Sierra Leone: Collecting Health Data In Areas With No Power Supply

For the last 14 years, the Department of Informatics at the University of Oslo has been engaged in the development of sophisticated health information systems for a number of countries in Africa. Now it is the turn of Sierra Leone.

Sierra Leone is one of the world’s poorest countries. It has been ravaged by civil war, but despite being plagued by deep-rooted ethnic conflicts, democracy is being strengthened; the opposition won the 2007 election and the transfer of power went smoothly. The infrastructure, however, has collapsed. There is no nationwide electric power grid, and most of the country has no electricity supply. The necessary power is supplied by diesel-driven generators.

Child mortality is high, and many mothers die in childbirth. Local traditional birth attendants, who are charged with registering these events, are often illiterate.

"Registration is often chaotic, with many local adaptations. Collected information frequently overlaps. We go in to standardize the systems so we can get comparable health data from all parts of the country," says Jørn Braa, Associate Professor at the Department of Informatics to the research magazine Apollon at University of Oslo in Norway

Counting stones

In the municipality of Tombodu, in the eastern part of the country, the village-based traditional birth attendant registers births, children who die immediately after birth, stillbirths and illness or death of the mother by placing small stones in a box with five compartments. Every month the box is taken to the health centre where the stones are counted and the resulting figures included in the health centre’s monthly report to the district authorities. The data are entered into a regional database which is part of the national system.

"The point is to make a standardized system for collecting health data from all parts of the country. This will give local and national authorities, as well as the World Health Organization (WHO) in Geneva an overview of the health situation and other data that will help them decide where to take remedial action."

In order to provide vaccinations for rural children, the authorities require statistics on local public health, such as the incidence of measles, tetanus, diphtheria and tuberculosis, the number of children, and the number of those who have already been vaccinated. Only then will it be possible to implement an effective vaccination programme.

"Sometimes we see that only half the children in a particular region have been vaccinated. Without reliable figures it’s impossible to assess the job, plan for improvements and draw up an appropriate budget," Jørn Braa points out.

A unique project

The engagement started when Dr Braa was working on his PhD degree at the Department of Informatics on the subject of regional and national health information systems in South Africa.

To date, in cooperation with several African universities, the Department of Informatics has established similar health information systems in a number of African countries – such as Zanzibar and Botswana.

"Our goal is to produce a system that will survive political turmoil. In this context, the department has the role of bridge-builder in Africa," says Professor Morten Dæhlen, Head of the Department of Informatics.

Much of the software and the concept can be reused in country after country. The technological and organizational circumstances, however, remain so variable that the system has to be adapted to each individual country. If the computer network is inadequate, the researchers sometimes attempt to achieve critical data capture using mobile technology. Low-energy PCs and data servers are used in Sierra Leone, their batteries being charged with solar energy.

To date, more than fifty Master’s degree students and more than thirty PhD candidates have participated in the project. At any given time, the project comprises from 20 to 25 doctoral students, most of whom come from African countries.

"This is in fact a very rare occurrence: it’s a successful Norwegian-based IT project in the health sector in developing countries. The main idea behind this aid project is to provide help for self-help. There’s a high degree of idealism behind this project. Solutions must be low-cost and high-quality. Commercial actors want to make a profit whereas we wish to help the poor countries develop their own solutions," Morten Dæhlen points out.

35 million Euro

Professor Nils Christophersen at the Department of Informatics refers to the project as action-oriented research.

"In action-oriented research, the scientists are participants rather than observers. Unfortunately, this type of research is frowned upon in many quarters," Professor Christophersen sighs.

The African project is currently the fourth largest research project at the department. 11,5 million Euro have already been spent, some of which has been aid funding from Norad. Over the next ten years, the department will spend more than 23 million Euro and thereby contribute directly to the strengthening of the health information systems and health services more generally in Africa.

"This is a gigantic aid project, even though it has maintained a low political profile. We are four or five million NOK short every year for maintaining research and development at a responsible level. If we don’t get additional funding we’ll have to consider scaling down the activities. Worst case, if the University of Oslo pulls out, the project may collapse. So far only South Africa has become self-reliant," Morten Dæhlen deplores.

Not fond of idealists

Jørn Braa points out that establishing IT systems in technology-starved regions is a difficult task.

"You have to use your imagination to make things work in Africa – more than you have to do in the US, for example."

All programming is done using open-source code. The software is free and available to everyone.

"Using open-source code is a key point. However, the commercial actors are not very happy about us. They resent idealistic projects that encroach on their turf. We represent an annoying type of competition. They want to have the market to themselves," Morten Dæhlen says.

The information scientists have chosen to use the free operative system Linux – a shrewd choice since a high proportion of African PCs are infected by computer viruses.

"Linux is virus-free. All PCs can therefore log on to our system without infecting the software and the health data," Dr Braa points out.

All data from the villages and health centres are collected, stored and aggregated in data warehouses, where they are linked with population censuses and data from other sources. Currently, the information scientists are collaborating with the WHO to develop an open-source country toolkit integrating the database applications with analytical tools, web-based maps and graphical representations. A medical record system is also part of this open source toolkit.

Academic benefits

Morten Dæhlen points out that the department derives great benefit from the research.

"This is a cross-disciplinary field encompassing the humanities, social sciences, technology and health. We need research to ensure that the cost of the developing systems remains low. The key characteristic of this work is that the research we undertake helps save lives," Professor Morten Dæhlen concludes.