that donors, nongovernmental organizations, and multinational companies alone cannot.
Njenga was humble about the project, but the problem he had tackled was critical in a nation where one in 25 is HIV-positive (10 times the U.S. rate) and AIDS, tuberculosis, and malaria are among the leading killers. In 2010, the Kenyan government realized it had to do something about its chaotic system for tracking infectious diseases in order to improve the response to outbreaks and report cases to the World Health Organization. Handwritten reports and text messages describing deaths and new cases of disease would stream in from more than 5,000 clinics around the nation and pivot through more than 100 district offices before being manually entered into a database in Nairobi. The health ministry wanted to let community health workers put information into the database directly from mobile phones, which are ubiquitous in Kenya. The ministry initially sought a solution the usual way: it explored hiring a multinational contractor. It drafted a contract with the Netherlands office of Bharti Airtel, the Indian telecommunications giant that also operates a mobile network in Kenya. The company proposed spending tens of thousands of dollars on mobile phones and SIM cards for the data-gathering task, and it said it would need another $300,000 to develop the data application on the phones. The total package ran to $1.9 million.
The contract was never signed; Kenya’s attorney general stopped the deal over questions about its reliance on one mobile carrier. A few years ago, there wouldn’t have been any options within the country. But Kenya’s director of public health made an urgent call to Gerald Macharia, the East Africa director for the Clinton Health Access Initiative (CHAI), a wing of the foundation started by former president Bill Clinton. Macharia then called an instructor at Strathmore, who quickly rounded up the four students. They spent the spring of 2011 at the CHAI offices, receiving internship pay of about $150 a month. They sat for days with the staff in the health ministry to understand the traditional way of gathering information. Then they pounded out the app and polished up the database software to allow disease reporting from any mobile Web interface. By last summer their “Integrated Disease Surveillance and Response” system was up and running at the ministry, obviating much of Bharti Airtel’s proposed costs. The process was “rough—but not too bad,” Njenga says. “There were some nights we worked until 2 a.m.” He and his colleagues are now finishing an SMS version so that health workers without Web access can make reports via text message from mobile phones of any make or model. The students are also working on another key problem: coming up with ways for the health ministry to track pharmaceuticals it ships to the government’s hospitals and clinics, to avoid shortages or waste.
Mobile phones are lifelines for Kenyans. Some 26 million of the nation’s 41 million people have phones, and 18 million use them to do their everyday banking and conduct other business; most use a service called M-Pesa, which is offered by the country’s dominant wireless provider, Safaricom. If mobile phones could play as big a role in Kenyan health care as they do in Kenyan financial transactions, the effects could be profound. A growing body of research worldwide is showing that beyond disease surveillance, mobile phones can improve public health by connecting people with doctors for the first time, reminding people to take medications or bring children in for vaccinations, and even enabling doctors in remote areas to view, update, and manage crucial clinical records.
Still, there are big gaps between the promise of mobile health technologies, or “m-health,” and their actual implementation. According to the mHealth Alliance, a Washington-based group, 45 mobile health projects are active or have already been completed in Kenya alone—more than in any other country. Most have been devised and paid for by philanthropies, aid agencies, and NGOs. The projects vary widely: one delivers money via M-Pesa to pay for repair of fistulas, a damaging complication of childbirth; another verifies the authenticity of drugs when workers text their serial numbers. Some have had substantial impact. But most are limited in scope and time frame. And there’s often no business model for sustaining them when the funding runs out, leaving the field suffering from a bad case of “pilotitis,” says Patricia Mechael, executive director of the mHealth Alliance. “The space is incredibly fragmented, unfortunately,” she says. “You have a lot of bits and pieces coming from different angles and lots of pilots going on.”
Meanwhile, IT contracts for government websites, electronic registries, and other large projects are typically conceived by NGOs or donors and carried out by contractors who may be remote from the specific needs of workers at the front lines. “You have people thinking at 30,000 feet: ‘Let’s do websites for every government ministry,’” Jackson Hungu, CHAI’s country director, told me over dinner in Nairobi. That’s good, he says, but it may not meet the needs on the ground: “Have we gone to that pharmacist and asked, ‘Look, what do you do? You are the one who meets the patient and feels the pain.‘ Have we understood it thoroughly from that guy’s point of view? Or are we building something so donors can say, ‘Oh, we are online’?” Successful national technology strategies, he argues, require people like the Strathmore students, who have the code-writing chops, can readily work with the people who need to use the technology, and are likely to remain in Kenya to sustain the effort.
