Dr. Pascal Namegabe offers an example of the type of problem he faces daily at his hospital clinic in the Democratic Republic of Congo (DRC). “A child had put a marble in their mouth, and it had moved into the child’s respiratory tract. The family didn’t know what course of action to take.”
Without training or knowledge of what to do in situations such as this, for many people the only recourse is to try and get to a doctor quickly, but there are often no clinics nearby. “They traveled 2km (1.25 miles) to reach the hospital, but the patient was already dead. They could have simply pressed on the abdomen and diaphragm, and the marble would have come out. In this case, the family wasn’t able to interact with the hospital so that a doctor could tell them what to do in the very first seconds to save a life.”
For Namegabe, this awful story illustrates the urgent need for clinics like his to embrace new technology to prevent unnecessary deaths — essentially, to localize existing technology for the region’s challenges. Training people in basic first aid might have helped prevent such a tragedy, but sufficiently quick access to trained or knowledgeable people in a vast area such as this isn’t always possible. Nor is phoning the hospital always an option. Many people cannot afford to. Instead, Namegabe envisaged new ways of using technology to get information to patients quickly enough to be effective. More fundamentally, he wished to overhaul the way his hospital clinic was organized by adding digital technology to free up time and resources to treat more patients.
This is where Project First Light has provided transformative help. First Light is an initiative created by Ensemble Pour La Différence, a nonprofit organization providing macro-loans and mentorship to small and medium-sized enterprises in the region, in alliance with Fjord, a design and innovation consultancy, and the peace organization Falling Whistles. Its aim is to work with local people and institutions in a way that empowers them with localized technological solutions to urgent problems.
With the help of this coalition, Namegabe’s clinic has now become a model for others in the region. Additionally, a separate pioneering program in Project First Light now connects a remote and impoverished island community in the region to the internet.
From manual to digital
New Hope Hospital treats patients who come from up to 50 miles away to the eastern DRC town of Kavumu — a journey that can take two days on the region’s dirt roads. The most common problems for the hospital’s patients are malnutrition, malaria and the consequences of sexual violence. The hospital was faced with a huge patient management challenge — records were handwritten on pages carefully cut from notebooks, then stored in humid conditions, at risk of loss or damage. Staff spent a lot of time trying to locate, update or replace records, add new ones and keep on top of billing.
In Kavumu, the First Light project team members were immediately struck by the need to build a solution so that patient management was entirely digitized. Involving hospital staff in the process from the outset was critical, enabling a sense of ownership of the new system’s performance. The team researched various digital options and settled upon Open MRS, an open source patient management system. The advantage of going open source was its public accessibility and the existence of a global web of volunteer contributors who could troubleshoot problems and further develop the technology for free.
The implementation of this system allowed Namegabe to expand his operation, double his staff and win a contract with the United Nations (UN) to treat up to a thousand UN employees. It also acted as its own marketing tool — people heard of this new digital system by word of mouth and traveled long distances to take advantage of what they saw as inherently advanced treatment. Instead of treating six or seven patients a week, the clinic now sees up to 30. Key to this success was a realization from the outset that local conditions had to be factored in when making important decisions.
Localizing the decision-making process
Local ownership of the process, as well as the solutions, has been crucial to the success of Project First Light — not only in terms of providing a sense of local ownership of the decision-making process and installed systems, but also in avoiding the perception of Western solutions to African problems. “Design methodology in general starts with people, not what the designer wants,” said Mike Beeston, cofounder of Fjord and founder of Ensemble. “Design methodology is rooted in user needs. In Eastern DRC, the idea is to give people time to voice their concerns and needs… ranging from their kids’ education to their own health to security.”
Identifying the most important needs required a process. “The best way to do that is to give them a single choice out of the ten they came up with so that if you have 12 to 15 people in a research group, you’ll usually end up with a cluster of around three needs which you then push them to prioritize into some sort of order. That’s how you end up getting focus into the service.”
