Dromedic Healthcare

Countries with strong primary healthcare (PHC) report better health outcomes, fewer hospital admissions and lower expenditure. People-centred care that delivers essential elements of primary care (PC) leads to improved health outcomes and reduced costs and disparities. However, such outcomes underscore the need for validated instruments that measure the extent to which essential, evidence-based features of PC are available and applied to users; and to ensure quality care and provider accountability.

• Validated PC performance measures are needed in Africa to guide, support and evaluate efforts to improve access to quality PC.

• Research is needed in Africa to evaluate instruments used and/or develop new measures to provide evidence necessary to strengthen PC and ensure universal health coverage.

There is however scanty information about PC performance measurement in Africa despite the commitment to strengthen PHC and universal health coverage.

Take an example of Uganda;

Uganda’s Human Development Index (HDI) value for 2019 is 0.544— which put the country in the low human development category as well as a least developed country—positioning it at 159 out of 189 countries and territories.Out of the  45 million citizens, over 74% live in the rural areas (World Bank, 2018) with limited access to basic services. As for primary healthcare in particular, we have an inadequate health workforce, with the doctor-patient ratio estimated at 1:25,725 and the nurse to patient ratio at 1:11,000 which is relatively low to the minimum recommended ratio of 2.3 of all healthcare workers (WHO, 2019). This has lowered the quality of health care given to patients and as such patients opt for more convenient ways of accessing care including self-medication through over the counter medicines and reliance on herbal medicines.

With limited healthcare workforce, measuring primary healthcare performance in remote areas becomes a big challenge. While many attempts are made to measure and/or improve the primary healthcare in remote communities, they generally focus on un-scalable and costly methods: digital platforms, online surveys, etc. for data collection, and TV campaigns, face-to-face community outreach awareness, emails, smartphone apps, etc for awareness and sensitization campaigns.

Simply put, these methods do NOT reach the illiterates, internet disconnected communities and all the most vulnerable demographic hence resulting to biased data which eventually leads to unrealistic healthcare programs.

Basic and feature phone technologies have revolutionised how people in emerging markets interact, as stated in GSM 2018 report on Mobile Technology for the SDGs: Reaching Further with Low Tech.
Despite growing smartphone penetration on the continent and the growing popularity of mobile apps, low tech continues to play a significant role in many emerging markets. Notably, nine in 10 mobile money transactions in Sub-Saharan Africa still flow through USSD (Unstructured
Supplementary Service Data). Specifically, USSD has proved to be a useful tool in dealing with the fallout of the COVID-19 pandemic.

In official government reports by the Uganda Communications Commission
(UCC), for the first quarter of 2021, mobile subscriptions stood at
almost seven SIM cards for every ten Ugandans (67%). With 71% of those connected using a basic phone or feature phones. We
developed a solution (Dromedic Healthcare) that allows even the most basic handset to access quality and affordable telemedicine healthcare services by simply dailing *271# with no barrier to entry: it is free of charge, available on all operators 24/7, works on any cellphone, and even works in areas with no data network. Our solution provides pertinent Ministry of Health-approved health information across multiple-channels (responsive website and USSD) and is bi-directional.
So while a user can get the latest information on preventive
disease/pandemic such as Covid19 measures or contact details for a
doctor consultation or find the nearest health facility, they can also
subscribe to receive notifications of particular health topics, submit
health questions, receive SMS campaigns on important health issues, etc.

All of this is accessed at any time and the information is stored in
our database.

In the back-end, we have availed a web interface where the Ministry of Health and partners can access anonymized and geo-referenced data/usage reports to help stay informed on what issues affect citizens in different areas of the country, and/or be able to measure the impact of primary healthcare services in a particular community to help guide programs, decisions and policies.

The recent GSMA State of the Industry Report states that at the end of 2019, smartphone adoption reached 60 per cent in South Asia and 46 per cent in Sub-Saharan Africa. While smartphones do outnumber basic and feature phones in over half of all countries in Sub-Saharan Africa, USSD remains the most common interface offered by providers globally. According to the IFC, the inability to use cash during the COVID-19 pandemic is increasing the use of USSD by the financially excluded.

