DigI:Roundtable Digital Health for Tanzania

= Agenda =
 * Welcome
 * Table round
 * How to bring Digital Health to everyone in Tanzania
 * Connectivity
 * Literacy
 * Formalities
 * Cost-efficient approach
 * Plans from the Norway-Tanzania collaboration through the "Digital Inclusion" project
 * Showcase TZ, e.g.: "Anthrax Outbreak Management", "Digital Health Education for Everyone"
 * Discussion
 * Steps ahead, action items
 * end of meeting

List of Participants
Norwegian Embassy
 * Johanne Bjørnflaten Walthinsen, Private Business Development
 * Noel Magoti, Private Business Development

Ministry of Health (MoH)
 * Dr. Mpoki M. Ulisubisya, Permanent Secretary
 * Marcos Mzeru
 * Elibariki Mwakapeje

UCSAF
 * Peter Ulanga, CEO

Tanzania Telecommunication Corporation (TTCL)
 * Eng. Enocent Msasi

Tigo
 * Jérôme Albou, Chief Technical and Information Officer (CTIO)
 * Anna Tesha

Vodacom
 * Noel B. Mazoya, Marketing Manager M-Commerce, Deputy for Rosalynn Mwori

Sokoine Unversity of Agriculture (SUA)
 * Helena Ngowi, Professor
 * Flora Francis Kajuna, PhD Researcher

National Institute for Medical Research (NIMR)
 * Dr. Bernard Ngowi, Director

Muhimbili University of Health and Allied Sciences
 * Dr. Felix Sukums, Director of ICT

University of Oslo (UiO)
 * Christine Holst, DigI Project Coordinator, Centre for Global Health

Basic Internet Foundation
 * Prof. Josef Noll, Secretary General

= Round Table Discussion on Connecting Digital Tanzania=

Purpose of the meeting
The purpose of the meeting was to have a round-table discussion on digital inclusion in rural Tanzania. The goal of the meeting was to identify approaches of bringing digital health, education, agriculture information, and e-Government services to everyone in the society, and especially addressing the needs of people in rural Tanzania.

Providing digital health information is seen as an enabler for knowledge uptake, behaviour change and entry for participation in the digital society. The DigI project is creating Digital Health information regarding the four diseases Tuberculosis, Cysticercosis, HIV/Aids and Anthrax. The three villages Izazi, Migoli and Selela have been selected for providing “Internet light” and specific health information, while 10 more villages will be connected in phase B of the project. The goal is to establish a common activity in providing free access to information (‘’Internet light’’) and update of mobile broadband to rural Tanzania.

Status of rural connectivity
The Universal Communications Service Access Fund (UCSAF) is used as an instrument to bring mobile coverage to Tanzania (TZ). Within the last 10 years, the mobile coverage has significantly improved, covering over 90% of the population. 500 wards with over 2000 villages haven been connected with at least 2G, covering 4 million people in rural Tanzania and a total of 150.000 km2, which is about 16% of the country. Over 300 schools are connected.

The goal of rural Tanzania is to reach 98% of the population, though this increase of 8% is difficult to reach due to the spread population. Already now the operational costs for running the 2G network with focus on voice and SMS are high. The main cost driver is the maintenance of the remote sites, in addition to security and power supply. When it comes to mobile broadband provided by 3G and 4G networks, the majority of wards have 3G in the centre, while 4G is sparsely deployed, concentrating on cities.

Obstacles in mobile broadband role-out
The main obstacles are (i) content, (ii) devices and (iii) incentives for uses and business model for operators in rural TZ. (i) Content needs to be available at least in Swahili, or even in local language e.g. the Masai language. Examples by Tigo show that adoption of Internet boomed when translating Facebook into Swahili. When schools were connected, the biggest challenges were content and devices. (ii) Regarding devices, most of the users have 2G devices. The biggest challenge in adopting smartphones is charging. In areas with electricity more people have smartphones, though only use about 5% of the capabilities, i.e. playing music and taking photos. Apps are underused due to the lack of network connectivity. Though 4G devices cost only about 20.000 TZS (~9USD) more than 3G devices, it is still a substantial add-on price when not being able to use the devices. Tablets are mainly unusable in rural Tanzania, due to the absence of Wifi hot-spots. (iii) The incentives for users and the business model for operators are key issues. Running costs for maintaining remote sites are high, both with respect to electricity and maintaining the infrastructure. The installation costs are about 200 kUS$ for a tower, with 1500-2000 US$ per months to break even. That requires at least 500 people using the network provided by the tower.

Digital Health information
Tanzania has achieved good advances in health services, indicated by a.o. the reduction of children from 112 deaths per 1.000 live births in 2005 to less 67 in 2015. However, maternal deaths has not decreased at a similar range, and is one of the priority topics of the government. Though most ward centres have connection to 3G, access to digital health content is de-facto not existing(?)

Experiences from digital, mHealth and Telemedicine have been positive. Tablets used in health services have never been stolen, as the care takers appreciate the value of the tables. UCSAF has joined forced with the Rural Energy Agency (REA) for health development.

However, infrastructural issues makes it hard to reach every Tanzanian. The deployment of health workers in rural areas failed. We need appropriate mechanisms of communication to have a better stand in the market. Examples from the digital village with i.e. diagnostics and ultrasound have worked out well, though one of the topics addressed is the access to electronic copies of service manuals. Though access is provided for the national hospital, zonal hospitals, regional hospitals, and district hospitals, connectivity to wards, clinics and health posts is a real issue, as a majority of them still lacks access to health care.

Conclusions and way ahead
During the discussion, specific focus was given to content, teaching of children, devices and incentives for end users. Future activities were agreed for the following topics:
 * (i) Content needs to be fostered at least in Swahili, covering local content, social network content as well as health and education information. Examples from field survey shows that information of best praxis in agriculture, and local information spreading, e.g. fishing conditions and prices is seen as driver for adaptation. Other services include inscription to e.g. secondary schools and similar activities From a commercial point of view Mobile Money like M-Pesa has highest priority, in addition to social network content such as Facebook and WhatsApp.


 * (ii) Schools: The government expressed that every child should have the ability to access digital content, and that several programs have been launched for providing digital curricula. Partners like the Khan Academy are contributing with content. Access to information from schools is a priority.


 * (iii) Devices: The majority of phones are 2G phones, while communities with electric power see the raise of smartphones. Lack of charging of smartphones is seen as a major hinder, followed by the limited roll-out of 3G and 4G networks. Priority should be given to the adoption of tablets and the availability of low-cost smartphones, evtl through a collaboration with India.


 * (iv) Incentives for users: The benefit of access to information is not obvious to users, resulting in a reluctance to subscribe to mobile broadband. A common approach is envisaged to foster uptake, e.g. to provide free air time, download of music or calling minutes to users participating in digital health education.

The Permanent Secretary Dr. Mpoki M. Ulisubisya asked Peter Ulanga from UCSAF to coordinate the further collaboration. In the upcoming weeks the DigI project will take contact with mobile operators on establishing the plans for connecting the villages of Izazi, Migoli and Selela, as well as identify the sites for phase B. In the week of 18April2018 the project will invite for dedicated workshops on digital health content, incentives for mobile broadband uptake, and plans for a nation-wide project on digital information access and digital inclusion for rural Tanzania.