barriers concerning standards and interoperability

mHealth in Nepal (part II of IV)

This is part two (of four) of mobile health series, which I am sharing after completing an online education on mHealth. For those who would like to read the Part One – its here.
The following are some of the concept we discussed in online class, and google group. I think this is very reasonable to developing countries like Nepal. Most of the barriers are specifically from mHealth Africa, but I have here tried to include my nepali perspective as well. Here are few of the barriers that I think I see in Nepal concerning standards and interoperability on mHealth.
  1. Language – Nepal despite being a small country, has a huge demographic variability. The mountains and hill terrain has made number of spoken language (culture) variation. “Nepali” is the official language, and English (UK) is taught from primary and secondary school. There are about 123 spoken languages (in 125 different community) and many who still do not speak or understand English at all.
  2. (limited) Mobile Technology – Most of the mobile handsets used in Nepal are under NRS.4000 (rough estimate USD=50  Euro=40). These are not Google Android OS phones, but Java based technology with proprietary OS from local market (mostly – China and India). There are about 5-6 different mobile company that have stronghold in budget feature phone in Nepal. The only technology similar (standard) in these feature phones is Java. However, almost all have Facebook (Java Application) installed in them. Facebook being number one Social Network in Nepal (at the moment).
  3. Lack of Government Initiatives – There is no standard Government based protocols regarding mHealth in Nepal. Although, Nepal Government has recently begun a trial phase of mHealth program in few districts; there is no details about this in government websites (This is something I  am considering to write for my first assignment also).
  4. Internet (Availability and Cost) – Internet access through mobile handheld is expensive; and this hasn’t reached throughout Nepal. As with mobile network, the mountainous terrain in most of the country is hampering the WiFi (WiDi, or WiMax, or LTE) rollout from Government and Private Initiatives. There is considerable progress, but more need to be done.
  5. mHealth education – is very new to Nepal. Health providers have very little knowledge about mHealth. Data Mining and Research are at its infancy in Nepali Health Community, very few if any are interested in mHealth (for this purpose) at present. Medical School (Doctors, Nurse, Health Assistant, Health Volunteers) do not have curricula to teach mHealth. Courses that offers technology (mobile or any) teaching is in Public Health related education. This education is concentrated in Data Entry, Evaluation and Analysis, but not in Health Education. I am a recent medical graduate and I had no proper formal education on Medical Technology. Most of the course work was limited to using MS Excel (2003) and SPSS (v11)
  6. Lack of (active) Open Source Community – There is a huge gap in programming education in Nepal, that most are financed/taught by proprietary holdings like Oracle and/or Microsoft. Most of the health initiatives related to technology are in the form of Outsourced Code writing by multinationals.
  7. Technical Infrastructures – present today in various Public and Private Health institute are scattered, rudimentary and closed source. Many hospitals and health care institution have both handwritten documents and e-records. Most of the time, its the physical documents that gets used, and the electronic records are forgotten. Most of the times doctors, nurses (or any other health worker) does not know how to use the electronic record. There is no inter portability between any two health care givers (both e-records or physical records).
  8. Lack of Adherence – Health providers do not seem to adhere to e-health technologies. Partly due to the lack of electricity or lack of proper motivation, or knowledge, electronic recording is seldom done in Nepal.
what can i explore for my next part?
well there are Ncell and NTC. and there network. There is Ministry of Health and its working, plus community members who love mobile. keep watch.

marketing gimmick – my true story

English: Gas cilinder
English: Gas cilinder (Photo credit: Wikipedia)

I’d read about it in inter-web, and saw it in popular culture based television shows, but had never experienced it first hand. I’d always thought I’d outsmart them, but time did tell me something different today. As I recall it now, five hours later, I am bemused and smiling. They were this close duping me into buying a complete garbage.

I took a break from my study and work today. A week long search through various movie collections led me compile a small list of movies from the late 80s and early 90s. Few were classic hits, few critically acclaimed, and few just didn’t made sense. I was through two good masterpiece and unto the next one, when Birkhe disturbed me. There was someone at the door. (Birkhe being the helper boy who lives with us for the last three months. We play Chess together every night from 9.30 to 10.00pm – time restriction followed strictly).

Birkhe has his exams coming, so I was to answer the door. With all my laziness I peeked out the window curtain and saw two gentlemen standing in our porch, outside. My face shaded by right palm to block the bright sunlight coming in from the crevices of curtains I’d broken apart from my left hand. I realized that my neglect to be covert made me visible to these two new faces. One of them saw me and raised a friendly gesture.

“Could you please open up, you might be interested in something we have” said the guy in blue jacket.

Now at these moment, I usually shy off. Close the curtain, and would be back to whatever I was doing as soon after. But today, was different. I was not agile, and I had been discovered. He was talking to me, and I couldn’t be rude. Not today I thought.

“Why are you here? what do you have?”

