5 Country Case Studies

Looking more closely at a selection of countries, the following section provides a snapshot of specific contexts and experiences to add to the wider mapping. Country case studies are informed by key informant interviews at country level and web-based desk research. Digital developments move fast and with that so do respective behaviour changes in the population with their use of the technology. Even in rural settings lacking infrastructure, solutions which were not appropriate 5 years ago are now becoming more possible. Such is the proliferation of initiatives in the digital health space, these case studies are not intended to be comprehensive country scans, but rather some indicative findings focused on interventions Gavi are likely to be interested in. We look at issues relating to aid effectiveness – country ownership, harmonisation and alignment (and interoperability of systems), managing for results (data quality and analysis) and mutual accountability.

Country selection

Countries were selected in agreement with Gavi based on several criteria: digital health maturity, high zero dose children, and covering the spectrum from fragile to transitioning countries; geographic spread.

Countries become eligible for Gavi support if their average Gross National Income (GNI) per capita has been less than or equal to US$ 1,630 over the previous three years (according to World Bank data published in July each year). When a country crosses the eligibility threshold, it enters the accelerated transition phase and starts to phase out of financial support. Indonesia was our ‘transitioning’ country.

Scoring on the Global Digital Health Index

The Global Digital Health Index is an interactive digital resource that tracks the institutionalization of digital technology for health across countries. Still in its early days, it includes a selection of countries that opt in to participating and being assessed.

Country scorecards produced in 2019 assess digital health against a range of areas, scoring them from 1 to 5 in a number of domains including health workforce training in digital health. There are some interesting results. For instance, Ethiopia with its high levels of government ownership and focus on digital health in pre-service training, scores very well in the workforce domain, whereas Pakistan, despite having high levels of digital infrastructure and in-country expertise, scores relatively poorly as it has not institutionalized training in digital health within pre-service or in-service health workforce training.

5.1 Pakistan Overview

Digital interventions for vaccinators and community health workers have proliferated in recent years in the areas of immunisation, maternal and childcare and diseases tracking. Two notable immunisation performance initiatives have been scaled up in partnership with the Expanded Program of Immunisation (EPI). Pakistan is a decentralised country with the Federal EPI Program under the Ministry of Health providing a coordination role, with provinces mandated to adopt, implement and fund digital technology. Most digital health activities in Pakistan have been initiated at the provincial level and presently efforts are underway to consolidate into a single central digital MIS for the EPI. A national digital health strategy is also under development that will support the National Health Vision 2016 - 2025. National level dashboards, registries, and other strategies have been initiated, and will be expanded in the coming years. 75% of the population report to have some form of mobile phone46 and 15.9% reported to have a smartphone in 201947 (with the figure rising all the time).

Example Interventions

Intervention Description

EVACCS Implementer: Acasus, Punjab Health Department, Punjab Information Technology Board (PITB) and the World Bank

Detail: Smartphone-based vaccinator monitoring application. The PITB gives all community-based vaccinators a low-cost mobile phone with the EVACCS app installed enabling them to report their immunisation activities by recording community visits using global positioning system (GPS) co-ordinate check-ins and photo uploads. Data uploads are managed by the Punjab Information Technology Board. Reports are displayed on dashboards using polygon-based maps that turn green when a vaccinator conducts immunisation activities in a community, driving both vaccinator performance and political accountability.

Scale: Dramatic improvements in immunisation coverage (up to 96% in Punjab) –primarily due to improved vaccinator performance and area coverage. In 2018, 75% of all 12-13m children in Punjab were fully vaccinated, up from 61% in 2014.

Zindagi

Mehfooz Implementer: Interactive Research and Development (IRD)

Detail: IRD and The Indus Hospital (TIH) provide technical support for the implementation of an Android phone-based immunisation registry to record and analyse program data in real time

Scale: All 29 districts in Sindh. Registered over 2.2 million children under 2 years of age and 0.7 million pregnant women over 2017-19. Used by more than 2,200 government vaccinators.

Immunisation

Roadmap

(Governance)

Implementer: Acasus, Gavi (funder BMGF) - 2019 onwards

Mott MacDonald, Acasus (funder DFID) as part of TRF+ - 2014 – 2018

Detail: Immunisation Roadmap is a supervisory application for use at tehsil and district level, which then feeds into a dashboard with digital data packs and portals provided to district and provincial governments. Focused only in Polio high risk union councils. A larger PHC Roadmap initiative for Punjab and KP provinces provides digital data on immunisation and maternity care for provincial planning: integrates independent assessments of health facilities, EVACCs data.

Health worker pilots for immunisation

Implementer:

Aga Khan university, Gavi – research trial: 2014-18

Detail: Android Immunisation Registry supported by vaccinator/ LHW training, peer support, district recognition and performance-based fuel transport awards

Scale 3 districts

Sehat Kahani Mobile App Implementer: Implementing partners: Ministry of Health; Zetsol Technologies; 10 Pearls Pakistan; Adamjee Insurance.

Detail: Allows healthcare providers to evaluate, diagnose and treat patients using telemedicine app via chat, audio or video. Patients can create their personal E-Health Record comprising of previous medical history, which is also visible to the connecting doctors. Adapted to COVID-19: suspected cases are forwarded to the relevant authorities helping to track the number of cases in-country.

Scale Over 50,000+ downloads, and over 18000+ consultations for both general medical complaints as well as COVID-19 concerns. Of these, 300+ individuals have been referred onwards as potential COVID-19 cases.

The app has strong government buy-in and has been invested in by WB, USAID and UKAID. The COVID work has been added on to the existing app so it has the potential as a wider multi-function platform that users and health care workers are familiar with.

