Kenya’s Startup Boom

BY DAVID TALBOT(MIT Technologyreview)

Erick Njenga, a 21-year-old college senior wrapping up his business IT degree at Nairobi's Strathmore University, has a gap-toothed grin and a scraggly goatee. A mild-mannered son of auditors, he didn't say much as we tucked into a lunch of grilled steak, rice, and fruit juice at an outdoor café amid the din of the city's awful traffic. But his code had done the talking. Last year Njenga and three classmates developed a program that will let thousands of Kenyan health workers use mobile phones to report and track the spread of diseases in real time—and they'd done it for a tiny fraction of what the government had been on the verge of paying for such an application. Their success—and that of others in the nation's fast-growing startup scene—demonstrates the emergence of a tech-savvy generation able to address Kenya's public-health problems in ways that donors, nongovernmental organizations, and multinational companies alone cannot.

Njenga was humble about the project, but the problem he had tackled was critical in a nation where one in 25 is HIV-positive (10 times the U.S. rate) and AIDS, tuberculosis, and malaria are among the leading killers. In 2010, the Kenyan government realized it had to do something about its chaotic system for tracking infectious diseases in order to improve the response to outbreaks and report cases to the World Health Organization. Handwritten reports and text messages describing deaths and new cases of disease would stream in from more than 5,000 clinics around the nation and pivot through more than 100 district offices before being manually entered into a database in Nairobi. The health ministry wanted to let community health workers put information into the database directly from mobile phones, which are ubiquitous in Kenya. The ministry initially sought a solution the usual way: it explored hiring a multinational contractor. It drafted a contract with the Netherlands office of Bharti Airtel, the Indian telecommunications giant that also operates a mobile network in Kenya. The company proposed spending tens of thousands of dollars on mobile phones and SIM cards for the data-gathering task, and it said it would need another $300,000 to develop the data application on the phones. The total package ran to $1.9 million.

The contract was never signed; Kenya's attorney general stopped the deal over questions about its reliance on one mobile carrier. Not very many years ago, there wouldn't have been any options within the country. But Kenya's director of public health made an urgent call to Gerald Macharia, the East Africa director for the Clinton Health Access Initiative (CHAI), a wing of the foundation started by former president Bill Clinton. Macharia then called an instructor at Strathmore, who quickly rounded up the four students. They spent the spring of 2011 at the CHAI offices, receiving internship pay of about $150 a month. They sat for days with the staff in the health ministry to understand the traditional way of gathering information. Then they pounded out the app and polished up the database software to allow disease reporting from any mobile Web interface. By last summer their "Integrated Disease Surveillance and Response" system was up and running at the ministry, obviating much of Bharti Airtel's proposed costs. The process was "rough—but not too bad," Njenga says. "There were some nights we worked until 2 a.m." He and his colleagues are now finishing an SMS version so that health workers without Web access can make reports via text message from mobile phones of any make or model. The students are also working on another key problem: coming up with ways for the health ministry to track pharmaceuticals it ships to the government's hospitals and clinics, to avoid shortages or waste.

Mobile phones are lifelines for Kenyans. Some 26 million of the nation's 41 million people have phones, and 18 million use them to do their everyday banking and conduct other business; most use a service called M-Pesa, which is offered by the country's dominant wireless provider, Safaricom. If mobile phones could play as big a role in Kenyan health care as they do in Kenyan financial transactions, the effects could be profound. A growing body of research worldwide is showing that beyond disease surveillance, mobile phones can improve public health by connecting people with doctors for the first time, reminding people to take medications or bring children in for vaccinations, and even enabling doctors in remote areas to view, update, and manage crucial clinical records.

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Still, there are big gaps between the promise of mobile health technologies, or "m-health," and their actual implementation. According to the mHealth Alliance, a Washington-based group, 45 mobile health projects are active or have already been completed in Kenya alone—more than in any other country. Most have been devised and paid for by philanthropies, aid agencies, and NGOs. The projects vary widely: one delivers money via M-Pesa to pay for repair of fistulas, a damaging complication of childbirth; another verifies the authenticity of drugs when workers text their serial numbers. Some have had substantial impact. But most are limited in scope and time frame. And there's often no business model for sustaining them when the funding runs out, leaving the field suffering from a bad case of "pilotitis," says Patricia Mechael, executive director of the mHealth Alliance. "The space is incredibly fragmented, unfortunately," she says. "You have a lot of bits and pieces coming from different angles and lots of pilots going on."

