mHealth technology enhances the value of Rwanda’s prehospital emergency system

September/October 2025 | Volume 24 Number 5

Photo courtesy of Dr. Sudha JayaramanDr. Sudha Jayaraman

In the United States, most of us think of trauma surgery as life-threatening bleeding that requires an emergency operation—car crashes and gunshot wounds. And when we think about that, we imagine an ambulance racing to a hospital where a surgical team rushes the patient into an operating room. While that does exist in many regions, it doesn't exist everywhere in the U.S.

And it doesn’t exist everywhere across the globe.

“In many parts of the world, there may be an investment made in hospitals or even in surgeons, but no investment has been made in the system that makes it all work,” says Dr. Sudha Jayaraman, a trauma and acute care surgeon and faculty member at the University of Utah. “Whether it's a car crash, or somebody having a heart attack, or a kid in respiratory distress, you need a system that functions and can handle all those different types of emergencies.”

Her current Fogarty grant, Rwanda 912: an mHealth Application to Improve Quality of Trauma and Emergency Care in Kigali, focuses on building out the country’s prehospital system for emergency care.

Political will

Jayaraman first began working in Rwanda in 2011 during her fellowship with Brigham and Women's Hospital in Boston. “It turns out that the Rwandan government had set up Service d'Aide Medicale Urgente (SAMU), a division of emergency medical services, which most governments in LMICs haven't. It was a small department, but it had a very methodically-kept system—all on paper, but methodical.”

Jayaraman immediately recognized that this existing system would be a great foundation on which to build and turned to Fogarty for support for a project: Evaluating the Quality of Prehospital Emergency Care in Kigali, Rwanda. “We did very natural things, such as ask: Who's trained and what are they trained in? What if we tweak their training to see if we can improve the quality of care … and then measure that change?” The buy-in was immediate among staff and those in government; everyone could see the value of more training, more organization, and more systems. Implementation of training, checklists, and standardized care followed, all with positive results.

The only problem was coordination, notes Jayaraman. If somebody called in an emergency, someone would be there and ready, 24 hours-a-day to answer the call. Unfortunately, that person couldn’t simply say, We'll send you an ambulance. “Instead, they first had to ask questions, like: What’s the closest landmark that we should look for to find you? Are you within 10 blocks of this landmark?”

When she saw an announcement for Fogarty’s mhealth program, she knew that it would be a “very robust, rigorous way for us to develop, test, implement and study the infrastructure, which we needed, because we didn’t know what the effects of making such dramatic changes might have on patients, on people.”

Strong partners

Photo courtesy of Dr. Menelas NkeshimanaDr. Menelas Nkeshimana

To help her with the Rwanda 912 project, Jayaraman turned to long-standing partners, including Dr. Menelas Nkeshimana, who’d studied for six years in China, receiving his MBBS from Tianjin Medical University in 2008, with an additional year spent at China’s Central South University as general scholar in cardiology funded by UNESCO. Since returning home to Rwanda, he’s become the guy everyone gives the most difficult problems. For example, in December 2016, just months after joining the department of internal medicine at Centre Hospitalier Universitaire de Kigali, his superiors tasked him with organizing and managing the hospital’s problematic emergency department. He also ran the case management pillar of national command center during the COVID-19 pandemic—after getting his master's in Global Health Delivery funded by Jayaraman’s previous Fogarty grant—and, for the last two years, he’s taken charge of healthcare workforce development at the Ministry of Health.

Another long-standing Jayaraman collaborator is Melissa Watt, PhD, a research professor at University of Utah who previously spent a Fulbright year in Tanzania and worked for the United Nations and an international NGO in South Africa and in Eastern Europe.

Watt notes that she’s been a frequent Fogarty awardee, so she is “very attuned to how we build capacity within the context of Fogarty grants. When Jayaraman started Rwanda 912, she brought me on board in order to contribute in the areas of qualitative methods, intervention development, and training of local mentors.”

Though these partners are strong, Jayaraman also needed to find collaborators outside her circle.

Accelerating change

Imagine a densely populated city of more than a million residents living in high-growth areas where change is rapid, businesses come and go, and street addresses have not yet become standardized.

Within this urban sprawl, how do you find someone experiencing a medical crisis?