Technological uptake

Vaccinators and lady health workers in Pakistan have had little issue in navigating mobile applications. Most frontline health workers were already either using android applications and social media platforms, or simpler mobile phones. However, there are issues with data manipulation by vaccinators with both immunisation tracking applications. Vaccinators were sufficiently technologically savvy to re-work the immunisation GIS tracker to show visits had taken place, and these were picked up only in separate field validations exercises by EPI programs. Digital use capacity is weak amongst government managers, particularly mid-level managers in district health offices and provincial EPI programs. So far there has been little investment in terms of dedicated IT posts and digital systems for EPI programmes. At the senior executive leadership level there is considerable policy appetite for digital data and dashboards for oversight and operations planning.

Smaller scale pilots that co-produced the application and invested in district performance accountability and recognition of vaccinator tracking had positive feedback from health workers. Vaccinators and LHWs report that the use of mobile apps improves self-imaging in the community, helped identify defaulting children for timely follow-up visits, peer recognition and support, as well as communication with other vaccinators/LHWs for experience sharing and trouble-shooting. There is good compliance from health workers without any financial incentives. Recognition by supervisor and the community was experienced to be a powerful incentive, and the fear of being tracked and that somebody may be looking at the data also spurred performance.

Data Attributes

Immunisation performance and compliance with visits is calibrated differently by the two vaccinator applications in place – EVACCS and Zindagi Mehfooz - making it very difficult to get a coherent national picture. There are also concerns that ZM’s vaccination data does not tally with field verified reports and this has led to hesitancy in scaling further.

The two applications are not interoperable and national stakeholders feel that consistency is required in terms of what is measured and in reporting methods. Vaccinator manipulation is more widely seen in districts where immunisation accountability is weak, especially in Sindh and Baluchistan. There is wider ownership and trust for the simpler EVACCS application produced by the government than for the more sophisticated, externally funded ZM application which was developed by the partner without government inputs. This is a good example of the need for codesign and co-production. Field monitors can play a critical role in providing accurate, quality data, improving delivery of immunisation micro-plans and need to be included in further rollout of digital technology for immunisation. Linking of digital applications to the household and births registration national database (NADRA) is recommended for improving data validity for immunisation planning.

Immunisation Governance

Use of data from ongoing mobile applications has had a variable experience in Pakistan when tied into larger immunisation governance experiences. While digital data is generated by EPI programmes and implementation partners, ownership by administrative leadership is necessary for performance management and use. Immunisation digital roadmaps help generate some level of healthy competition amongst districts to improve immunisation performance, but ongoing strong leadership support is instrumental in sustaining gains. Leadership change within the government hierarchy and within downstream district health systems affects use of data. For example, leadership change in Punjab has negatively impacted the use of EVACCs for immunisation performance accountability, whereas in Baluchistan, fragmented provincial leadership results in poor data compliance by districts. Frequent transfers of district health officials means staff do not have sufficient time to get familiar with digital interventions and this compromises ownership. Taking vaccinators to task on immunisation coverage has faced challenges and backlash, due to political patronage enjoyed by the health workforce in several districts.

Sustainability

While there is widescale acceptance of digital interventions, the absence of dedicated government funding and in-house digital expertise compromises sustainability. Government typically budgets for extra vaccinators but not for implementing digital innovations, as development partners usually foot the bill. There is some progress as immunisation activities have been recently transitioned to the long-term recurrent budget, but budgeting for comprehensive digital innovations also needs to be reflected. A consolidation of applications rather than a proliferation of parallel ones that don’t ‘speak the same language’ is also required to have unified health workforce training and reporting. NGOs are cautious regarding Gavi funded scale up of digital innovations preferring home-grown applications overseen by the government. Government stakeholders, while in favour of digital technology for immunisation, feel that they do not sufficiently challenge donors with alternative strategies/ solutions.

Interoperable platforms such as UNICEF’s RapidPro (which can operate with DHIS2 as well as social media messaging platforms such as Facebook Messenger and WhatsApp) have shown potential and offer a sustainable approach – for instance, in 2018 RapidPro was used in reaching 37 million children in 163 districts through real-time information to increase demand for routine immunisation with an initial focus in poorly performing polio tier 1 districts.

5.2 Ethiopia Overview

The Ethiopian government has taken a strong lead in advancing digital health. It is one of the four pillars of their Health Sector Transformation Plan and is referred to as the ‘Information Revolution’. Central to this has been a radical shift from traditional methods of data utilisation to a systematic information management approach powered by a corresponding level of technology.

As seen from the Global Digital Health Index table, the government has focused on the enabling environment of digital health and has prioritised training of the health workforce, right down to community level. As some of the interventions below highlight, the government has also taken on strong ownership and involvement in vertical programmes with their sustainability and interoperability in mind. They have very much pushed digital advancements and insisted that donor plans are aligned to their overall vision and helping to ensure the interoperability of systems and sustainability of initiatives.

In August 2020, the MoH with support from the Gates Foundation and JSI’s Data Use Partnership, launched the Digital Health Innovation and Learning Centre (DHILC); a place where health professionals can design and validate digital health tools, synthesize and promote best practices, and scale-up innovations.48 JSI are very active in the digital health space, leading the USAID funded Digital Health Activity (DHA), a five-year project that supports Government deliver their Information Revolution Roadmap. JSI work with Dimagi, IntraHealth, Orbit Health, Simprints and Websprix to deliver this work.

41% of the population report to have some form of mobile phone49 and 11.2% reported to have a smartphone in 201850.

Example Interventions

Community Health Academy

Detail: Supporting the MoH to improve health worker training by deploying mobile phones equipped with high-quality digital content to frontline and community health workers. The Academy is developing a global blended learning curriculum for CHWs that can be easily adapted to local contexts. The curriculum will be offered as a public good for Ministries of Health worldwide to adapt and localize, and will be aligned to WHO guidelines, protocols and global standards for quality.

Scale: Started with health workers in Addis, now expanding to CHWs outside Addis and outside health centres. Recently requested to re-start HEW training and expand to 100 districts.

