DigI talk:Roundtable Digital Health for Tanzania

= Notes by Project participants =

Roundtable discussion, for official Minutes see DigI:

Christine's notes

 * Professor Noll briefed on goals of the meeting and core messages of the foundation and project. See http://digi.basicinternet.no for all information
 * Q: Funds available, or looking for funds? A: Initial pilot funds are available but we are working with NORAD on getting the funds from NAVA, Norfund, Swedfund, Finnfund. Put results together to show the impact and effect.


 * A discussion on diseases. Why were the villages and diseases chosen? Cholera, malaria and malnutrition should be addressed (a cholera video is projected and will be available ). Malaria is the number one disease, impact is bigger when addressing this diseases. Also AMR, and one-health diseases and NTDs, stunting and malnutrition. Common approach. Mr Mwakapeje and ass. Professor Ngowi commented on the one-health approach. NTDs continuously endemic in our area. Comment from Dr. Ngowi on the roll-out of this piloted priority diseases, and then add on more diseases and prevention material. Build out the platform is one of the main aims of DigI.


 * The background – ground work, areas and villages, start fresh. Sustainable business model – what are the criteria to roll out, and make it work?


 * We want to reach the people – they will access the entry point and use the digital health platform. What are good entry points?


 * Mr Ulanga from the Universal Communication Service Access Funds presentation. Priority diseases may have research impact, but less societal impact. Hard to demonstrate significant outcomes. 2G, 3G and 4G illustrations on map.

In another initiative MUHAS and MOH and district is working on Telemedicine project at Ololosokwan, a location close to Kenya – installed a digital village with i.e. diagnostics and ultrasound and internet school. This have worked out well. Examples from the digital schools. Another WB project connected the national hospital (MNH) with other 7 regional hospitals, and district hospitals, thereafter health centres/ wards, clinics and health posts. Still; not all have access to health care.
 * Dr Mpoki on the telemedicine project. Infrastructural issues makes it hard to reach every Tanzanian. The deployment of health workers in rural areas failed. With appropriate mechanisms of communication, we have a better stand in the market. Base at Muhimbili – connected the hospitals (i.e. Bagamoyo and Ngorongoro). When planning scaling up, the equipment became obsolete, new approach was developed. Currently looking for sources to equip the staff.


 * Mr Ulanga: An unified approach among the various stakeholders is most important.


 * Mr Albou, TIGO. Broadband work started 2008. People were not using it due to language barrier. Facebook was translated into Swahili. Adoption of internet boomed when local language was used. Two areas were focussed in the project: Health and education. But the platform was not used, due to lack of content and lack of devices. The old curriculum was made available online, and program schools were funded for two years. Also related to birth registration and monitoring. Free is dangerous, needs to be sustainable.  Much is already invested in infrastructure, but rural areas are really complex. Investment and running costs are both drivers that drain the projects economically. Theft of solar panels has also been an issue.  How can we bring the broadband into the picture? Broadband was pushed in six villages. Penetration ran very fast, especially in the younger segment. People know how to send SMS, but not use of data, due to lack of devices. 4G devices is very costly, even 20.000 TSH can make a  huge difference for many people. When the old mobiles are charged, last for two weeks. With the smart phones, lack of electricity to charge can represent a huge barrier. To reach the people is also a problem. The videos reaches only the people that is already educated. When there is specially needs . Content is Swahili, but local language is needed in order to reach all. The main problem is the lack of devices. Mpesa example. There is a need, because there is no banks. This is why it is successful. Making people able to pay for health care services.


 * Mr Msasi, TCCL – public company, corporation owned by government of Tanzania. The company have been working closely with UCSAF, also through competitive bidding. Connectivity have been rolled out to 5-6 villages, population of about 720.000. Voice and SMS, plus low speed internet (2G). Challenges are mainly the devices, power and the operations. Running costs are high, but the services must remain affordable. We are obliged to go to rural areas, but now we have UCSAF, which makes it easier. Expectations: cost-effective solutions. What are these? Are we using the same infrastructure in DigI? How can we make the content accessible for all?


 * Mr Noel, Vodacom: woking mainly on digital financial inclusion. From the Telecom side: we like to get into partnerships, in which we can reach large numbers of people. Digital platforms can help us pass on the content and knowledge. Pilots on access and use of digital financial services, improve businesses and wellbeing: after a year the program reached 30.000 farmers, could reach 100.000 in less than three months. Huge opportunities to use digital platforms for education on health. Mobile money platform i.e. mPesa, to deliver content. How do we marry initiatives from the foundation and the business side – how can we make it sustainable?

Discussion on content, devices and business models
We had an extensive discussion on content, devices, 2G, Wi-Fi and business models. Examples from India on a sustainable business model were presented. Where are the entry points on digital literacy, use of money transaction, what is the value of internet? Is it schools, market places? India example on people who travel for days for registration, while they could do it online. Comment on the demographics in India being different from Tanzania, especially with regards to the population density. No place in TZ where you can drive without crossing a river. Villages are small, distant apart and many, thus the need to concentrates on areas with multiple sup-villages. Dispensary in the villages are usually unsustainable. Wherever you built a health centre – people will have to walk for 15 km. Local government provide for the local village; ward, division, district in order to give primary health care and other services. They geography and the distances makes it very difficult. However, points of services draws people. For example; pastoralists in the North are typically hard to reach populations, both push and pull. But at the market day – people come to exchange, sell, buy. Health points, dispensary’s, schools, churches all play roles in the everyday lives for people, where they go. For instance, A well was built near to the tower. This could illustrate an entry point where Wi-Fi was offered, but 20-25 meters away, there was no coverage. Josef explained the Wi-Fi model, on coverage in village hot-spots. See TI1.2 Pilot installation Kjeller. Videos, text and pictures are stored locally. Example from the pilot installation in the Caritas Kinderdorf in Bottrop, Germany. The Foundation connected 60 children with 30-40 support staff by providing Wifi to the children village. The usage pattern shows that 70% FB, WhatsApp dominates. First step on triggering the interest – then follow with basic information.