USSD-run applications are easily accessible by people with both smartphones as well as basic and feature phones, therefore reaching a wider audience than smartphone apps. There are several other benefits that make USSD a valuable tool for emergency situations, including the COVID-19 pandemic: it does not require internet connection or data to work, and it can work across all mobile networks, needing only a GSM connection. USSD is also interactive – users can quickly see responses and make further requests, enabling faster interaction. Finally, USSD content can be personalised and accessed anytime and anywhere. These benefits position USSD as an innovative tool in responding to the call for innovative ways we can measure the improvement of primary healthcare performance in low and middle income countries.

Our solution serves all Ugandan citizens, particularly the under-privileged in the rural areas and with low-tech phones. 

We are feeding the platform with relevant information, and have received positive feedback having just reached over 15,000 new users/month with a quarter of a million visits per day. We have a voluntary self-registration section where the citizens provide their gender, age, and location, for us to understand how the usage and needs vary based on the users demographic. While we do have a free questions section (answered by the Ministry of Health’s call center), we plan on introducing satisfaction surveys in the near future to ensure we are constantly meeting the users expectations and providing the content they want.

As for the Ministry of Health (MOH), they have grown to rely heavily on our platform. It is front and center of their posters and campaigns, particularly during the Covid19 pandemic where traveling and community meetings were discouraged. At the request of the MOH we have sent out SMS awareness campaigns on rabies/vaccinations, performed surveys, provided self-screening, etc. Most importantly, we also provided usage data/reports to help guide their decisions and policies.

The team is led by Joseph Mulabbi who has a Bachelor’s degree in Communication and Media Technology with 10 years’ experience in digital health products, software development and in telecommunications. He is the Dromedic Healthcare project lead and software architect. Carol Nasil a software engineer with over 5 years working with the Ministry of Health in Uganda, Evelyn Nengoni an economist with a Masters in national development and project planning with over 10 years’ experience of development in Uganda and beyond. She provides social development advice to Dromedic Healthcare. On the other hand we have Izaac Wambi a software developer, involved in the design and development of Dromedic Healthcare software components, and Mercy Chelangat Yego, a female with a Masters in Law, as the Content Manager for Dromedic Healthcare, they are both young and energetic.

Our management team has over 20 years of experience in startups, clinical
medicine, software engineering, and business development. This colossal
challenge resonates with the founders having worked in healthcare
facilities where patients are affected by poor access to maternal health.
DroMedic is formally registered in Uganda and works closely with partners like National Information and Technology Authority (NITA): incubation support, United Nations Population Fund (UNFPA) Uganda office, and United Nations Development Program: for collaboration and acceleration of solutions, DroMedic: a digital health platform democratizes access to
maternal + neonatal health. Our team is well-positioned because we understand what it means to feel helpless when a child is lost or is fighting for life. The directors of DroMedic are from the paramedic, EMT, EMS, Management and IT background. We have worked for over 5 years in rural communities and understand the great challenges regarding EMT during emergencies within these communities. We have great experience in creating a centralized EMS platform, which brings health-logistic to some of the hardest to reach communities in rural Uganda and every part of the country.
Our Country Director and Fundraising and Programming Officer, are Ugandan
nationals, with a deep understanding of the local contexts we are operating in. Our Ugandan CD is well-positioned to both supervise DroMedic’s operations and build relationships with local officials to expand and sustain the work.

Our project also has the support from the Ministry of Health, the Tony Elumelu Foundation that financed the development of the initial project, Women Entrepreneurs for Africa Program (WE4A) that supported the delivery of essential products to patients during Covid-19 and all the mobile operators: Airtel, and MTN.

The Ministry of Health is our (contractual) partner in the Dromedic Healthcare project, regarding the insertion and dissemination of health information.

We are currently seeking funding that will be directed to product development and funding customer acquisition. The funding from this challenge would allow us to expand our team and work with even more organizations to close gaps in primary healthcare especially for mothers and babies. The funding will be used to expand Dromedic 's team of community-based provider network and roster of payor and health system partners. The Dromedic Network currently includes more than 10 practices and community-based organizations across the country.