COVID-19 Digital Classroom

Implementer: Last Mile Health and partners including Medical Aid Films

Detail: Brings together global leaders in community health systems strengthening, training, content development and communication to provide high-quality digital health education content for community-based health workers. Uses national guidelines and has free airtime for health workers. Available offline too.

Scale: Also, in Liberia, Sierra Leone, Uganda & Malawi.

Supportive Supervision Implementer: Acasus eCHIS Implementer: Dimagi/CommCare with Federal Ministry of Health

Detail: Health facility independent monitors are given phones and trained so that they can monitor facilities on immunization data. This data is fed into a dashboard that is managed by Acasus and that is reported to Regional Health Bureaus as part of performance management.

Scale: Potential for scaling as indicators and locations can be quickly added, although hardware costs will add proportional cost.

Digital Health Activity Implementer: JSI with Dimagi, IntraHealth, Orbit Health, Simprints and Websprix to deliver this work.

Detail: USAID funded five-year project that supports Government deliver their Information Revolution Roadmap.

Detail: Electronic Community Health Information System. Using CommCare, the previous manual system was digitised. The app serves as a job aid for HEWs allowing them to review household and individual information, to respond more effectively. The app improves data quality and analytics and facilitates referrals. Currently includes RMNCH modules with malaria and TB to be added, and there are urban and pastoralist versions.

Scale: Implemented in 1,250 rural health posts. There are plans to scale up in all agrarian, pastoralist and urban health posts. Training planned for Master TOT, TOTs and end users.

Technological uptake

The Community Health Academy (CHA) work has been promoted through videos and social media influencers and as a result has attracted much more use than anticipated (more than 10k downloads of the app). Use of the app has extended beyond health workers, and it is seen as a potential launching pad for a culture change to widespread use of digital learning for health. There have been issues though: only 32% of users are female - most female rural health workers are unable to access the internet; only 6% completed all modules suggesting problems with compatibility and/or engagement; and nearly one third had issues with internet access when using. Learning from this, CHA has tweaked content (using more animations), marketing it more to women, focusing more on HEWs with RMNCH modules, as well as researching why learners drop off.

In 2016, a Johns Hopkins’ review of mobile technology reported on feedback from HEWs that power/electricity access was the main barrier in mHealth interventions, especially for those using smartphones, with shorter battery life.51

Governance

Acasus’s work enjoys good levels of government engagement, seeking to strengthen governance and accountability whilst building technological capacity. Acasus is responsible for training supervisors who are provided with tablets to monitor facilities. Incoming data is fed into a dashboard that is reported to Regional Health Bureaus to strengthen data quality, coverage and accountability. Engagement and leadership of government ensures good levels of accountability with government driving the need for interventions, ensuring interoperability between systems and using data/results which emerge.

Sustainability

The Ethiopian government has a high level of interest in and is taking ownership of the mainstreaming of digital health enabling good prospects for genuine sustainability. It will still require coordinated funding decisions to ensure that established effective interventions continue to receive the necessary support – with the Ethiopian government ideally taking on more funding responsibility over time.

Across the interventions reviewed, government has, critically, been involved right from the start. As a result of that, implementers also appear to be well connected, both directly with government but also between themselves. JSI, with the largest digital programme, appear to be the common thread that helps connect them together. LMH are part of this programme, helping to ensure compliance and interoperability between different interventions.

The work Acasus is doing sits somewhat outside this main circle of stakeholders. Capacity building is central to their work and they have a focus on sustainability, but it is too early in the process to assess how sustainable it will be in the longer term. There will need to be a gradual transfer of capacity to avoid the work needing to be taken on by the same/different donors at the end of each funding cycle.

A COVID-19 app developed by Last Mile Health/Community Health Academy had government involvement, linked to an existing partnership providing digital health modules on RMNCH. Much like the eCHIS app that uses the CommCare platform, this app is government-branded. It was launched using government-generated content based on the national guidelines and free air-time incentives. This is facilitated in the case of Ethiopia as government owns the telecoms.

5.3 Somalia

Overview

Somalia is a Federal country with several regions pushing for some measure of independence. Somaliland has already gained this in all but international recognition. Consequentially, the relationships between the regions are often competitive and can directly prevent cooperation in areas where it is needed, such as in sharing health data.

Nevertheless, Somalia offers some of the most technologically advanced and competitively priced telecommunications and internet services in the world. The numerous telecom companies provide collective coverage of every city, town and hamlet – far higher than neighbouring countries, including Ethiopia. 48% of the population report to have some form of mobile phone52, while three-fifths of the population are nomadic pastoralists or agropastoralists.

51 Mobile Technology in Support of Frontline Health Workers - A comprehensive overview of the landscape, knowledge gaps and future directions. Johns Hopkins University, 2016.

Decades of conflict and recent uprisings have taken a heavy toll and health systems remain extremely weak. It is also a crowded donor space with aid directed separately to Somalia and Somaliland as well as across both regions which also hampers coordination efforts. Key informant interviews with both Somaliland and Puntland ministries of health referred to weak coordination with and among development partners.

Pre-service training is the purview of teaching institutions (government or private), while inservice training and continuing professional development is provided mainly with the support of implementing partners, the main ones being Save the Children, World Vision, Care, Somali Red Crescent Society (SRCS) and UNICEF, who all have budgets to provide training. A point of feedback from providers reported by Puntland MoH was that the language of instruction and some materials were in English and were not well understood.

Depending on the topic, training might consist of classroom training (lectures, role plays) followed by 2-3 days practical training in hospitals, with training led by doctors or other experts. During COVID, for first time the Puntland MoH provided training – in nutrition and COVID-19 case management - online via a zoom call, training over 500 participants this way. They reported, however, not having the means to do any assessment of this training and a concern that delivering remote training might compromise quality as they are not able to check what people have understood.