The Ensemble volunteers had to adapt to several fundamental context-specific problems. The spectacularly mineral-rich DRC experienced a civil war, exacerbated by neighboring countries intervening to plunder resources, between 1997 and 2003. Over five million people were killed by conflict or disease in this African World War, little-covered by the media elsewhere in the world. Conflict has persisted in the east of the country, where militia still operate and UN peacekeepers patrol. The area around Kavumu is not secure — people who work around the edge, where town meets forest, are not safe even during the day. The proximity of this insecurity, according to Beeston, was quite a culture shock.
Power cuts are a daily occurrence in Kavumu. The unreliability of the electricity influenced the team’s choice of hardware. “We took a decision very early on to be independent of the electricity grid, and simply use solar,” Beeston recalls. They repurposed a low-power home entertainment PC as a server, and supplied nursing staff with rugged Android tablets that could still be used to log records in the event of power switching to back-up motorcycle batteries. A Kenya-made rugged internet router, BRCK, was chosen to back up records to the cloud. “We wanted something that was developed in a dusty, fairly basic environment.”
The proactive attitude of Namegabe and the hospital administrator meant that the groundwork was laid for the system’s continuing upkeep and maintenance – they found two local tech enthusiasts to develop add-on modules. Staff were trained on-site because they had never used such devices before, and, to counter the problem of a much lower literacy rate in DRC, low-literacy digital guides to the server and tablets were created in the local Swahili dialect of Mashi by local Ensemble volunteers, translated from English.
The fact that the entire solution was being designed and implemented from nothing — the people in the area had never experienced anything similar, and the infrastructure ranged between poor and nonexistent — meant that there was no resistance to the new design culture. People and organizations in advanced industrial economies are already technologically equipped and have ingrained user habits. When someone suggests a new idea or a design concept that marks a departure from existing methods, there is considerable opposition. In places such as Kavumu, however, the new system represents such a step-change that people embrace it enthusiastically. For companies such as Fjord, this level of adoption of a design culture is on a different plane from its experience in wealthier countries.
Starting from zero in terms of infrastructure, user behavior, hardware and so on was an extremely useful experience for many Ensemble and Fjord participants. Knowing when to work with what already exists and when to start completely over is key to providing technological solutions — and obviously context-dependent. In this part of Africa, the team worked in what was in effect a startup environment. Beeston observes that “It’s not like starting in the UK or Sweden. You can’t scale a project very quickly. You have to scale a project by building on sustainable building blocks.” What was needed was obvious and fundamental — a resilient, ground-up digital management system — and so they went straight to the mode of finding solutions.
Being digital and so far in advance of anything patients had been used to meant that the system advertised itself. “The low level of expectation (relating to health care provision) took some getting used to,” says Beeston of the situation beforehand. Now, however, people come from up to 50 miles away having heard of the new technology, presuming that the hospital must be worth traveling to purely because this aspect of patient service is so advanced relative to other clinics in the region.
Namegabe wishes to develop outreach services also. The team was tasked with developing a cell phone app that would allow him to interact with patients at a basic but critical level. They had to adapt both to the lower literacy rate in the area and to the fact that most people own basic cell phones, not smartphones. Many can’t read or understand prescription information and often cannot afford to call to ask. To that end, they developed a simple app with a recorded message from the doctor with information about prescriptions, common illnesses, using mosquito nets and effective home cleaning. They hope to extend the service to include basic first aid, which could prove vital in cases where people might otherwise die en route due to lack of knowledge or confidence on the part of those looking after them.
Namegabe is also looking at a motorbike and sidecar ambulance service, such as has already been pioneered in South Africa. Here too, local-specific problems must be confronted. Very few people in the region have formal addresses. One potential solution envisaged is to use the local chief’s name to identify the village in which the patient can be found. Such a service would, in Namegabe’s view, help revolutionize treatment in the area. The priority right now, however, is not to get patients in to the clinic, but to get medical aid out to the community, whether through first responders or via digital communication.
