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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

USCAF

• Peter Ulanga, CEO

Tanzania Telecommunication Company (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 Agricultue

• Helena Ngowi, Professor
• Flora Francis Kajuna, PhD Researcher

National Institute for Medical Research

• Dr. Bernard Ngowi, Director

Muhimbili University of Health and Allied Sciences

• Dr. Felix Sukums, Director of ICT

University of Oslo

• Christine Holst, DigI Project Coordinator, Centre for Global Health

Basic Internet Foundation

• Prof. Josef Noll, Secretary General

Thumb	Title	Keywords	Date	Author/Project
	Partnership for Digital Tanzania Click to Open Roundtable Digital Health for Tanzania	Digital Tanzania, Digital Global Health	12 February 2018	Josef Noll

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 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 the 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 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. USCAF has joined forced with the regional 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 marked. 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 five national 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 USCAF 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.

Further reading

• More elaborated meeting notes are available at http://its-wiki.no/wiki/DigI:Roundtable_Digital_Health_for_Tanzania
• Presentation on Collaboration for Digital Tanzania, given at the Embassy of Norway on 12Feb2018
• information about the “Digital Inclusion” project is available at http://DigI.BasicInternet.no

Notes by Project participants

Christine's notes

• Professor Noll briefed on goals of 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: 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? [1]Cholera and malaria should be addressed (a cholera video is projected and will be available [2]). 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 research impact, but less societal impact. Hard to demonstrate significant outcomes. 2G, 3G and 4G illustrations on map.

• 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 marked. Base at Muhimbili – connected the hospitals (i.e. Bagamoyo and Ngorongoro). When planning scaling up, the equipment run out, new approach was developed. Currently looking for sources to equip the staff. Location close to Kenya – installed a digital village with i.e. diagnostics and ultrasound. This have worked out well. Examples from the digital school. Five national hospitals, regional hospitals, thereafter district hospital, and wards, clinics and health posts. Still; not all have access to health care.

• 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

A discussion on content, devices, 2G, Wi-Fi and business models held out. Example 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, marked 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 and many, this 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. The 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 marked 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. 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 stuff 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.

Notes by Josef

USCAF

• 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

USCAF - 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 Sweden
• “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 Shuledirect project
• schools: 2-3 years funding from TIGO, then own funding
• “communication at a favourable rate”

Running cost

• 200 kUS$ for the tower, running the tower (1500-2000 US$ per months to break even)

for 500 people

• solar panels and battery
• security, - running costs
• investors

500 wards: 100 sites from TIGO

( ) literacy: content (not in all villages) Airtel, Vodacom(?), TIGO - 40.000 people penetration ration

• mobile financial service
• data not used: availability of devices
• 4G push, difference of price (20.000 TZR) extra

Birth certificate: communication through SMS and USSD

( ) Video only reaches ( ) power, charging ( ) mobile money, need

TTCL

• cooperation
• 506 villages, 720
• voice and SMS, 2G
• affordable service - kind of services: price of devices (2G)
• Region - district - village
• 2G coverage:

( ) connectivity, access of that content - connectivity

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. [3]
• 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. [4]

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

• Content
• Schools
• Devices
• Incentives

Ulanga to coordinates

Suggestions towards the platform of knowledge

• what youtube can facilitate
• big screens (TV) vs tablets