Community level training is generally not at all harmonised, with different CHW curricula in use. Integrated Community Case Management (ICCM) is implemented but not well institutionalised. The new cadre of Female Health Workers (FHWs), however, is starting to become better institutionalised because of strong Gavi support and more recent World Bank support to continue. FHWs undergo a 3-months pre-training.

Within both Puntland and Somaliland MoHs, there was some general awareness but not much ownership of some of the ongoing donor funded interventions. While government respondents were not familiar with specific films that have been developed, they agreed that the medium of film, or pre-recorded lessons, was useful, especially on topics such as EPI, cold chain management and that it was important they should be in the Somali language. For EPI, 60-70% of workforce are young graduates and turnover is high. Puntland MoH reported skill gaps (injecting techniques, stock management, reporting) as well as missed opportunities, such as screening child outpatient visits for immunisation history or nutrition when they come for other reasons.

Example Interventions

Intervention Description

HNQIS Health Network Quality Improvement System

Implementer: PSI, through the SHINE programme

Detail: An electronic, tablet-based application used to improve quality of health services and monitor compliance to national guidelines. It covers 11 health areas, over four modules that support healthcare supervisors to: (1) plan supervision visits, (2) assess providers’ quality of care against clinical standards, (3) improve providers’ quality of care through tailored feedback, and (4) monitor quality

Scale:

PSI only operate in 3 regions within Jubaland, Puntland and Somaliland so their footprint is quite limited. All data are currently on a PSI server although plans in place with UNICEF and University of Oslo to adapt DHIS2 to support HNQIS. There is an opportunity to extend HQNIS to immunisation and to extend to private sector / urban immunisation strategy

ODK Detail: ODK is a free open-source suite of tools that allows data collection using Android mobile devices and data submission to an online server, without an internet connection or mobile carrier service at the time of data collection. In Somalia they have developed a COVID-19 application where contact tracing data from 4,000 healthcare workers (trained by the WHO) flows through ODK.

COVID –19 vaccine preparedness animation

Implementer: Medical Aid Films

Detail: Animation on vaccine preparedness https://vimeo.com/477496771/fc301276e9. Developed with LSHTM, World Vision and a panel of reviewers, now in Phase 3 – engaging with Ministries. Commissioned, as one of 12 films, by Digital Classroom, a group of mostly USbased e-learning organisations led by Last Mile Health. Already have successfully embedded animations into nursing and midwifery curricula in Somaliland.

Technological Uptake

Despite good mobile service provision in Somalia, supervision of any new technologies in health facilities is very challenging as it is hampered by time, distance, logistical and budget constraints. As part of the SHINE programme, PSI’s HNQIS supports the use of technology for quarterly joint E-supportive supervision. While this has helped District Medical Officers and implementing partners work together to improve facility performance, it has been rolled out to limited locations so far.

Medical Aid Films report an enthusiastic response to the blended curriculum for nurses and midwives that they have developed in partnership with the government of Somaliland. The subsequent COVID-19 animation is at final stages and reported to be well supported by MoH.

Somalia (and Somaliland) uses DHIS2 to track aggregate data, and DHIS2 Tracker for individual data in community or facility setting. The DHIS2 Tracker has been built to work seamlessly with DHIS2, and as part of that they have also deployed COVID-19 specific applications.

Governance

Federal versus regional autonomy inhibits smooth rollout of initiatives and delays decision making. The Somaliland MoH and to a lesser extent the Federal MoH are relatively well engaged and working with donors on, for example, DHIS2. However there is a lack of capacity for effective DP coordination.

The Puntland MoH reported four key areas in which they would like support:

Training for mid-level managers - while implementing partners train health workers, there is a lack of management training or mentoring for mid-level managers – the last time anything was provided was in 2015.

Database to harmonise training plans – it is “overwhelming” to monitor and keep track of what training is going on by implementing partners. MoH does not even have a database where they can track who is being trained and see any overlaps.

Skills analysis - to identify what competencies exist and where there are gaps

Supervision system – while there is a nominal supervision system, there is no mechanism to provide on the job training. The nurse in-charge at a facility is also the person, for example, administering injections and there is no one able to verify if she is doing this correctly or not.

The Puntland MoH is motivated to ensure quality of care and would like better ways to measure impact of training and have feedback on how services are being performed. Somaliland reported similar issues, with better systems to organise their HRH data a priority.

The sustained and recent worsening of conflict in the region hampers all activities.

Sustainability

HNQIS offer potential for digital assistance in quality monitoring and support, but the application is restricted by two factors: first it is only operating in 3 out of 18 regions, and second it holds data on PSI servers rather than a compatible application to the local DHIS2. The latter issue is currently being addressed with the help of the University of Oslo.

UNICEF are reported by various NGO implementers to resist any private sector involvement in immunisation.

5.4 Rwanda Overview

The Rwandan government has taken a strong lead on digital health and is involved in all initiatives, as it is with development work more generally. Through a Partnerships Unit they are able to convene, decide and communicate what the government wants to do and how.

Rwanda was one of the first countries to implement a national health information exchange (HIE) and whilst this was dormant for several years, the country is devising plans to revive certain aspects as part of the Healthcare Digital Transformation Strategy. The development of the HIE facilitated coordination of systems and reduced many silos, but the health information system still suffers from fragmentation, owing to a lack of data exchange standards and terminologies and uncertain funding for digital health initiatives. Recommendations that have been made include establishing a national health informatics society or association as well as restarting the eHealth technical working group, bringing donors, partners and government together to agree a common vision for digital health in Rwanda. A new Digital Health Department has been established - previously work involved both the Ministries of Health and ICT.