To improve Rwanda’s emergency system, “step one was being able to find people efficiently and getting there efficiently” in a country where Google Maps does not function outside of “touristy areas,” says Jayaraman. Given that Fogarty’s mHealth program focuses on innovating technology, she turned to a Kigali-based start-up, Rwanda Build Program. The software accelerator had been working for local businesses, including a flower delivery company and a fintech firm, and for these previous clients, the tech team had gathered location data which they’d learned to deploy on top of Google Maps. “Essentially they asked, How do you need to apply all this data for ambulances?” says Jayaraman.

Nkeshimana admits, “The IT people, the developers—it was not always easy to get along. We clinicians have ideas and sometimes we think things can be done overnight.” Despite some rough moments, Rwanda Build made progress constructing a software platform for emergency infrastructure that could guide critical functions, including dispatching ambulances, tracking ambulances, route navigation, and geolocation.

“We were in the top five at a couple of different hackathons, including one sponsored by Toyota,” says Jayaraman.

Incremental steps

As development of the software platform advanced, new challenges arose. The folks who knew every road like the back of their hand now needed to learn how to navigate using an electronic map on cell phones. Naturally, this required training. Jayaraman says, “We had to create the software in multiple stages since you can’t go from writing things on a notepad to using a sophisticated application.”

The team included the end-users in their design process, says Jayaraman. “First, we built a rudimentary start-stop application and got everybody to use it alongside providing their usual care,” and then they released “increasingly sophisticated” iterations of the program. Watt believes this “human-centered design process” is what helped the project gain traction. Nkeshimana says, “It’s easier to acquire something someone designed, plug it in and then ask people to learn to use it. But when people help create it themselves, they like it better and they embrace it.”

Eventually users could see where ambulances across the entire city were located, the availability for each, and which one was closest to an emergency caller. “That capability just opened up a whole world for them in efficiency. They ended up getting more ambulances and putting out more ambulance bases. They began to really build,” says Jayaraman.

Nkeshimana says, “This project has also helped to build very good working relationships between all the involved people in the continuum of emergency medical services.”

So where do things stand now as the project nears its completion date? Initial development, testing and implementation, including assessing usability and quality, is done, says Jayaraman. “This next year, we'll be working on doing comparisons from before we had the software to now.”

International innovation

Watt says, “The tools that we're developing in Rwanda could be adapted and used to help improve healthcare systems in the U.S., making them more efficient.” Jayaraman also sees this work as having “enormous applicability” in the U.S. “When we first talked about this concept back in 2019 at a conference (attended by mostly North American researchers), half the audience said, How can we do this here? Because we don't have that here.”

Still there are challenges when translating technology from one country to another—even from one place to another within the same country, says Jayaraman. “In the U.S., we have existing systems that we can’t change and existing commercial systems in place. When you have to build on top of something else, it becomes very complicated.” Another difficulty: trying to assess whether the system has benefits or not and whether it's causing harm or not. In anticipation of these challenges, the team carefully structured their project—slowly adding capabilities and testing them—to understand how best to implement in other contexts. “We've been very diligent about making sure that we think about scale and impact and sustainability the whole time, while ensuring that we're adding value locally,” says Jayaraman.

Beyond Fogarty, Jayaraman and her team will collaborate with Professor Justine Davies at the University of Birmingham, who has received a multi-million-pound grant from the UK’s National Institute for Health and Care Research to develop additional aspects of this project.

“This work has caught the eye of international organizations,” says Jayaraman. “There is enormous opportunity for us to become an international player and to have international respect and prestige.” Three papers are in progress and will be published imminently and two others have already been published, she adds.

Increased capacity

Seventeen candidates have received training and acquired advanced degrees through Jayaraman’s two Fogarty grants in Rwanda. Helping Rwandan health professionals get master's degrees is “an enormous step in the right direction” toward improving their ability to identify problems, to solve problems, to troubleshoot problems. The capacity building impact also includes five or six software developers and “literally more than a hundred people who have now learned how to use the software and deliver care for the 1.2 million residents of Kigali. The scale is immense and transformative,” says Jayaraman.

“Historically, there's not been a whole lot of support for surgeons engaged in global health work,” says Jayaraman. Yet surgeons see parts of the health systems that others don’t and have a lot of expertise to share. “I think this work is a great example why more support should be given to surgeons.”

Beyond the positive impact of individual projects, Watt sees the greater gains due to Fogarty. She’s worked with many researchers in academic medicine who’ve trained in global health settings, courtesy of Fogarty funding. “Now they’re really bringing innovative and flexible approaches to solving intractable health issues related to health systems and health challenges in the U.S. So, this investment that Fogarty is making in global health is also improving health in the U.S.”