Hospital-in-a-Box

4 billion people worldwide live with no Internet access. In a technology-focused world, this severely impacts the efficiency of healthcare institutions, who are limited in their access to up-to-date medical information to diagnose, advise and treat patients.

Our proposal is to provide an offline copy of the most essential medical resources currently available. Hospital-in-a-box (HiaB) will allow healthcare professional in developing countries and remote locations to browse Internet-based medical resources without Internet access. 

Hospital-in-a-box contains: 

• the NIH Drug Information Portal 
• Open MRS - an open-source patient management system
• WikEM - the largest emergency medicine open-access reference
• WikiMed - the largest available medical encyclopaedia. 

HiaB is based on Raspberry Pi devices creating a local hotspot that can serve up to 30 users at a time directly on their smartphone. Each Hospital-in-a-Box device costs less than 100 USD to set up.

Unconnectivity hits the healthcare sector hard. In most of the developing world, hospitals and dispensaries have no Internet-connected computers available to staff. This is particularly problematic when working on complex cases, or when specialised or up-to-date information is required. 

When it takes such a long time to find the right information, diagnoses can be slow or inaccurate, leading to negative health outcomes that could have been avoided with right information available at the right time to the right people. This has become especially acute with the current COVID-19 outbreak, which is putting an additional strain on health professionals' time and resources. 

Internet connectivity has been plateauing in recent years, and budget cuts often mean that many health facilities will have to do more with less. Yet, 68% of residents of Latin America and the Caribbean own a smartphone. If data packages are often unaffordable, especially for the high usage required for medical files, an offline solution that would bypass this bottleneck would prove invaluable.

Hospital-in-a-box brings healthcare data to the poorly serviced parts of the world that need it most. For less than 100 USD, healthcare professionals are no longer restricted in their knowledge by outdated and impractical reference books and expensive data plans. 

Hospital-in-a-Box combines professional-grade content packages into a plug-and-play device. A hotspot powerful enough to connect up to 30 users at the same time delivers medical resources directly onto staff' smartphones or personal computers.

A single box contains: 

• the NIH Drug Information Portal 
• Open MRS - an open-source patient management system
• WikEM - the largest emergency medicine open-access reference
• WikiMed - the largest available medical encyclopaedia.

The whole concept is based on off-the-shelf technology: we use the Raspberry Pi, an inexpensive, low-consumption single-board computer that can be procured for under 50 USD in most countries. All content included is  open-source and open-access, and stored on commercially available microSD cards smaller than a postage stamp. 

Once installed, HiaB is completely independent and requires no maintenance. 

Although initially aimed at helping healthcare professionals, this tool could easily be adapted for use with medical students or even younger learners. Once this project has been successfully implemented, the Kiwix Hospital-in-a-Box package will provide an easier solution for all departments and areas of diagnosis and treatment in healthcare centres, including remote rural areas. It makes searching for information easy, and the breadth of information much wider. This means that a range of diagnoses can be explored, meaning that effective treatment will be easier to deliver quicker. In short, the community impacted by our proposal will be one step closer to being as equally equipped as their online counterparts. In light of the COVID-19 pandemic, it is more important than ever for reliable information to be readily available to all. With Hospital-in-a-Box assisting in diagnoses being faster and more accurate, we can help healthcare professionals and their patients access the information they need to prevent the further spread of disease.

By ensuring that reliable information is available even in low-connectivity areas, we can play our part in preventing and mitigating the spread of diseases such as COVID-19. Hospital-in-a-Box is primarily aimed at supporting healthcare workers who deal with such pandemics, by providing the tool for rapid response. With expert information close to hand, individuals in and outside of hospitals are better equipped to handle outbreaks, slow their progress, and apply the knowledge learned to any future warning signs of new epidemics.

The Hospital-in-a-Box solution takes a problem of lacking (Internet resources), and uses existing resources (smart phones to access the hotspot) to provide a solution.

Healthcare centres in developing countries struggle to refresh their existing information sources regularly, and to easily and quickly access answers to the specific questions they have. All this could be resolved with a reliable Internet connection, but the infrastructure and the funds are lacking to implement this. Our proposal removes the barrier presented by Internet connectivity as a requirement for better resources, by creating the technology to access the information needed offline. 

The programme then creates an opportunity for all potential users as it can scale pretty seamlessly. Each low-cost single-board computer that is used can serve up to 30 people at no additional cost than the initial 100 USD purchase price. As it is deployed in a place that will serve the whole community in providing better healthcare, the project's impact casts the net wide. This resource ultimately results in large-scale improved medical care and understanding; as better learning resources increase, and patient records management is streamlined, more patients can be treated appropriately in a shorter space of time. As Kiwix holds to technology to turn any website offline, the tool has the potential to be adapted for training of medical students or more specific medical environments. 