In 2019, the Ministry of Health (MOH) of Rwanda partnered with MEASURE Evaluation a project funded by USAID and PEPFAR to conduct an assessment of the interoperability and readiness of the country’s HMIS. With regards to technology Rwanda scored well. In 2020 Rwanda launched its Electronic Immunisation Registry (EIR) which will reduce costs and provide live data, improving efficiencies and decision making.

Rwanda has ambitions to create Africa’s first universal primary care service and become a world-leader in digital health. In February 2020, the government signed a 10 year contract with Babyl, a mobile based primary health care provider (known elsewhere as Babylon). Babyl launched in Rwanda with BMGF support, and within 18 months, by April 2018, had registered 30% of adults. The aim now is to roll out Babyl to all Rwandans over the age of 12 through the government’s community-based health insurance scheme, Mutuelle de Santé.

73% of the population currently report to have some form of mobile phone53 and 14.6% reported to have a smartphone54

It was a Rwandan software engineering firm who developed the RapidPro open source platform for UNICEF. Having already adapted UNICEF’s RapidSMS platform to create TextIT, they then went on to partner with UNICEF to develop what became RapidPro.

Example Interventions

Intervention Description

Babyl As set out above the aim is to provide primary health care appointments, prescriptions and booking lab tests via a mobile phone. Babyl has signed an agreement with RSSB, the largest national insurance company and patients can access their prescriptions and lab tests using their MUTUELLE and RSSB (ex RAMA) insurance cards.

Babyl’s AI chat-bot enables non-healthcare trained providers and triage nurses to improve diagnostic capabilities and signposting to appropriate care more cost effectively.

Mental Health Issues

Implementer: Viamo with Partners in Health, Ministry of Health/Rwanda Biomedical Center. Funding from Johnson & Johnson.

Detail: Remote training solution – via audio lessons focused on mental health. Collaboration with non-profit Partners in Health (PIH) to bring needed services to two districts in the Eastern Province and build a new generation of mental healthcare professionals by having psychiatric nurses from district hospitals train nurses in local health centres to diagnose and treat mental health. Delivered via a series of five-minute, pre-recorded voice calls on such topics.

Scale: 55,000 community health workers. Previously the government could only reach 25,000 workers, traveling from village to village for several years. Not only have patients seen improvement in their symptoms, but there has also been an economic impact - patients have missed fewer workdays, enabling them to better contribute to their families and communities. The platform had previously been used in the Ebola crisis and is now being used in the COVID pandemic (over 1 million messages sent) so there is big potential for scaling.

E-Heza Data Solutions

Implementer: TIP Global Health with Ministry of Health. Funding from Grand Challenges Canada, Izumi Foundation, Johnson & Johnson and Save the Children

Detail: Rwanda’s first point-of-care digital health record gives nurses and CHWs tools to adopt evidence-based clinical care protocols, provide high quality care and utilise real-time data trends to tailor health education and improve health care. Serves as an effective end-user interface that integrates with national databases such as OpenMRS and DHIS2 or serve as a stand-alone health record.

Technological uptake

Babyl shows the extent of technological uptake when solutions are perceived to have value. However, Babyl does not deliver preventive health care including immunisation.

53 www.datareportal.com, January 2020

54 Ministry of ICT, 2020 - Rwanda aims to collect 1M smartphones for poor families

Viamo’s IVR activities have been delivered at scale, more than doubling the number of CHWs previously reached.

Governance

The strong government interest and leadership ensure good levels of governance and country ownership. However, the top-down structure of government, with decision making power concentrated at senior level, can mean that progress on decisions / new innovations takes a long time.

Sustainability

Babyl would appear to be sustainable. The Viamo mental health pilot programme does not complete until 2023 and assuming continued positive results the aim is that it is scaled to other countries in sub-Saharan Africa. Now that the platform is in place, the Rwandan government will be able to use it for other kinds of remote healthcare training. It is not clear, however, if this would require continued input from Viamo and funding from external sources / donors.

The E-Heza project has strong elements of sustainability and scalability hard wired into their approach as they are working directly with the Rwanda MoH to integrate into their national datareporting systems (DHIS2 and OpenMRS) while adding additional functions to the product. The aim is to bring E-Heza to all health centres and CHWs in Rwanda by 2021 and all of East Africa by 2023. While externally funded, critical to the success and long-term sustainability has been the Rwandan government investing people and time and being central to its development.

5.5 DRC Overview

Historically, digital health has been very fragmented, built organically, without coordination or leadership. To address this, the MoH is proposing the establishment of a decentralised public agency, Agence Nationale d’Ingénierie Clinique, de l’Information et d’Informatique de Santé (ANICiiS) to consolidate and drive forward all things related to digital health, health informatics and mHealth.

The Government of the new elected President is committed to improve immunisation coverage across the country. A comprehensive plan called Mashako (the country’s Emergency Plan for the Revitalisation of Routine Immunisation) was adopted in 2019, which is being used as a coordination platform and tool for mobilising additional support to immunisation. Digitalisation of all sectors, including health is now government policy. The recently created Digital Agency is the main institutional driver in this area. 40% of the population report to have some form of mobile phone55 (phone sharing also common). There is no reliable data on smart phone penetration.

Example Interventions

Intervention Description

‘Audio job aides’ and ‘Remote mobile based health worker training’

Implementer: Viamo working with IMA (UK funded) in Kinshasa and with Village Reach to reach 15,000 in 9 provinces (US funded)

Detail: 1. Audio job aides, uses IVR – 2-3 minute recordings on topics. Works by a “pull” mechanism, available on demand. Users dial a short code (42502) and hear message.

Appli Gestion PEV RD and Outil Suivi PEV RDC

2. Remote training - 8 module training on COVID; 5-6 minute recordings with 1 minute quiz at end. These are “pushed” to health workers. Village Reach collects mobile numbers of health workers.

Scale: 1. Audio job aides - up to 10 messages a month are free to Vodacom users, 11th message onwards charged at reduced rate.