 * Conclusion: Mr Ulanga had the closing remarks for the meeting– we need to gather what is available locally, using the content provided. We need to support the communities ability to access information. Let’s learn from what is already going on in Bagamoyo and Ngorogoro. Let’s add on diseases as we walk the way.

UCSAF

 * connectivity of rural and urban underserved areas
 * connecting public schools and public

Achieved
 * 500 wards with over 2000 villages with at least 2G
 * 4 million people
 * 150.000 km2, 16% oW area covered
 * over 300 schools connected


 * cover 90% of population covered by a mobile network
 * expected to reach 98% of people, though the remaining 8% are difficult to reach due to spread population
 * coverage: 2G is coverage is good, 3G is around the majority of wards, while 4G is only

Funds
 * cover areas with less than 1000 people
 * infrastructure as enabler
 * fostered by the transition in economy as stated in 2003: “The knowledge based economy”


 * add value to infrastructure: “more access to information” - no access to water, electricity, communication

UCSAF - reverse option: the operator being able to deploy with lowest subsidy wins the area
 * prioritised the areas to be covered, e.g. borders first

MoH
Geographical location
 * access to specialised services
 * look for facilities that are connected: regional hospitals, 5 zone hospitals currently connected
 * challenge is equipment for
 * Samsung, MoH, UNESCO, MUHAS, Local government is working on telehealth project in Ololosokwan village, close to Kenya with diagnosis
 * classroom, digital - countries
 * telemedicine for remote monitoring, (costs of reducing transport)
 * links with Indian institutes

TIGO, Jerome Malbu

 * owned by Kinnevik AB (SE)
 * “not usage”, no content (Swahili)
 * Facebook Swahili
 * Broadband connectivity: 100 schools, lack of content and devices
 * Program to develop content: Secondary school curriculum online through [Shule Direct project]https://www.shuledirect.co.tz/
 * schools: 2-3 years funding from TIGO, then own funding
 * “communication at a favourable rate”

High Running cost for 500 people
 * 200 kUS$ for one tower, running the tower (1500-2000 US$ per months thus difficult to break even)
 * solar panels and batteries
 * security, - running costs
 * investors want return on investments (ROI)

500 wards: 100 sites from TIGO

literacy: content (not in all villages) Airtel, Vodacom(?), TIGO - 40.000 people penetration ratio
 * mobile financial service
 * data not used: availability of devices
 * 4G push, difference of price (20.000 TZS) extra

Birth certificate: Involved in birth registration/certificate working with RITA. communication through SMS and USSD

Video only reaches power, charging mobile money, need

TTCL
connectivity, access of that content - connectivity
 * corporation now, government owned
 * 506 villages, 720
 * voice and SMS, 2G
 * affordable service - kind of services: price of devices (2G)
 * Region - district - village
 * 2G coverage:

About rural Tanzania

 * 945.000 km^2 with 55 Million, only 2 settlements with over 1 Million
 * Capital Dodoma 400.000
 * more than 100 km and need for cross river
 * Medical intervention: There are dispensaries in about 20.000 villages

access & service
 * service model in schools
 * valuable …. content - crowdfunding

Electricity: high prices for electricity, and outage. When the Rural Energy Agency (REA) connects regions, the connection costs are 35.000 TZS for being adapted to the grid. After this REA introductory lasting for 3 months, the operation of the grid and the connection to the grid is handed over to Tanzania Electricity Supply Company (TANESCO), who takes roughly 135.000 TZS for connectivity to the grid.

Discussion
don’t know where the people are
 * 1 tower covered where people are

Complexity: of deployment
 * Khan academy site, demonstrated in pilots that internet usage better used to ???
 * 70% ???
 * 4 Aga Khan schools in Tanzania: http://www.agakhanschools.org/Tanzania/Index
 * two curricula, Tanzania national curriculum (NECTA) and International curriculum (Middle School Programme, IGCSE and IBDP). NECTA curriculum runs from Form 1 to 6. International curriculum covers Middle School Programme; this is offered from year 7 to 9 leading to International General Certificate for Secondary Education (IGCSE) which is year 10 to 11 (from Mzizima School in Dar es Salaam)
 * see also Aga Khan Development Network http://www.akdn.org

Program on reducing mortalities of women
 * Maternal deaths in Tanzania, with a ratio of 578 per 100 000, represent 18 percent of all deaths of women age 15-49.
 * women get a fine of 5.000 RSD when not participating in the governmental health programme
 * Under-five deaths per 1.000 live births declined steadily from 166 in 1990 to 112 in 2005 and 67 in 2015. Infant mortality decreased from 68 to 43 per 1.000 live births between 2005 and 2015.

Experiences
 * Tablets in health services never been stolen
 * places where they have the tablets -
 * “every child” - ability to access


 * SMS, more devices
 * Jerome: health UCAF - cross-alignment (work with REA) - health development
 * electronic copies of services manuals

= Open Topics for follow-up = High-priority topics Ulanga to coordinates
 * Content
 * Schools
 * Devices
 * Incentives

Suggestions towards the platform of knowledge
 * what youtube can facilitate
 * big screens (TV) vs tablets