IN the eastern-most tip of the Central African Republic, nestled between the borders of South Sudan and the Democratic Republic of the Congo, health worker Yves Ngonakpa makes sure that the health clinics in his remote corner of the country are stocked with life-saving malaria drugs.
Located more than 2,000 kilometres from the country’s capital Bangui, the town where Ngonakpa is based, Obo, is not an easy place to send supplies to in the best of times. After the country became engulfed in an internal conflict in December 2013, the few supply routes that existed were blocked entirely. Even sending basic information about the monthly number of malaria cases or levels of drug supplies to health ministry headquarters in Bangui became nearly impossible.
“Due to the distance and logistical challenges, as well as the increased insecurity, taking reports to Bangui in the conventional way would take me at least one month,” Ngonakpa says. “There are no vehicles going from here to Bangui and the roads are almost non-existent. Also, with the increased kidnapping and robberies along the way, no one would be sure of reaching Bangui.”
The problem is that with malaria, a delay in treatment of just one day could mean a death sentence for victims of the disease, especially for young children. Now a mobile-phone-based reporting system called RAMP (Rapid Mobile Phone Data Collection), which uploads comprehensive health data directly to a centralized web platform, is helping health ministry employees such as Ngonakpa to ensure patients get the malaria drugs they need in time.
“With the use of mobile telephones to send and receive data, I can cover the vast distances in a short period of time,” he says. “When our stocks are limited or when we have other problems, I can communicate with Bangui in good time compared to the past when it would take weeks.”
In places such as Obo, it is important to know when drug supply levels are running low as the planes that deliver them, chartered by humanitarian organizations, do not come frequently. Thanks to the RAMP system, Ngonakpa says that these days, when they are just about to run out of stocks, new shipments arrive.
“When we started, we were shocked that 30 per cent of health facilities in Bangui had no stocks of malaria drugs. So weresponded and after three to four months, the numberof stock-outs went down to zero.”
Mac Otten, medical doctor and
head of IFRC’s monitoring and
evaluation team in the Central
Killer number one
This is not just an issue in remote towns such as Obo. “Malaria is the number one killer for children in Africa and the Central African Republic has one of the highest malaria rates in the world,” says Mac Otten, a medical doctor and head of IFRC’s monitoring and evaluation team in the Central African Republic. “Malaria is by far the leading killer of children in the country.”
Visit any hospital ward in the capital Bangui, or elsewhere around the country, and more than half of the beds will be taken by people who are hospitalized due to malaria. And about half of the people who die in these hospitals will perish from this preventable mosquito-borne disease.
Decades of civil strife and insecurity had already weakened systems of community health that might have kept the disease in check. Since fighting expanded or intensified in December 2013, the fragile social system fractured even further and almost brought the already tenuous economy, and its social, political and health systems, to a complete halt.
By April 2014, nearly one-third of the country’s 900 health facilities had closed or been looted as staff fled to neighbouring areas or countries, or were simply too scared to come to work. Elsewhere, health workers stayed, but stocks of medicine and other supplies ran perilously low or were used up entirely, while many doctors and nurses have worked without pay.
In this context, the IFRC took the lead on a project, supported by the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria, to distribute more than 2 million bed nets country-wide and to develop a programme to support up to 166 health centres with malaria medicines. (Other humanitarian organizations signed on to support another 200 health centres.)
How a mobile-phone-based database is helping to save lives in the Central African Republic (top clockwise)
Photos: ©Juozas Cernius/IFRC
1. When fighting makes travel dangerous, people often come to health centres only when they or their children are already sick.
2. After people are cared for, information about cases of malaria and other health problems are recorded in health centre logs.
3. Data about caseloads and the amount of malaria drugs and testing are entered into electronic forms on smartphones. Those forms are then sent using mobile-phone networks to Ministry of Health headquarters in Bangui.
4. Using this information, the Health Ministry sends drugs where they are needed most.
5. People who are sick are then more likely to be properly tested and treated for malaria. Information about treatments is also entered into the electronic system, which helps health officials track their progress against the disease and ensure that drug-stock levels remain adequate.
Many more people are now getting drugs that will save their lives and potentially break the cycle of reinfection caused when a sick person is bitten by a mosquito capable of carrying malaria.