2. Remote training - calls are free of cost to recipient (paid by external funder, negotiated contract with mobile operator including a PPP transition plan designed to make possible the continuation of the scheme under domestic funding (although unlikely to happen in DRC).

Implementer: Acasus with in partnership with Immunisation Academy with funding from Gavi, BMGF, UNICEF.

Detail: 1. Appli Gestion PEV RD was developed as part of the support provided by Gavi to the MASHAKO Plan. Tool to be used by the supervisors of EPI activities at Health Zone level.

2. Outil Suivi PEV RDC is a micro-planification tool developed by GRID3 (GeoReferenced Infrastructure and Demographic Data for Development) which provides maps with the estimated number of people to be vaccinated per village. Vaccinators can also use it for reporting their activities. The combination of these two elements will enable a real time situation of the immunisation coverage per antigen.

3. Immunisation Academy (IA) App has 52 videos that will be forwarded to vaccinators (one per week for one year). Each video is 5 mins + quiz (5 questions). Internet is needed to download the videos, but they can be seen offline. IA App is free of charge and the project provides the smartphones.

Scale: The interventions are planned to be scaled up to the whole country. Started in 3 provinces in 2019; 21 provinces are currently covered; all 26 provinces should be covered by the end of January 2021.

There are various other interventions funded, mainly by the US Government (under PEPFAR, M-RITE and Digital Square) and the BMGF implemented by PATH.

Technological uptake

Interactive Voice Response (IVR) is simple and easy to use. There is a low pick up rate for “push” calls can be as low as 30-40% in DRC but where supervisors have really got behind the training, response rates rose to 70%, showing its potential. Although calls free, the user needs to have credit on the phone to receive calls.

With the Appli Gestion PEV RDC intervention, supervisors receive a smartphone + SIM with data and enter data (offline) and send these through the system (health zone ->province>central level) when they are Internet connected. The data are managed centrally and used to populate an EPI Dashboard.

There is good ownership of regular mobile phones and reasonable 2G coverage although internet access is still an issue in rural areas. CHWs do not all have a smartphone, so they usually rely on devices provided by the projects. One major constraint is that per diems tend to represent a significant part of the health workers’ incomes so it is a difficult cultural change to move from face-to-face training.

Governance

DRC is a huge country with a lack of staff at all levels of the health care system. Dealing with EPI at the central level is not enough as health programmes, including immunisation programmes, are increasingly managed at the provincial level (where technical and managerial capacities are very limited). Due to a somewhat dysfunctional but centralised system, some delays were reported in obtaining approvals as provinces imposed their own requirements.

Sustainability

The initiatives largely rely on external funding and their scalability mostly depends on the will and capacity of the funding and implementing organisations to expand or continue support. These initiatives are driven and funded by donors and external implementers so scalability and sustainability in terms of government ownership and funding are not really achievable in a context like DRC at the current time.

5.6 Senegal Overview

Senegal currently appears well placed to make the most out of digital health developments. It has a Strategic Digital Health Plan (PSSD) 2018-2023 in place, the aim of which is to drive and promote access to quality care, promote prevention and management of health risk.

In addition to this, the capacity, leadership and willingness of the EPI team in particular present an opportunity for the development of training and capacity programmes of vaccinators which fit with the actual needs and gaps.

Access to mobile phones is good with ownership equivalent to 109% of the population (suggesting some people have more than one) 56 and 34% reported to have a smartphone in 2018 57

Example Interventions

Intervention Description

Coach2PEV and VacciForm

Implementer:

Ganeshaid (as part of their Gavi HSS Grant to Senegal)

Detail: Coach2PEV is a digital solution to measure EPI Performance Indicators and coaching immunisation workforce performance.

The tool can be used for several purposes: Collect data for surveys, E-supervision (Performance coaching function), training (VacciForm), a community of practices

Scale: Currently being piloted (2018-2020) in some health districts, it should be scaled up during the next phase (2021-2022). Designed to be easily expanded: other countries (Benin in 2021) and other essential health programmes

Informed

Push Model (IPM) or Yeksi-Naa (“I arrived” in the Wolof language)

Government of Senegal: Ministère de la Santé et de l’Action Sociale (MSAS)Ministry of Health / Pharmacie Nationale d’Approvisionnement (PNA) - National Supply Pharmacy

Implementer: IntraHealth International, Dimagi

Detail: Informs a push model of supply chain management in targeted health facilities, focusing on reducing contraceptive stockouts. A promising pilot led to a three-year expansion of IPM to all public health facilities nationwide.

56 www.datareportal.com, January 2020

57 2017, Basic mobile phones more common than smartphones in sub-Saharan Africa | Pew Research Center

The system is tracking real-time facility-level data and making them available through a series of costumed dashboards at the district, regional, and national levels allowing for improved supply forecasting.

Scale: Nearly 1,400 facilities. Extended to 118 essential drugs. Delivers more than 100 essential health products to facilities and reduced contraceptive stockouts to an average of 2 percent across all health facilities, improving access to family planning for an estimated 3.2 million women.

There have also been a number of other solutions aimed at training health staff have been developed and tested by a range of implementing partners - AMREF (‘Cellal e Kisal’, ‘PRECIS’ and ‘JIBU’) and RAES.

Sustainability

The GaneshAid Coach2PEV work was developed with government (the MoH IT Department) and is relatively low cost (≈158K$, 2018-2020) – indicating good potential to be both sustainable and scalable. It is embedded into the domestic systems with planned migration to the country MoH server; capacity building for national leadership; and linkages with training institutions. Outcomes of the pilot phase should provide useful lessons for the development of similar interventions, taking advantage of the improving connectivity and the appetite of the Senegalese population for new technologies. There is currently an evaluation of the pilot currently being conducted (February 2021) and will results will be available in due course.