Meanwhile, IT contracts for government websites, electronic registries, and other large projects are typically conceived by NGOs or donors and carried out by contractors who may be remote from the specific needs of workers at the front lines. "You have people thinking at 30,000 feet: 'Let's do websites for every government ministry,'" Jackson Hungu, CHAI's country director, told me over dinner in Nairobi. That's good, he says, but it may not meet the needs on the ground: "Have we gone to that pharmacist and asked, 'Look, what do you do? You are the one who meets the patient and feels the pain.' Have we understood it thoroughly from that guy's point of view? Or are we building something so donors can say, 'Oh, we are online'?" Successful national technology strategies, he argues, require people like the Strathmore students, who have the code-writing chops, can readily work with the people who need to use the technology, and are likely to remain in Kenya to sustain the effort.


Nairobi's Prestige Plaza shopping center would look familiar to anyone from a rich country: it's got an anchor megastore, called Nakumatt, and a food court (the Swahili Plate concession, which dishes up beef stews and curries, is a clue you're not in Kansas). But one block away, a rutted dirt road perpendicular to the complex leads to the maw of one of Africa's largest urban slums, Kibera, with 170,000 residents. The outskirts bustle with stalls selling kale, peanuts, sugarcane, herbs, and cell-phone SIM cards. The ground is hard-packed mud littered with stones and garbage. Single-story huts flank alleyways. Rusty corrugated-metal roofs shed the rains. At the nicer huts, curtains blow through openings. But the smells of smoke and feces linger, and children play near fetid rivulets lined with plastic refuse. The river at the lowest end of the slum becomes like a sewer when it rains. Kibera is, unsurprisingly, a hotbed of infectious disease, including HIV and tuberculosis.

Zuhura Hussein was born in Kibera 38 years ago and never left. (Her roots in Kenya are deep: she is descended from the Nubians conscripted in the Sudan by British colonial forces a century ago and permitted to settle in what was then a lush forest.) A mother of three and grandmother of one, Hussein is one of 140 community health workers attached to one of the clinics that serve the slum. She encourages the people of Kibera to venture out for medical checkups and vaccinations; she also urges patients with HIV or tuberculosis to take their medications every day. She and thousands of Kenyan workers like her are crucial to the success of many global health initiatives, such as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which spends $500 million per year in Kenya alone.

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The day of my visit, Hussein and I snaked through a four-foot-wide alleyway, past two girls peering into a fragment of shattered mirror as they braided their hair next to a pot of boiling meat. We ducked into one of Kibera's dim, cramped habitations. When our eyes adjusted, a bed came into focus. A figure wrapped in blankets stirred. The woman (who wasn't well enough to give permission to use her name) was 48 years old but looked 75. She was HIV-­positive and was struggling with a severe case of tuberculosis. "The TB has come back—so many times, I don't know why," Hussein said. Asked what she needed, the woman whispered in Swahili: "I want just food—only food." Amid this scene of despair, a phone rang; Hussein reached into her dress and produced a Nokia model 6070. Later, I scrolled through her contact list and found more than 300 names, from Abdala to Zubeda. Many, she said, were patients she's worked with.

Phones like Hussein's hold great potential to improve the way health services are delivered. One major study demonstrating as much was started five years ago by Richard Lester, a Canadian infectious-disease specialist. After arriving in Kenya for a research fellowship, noting the ubiquity of mobile phones, and recognizing that the country has only one doctor for each 6,000 citizens, Lester and his team developed a communication link with HIV-positive patients at three health centers, asking them weekly by text message whether they needed any assistance with their antiretroviral drugs (ARVs). Once 500 people were participating, Lester conducted a clinical trial. The results, published in 2010, showed not only that a higher percentage of those receiving the reminders said they took their drugs regularly, but also that viral loads were suppressed in 57 percent of them, compared with only 48 percent of the control group. Today he estimates that expanding that system to all 410,000 Kenyans on ARVs would suppress HIV in 36,000 people, saving $17.4 million in health-care costs by averting the onset of AIDS or making more expensive drugs unnecessary.

More evidence is streaming in. In western Kenya, a research project called Academic Model for Providing Access to Healthcare (AMPATH), led by the Indiana University School of Medicine and the local Moi University, recently began keeping track of 130,000 HIV-positive patients using electronic health records and automated reminders on Android phones. Now workers in 55 clinics can quickly and easily see what tests or drugs patients need. Published research suggests that the proportion of HIV-positive mothers passing the infection to their babies has dropped below 3 percent, compared with nearly 15 percent in other areas, probably because more of the pregnant women are receiving antiretroviral drugs consistently. "These reminder systems are an extremely important way to make sure all of the ts are crossed and better quality of care is provided," says Paul Biondich, a research scientist at Indiana's Regenstrief Institute, who co-developed the underlying open-source records system platform, called OpenMRS. Click to read more