We also seek to tap into the MIT Solve and the Bill & Melinda Gates foundation networks for scale, mentorship, partnership and collaborations to strengthen primary healthcare outcomes across Africa's remote and vulnerable communities.

USSD technology is a real time session based messaging service between the cell phones and an application server in the network. The service is a cross-platform hand-set support facility (basic feature phones and smartphones).

Basic and feature phone technologies have revolutionised how people in emerging markets interact, as stated in our 2018 report on Mobile Technology for the SDGs: Reaching Further with Low Tech.
Despite growing smartphone penetration on the continent and the growing
popularity of mobile apps, low tech continues to play a significant role in many emerging markets. Notably, nine in 10 mobile money transactions in Sub-Saharan Africa still flow through USSD (Unstructured Supplementary Service Data). Specifically, USSD has proved to be a useful tool in dealing with the fallout of the COVID-19 pandemic.

The innovation of our platform comes from its user-centric approach. Rather than building an app, deploy VHTs who are under paid and therefore can't perform as expected, for our system to serve the user, we looked at what they had readily available, and build everything around that. This allowed us to provide relatively "advanced" features to an often ignored or unreachable demographic.

Since it has been an effective tool for us and for our partners, we believe it can adequately enable governments and their partners properly measure the improvement of primary health care performances in low-income communities.

Another innovation about our solution is the back-end database. We are providing the Ministry of Health (MOH) with information on users that they do not have on any other channel like ours. Also, we provide services not previously made available to the demographic, such as surveys and tests. Finally, the modular build of the software, facilitates extension and integration with other platforms.

Other methods such as deployment of SMS method to collect data by the Ministry of Health especially in remote villages have failed because majority are illiterates.

In SMS we need to type everything, send to some specific telephone number and wait but for some people this way around can be little bit annoying. Everything about USSD is just much faster and simpler. The reason for it is an interactive user experience which is created by technical features of the technology. Unlike SMS, USSD maintains a session so users receive response almost immediately. There is no instant user involvement with SMS. You have to wait each time after your response and sometimes a dialogue can be  interrupted by a slow delivery of a message. With USSD users get the feeling of a common browsing through mobile phone application. It’s just doesn’t require any installation and works on any phones, from low to hi-end range which is an another big advantage.

Using the USSD, we can design simple short codes that require YES or NO in order get all the data we want about the impact of primary healthcare performances in remote communities without reliance on internet, and/or smartphone.

We also desire that our solution becomes the number one stop center for measuring primary healthcare performance in Uganda and East Africa, we shall therefore be involved into making meaningful partnerships and collaborations with governments and private entities.

Within the next year we need to make the platforms, and systems surrounding our solution, more sustainable and efficient. This involves first creating clear processes for content insertion and guaranteeing it meets the needs of the user. Content involves not just the information and features provided, but also the way it's delivered (i.e. local languages, voice, etc). Second, we would like to generate revenue that is organic to the platform. We are exploring SMS campaigning of health events, renting of space on the platform for private health facilities/clinics as well as pharmacies, and additional services linked with pharmacies.

Our solution currently serves 1.5 million people, and with the current growth rate we will reach 5 million within a year. After 10 years we'd like to reach 10 million.

Within 5 years, after we have perfected a sustainable model, we would like to expand the solution internationally, particularly in the African region, but hopefully later to Asian and Middle Eastern countries with a similar demographic to ours.

We measure impact based on the number (#) of subscribers.

#Successful health data collection and health awareness campaigns conducted.

#Partners, grants, donations, and awards received.

-Reach of our services

-Replicability/ potential to scale to new markets

A 3rd party research conducted by the LivingStone International University using anonymized data of Dromedic Healthcare users, showed that during the Covid-19 pandemic the last two years, users in the affected areas increased their access of Dromedic Healthcare. This was an early indication of how the platform is positively altering and affecting the health behaviour of the population. 

With this report and increased usage of the platform, we would like to perform further studies to show how positively we are affecting the lives of the underprivileged.

