SMS-based smartphone application for disease surveillance has doubled completeness and timeliness in a limited-resource setting – evaluation of a 15-week pilot program in Central African Republic (CAR)

El-Khatib, Ziad; Shah, Maya; Zallappa, Samuel N; Nabeth, Pierre; Guerra, José; Manengu, Casimir T; Yao, Michel; Philibert, Aline; Massina, Lazare; Staiger, Claes-Philip; Mbailao, Raphael; Kouli, Jean-Pierre; Mboma, Hippolyte; Duc, Geraldine; Inagbe, Dago; Barry, Alpha Boubaca; Dumont, Thierry; Cavailler, Philippe; Quere, Michel; Willett, Brian; Reaiche, Souheil; de Ribaucourt, Hervé; Reeder, Bruce

Overall, the median completeness of Weekly Reports was significantly higher in MK 2016 (81% (IQR 81-86%)) than in MK 2015 (29% (IQR 24-36%)) and NM 2016 (52% (IQR 48-57%)) (p < 0.01; Fig. 4a) . Similarly, the median timeliness of complete reports was significantly higher in MK 2016 (50% (IQR 39-57%)), than in MK 2015 (19% (IQR 19-24%)) and NM 2016 (29% (IQR 24-36%)) (p < 0.001; Fig. 4b ). The median duration of transmission of complete reports was 12 h (IQR 1-63 h). If one were to consider timeliness as the receipt of the first SMS transmission of a Weekly Report, the timeliness in MK 2016 would be 74% (IQR 60-80%). Figure 5 shows the Kaplan-Meier survival analysis for time to transmit a complete Weekly Report grouped by 3-week time periods during the pilot. There was a significant progressive reduction in transmission time over the 15-week period (p < 0.01). Consistently each week, health centers across the district initiated electronic transmission of the Weekly Reports as required by the study protocol (96% of occasions); notably, sub-districts showed no significant difference in this regard (Table 2 ). Yet, completed transmission and report timeliness was significantly lower in a number of sub-districts in both centrally-located lowrisk security zones, and in more distant medium-risk security zones. The mean scoring of the usability of the app reported by the 21 focal points was 4 . 5-5/5 for all 27 questions on the three dimensions studied: ease of use, usefulness and efficiency (data not shown). The total cost for the 15-week pilot was US$40,575. This was composed of i) US$10,950 in capital costs: 30 smartphones (US$2250), 30 solar chargers (US$2700), and two laptop computers (US$6000)); ii) US$5200 communication fees (US$1800 fleet services, US$3400 SMS charges); iii) US$225 transportation costs in three isolated health facilities iv) US$4100 local personnel, and v) IT consultant services based in Geneva (US$20,100). It is estimated that to maintain the system in the 21 health facilities of MK will cost approximately US$18,800 per year in communication fees; this represents US$17.20 per health facility per week.