March 18, 2012 Porto Novo Training Session Recap
Over the past few years, we as an organization have experienced our fair share of obstacles to overcome and other generally difficult tasks. After Thursday though, I think I can say we have finally stumbled upon the single most onerous task to date: training. And I have every expectation that it remain one of the most challenging aspects for projects far into the future.
Our large training cohort in Porto Novo
This past Thursday we conducted the first of several training sessions to introduce our vaccine tracking system to the frontline health workers responsible for the system’s successful use. In fact, the success of this project in Benin–and of the organization as a whole–is far more dependent on the people sitting on the other side of those desks than it is on us. In this particular session, those people included the state director of health and his lieutenant in charge of primary health delivery (under which fall vaccination services), the WHO national vaccination coordinator, municipal-level vaccination program officials and two representatives from each clinic that has been selected for participation in our pilot project.
Dr. Biey Jose of WHO
The training lasted nearly six hours, and even with that marathon session, we will still need to do individual follow-up at clinics to answer questions and ensure proper use. We had approximately 40 people in attendance that represented a wide array of capability. Training was conducted in French by our new regional coordinator, Fidele Marc, supported by our far less fluent staff, Shawn and Mark.
Some of the training is intuitive. At the highest level, we are teaching vaccination professionals about a vaccination tracking system, something that is, at a high level, very similar to what they’re already using. The real difficulty comes from the fact that we have to teach people how to use a computer. We take for granted our own computer literacy which makes it challenging to teach someone who has literally never typed a single character nor even once clicked a mouse. We planned for this as best we could from day one. The software is designed to be as basic and intuitive as possible; the process flow mirrors what the health workers already do with paper records. Also, a large part of our training is dedicated to basic computer usage: turning it on and off, moving the cursor with the track pad, selecting options, entering information with the keyboard, etc.
The good news is that while training is difficult and time intensive, it is entirely within our own ability to overcome. So many other aspects of our project rely on external input: e.g. funders deciding to support us, government officials providing approvals. Training is unique in the sense that all we have to do is dedicate enough time and effort to reach our goals. As an added benefit, we are teaching basic computer literacy to a cadre of people that otherwise would never build that skill set. This prepares them well for a world, even here, that is rapidly becoming digitized and greatly enhances their career prospects.
Vaccination workers learning how to use the system
March 11, 2012 The week ahead
We have spent the last few days, and the entirety of our weekend, holed up in our hotel putting the finishing touches on just about everything. When we left the US, we figured that we were about 99% ready, leaving us to finish up that final 1% in the first few days here. In hindsight, that 1% was probably closer to 10%. But now it’s done. All of it. We have training materials–in two languages. We have fully functioning and fully translated software. We have 25 computers and 25 fingerprint scanners sitting in 25 backpacks ready to find new homes in 25 Beninese clinics. And the most exciting part, we have our first international VaxTrac employee!
Fortunately, the hard work starts paying off tomorrow. First thing Monday morning, we start training, and we start at the top. We will be teaching the Ministry of Health officials and policymakers in the vaccination program how our system functions. We will get to make high-level health officials treat each other like they’re children about to receive vaccines. The role-playing part of the training is going to be the most entertaining part for us; more importantly, it will likely be the most instructive part for those being trained.
Once we finish with the Ministry on Monday, we will move out into the field for the rest of the week to train frontline health workers. As a key element of that training, we will get to introduce many people to a computer for the first time. Updates over the course of the week may be sporadic due to internet availability, but when present, they should be chock full of photos.
VaxTrac has had many milestones to celebrate over the past few years: winning the Gates grant, successfully testing the prototype, hiring additional staff members. This coming week will rank among those achievements, if not above them. By this time next week, hundreds of health workers will be using the VaxTrac system as an integral part of their everyday work. Hundreds of thousands of people will begin to see improved health outcomes in their communities.
As exciting as this is to us, we have not lost sight that this is arguably the first step–or certainly among the early steps–of a long road to success.
March 9, 2012 Atmosphere of Success
We have now been around the block–er, world–enough times to see national vaccination systems across the spectrum of capability. Inevitably we start to compare what we see with what we have seen. I realize we have been in Benin for all of a week and our exposure has been extremely limited, but I am encouraged from what I have seen so far. Let me recount an exchange we had to support this opinion.