“The most remarkable thing is that we now get reports from areas that we never thought we would get information from,” says Désiré Takoumbo, malaria monitoring and evaluation delegate for the IFRC in the Central African Republic. “Now we know on a weekly basis where they have the drugs and where they don’t and we can use that information to save lives.”
The data were also useful in determining which facilities were still operational at any given time, given the fluidity of the fighting. Before, these reports would have to be brought by car from all corners of the country — a long and slow trek in some areas at the best of times — before the data were entered by hand into a central database. “You can imagine the task of getting 900 paper reports into the central system,” says Otten. By the time health ministry epidemiologists looked at the data, it might have been more than three months out of date.
With the RAMP system, the information is uploaded from the field to the central database in real time. “The main advantage is the rapidity with which we receive the information and with which we can put it into action,” says M’bary Siolo Mada Bebelou, a doctor of public health and malaria focal point for the IFRC in the country.
A case in point came during the early phases of the project’s implementation. “When we started, we were shocked that 30 per cent of health facilities in Bangui had no stocks of malaria drugs,” Otten says. “So we responded and after three to four months, the number of stock-outs went down to zero.”
The difficulty now is reaching the rest of the clinics that are operational but are not participating in the RAMP data collection system. Those who manage the RAMP programme say it has already proven its potential to become a system-wide health reporting tool for numerous health indicators, not just malaria. “We don’t see this is as a project database,” says Otten. “We want to build a national reporting system so that all 900 health facilities are reporting.”
Beyond malaria, for example, could the system be used more widely to track and respond to other major killers such as HIV/AIDS and tuberculosis, both of which require more complex treatment regimens and potentially new systems for tracking patients? Might RAMP be used more widely beyond the health centres to gather information about community health, as has been done with some success in Kenya, Namibia and Nigeria?
But there are challenges to scaling up even a relatively simple, low-cost system like RAMP. In contexts such as the Central African Republic, mobile phones are common but not ubiquitous and network coverage is only available for two hours a day in some areas. Then the lines are jammed with people trying to make urgent calls.
Also, many of the health staff who collect the data have a strong understanding of the medical data they need to gather. But they may not be very familiar with smartphones. Project managers quickly realized they had to expand training on smartphones from one day to three in order to ensure data were being entered and sent correctly.
No time to wait
Security problems in the country also mean that supervisors are not present in the field to correct errors or verify data. So the system relies on other checks and balances. For example, paper copies of health reports stay at the health centre and the focal points keep a copy at district headquarters. That allows for quality controls or cross-checking between what arrives in Bangui and the caseloads and use of medicines at each clinic.
For Jason Peat, a unit manager at the IFRC in Geneva, the RAMP project shows that despite these difficulties, the use of readily available technology can play a big role in helping health systems to function, even in societies deeply fractured by violence.
“It shows that even in a country as fragile as this one, it can be done,” he says. “So the reluctance that donors sometimes express about investing in the Central African Republic, because there are no systems for accurately assessing the needs or providing accountability, for example — RAMP has taken these excuses off the table.”
Most patients, such as those who come to the Mamadou Health Centre in Bangui, have no knowledge of the RAMP system — it’s completely behind the scenes. What matters to them, during times of scarcity and limited safe periods between outbreaks of violence, is that the testing supplies and drugs are available where they are needed.
“The rapid testing is good because it saves us from having to wait during these times of insecurity,” says Edwidge, whose 1-year-old baby tested positive for malaria. “And the fact that everything, including the medicine, is free gives me hope.”
Like all the patients here, Edwidge has been deeply affected by the persistent violence. “I have no money having lost my market stall to the crisis,” says Edwidge, who also has a 3-year-old child. “So I am very happy to have the free malaria consultation for my baby.”
By Nelly Muluka
Nelly Muluka is an IFR C communications officer based in Bangui.
“Now weknow on a weekly basis where they have the drugs and where they don’t and we can use that information to save lives.”
Désiré Takoumbo, malaria
monitoring and evaluation
delegate for the IFRC in the
Central African Republic
This little girl who lives in
Bangui, Central African Republic, is
able to get the malaria treatment
she needs in part due to RAMP,
short for Rapid Mobile Phone data
Photo: ©Juozas Cernius/IFRC
“The rapid testing is good because it saves us from having to wait during these times of insecurity. And the fact that everything, including the medicine, is free gives me hope.”
Edwidge, mother of two
who went to the Mamadou
Health Centre in Bangui with
her 1-year-old baby, who tested
positive for malaria