The IPM / Yeksi-Naa programme developed by Dimagi and IntraHealth in close collaboration with MoH and National Supply Pharmacy, whilst not targeted at the direct learning and performance management of health workers, is a good example of government ownership and input into a successful nationwide intervention (that has been scaled over time) working with private and NGO partners. It also uses Dimagi’s CommCare platform.

However, whilst these interventions show the potential of what is possible, many others appear to face limitations and constraints:

Lack of support from the Government making digital solutions not really sustainable (in the sense they will still be dependent on external funding at least) even when they are aligned to national strategies.

Financial barriers to end-users – training is now always free to end-users.

Internet access is still an issue in rural areas (even 2G is not available everywhere). Limited engagement and support from mobile operators (which would help with cost and accessibility)

5.7 Indonesia Overview

Indonesia enacted the National eHealth Strategy in 2017. Despite this, and the fact that in recent years the telehealth and telemedicine industry has expanded in Indonesia, the use of digital innovation for the training and performance needs of its health workforce has not been maximised. Given its unique geographical composition, with numerous remote islands, and its large population size, further use of technology could add real value as the country transitions out of Gavi support. With its high levels of mobile connectivity, infrastructure and exposure to technology, it is well placed to do this, with mobile phone ownership equivalent to 124% of the population and 31.1% reported to have a smartphone in 2019. As detailed below, a number of interoperable global goods are already being used in Indonesia and that, along with consolidated government leadership, mean that it is well placed to take advantage of the benefits of digital.

COVID-19 has served as a catalyst in accelerating digital solutions and effective collaboration to deliver them. UNICEF has been central to this with three members of staff embedded in the MoH for the last year working on a range of digital communications and training focused on dispelling myths and ensuring health workers are appropriately trained in providing the vaccine – all with strong government leadership.

The WHO South East Asia Regional Office (SEARO) has identified some important lessons via feedback from the early introduction of the COVID-19 vaccine in Indonesia. First, the large-scale cascaded training and dry runs seem to have been key for logistical preparation and community confidence-building; and second, the innovative digital platforms used were adapted by the Government from existing platforms already used in country (e.g. Gavi-supported eVIN platform).’

Interventions

Community Health Toolkit (Medic Mobile)

The Community Health Toolkit has been deployed in one district health office in the Timor Tengah Selatan District and the Universitas Indonesia’s School of Medicine on an antenatal care coordination and gestational diabetes management project. Health care workers use the platform to manage the screening of gestational diabetes during pregnancy and after delivery, refer women with gestational diabetes for follow-up, and report on birth outcomes and gestational diabetes post-delivery.

CommCare (Dimagi)

The Commcare platform has been deployed in Indonesia for some time. In 2014 World Vision, in cooperation with the MoH, used CommCare to develop an application integrated with an existing application, MOTECH Suite, for Integrated Health Posts (Posyandu) service and monitoring. This app meant that Posyandu staff were no longer required to write children’s health scores down manually in a book (which was regarded as a waste of time since nothing was done with this data) but instead, using a smartphone, they sent this data directly to midwives - their supervisors - through the online application who could download and analyse the data.

A number of key stakeholders were involved (MoH; Smart City; Institute of Development Studies UK; Dimagi; Grameen Foundation; Woman Welfare Association) and funding was provided by World Vision Canada and Indonesia as well as HSBC Bank. The programme ran from April 2013 - December 2017 and involved 220 Community Health Workers and Health Facility Workers and reached 11,300 children under 5. An evaluation concluded that cadres who used the mobile phones were more likely to provide feedback, accelerate the procedure of nutrition data collection, and improve data accuracy by 80%. Despite this success it is not clear if this programme continued once this phase came to an end.

RapidPro

UNICEF has led a mobile health pilot aimed at boosting immunisation in urban Java utilising the RapidPro open source platform. A key principle underpinning RapidPro is that it both complements and integrates with national health systems – improving efficiency and ensuring both sustainability and country ownership. For instance, many of the digital health interventions powered by RapidPro have been linked into foundational digital health systems such as the DHIS2 and OpenMRS, resulting in easy user experiences for governments and reducing duplication and costs.

For this pilot, local health workers go door-to-door to register newborns. Following that, automated reminders are sent to parents and guardians about upcoming vaccinations at local health posts (Posyandu). A separate feature allows health workers to record when vaccine stocks dip, permitting real-time monitoring of coverage by Government officials. Two years after the intervention’s launch, progress has been strong: nearly 3000 infants have been reached, and the programme has spread from Jakarta into dozens of urban districts in the neighbouring provinces of East and Central Java. All enrolled health facilities have provided monthly updates on the stock levels of each of the six vaccines monitored in the intervention.

Using the RapidPro platform, UNICEF has also been working closely with the Ministry of Health team for a national assessment of cold chain for COVID-19 vaccine distribution. It has also been used by health workers to feedback on their experience of training (60,000 trained) and ask about their experiences of the vaccine. About 10% of those trained (mainly nurses) have actively used it and the experience has been considered very positive and useful both for the health workers as well as policy makers and programme managers.

OpenSRP

OpenSRP is an open-source mobile health platform that allows frontline healthcare workers to electronically register and track the health of their entire client population. It also provides programme managers and policy makers with data for decision-making. The COVID-19 track and trace application of OpenSRP is currently being tested and deployed in Indonesia with 200 healthcare workers but is too early for any results.

Viamo

Viamo has been working with UNICEF Indonesia to develop an interactive voice response (IVR) mobile technology intervention to support the remote capacity building of 4,981 health workers on COVID-19 prevention and response in Papua and West. Viamo delivered three training curricula comprising 17 modules, on: Risk, Communication, and Community Engagement (RCCE); Infection, Prevention, and Control (IPC); and Safe Health Facilities. It was delivered in Papuan native language with calls lasting up to a maximum of 5 minutes. Included were preand post-tests were conducted to see the increased knowledge. The results data along with quiz results, metadata, number of calls, and completed lessons, were made available to UNICEF and partners via a hyperlink that enables the results to be downloaded as a CSV file for further analysis.

