How data are helping people in a fractured country avoid the death sentence imposed when life-saving malaria drugs are not available.
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.
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.
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 IFRC communications officer based in Bangui.
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