The second, separate arm of Project First Light’s work came about at the behest of the King of Idjwi, an island in one of DRC’s great lakes, Lake Kivu. The island is poor, with local occupations generally being subsistence farming, fishing, coffee cultivation, textiles and some tungsten mining. Island life is hard, with necessary trips to mainland DRC often involving a perilous and, in many cases, deadly journey by boat. Emigration is common, with many young people leaving to make a better life for themselves elsewhere.
The king (or mwami), Gervais Rubenga, approached Beeston with the idea of installing an internet connection that would boost the economy, provide vital information to people on the island, and help prevent emigration. The idea was to provide a two-pronged service. One element allowed for the community to access websites and to participate in social media and other services. The other part was fully embedded in the local community — news, information, notices — and was not reliant upon access to the world wide web.
This second element was important because most Idjwi people had never used a computer or smartphone, and many are not able to read and write. It was vital that access to digital services reached as many people as possible, unlimited by lack of literacy or technical know-how. According to Beeston, the word-of-mouth relaying of information by those who can read to those who cannot will amplify the network’s reach. “We can go beyond that too, and start to develop services that are enabled by the internet but which are delivered through voice technology.”
“When it comes to connecting up rural areas in Africa, you don’t have much choice,” explains Euan Millar, technical consultant to Ensemble. “You can use satellite, or you can do Wi-Fi point-to-point which ends in optical fiber somewhere.” Satellite was dismissed as being too expensive, needing at least $5,000 as a starting budget. It would also have been slower, with delayed signals when using applications such as Skype, so point-to-point Wi-Fi was chosen. “Optical fiber goes around the coast of Africa and then it goes into Africa at certain points, but that depends on whether the government has invested in optical fiber links across the country,” explains Millar. “The governments of Kenya, Rwanda and Uganda have invested quite a bit in optical fiber, so we could get optical fiber up to the DRC border. We knew we could connect with a Wi-Fi point-to-point link from Rwanda.” Research into approaches used in other parts of the world such as rural Afghanistan or Brazil’s favelas led to the adoption of a mesh Wi-Fi model whereby a powerful signal from a main transmitter is distributed across a local community via a series of homemade antennas.
The main problem, in terms of internet access, was that a reliable signal was needed from the town of Bukavu, 30 miles away, to Idjwi over a large expanse of water, with mountains in the way. “A point-to-point Wi-Fi link has to be line of sight. You have to be able to see the other end. You therefore have to go over the top of trees, so you need to be up high,” says Millar. Another reason to go high is because water and Wi-Fi/radio signals don’t mix — when a signal goes into water, it is lost. Additionally, the further a signal is sent, the wider the signal becomes, causing it to dip toward the water and lose speed. Thus an 82-foot-high mast would be needed in Bukavu, connecting point-to-point with a mast on the top of the highest mountain on Idjwi, to ensure that the signal did not touch water on its lake crossing. Maintenance of the hardware would be further complicated by Idjwi being the “lightning capital of the world.”
Rather than the messy logistics of shipping people and equipment to DRC at huge expense just for testing, the team decided to test the equipment in a not dissimilar environment closer to home — in the Scottish Highlands. In the remote part of the Highlands they chose, there was the advantage that no Wi-Fi signals existed to be interfered with (something that could have brought them into conflict with British authorities).
By luck, the team met Alex Matheson, owner of the Brahan Estate, a large and rugged area near Inverness and popular with tourists. Matheson offered his lands as a test ground because the estate also needed help overcoming similar problems receiving Wi-Fi signals. In trying to solve an African problem, the team inadvertently also helped connect people thousands of miles away. The success of the Scottish test run meant that they could ship the hardware to DRC with confidence. The team then worked with local people to build the equipment there, and taught them how to maintain it.
As with the hospital system, it was vital to involve local stakeholders from the outset to give them a sense of investment in the network’s success. “It is critically important not to ‘drop’ technology on local people without their engagement,” says Millar. “From the beginning, this was a community-owned, community-designed initiative.” The mwami — the chief — is the major stakeholder, and has signed a manifesto stating that the network belongs to the people of Idjwi, further adding to the sense of collective ownership. “We have not had a single incident of vandalism or theft of any of the equipment. That shows how much people respect it and feel that they own it.”
