Stones instead of PCs to collect Sierra Leone health data


A new health data system has been introduced to rural parts of Sierra Leone, where lack of electricity and widespread illiteracy has prevented authorities and UN agencies from collecting reliable data about infant mortality and other health indicators. The method: Counting stones.

The euro 35 million project was initiated by the Department of Informatics at the University of Oslo, Norway, which has 14 years of experience of developing sophisticated health information systems for a number of countries in Africa. As a system was to be designed for Sierra Leone, however, the country's extremely poor infrastructure at first seemed an overwhelming challenge.

Sierra Leone remains one of the world's poorest countries after having been ravaged by civil wars. While democratic institutions are in place and economic development is finally being notable, the country's infrastructure remains collapsed. There is no nationwide electric power grid, and most of the country has no electricity supply at all. The necessary power is supplied by diesel-driven generators. The war also interrupted education, leaving Sierra Leone with one of the world's highest illiteracy rates.

Child mortality is high, and many mothers die in childbirth. And also the local traditional midwives, who are charged with registering these events, are often illiterate. Therefore, "registration is often chaotic, with many local adaptations. Collected information frequently overlaps. We intervene to standardise the systems so we can get comparable health data from all parts of the country," says Jørn Braa, Associate Professor at the Oslo Department of Informatics.

Innovative solutions were therefore needed to improve data collection in rural Sierra Leone. The engineers worked out a simple system that required neither electricity nor literacy - by counting stones.

In the municipality of Tombodu, in the eastern part of the country, the village-based traditional midwives register births, children who die immediately after birth, stillbirths and illness or death of the mother by placing small stones in a box with five compartments. Every month the box is taken to the health centre where the stones are counted and the resulting figures included in the health centre's monthly report to the district authorities. The data are entered into a regional database, which is part of the national system.

"The point is to make a standardised system for collecting health data from all parts of the country. This will give local and national authorities, as well as the World Health Organisation (WHO) in Geneva an overview of the health situation and other data that will help them decide where to take remedial action," Braa explained.

In order to provide vaccinations for rural children, authorities require statistics on local public health, such as the incidence of measles, tetanus, diphtheria and tuberculosis, the number of children, and the number of those who have already been vaccinated. Only then will it be possible to implement an effective vaccination programme.

"Sometimes we see that only half the children in a particular region have been vaccinated. Without reliable figures it is impossible to assess the job, plan for improvements and draw up an appropriate budget," Braa pointed out.

To date, in cooperation with several African universities, the Oslo Department of Informatics has established similar health information systems in a number of African countries – such as Zanzibar and Botswana. "Our goal is to produce a system that will survive political turmoil. In this context, the department has the role of bridge-builder in Africa," says Professor Morten Dæhlen, Head of the Department.

The project is currently the fourth largest research project at the department. Euro 11.5 million have already been spent, some of which has been aid funding from the Norwegian development aid agency Norad. Over the next ten years, the department plans to spend more than euro 23 million on related projects in Africa, hoping to "contribute directly to the strengthening of the health information systems and health services more generally in Africa."

All programming is done using open-source code. The software is free and available to everyone. "Using open-source code is a key point. However, the commercial actors are not very happy about us. They resent idealistic projects that encroach on their turf. We represent an annoying type of competition. They want to have the market to themselves," Professor Morten Dæhlen says.

African Future