At this time, it is possible to verify the impact on our Covid-19 pandemic solution, as our solution was created to provide information on infectious diseases that most attack the country and on Maternal and Child health. However, since the discovery of Covid-19, we started to include information on this disease on the platform (such as causes, prevention methods, quarantine, among others). And since the introduction of information about Covid-19, in January 2020, the average daily views/queries on the PENSA were about 2,000, but this increased to 150,000 in May. We have now reached the historic milestone of over 1 million visitors/users with 10 million views.

Dromedic Healthcare (USSD) is build on a hardened cloud-based LAMP architecture configured with security in mind: Host Intrusion Detection/Prevention, firewalls, VPN's, anti-virus, backups, etc. We are using Apache, MySQL, and Tomcat.

From an application perspective we developed everything using Java, following the Model-View-Controller architecture. The code itself follows several of the Gang of Four design principles to deliver consistent quality. Test-driven development was used, to further help guarantee code quality.

The application has Adapters to abstract away the variations/complexities of the USSD and SMS gateways of each Mobile Network Operator, and the core PENSA application uses a REST interface.

Using our team of software engineers in partnership with the Ministry of Health, data collection is made easy at the back end of our system allowing authorized ministry of health officials and our team to collect, analyse and share data in line with the guiding principles.

The individuals are full-time employees of both our startup and the ones from the Ministry of Health are dedicated individuals fully employed by the Ministry but deployed to work with Dromedic Healthcare for data collection, analysis and disemination.

Our staff members, board of directors, development committee, and volunteers exhibit diversity in ethnicity, gender, age, and geographic regions. Staff represent Asian, African, Indian and northern European heritage, and range from age mid-twenties to mix-fifties. Our board chair is a co-founder/woman, and our volunteers hail from Uganda to India, across the United States to California. The majority of staff is based in Uganda.
We don't believe geographical limitations should exist for people to receive medical care—nor do we think our supporters or staff should be limited to any state, country, or region. We have strong focus on human-centered design including community voices in all we build.
We listen to the concerns and suggestions of the community members we serve and carefully consider them all as we design and build our services.
Looking at expansion, we push to hire women, particularly Ugandan women, as we grow. Joseph feels privileged to be part of the MIT Solve and Bill & Melinda Gates Foundation network, knowing he and his team have the power to make change and make a difference thanks to education, community connections, and a greater global understanding and appreciation that we are all connected in health.
Our mission to inclusion is at the heart of all we do—from simply scheduling meetings at convenient times for global staff, to understanding the challenges of terrain, transportation access, and healthcare in Uganda. Our core values lie in the belief that we are one humanity, with our individual perspectives. We recognize them, respect them, and also seek to learn from others.

So far we have not started generating revenue off the solution, as the goal was to increase usage. In the near future, however, we will introduce:

• Paid SMS campaigning of health events;
• Renting of space on the USSD menu for private health facilities/clinis;
• Renting of space on the USSD menu for pharmacies, and ordering of materials through the platform.

For our major services, we charge for doctor-patient consultations, sale of maternal and infant medicines, antenatal and postnatal services as well as charge for delivery of essential medicines to clients homes and offices.

As noted above, our revenue models currently/shall include

• Paid SMS campaigning of health events;
• Renting of space on the USSD menu for private health facilities/clinis;
• Renting of space on the USSD menu for pharmacies, and ordering of materials through the platform.

For our major services, we charge for doctor-patient consultations, sale of maternal and infant medicines, antenatal and postnatal services as well as charge for delivery of essential medicines to clients homes and offices.

The funds generated through those modules enable us to become financially sustainable as we continue to serve the needs of our target customers.

Other financial sustainability plans include fundraising drives for grants and donations and so far, we have received grants for the Tony Elumelu Foundation, Women for Africa Program (WE4A), Ministry of Health etc. We shall continue in this way through grant proposal writing and participating in different grant challenges within the healthcare sector to raise more funds for sustainability.

We have received grants for the Tony Elumelu Foundation - $5000, Women for Africa Program (WE4A)- €60,000, Ministry of Health etc. And have generated over $250,000 in revenue for our products and services.