As part of the theme of local ownership, four full-time “network guardians” were recruited locally at the start and trained to keep the network running (male and female, to ensure representative diversity). Millar explains that “Each Wi-Fi hotspot has a permanent staff member whose job it is to educate and to find out what people want from connectivity, how to keep (the system) sustainable.” A management system was created so that the guardians could set up new users, manage payments and maintain connectivity. To further involve the community, people on whose land the masts are placed receive regular rent payments.
It thus became possible to launch Pamoja.net (pamoja means “togetherness” in Swahili) as an internet resource designed specifically for the needs of the islanders. The volunteers built a kiosk in the small island town of Bugarula, in which people can access the new service through Raspberry Pi computers or tablets. On average, 350 people use the service each month to call, text and go online, some walking from over ten miles away.
These users are literate, but the population of Idjwi is over 300,000 (most are children, perhaps 100,000 being adults with low literacy). So, a public display that does not require high literacy was installed, giving information in the local Swahili dialect of Mashi about topics such as local weather conditions (vital for those considering sailing), health, education and announcements (particularly from the mwami). It was even used to reunite a lost child with his parents.
The service is also used to convey information from bodies as diverse as the local police, teachers, religious leaders, the country’s electoral commission and Heal Africa, the non-governmental organization hospital in Goma. There is now an Idjwi WhatsApp group too. “When people get access to something like a mobile, they tend to be quite keen,” observes Beeston. Crucially, the network is enabling small businesses to better organize and reach customers.
Key to the new system’s arrangements is the method of paying for its upkeep. In this part of Africa, internet connectivity is sparse and expensive. Fees and device costs can be exorbitant and exploitative. The people of Idjwi are poor, and there are families with children surviving on a dollar a day. After local consultation, it was decided that local businesses and organizations would use Pamoja.net during the day, each paying a small monthly subscription, and then everybody else could use it for free after 4 pm. This way, a sustainable internet link to the rest of the world has been established that involves the entire community without prohibitive cost to anyone. “Some of the comments that we get are very inspiring,” says Millar. “People are saying that without internet they feel without life on Idjwi, it connects them with the world.”
Future challenges and hopes
A third area being explored by Fjord and Ensemble, beyond healthcare and community services, is the way in which cell phone payments might transform the local economy. The cost and unreliability of services in this part of Africa mean that getting momentum behind such a development will be slow. “We have three tracks,” relates Beeston, “but we’ve got a long way to go with each one. We certainly don’t need to look for a number four for a long, long time to come.”
Euan Millar thinks that the biggest problem facing digital initiatives in many parts of Africa is that so many people cannot read and write, and therefore need to talk. This presents a challenge in terms of cell phone spectrum — the spectrum being a resource that the government sells to telecommunications companies for large amounts of money. Despite promises to the contrary, telecommunications companies across the world often fail to provide adequate coverage to rural areas, even in advanced industrialized economies. “We have a problem where telcos sit on the spectrum and don’t open it up to smaller communities because they don’t want competition,” says Millar. “That’s the problem — to bring in voice calls to places where people don’t have smartphones and need mobile coverage which is not there.”
“The real front line is in mobile, and that’s what we are trying to do next. We’re working with the Telecom Infra Project at the moment. We hope to find a telco that is helpful and understanding to help us show how a community can sustain a network in a rural area and to give back to the telco in terms of revenue share, for example.”
The participants are hopeful that their work will inspire others, whether in DRC or beyond, to pursue local solutions to local problems. “We would really love it if other people had a similar approach and intention,” says Beeston. “In Kenya, Rwanda and Uganda there are enterprises of a similar kind, so we can learn from people outside the country. Inside the country (DRC), it’s still tough going. But we enjoy it. When you get to know people on the ground you see that these are good people.” It is these people who will ultimately take full control of the new technology and, in turn, pass on their know-how to others, further reinforcing a heavily localized design culture.