5.8 Summary

All the countries assessed are embracing digital health in some form and are developing capacity within government to better coordinate digital health activities going forward.

It is clear that while some interventions have been adopted at scale, others are more stand alone, relatively small scale, in isolated geographical areas, with no clear route to sustainability. It seems to be common for even the most effective and popular interventions to struggle in terms of sustainability once donor support comes to an end with no plan in place for the longer term. In countries such as Ethiopia and Rwanda where the government takes a strong lead in setting the agenda of what they want (formalising this through plans and strategies) and coordinating partners accordingly, the risk of this happening is far less.

The challenge appears to be three-fold: firstly, there might be no overall landscape analysis at a country level of what is needed; secondly, there is often a lack of coordination in ensuring the alignment of initiatives that do show potential when scaling up; and thirdly, it is rare for initiatives to have a longer term sustainability plan in place. In some settings, such as Somalia, the lack of coordination mechanism between development partners becomes an aid effectiveness issue.

Many interventions by their nature are innovative and dynamic and it is important that the creative space to be able to do this in a responsive and timely manner is not squashed. Responding urgently to a crisis such as COVID requires swift action and thorough analysis and gaining buy-in from multiple stakeholders might be unrealistic.

Nevertheless, donors and implementing partners have an important role to play in helping ensure solutions align as far as possible to a coherent national plan - particularly in settings where capacity and digital maturity is less advanced. This means ensuring an aligned approach, investing in interoperable systems and ensuring that new innovations are compatible with the existing digital infrastructure.

There are a number of more commonly used ‘global goods’ that exist that have received significant and sustained funding from USAID, BMGF, Gavi and the Rockefeller Foundation. The likes of Dimagi’s CommCare, Medic Mobile’s Community Health Toolkit, OPENSRP, DHIS2 Tracker have become widely used open source platforms, offer good levels of interoperability and are easily adapted to various needs and situations – such as responding to COVID quickly.

If countries are able to reach the point where their national HMIS systems are built on platforms stemming from such global goods, it reinforces an expectation that any new intervention, by default, must seamlessly integrate also. Ethiopia and Rwanda, with their strong leadership and drive on harnessing digital technology, are good examples. Interventions such E-Heza Data Solutions in Rwanda and the eCHIS in Ethiopia are interoperable with DHIS2 and OpenMRS.

While there is limited evidence of initiatives being taken on and funded by government, there has been progress and it is now more common for interventions to be taken on by other donors when one funding cycle ends, so at least the intervention (if successful) continues. Critically, as examples in Ethiopia (COVID app) and Senegal (GaneshAid) have shown, governments increasingly progress to running interventions using their own systems, on their own servers, even if not yet fully funding it.

As countries increasingly develop national digital health strategies with associated costed plans, budgets should help to streamline funding for a core set of digital tools. As tools are rationalised, funding these tools could be more easily distributed across donors and increasing levels of support from country governments with the aim of full ownership and funding over time. The leap to full country funding is unlikely in most circumstances and some recurrent funding is needed. The speed at which digitalisation is progressing is significantly faster than that of progress on health systems strengthening, so limitations on digital rollout will become increasingly related to health systems weaknesses.

Considerations and feasibility in fragile and very low resources settings

When it comes to frontline health workers’ performance management needs, fragile and extremely low-income countries are not considerably different from the rest of the Gavi eligible countries. As in most LMICs, both the number and distribution of properly trained health staffs are inadequate. The initial training received is usually of poor quality, working conditions are difficult (they have an important workload, operate in highly dysfunctional facilities as a result of weak health systems, receive minimal wages and sometimes need to dedicate part of their time doing a second job) and they often benefit from no or limited supervision and support. Also, many global platforms and open source digital tools cover and/or are used in fragile states, both in Africa and Asia. And the constraints and challenges training and performance management interventions face in fragile settings are not really different from those observed in more stable countries or at least in most of the rural or remote areas in these countries.

The difference between these settings and the better off and/or more stable ones is thus not a difference of nature, it is a difference in degree. The needs, constraints and challenges tend to be exacerbated: capacity gaps are deeper, health systems are even more dysfunctional or sometimes just non-existent, connectivity is more limited, health workers are more unlikely to be equipped with a smartphone, supervisions are more irregularly carried out. Despite this overall similarity, settings in fragile settings may face additional difficulties, such as threats put on the health works in case of conflicts, extreme isolation when communications are affected by insecurity issues or when there is no road, outbreaks affecting mostly vulnerable populations (Cholera, Ebola, etc.), the presence of displaced populations who put an additional pressure on the health care delivery system, live in precarious housing or in camps and sometimes do not speak the same language. All these factors must be taken into account when designing training interventions.

Due to these possible specificities and the higher degree of constraints health care workers face in fragile settings, the balance between traditional face-to-face training and remote training options, namely through digital solutions, has to be reconsidered with more emphasis put on the remote approaches (using solutions that work with limited or no connectivity, no or minimal support from the peer and/or the supervisors). To be effective, digital solutions need to favour the simplest options, to be designed for trainees with sub-standard background and sporadic availability, to match with the languages used by the target populations.

Ideally, the content itself of the training should also be tailored in a way it provides the health workers the capacity to operate in their specific and unfavourable environment. Examples of factors that need to be reflected in the curriculum include: the special difficulties of the logistics (SCM, cold chain, power supply, etc), simplified schemes for collecting data and reporting and adequate support and supervision modalities.

The Figure below sets out the sort of interventions that could be appropriate based on the country context and maturity of digital health infrastructure. It is purely indicative and should not be treated as prescriptive.

Classified as Internal

An indicative summary of what works where: