Design and Implementation of an Open Source ‘Thin SIM’ System for Collecting Data & Supporting Global Health Care Isaac Holeman 1,2 Amanda Yembric 1 David Brown 1 Dianna Kane 1 Jane Katanu 1 Marc Abbyad 1 Ranju Sharma 1 {isaac, amanda, david, dianna, katanu, marc, ranju}@medicmobile.org 1 Medic Mobile 3254 19th Street, Floor Two, San Francisco, CA 94110 +1(415) 746-9758 2 Judge Business School University of Cambridge Trumpington St, Cambridge CB2 1AG, United Kingdom ABSTRACT Cutting edge communication technologies such as smartphones remain far from prevalent in most of the settings with the greatest need for improved health and development programs. As a result, designers of ICT4D initiatives often weigh difficult tradeoffs between the usability of smartphone applications for structured data collection versus the battery life, durability, cost and familiarity of basic phones. However, as this paper and our deployment experiences demonstrate, such tradeoffs are not always necessary. Most mobile network operators in sub-Saharan Africa offer value added services via simple, menu-driven applications that run directly from the SIM card. While conventional SIM applications can only be accessed by mobile network operators, this paper describes the design and implementation of a ‘thin SIM’ approach that does not require mobile network operator involvement. We have implemented this tool with more than 3,000 health workers and describe particular deployment experiences in Kenya, Benin, Nepal and Guatemala. We then reflect on a number of important limitations of the thin SIM approach, and opportunities for further development and deployment. Ultimately, we argue that there is an important role for SIM applications as one part of a configurable data collection toolkit for supporting global health and development programs. CCS Concepts  Human-centered computing ~ Ubiquitous and mobile computing systems and tools Keywords ICT4D; data collection systems; global health; mHealth; SIM card; SIM applications, SIM Tool Kit (STK) 1. INTRODUCTION In recent years the percentage of the world’s population that lives within reach of a 2G mobile-cellular network has grown at a remarkable pace, from an estimated 58% in 2001 to 96% in 2016 [9]. While most global health and development programs still rely heavily on paper, growing digital infrastructure affords many opportunities to transform the way that these efforts deliver services. As early as 2010 a number of ICT4D initiatives began focusing on smartphones in particular, anticipating rapidly falling prices and growing availability in developing countries, ease of development and advanced features such as GPS and built-in- cameras [8]. Despite a number of remarkable successes with smartphones and advanced feature phones [3,11,15], smartphones remain unfamiliar in many areas and may be unsuitable for some ICT4D endeavors. As of 2016 there are 46.1 mobile broadband subscriptions for every 100 persons globally, yet only 12.1 per 100 persons in the least developed countries [9]. Rural areas tend to lag far behind urban areas, at 89% mobile-broad coverage versus 29% coverage for rural areas globally and far lower in rural areas of the least developed countries [9]. While smartphones are now available and falling in price in many lower income countries, adoption is concentrated in urban areas. This trend is driven not only by up- front costs but also by availability of repair services and access to electricity. The World Bank estimates that access to electricity in Kenya’s urban areas increased from 48.2% of the population in 1990 to 58.2% in 2012, while rural areas of Kenya expanded access from 3.4% to 6.7% during the same time period [20,21]. In Malawi, electricity was accessible to a mere 2.0% of the rural population in 2012 [21]. While these statistics paint only a partial picture and may lag somewhat behind the reality, it is nonetheless clear that mobile phone ownership has now surpassed the rate of access to electricity in much of sub-Saharan Africa. This means that many people charge their phones at electricity charging shops, a time- consuming and relatively expensive practice that may help explain why few people in rural communities opt for smartphones that must be charged daily. Many of the locally available smartphone options are low-end devices with smaller screens and slower CPUs, affording days or even a week of use between charges. However, they still must be charged far more frequently than basic phones and their larger battery capacity means that they take longer to charge, which is important if one is paying for electricity on a per-charge basis or when using small solar panels. These trends are important not only because 3.4 billion people live in rural areas, but also because rural communities in the least Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for components of this work owned by others than the author(s) must be honored. Abstracting with credit is permitted. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. Request permissions from Permissions@acm.org. ACM DEV '16, November 17 - 22, 2016, Nairobi, Kenya Copyright is held by the owner/authors. Publication rights licensed to ACM. ACM 978-1-4503-4649-8/16/11…$15.00 DOI: http://dx.doi.org/10.1145/3001913.3001923