This project offers a self-sustaining, inclusive solution, with little maintenance and cost.

Kiwix relies on the openZIM technology for offline browsing. A copy of a website is made using this open-source compression format, which allows the creation of an archived version of the desired website as a unique .zim file. It can then be copied, shared and accessed anywhere without further need for an internet connection. The user experience is similar to actually being connected to high-speed internet - except that they can be fully offline.

The ZIM Farm is a cluster of servers that automatically update all of the content on a monthly basis. In this way, the information we capture remains relevant and up-to-date.

All the code we use and produce is Open Source and made available in more than 50 Github public repositories: it is free to use, study, modify and redistribute.

This package can be installed on personal computers (macOS,GNU/Linux and Windows), smartphones (iOS/Android), and inexpensive Raspberry-based hotspots as well as local area networks (via Kiwix-serve). For Hospital-in-a-Box, the Zim files will be locally stored on the Raspberry Pi device used as a hotspot. 

Using the same openZIM technology that Kiwix’s general app works with, WikiMed has been running since 2017. Since then, we have received feedback from users all over the world thanking us for making so much useful information available offline. The app is currently available in 10 languages and has more than 200,000 users, with a 70% retention rate at D+30 (vs. 15-20% for most apps). 

Kiwix hotspots have also been deployed around the world and have about a million users, mostly in West Africa and South America.

Starting with the micro change of providing better access to a broader range of medical knowledge (Wikimed/WikEM/NIH drug database), medical professionals spend less time searching for the information they need, and less time maintaining/sharing patient data thanks to openMRS. With slicker tools and processes, healthcare workers are able to treat more patients more accurately, impacting the overall health of the area served by the health centre. As we deploy Hospital-in-a-Box in more areas, we will continue to grow its reach in urban and rural environments alike, compounding its effect on regional medical outcomes. 

According to the UN, at least half the global population does not have access to essential health services. With a tool like Hospital-in-a-Box, we can make a dent in this figure with an affordable, simple, informational solution.  

Kiwix has an estimated user based of 3 to 4 million people in 202 countries and territories in 2019, although due to the nature of offline, this data is difficult to track. We rely on server statistics as well as direct feedback from deployment partners and our numbers should be seen as a conservative estimate. We have anecdotal evidence from different countries that Kiwix is also distributed laterally (meaning that one person will download the application and contents and share or resell them with friends and neighbours).

Based on current trends and strategy, we expect our user base to roughly double every year meaning 6 million users by the end of this year, and 100 million by 2024-25.

Our short-term goal is to establish long-term partnerships with local actors who can then be leveraged to propagate Kiwix across their own networks. They have a local understanding at their disposal that we cannot and never will have, and are best equipped to provide users with a relevant offer, as well as guide our own development efforts by providing structured feedback. Using them as a support to develop and maintain the ubiquitous reach of Kiwix, we will then use it as a tool to engage more owners of online content inclined to offer it offline, showing them than there is more benefit from investing an established, agnostic platform rather than invest in the development of a limited, bespoke solution from scratch. In short, local distribution partners help us increase our user base, which in turns helps us broaden the variety of content offered by attracting new partners (and thus making Kiwix even more enjoyable for more users, etc.).

Kiwix was established in 2017, and we have been expanding ever since and looking for this to continue. From a 130 kCHF budget in 2017, we grew to 300kCHF in 2018, and look to exceed CHF 1 million by the end of 2020, most of it dedicated towards platform stability and maintenance. With this goal almost reached, the next step for us will be to increase the variety of content on offer at an industrial pace, particularly as far as minority languages are concerned.

There is a cultural/legal barrier with the limited availability of freely-licensed educational content. This might be a medium-term barrier, as we work on industrialising content harvesting. However, things are moving forward; there is a growing acceptance of OER and open-access as default release options, but this movement is only starting to take hold in the Anglophone world. We do expect some capillarity and for it to make its way into the Spanish, French and Arabic educational resource communities, but this might take some time. Sadly, the 20th century view that content restrictions somehow help reaching new audiences is still widespread.

There are also market barriers. Even though single-board computers are extremely cheap, trade barriers (custom duties, bureaucracy) in poorer countries are extremely high, and blocking access to equipment is common. This makes the choice of distributors more limited than it should be.

There is a global push for open-access, and it is only accelerating, so we are certain that availability will increase. Multiplying solutions is not that helpful, hence our focus on re-using proven ones such as openMRS; a community-driven effort with the mission of improving healthcare delivery in resource-constrained environments. OpenMRS is already used by over 5,500 health facilities around the world, and we want to bring this working solution to offline communities.

 The ultra-dominance of anglophone content and teaching models is more concerning, as they do not take into account local specificities. Many times we have seen local elites publishing their content in English because of the pressure of funding or simply academic/media recognition.

We have developed a cooperative financing model where we try to support would-be distributors with seed funding or resource access.

9 staff/6 FTEs  + around 50 volunteers developers from around the world.

As a technology, Kiwix simply is the only content-agnostic solution to bringing internet content to people without connectivity. Most other platforms we  are aware of that cater to the offline world are there to sell/promote/distribute the content of their funding organisation alone. This has helped us become the default solution for a wide range of initiatives, as we have no issue white-branding our product and passing it on for someone else's work. As a non-profit, our mission and vision are to bring knowledge to as many people as possible, a user-oriented philosophy that helps us corner the offline market. 

On the team side, just under half of Kiwix’s coders are located in the Global South (Mali, Ghana, India) and have hands-on experience with connectivity issues. Kiwix’s advisory committee is also comprised of five members representing its main areas of deployment (US, Africa, Middle-East, South-East Asia, South America) and are tasked with providing user and deployment input.

We work with many organisations in a non-contractual collaboration capacity, whereby we share information with each other on who Kiwix is serving and for what purpose, and how we can improve the software. We provide them with the software and content to run their operations, and they give us feedback on use cases and audience in return. Some of them may decide to contribute funding for specific areas of software development which more closely match their needs. Among these, we have Libraries without Borders (France), the Orange Foundation (France), Fair Denmark (Denmark), eLiS (Germany), Teach-a-Class (India) and Offline-Pedia (Ecuador) to name just a few.

We also have a formal agreement with the Wikimedia Foundation whereby they contribute funds to further enhance offline access to Wikipedia worldwide, as is part of their mission (80% of Wikipedia users are in the Global North, whereas 80% of ours are in the South). More specifically, they have assisted in the development of Kiwix desktop and WikiMed - a staple of Hospital-in-a-Box.

Our business model relies on three pillars:

- direct sponsorship from like-minded organisations (e.g. Wikimedia);

- IT services for the conversion of content (for a partner interested in deploying specific resources not yet available offline) as well as bespoke software upgrades;

- Sale of pre-loaded, ready-to-deploy hotspot devices via an online hotspot installer.

- In terms of grants, we usually look for multi-year structural grants that allow us to build and maintain our infrastructure. We occasionally apply for programme-specific grants if they match our R&D objectives (e.g  a 2019 grant from the Mozilla Foundation to create a universal content scraper)

- Sale of IT services (software development, installing Kiwix on servers) is done on a standard consulting fee basis

- Sale of equipment and content is done through a variety of local distributors to save on shipping costs and import duties, meaning that we provide users with content that they are allowed to sell at the price they choose, with a 10% cut being sent back to us

Our reasons for applying are simple: we believe that Solve could help us further our cause greatly, and we believe that our proposal fits.

We meet the Solve criteria in that we have a successful solution to our problem (lack of Internet connectivity affecting livelihoods globally) which has been successfully implemented, and has grown significantly since its implementation. We are now looking to scale our solution so that it can grow in range (of informational material we provide) and spread (who we provide it to). Our proposal is also simple, yet highly effective, and easily replicable for a variety of different contexts. 

The offer of connection with experts would be a huge benefit to the deployment and development of Kiwix. As a non-profit, our ultimate aim is to connect the unconnected and to ensure that our software satisfies the needs of those who are most lacking in Internet resources. To have expert advice (be it technical, administrative, communicative, or other) would help us to streamline our processes and get our software where it needs to be more effectively. 

Working with local partners hugely helps to understand local users' needs and to adapt the tool accordingly, but we know that we can do more. There are still significant communities with no Internet access who are yet to hear of Kiwix, and we want to be able to reach them with our resources. Finding the right support to help us break into these places would be key to helping us further our mission and vision of connecting the unconnected.

We want to work with medical and/or digital solutions organisations, who could use Kiwix as a tool to bring Internet content as an informational tool for the advancement of a community.

Many of our deployments are in refugee camps. WikiMed and WikiEM are used by roaming healthcare professionals who enter these places to provide healthcare to those on the margins of society, who live outside of structured housing where Internet connection would happen. Using these offline medical tools as an easy to consult reference resource is of the utmost importance when providing mobile healthcare. It means that those providing treatment can refresh their knowledge on-the-go, find vital information for rare or complex ailments, and easily evaluate treatment options to find the most suitable solution.  

As WikiMed and WikiEM are offline solutions which can be accessed on most smartphones, it also provides a tool for any medically trained refugees themselves to serve their own community. Many countries require qualified medical professionals to re-train in their country of immigration, meaning re-learning familiar medical terms in an unfamiliar language. With these tools available in 10 different languages, refugee healthcare professionals can quickly consult a concept, treatment, or disease in their native tongue, even when out in the field. 

With better healthcare, refugees are better provided for in the country that receives them. By providing the informational tools to allow refugees' health to thrive, they are more able to access the economic and social opportunities for the better life they seek.