We were able to enjoy a relaxed workload for the first few days upon arrival. Our key contact, the WHO country manager in charge of childhood vaccinations, was stranded in Chad. As such, we were left to our own devices with the majority of our meetings pushed to the end of the week. This suited us just fine as we had a backlog of work that needed to get done. The accelerated nature of this project meant that we were still putting the finishing touches on the software translation and training materials.
Work has ramped up the past few days. We spent Thursday at the Ministry of Health providing a summary of the project to the Director General. She is already aware of the project and had already signed off. This meeting was as much to make introductions as anything else and to fine tune a couple of the project’s details. I provided a general overview of the project in French (my apologies to the Francophone world for what I did to your language). After I wrapped up, she only had two questions for me.
As background, I have sat through these meetings before. In fact, we do this in every country we visit. The results of these meetings are rarely positive. High-level policymakers are forced to sit through meetings where a couple of young Americans tell them how their vaccination systems can be improved. In most cases, these are the same policymakers who helped shepherd their health programs from coverage levels of 40% up to current levels of anywhere from 60%-90%. For the most part, they have done admirable work. So the only questions we usually get are to the tune of “Why are you here?” Which is why we were pleasantly surprised by the questions posed by the Director General in Benin.
Question the first: “When can we scale up?” For context, we are four days into a six-month project. We have not trained a single health worker. We have not scanned a single child’s fingerprints. And yet already, the Director General is thinking about how we can maximize the impact by moving from a small pilot project to a sub-national or national size. Here at VaxTrac, we probably consider ourselves big thinkers (we are out to revolutionize the international vaccine system, you know). And even we were thrown off for just a minute by the Director General’s ability to see the potential benefit and already start to move down the path of progress.
Question the second: “What assistance can we provide?” We do not ever work without government approval of our projects, which generally amounts to government officials not actively objecting to our work as long as we do not place any increased burden on their staff. Essentially, they will let us do what we need to do but that’s the extent of their involvement. To hear a high-ranking official offer us a blank check gave us pause a second time in as many minutes. We rattled off a few “would-be-nice-to-have”s and each duly got a response of “Done.”
I get the impression that the further we delve into the vaccination system of Benin, the more often we will find ourselves pleasantly surprised. Benin is still one of the poorest countries on Earth. Yet, they have one of the most admired vaccine track records among their peer nations. And even they would likely say that their vaccination system has room for improvement. It is this open-mindedness and the general willingness to collaborate and embrace innovative ideas that bodes well for further improvement.
March 7, 2012 What is the VaxTrac “system”?
As often as we talk about our “system”–and will continue discussing how it fares in the field over the next six months–we thought it might be a good idea to give you an idea of what exactly we are talking about. If you are reading this, you are already likely aware that we are here in Benin implementing a mobile, biometric-based vaccine tracking system: in essence, a database of electronic vaccine cards. The overall system is comprised of single physical data acquisition units that reside everywhere vaccines are administered, e.g. hospitals, clinics, mobile vaccination teams. Each unit can be described both in terms of the hardware and the software.
Hardware
The cornerstone of one of our tracking units is a small, inexpensive netbook computer. Netbooks offer several advantages for how we use them. They are lightweight which puts less of a burden on vaccinators already often tasked with carrying cold boxes full of vaccines. They are energy-efficient which allows them to run on battery out in the field for days without requiring access to electricity. In addition to the netbook, the other key hardware element is the fingerprint scanner, which attaches via USB.
Software
Our software is rather unique. We custom built it, including the fingerprint processing since the use case (tiny fingers of small children) is unaddressed by commercially-available software. Because of the weak or nonexistent communication infrastructure in the most rural areas, we rely on physical data transfer. This requirement led us to employ a less-common type of database. Expect more detail on some of the technical features in a future post. For now, we will walk through a couple of the steps and you will be able to see actual screenshots of our software.
The process starts by gathering basic information about the child. In the picture below, the health worker is being asked the gender of the child. We also record the date of birth and can record other ancillary information that might be of interest, like what relative brought the child in to be vaccinated or the literacy of the parents. This screenshot highlights an important design feature: simplicity. Health workers fall all across the spectrum of training and capability, so we were forced to design for the most minimally trained. As such, the choices available to the health worker are been minimized and the software flow is as linear as possible. The health worker does not have to choose between several available paths. There is one path and the user can only move in one dimension (forward or backward along the same path).