My reply was in as plain and polite manner as possible. There were few more sentences exchanged and pretty soon I was letting them inside the house. Apparently they were from the Gas Company, here to check the fuel efficiency and to identify and report of any leakage that might have been happening at present. To tell me of the dangers and or warn me of the potential threat level I was living with my kitchen – in short to explain if my Gas Cylinder was in risk of exploding or not. I knew this to be a kind of scam. However, a small voice inside me told to eventually look into what they had to offer. Plus this was broad day light, and since my neighbor had his house under renovation there were plenty of people around (if in case they turned out to be vampires and ghouls)

Two gentlemen, in their late 20s. The first one I met guy was wearing blue jacket, khaki trousers, in black canvas, with a worn out bulging black satchel in his right shoulder. I’d first inquire about their ID card, upon which he gave me a black file with few documents. First page had his ID paper, weird to think that this was am ID paper and not ID Card. Few pages that followed were some official looking documents in Nepali and English. This could easily have been made by any one. In fact I do know a shop that does this.

Following the first, and a little lost was the second person. I was checking the papers as both stood in front and made themselves known to the environment inside the house. A little stout, and with firm speech he introduces himself. He also had an ID card around his neck. His surname was “Khatiwada” (same as mine). “Wonderful” I thought to myself, as I inspected his attire. Black Jeans, shiny black shoes, peach green shirt, with an English Jacket unchained.

The scorching heat, and exposure of bright light had its toll on them. Firstly, they were sweating, and were smelling too. A strong olfactory sense made me realize about my own hygiene. I too had overdue to my cleaning habits today, and made the resolution to get started as soon after they were gone.

“Your Gas Cylinder looks good for now, but the next time you buy new or exchange this finished one with a new one, please look here and know the expiry date”

“Do not get the one that says expiry date on 2013”

“Your cooking range is okay, but the small pipe that connects this cylinder to the cooking ware, is damaged, and can explode any time. You should prevent the disaster from happening”

I saw a documentary in YouTube about the three marketing gimmicks to sell any product.

1. Create a problem,
2. Convince that this problem is real,
3. Give a solution, your solution, and say its the best out there

These two sales men were pitching this idea with an utmost sincerity and reality. I had a real problem and they were offering me to sell their solution. They were here to sell a small piece of plastic wrapped up in some metal that would connect my fuel cylinder to the cook ware I have. By this time, Birkhe was standing besides me and got exited, with this solution. Birkhe was happy to find a solution to a problem that until five minutes before had not existed, I had few of my own questions before I went ahead to ask the price of this wonderful solution.

“Are you from the Government? Does the government know about this? Is this a research?”
I’d so much hoped that this would be a research or something similar. As a person who is fascinated my Freakonomics.com (regular listener to their podcast) and the statistics, I’d very much hope that one of them would suddenly bring out a questionnaire and ask me fill. Nop, that was not the case.

No, there were not from the government, nor was this a research. They were simply doing a good work of making the citizen aware of the dangers about the wrong connection in LP (Liquid Petroleum) gas. Conveniently there were from “LP Company” (I had never heard about this up until today. Apparently there are some 20 to 25 of them, sweeping around, house after house, doing this good work of giving awareness. There are here (in this locality) today, and tomorrow after which they go to Bhaktapur (some 30 km away).

“So, what is the price of this great invention?” (a lame pipe with gimmicks) I asked

“Only NRS. 1750” was the answer.

This is about 20USD (17 Euro), At present, we get a new LP gas cylinder at NRS.1500 which usually lasts for about 45 days in a small household like me. A normal Nepali cook ware comes in NRS.1000. As I see it, this is a plain rip-off. I was angry, very angry. It dawn upon me, that they were simply doing there work. A smart work of ripping innocent bystanders and this occurs everywhere in the world. The best I could do was to make myself aware, and to the people around me. Calling the police would not work, well not now, not in today’s Nepal.

I lied. Instead of confronting them for their dirty work, I told them that I had no money today. I politely asked them, if this remarkable invention was available at any shop. No it wasn’t. My next question was to ask them, if I could call them up and come to their company headquarters or not. No was the answer again. Apparently, as I think now, they may not have any LP Company. My last resort was to take one of their name and mobile number, and cordially lead them to the door. A gesture to “get out” was promptly understood, and they left with no bad feelings. I explained to Birkhe about what had happened, and within minutes, he was back with this books to study for the exams.

Five minutes later, I went to a neighbor. A housewife who had settled in from the remote Himalayas. I wanted to warn her, of these men. Sadly, I was late, they were with her before they came to visit me. She had sincerely bought this magical invention. This magical marketing gimmick was worth 20 minutes and NRS.1750; with a warranty of three months.

I still have one of their number, and am looking forward to meet them tomorrow.

