In his small office on the second floor of the Rwandan health ministry, Eric Gaju heads a pioneering department in connected health. Since 2009, he has coordinated the RapidSMS initiative, the first African e-health application to have sustainably reversed infant and maternal mortality figures for an entire country. A sort of health “M-Pesa” (the Kenyan-born mobile money system is used by nearly 30 million people), which saved the lives of 590,000 Rwandan babies between 2009 and 2015, according to a statement established in 2016 by the United Nations Children’s Fund (Unicef).
How did the RapidSMS project start?
Eric Gaju In 2009, the death rate for Rwandan babies under 1 year old was very high, at around 47 deaths per 1,000 live births. Noting the rapid rise in the mobile penetration rate, including in the most remote hills, the Ministry of Health has decided to experiment with the practice of telemedicine in partnership with Unicef, in order to lower our rate of mortality at the level of the international average. Unicef provided our ministry with specialized e-health consultants to help us develop a first prototype in partnership with Rwandan technology companies. The objective was to enable community workers recruited from the villages to report all cases of high-risk pregnancies by SMS to the nearest hospitals.
Where did you start the tests?
We started our first tests in several isolated villages in the district of Musanze, which is located in a landlocked region in northern Rwanda. There are many hills there and it is very difficult for the locals to access medical care. We thought that if RapidSMS succeeded in reducing infant and maternal mortality in this district, we could then replicate this technology in all regions of Rwanda. After six years of experimentation followed by nationwide scaling up, RapidSMS dropped the number of deaths per 1,000 live births to 31 in 2015, just below the international average.
How do community workers use this app?
The health ministry recruits three community workers in each village – usually two women and one man – who are trained to recognize and report warning signs of complications in women aged 15 to 49 of reproductive age by text message. Agents work in coordination and exchange information with each other. Each problem is identified and then reported to the emergency services or to a doctor at a nearby hospital who can then intervene. Community workers are given a list of codes in the form of acronyms which correspond to the different types of illnesses to be reported as soon as possible: hemorrhage, fever, malnutrition, etc. Thus, the RED shortcode, for example, means that the patient is found in a vital emergency. The NP shortcode, for “No Problem”, shows that the pregnancy is taking place in good conditions.
What’s the benefit of having so much real-time data?
The mass of data transmitted by SMS allows the hospitals concerned to accurately anticipate the number of deliveries expected in the next two weeks and therefore the departments concerned to organize themselves accordingly. For example, if 50 deliveries are due next week, the medical services concerned will ensure that they have the necessary staff available during this period. The level of precision of the information transmitted by community workers also allows doctors to identify, among the 50 expected deliveries, which may turn out to be complicated and therefore to make a number of arrangements in advance.
How many community workers do you work with today?
The Ministry of Health has recruited and trained 45,000 workers to date in around 12,000 villages across Rwanda. Community agents are not appointed by the government but elected by the village community and are paid according to the quality of the information sent by SMS. Mobile phones are provided by the government to each community worker. The government also maintains its phones.
Are these smartphones?
For RapidSMS we use basic cell phones, this is more than enough to send SMS and to function for several days, even in the event of a power cut. We do not need smartphones and we make sure that the technologies that come from outside correspond to our needs and are adapted to our constraints. Let me give an example: one day, South Korea came to see us to offer us to equip our community agents with the latest smartphones from the Samsung brand. However, a smartphone discharges in a day and in remote areas of Rwanda, there is no electricity. Out of pragmatism, we therefore declined this offer.
Is there a charge for the RapidSMS application?
The application is completely free and the costs are covered by the government. In addition, RapidSMS is an application which was entirely developed in Rwanda thanks to free Open Source software. This means that anyone can download the application and contextualize it according to particular needs. For example, in Zambia, RapidSMS was completely “customized” with new features to enable the Zambian Ministry of Health to fight malaria.
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