Selecting the child's gender
After we collect basic information about the child, it is time to scan his or her fingerprints and search for those in the database. In the two images below, you can see the interface health workers use to acquire those fingerprints. From the first screenshot, the health worker will scan the child’s left thumbprint and then the right thumbprint. Once an image is acquired, the software immediately evaluates the quality of the image. Essentially it asks: “Is this image of a high enough quality that it is able to be matched?” We do not want to waste time trying to match a really bad image. The green check marks in the second screenshot tell the health worker that good images were acquired and the system can now search the database for the child. If the images are not good enough, the health worker is told to re-scan the fingerprint.
Prompting the health worker to scan the child's fingerprints
Confirmation that the fingerprint images are of an acceptable quality
Once we have identified the patient, the health worker has several options. As our systems are adopted into new regions, it is inevitable that we will be seeing children at various stages through the immunization schedule. The “View or Modify Patient History” option will show the health worker the vaccination record and allow it to be manually updated. This is useful if we see a child for the first time but he or she has already received some vaccinations. We can copy information from that child’s vaccine card into the system. This option is also useful if a parent has lost the child’s vaccine card and is curious about which vaccines the child has received, which vaccines the child still needs, and when the parent should return with the child for those needed vaccines.
Options available to health worker after patient is identified
When the health worker goes to administer vaccines, they see the electronic version of the vaccine card with more information shown to them to make their job easier. Each row represents a specific vaccine (the Measles vaccine, for instance, or the Diptheria-Tetanus-Pertussis combined vaccine) and each box to the right of the vaccine represents a required dose according to the national immunization schedule. The vaccines and doses are color-coded so the health worker can quickly determine which vaccines to administer. If a vaccine is highlighted in green, the entire series for that vaccine has been completed; if it is orange, then the child is eligible to receive a dose of that vaccine that day; if it is not highlighted, then the health worker knows that the child needs one or more doses but is not eligible for them that day based on either the child’s age or time since the last dose. The health worker can then direct the parent to return in a specific amount of time.
Doses are colored similarly to the vaccine. If a specific dose is in green, it has been previously administered. If it is orange, the child is eligible to receive that dose on that day. If it is in gray, the child still needs the dose but is not eligible for it that day.
Electronic version of the vaccine card
March 6, 2012 Benin: Our home away from home
We have the privilege of implementing our six-month pilot project in the West African nation of Benin. The Republic of Benin, as it is officially known, is not a large country, nor does it appear frequently in the news–which is generally regarded as a good thing in this part of the world–so we thought it might be helpful to give a short overview of our host nation. Considering we have only been in the country for a short time, we cannot yet provide an extensive first-hand account. So for a more comprehensive overview, feel free to do further research at your favorite source; let me suggest Wikipedia for general information and the CIA World Factbook for statistics of all kinds.
Benin is a sliver of a country sandwiched between Ghana and Nigeria (with the slight buffer of Togo on one side) along what used to be known as the Slave Coast of Africa. It is home to nearly 10 million people, with French as the national language. Most notably, Benin is the birthplace of Voodoo and was also the departure point for the many of the slaves exported to the Americas.
As of late, Benin has much to be proud of. It boasts one of the longest-lasting and most stable democracies in Africa. And from a purely personal standpoint, Cotonou, the most populous city in the country and the capital in all but name, is one of the most developed of the “developing” places we have been. While the country is still quite poor compared to other nations–it ranks 170 of roughly 198 countries in terms of GNI per capita–Benin projects an image of enhanced development in relation to other countries of similar economic status.
We chose Benin as the target country for our pilot project for several reasons. First and foremost, we found a strong operational partner in the country office of the World Health Organization. The WHO has been actively working on our behalf to coordinate with the Ministry of Health and UNICEF prior to the arrival of the VaxTrac team. The other reason we chose Benin was for the country’s track record when it comes to immunization. We can evaluate the government’s emphasis by looking at a few statistics, notably the percentage of vaccines for routine immunization funded by the Government and the improvement in coverage level over the past few years. The former shows the government’s willingness to spend its own money on the problem and the latter shows how effective it has been at using the money.
We have chosen to work in the two communities of Abomey-Calavi and Allada. Abomey-Calavi is practically a suburb of Cotonou, less than 10 km to the north and with a population of over 400,000 people. This town is entirely urban and is served by 12 health facilities. Allada is quite different. While it is only 30 km to the north, it is entirely rural. In fact, it also has 12 health facilities but only serves a population of a little over 100,000 people. Over the next few weeks, we will be training 140 vaccination health workers across the 24 health facilities. Over the course of the six-month project, the VaxTrac systems in those clinics will see approximately 30,000 children to be vaccinated.
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