P.S. Next post will resume/continue mHealth (with my perspective of Nepal’s application on Mobile Health Technology) in four days time.

mHealth – outside Nepal (part I of IV)

The original advisory opinion was requested by...
The original advisory opinion was requested by the World Health Organization in 1993. (Photo credit: Wikipedia)

I got accepted in this wonderful mHealth (Mobile Phone Health) online program/course this past February. Course ware by GFMER (in collaboration with WHO) [details here] Its a six week program, from March to end-April; during which some eighty participants from throughout the world learn more on this topic. I have limited or no knowledge, so am exited to learn about this. Interested in the use of technology in medicine – clinical, non clinical, or even educational. I share here some of the wonderful ideas I came across during the first week of our course. We were to share personal interests and experiences. Very energetic and empowering.

On the assumption of 60% mobile network penetration, and rapid telecom growth in Nepal, here are few great ideas that Nepal could use. Most of them are directed towards rural Nepal. Some of them are already in use, in smaller scales. Most of the list below are ideas and only some are implemented at present. I see some with great potential, and if economy and my team permits, I’d love to collaborate and implement them in Nepal.

use of mHealth for callbacks
phone based intervention
a simple and effective way. I found examples of calling back patients for their scheduled appointments which required them to take medicines. Examples from Africa included HIV/AIDS retroviral therapy and Tuberculosis. While the former is not as big as in Africa, TB is very big in Nepal as well. May be, DOTS program that we have, here could implement callbacks from health centers for increasing regularity on medicine uptake. A phone call every fortnight just to check on patient.

Another big use was calling soon to be mothers, for their Antenatal Visits. World Health Organization (and Nepal Government) recommends at least four visits before delivery. May be health workers / Community Health Volunteers (FCHVs in Nepal’s Case) could start this call backs of all the registered pregnancies. At some level, this is being used in African nation, along with Postnatal callbacks and feedbacks also. If not all, high risk mothers (those with diabetes, gestational hypertension, seizure/epilepsy etc) could be followed up by this method. I know some hospitals in Nepal (read my alumni hospital – Kathmandu University Hospital*) have already begun unofficial callback programs on these high risk matters.

Lastly, vaccination program for the new borns could be assessed by these methods as well. Not that Vaccination and ANC visits are poor in Nepal, but mHealth could also be used to assist in whatever lag there might be, if any. On top of it, these could also be used to gather data, which brings to my next point (below)

use of mHealth for data mining
So there is a huge potential for mHealth and Data. As a clinician who is interested in research and evidence based medicine, I would love to see mHealth approach on it. There were lots of great ideas on data collections – from reporting a local health post for child being sick; to referring a critical case to Tertiary Health Clinic.

There are great examples of implementations as well. Like in one African nation, mHealth is being used to report the lab reports of a patient. Specifically focussing reporting on Anti-Retroviral Therapy and HIV/AIDS status. Other example use data gathering of children who are ill with chest diseases, this way knowing the prevalence of the community.

use of mHealth for education
Once in while (or scheduled) a SMS comes up, reminding me of the bad effect of smoking. Or this SMS has something to say to a pregnant mother, on what to do (or not to do) during her second trimester. There may be also an SMS reminding Female Sex Workers (FSW) of the importance of barrier methods in preventing Sexually Transmitted Infections (STIs); the same SMS may also go to sexually active couples, teens, etc.

In rural and remote areas, a SMS can inform of the doctor visit for health camps, or scheduled health awareness programs. A Female Community Health Volunteers (FCHVs) could get sms reminding / reviewing them of Maternal and Child Health Care topics. They may also do a QnA session via SMS for health information. [Remind you, these are speculations and ideas, I have my own questions of illiteracy in Nepal and optimum-mobile-use know-how].

future is in mobile……?

English: Open Data stickers
English: Open Data stickers (Photo credit: Wikipedia)


Well may be not, but with the ideas presented, mHealth could be a real boom for Nepal. As the technology prices are coming down, smartphones will soon be available to the masses. With new and open technologies like Firefox OS, Linux (read Ubuntu and Android) people have already begun the wheel for innovation in mHealth. Something of greater interest I found in this past week was – Open Data Kit (ODK) . I had heard (not in detail) about EpiSurveyor which is a closed source pricey alternate to ODK.

what is ODK?
Mobile data capturing using Open Data Kit (ODK) is a set of open-source kits of tools to manage mobile data collection solutions. Open Data Kit provides a mobile data capturing solution as stated below:
1. Builds a data collection form or surveys replacing traditional pen and paper data capturing;
2. Collects the data on a mobile device and sends direct to a server;
3. Aggregates the collected data on a server and exports to required Excel format for further analysis in SPSS, SAS, STATA etc.

the above quote is copied from website. not my own words, and I have yet to look into it. But this is pretty interesting, and is a big reason for me to make 2013 as my programming year. Will start with Script language, but thats another story. I end my post here, with a word to look into Open Data Kitt (ODK) and write about it in my next post. I am also weighing in Firefox OS and how it could be used in Nepal (my perspective). So these are the two topics for my next post.

P.S.i. – have decided to write in a schedule of four (or five) days. That way, I can read longer and write louder. My writings will be still first draft, and so filled with (may be) few errata.

P.S.ii. – Next Post – Saturday, March 16th, 8:30am NST.

Part Two – Published on April 24 – Here