AfyaCheck_mHealth Deck

A Mobile Health Application for the New MA-CHW Cadre in Tanzania

Initiatives mHealth Consulting GroupCaitlin Gillespie, Lauren Hodsdon, Sarah Jacobson,

Paola Peynetti, Natalie SanfratelloInitiatives Liaison: Rebecca Furth

Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions

Slide deck purpose: Product, impact, why now?1. To present and explain the logic, processes, and prototype of 2. To outline the impact that can have on policy-making, supervision, patient

satisfaction, and MA-CHWs quality care.3. To provide the context and evidence that drive the Tanzanian government the

opportunity to be a leader in the implementation of a comprehensive mHealth tool for frontline health workers.

PRODUCT:

Application

IMPACT: Standardized, Quality Care & Performance

Feedback

WHY NOW?An Opportunity for

Tanzanian leadership in

mHealth


Identifying the problem: No standardization of mHealth

Current rural health system relies heavily on voluntary Medical Attendant Community Health Workers (MA-CHWs). Government has begun transitioning

to hiring and training MA-CHWs as paid state employees.

Primary Problem:Lack of coordination of MA-CHW performance,

no standardized monitoring or feedback

system.

Secondary Problem:Current mHealth context is diverse & widespread, but

not collaborative or comprehensive


A comprehensive mobile health application for MA-CHW home visits


New MA-CHW program: A response to a disjointed system

A single, national, cadre of MA-CHWs:● to standardize care, ● ensure sustainability, and ● promote community health

Which includes:● Standardized training● Salary - half minimum gov’t wage● Supplies - transport, health kit, & a job

aid ● 1 MA-CHW per 25 people after

program completes (34)

To establish: ● Appropriate supervision and support

systems, ● Incentive structures, and ● Linkages between health facilities and

health management information systems (HMIS)


Involves MA-CHWs,supervisors, patients, & government

MA-CHW receives patient visit list from local clinic via SMS

MA-CHW takes phone to home visits

MA-CHW registers patient if unregistered

MA-CHW completes necessary modules

eg. ART Adherence Counseling

MA-CHW Uploads data once a week

Supervisor reviews data on patients and MA-CHW performance

Supervisor provides feedback to MA-CHW via SMS or in person

Supervisor uploads data to Tanzanian government monthly

Tanzanian Government uses data to inform policy & practice

START

END


The logic behind


: A checklist to improve quality of care

Objectives:

● To provide a streamlined checklist for MA-CHW home visits that is: ○ For all components of Tanzanian MA-CHW visit SOP ○ Interactive and collects patient data ○ Able to flag and prioritize patients

● To improve and standardize quality of care to provide comprehensive quality services.


will address all components of MA-CHW visit (34)

Reproductive Health & Family

Planning

NutritionHealthy Behaviors

& Disease Prevention

Linkages to the Health System

HIV Counseling

Prototype addresses:ART Counseling


The logic behind

ART counseling module prototype


ART counseling module prototype: A checklist to improve ART adherence & provide referrals

ART Counseling module: Situated within larger application of all MA-CHW visit components to showcase application use:

○ Reference tool for MA-CHW professional development ○ Ensure data captured is high quality○ Feedback & data analysis for MA-CHW supervisors○ Decision-making support at all levels

● User Guide in Annex


: A reference tool for quality care

Promotes decision-making skills and

prioritization of patients according to immediate

need


Overview of patient case load and needs -

case management

Recording tool of visits completed and needed

to complete

application will ensure high quality data

Through Data Control:● Display and validation logic ● Case management ● Monitoring data


Sample dashboards: improved quality care

CLINIC SUPERVISOR DASHBOARD NATIONAL STAKEHOLDER DASHBOARD

# Patients Reporting ART Stockouts

% Patient Visits within 30 Days of Previous Visit


a. Data: Visit data collected and aggregated in background on■ MA-CHW performance data (supervisor sees MA-CHWs as cases)■ Patient consultation data (confidentiality)

b. Supervision: Quality care and performance feedbackc. Patients:

■ Empowers patients to feel informed and provide feedback ■ Facilitates Confidentiality

: Feedback mechanisms between supervisors,MA-CHWs, & patients


● Data collected will support decision-making at different levels of Tanzanian MOHSW:○ National, regional, district health offices and MA-CHW supervisors

● See suggested dashboard in IMPACT section.

The Tanzanian MOHSW● Pharmaceutical Forecasting ● Rural Epidemiology● Demographic and Population Data● Rural Health System Performance

Clinic Levels● MA-CHW Quality of Care● MA-CHW Visit Timelines● Clinic Level Stock Outs● Patients with Access to Health Care● Clinic Referrals

Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV The Time Is Now

: Decision-making support at all levels

Scale-up & sustainability of

● Increase Quality of MA-CHW performance and care

● Measurements:○ # of MA-CHWs ○ % of Population

Coverage

● National eHealth Strategy

● Limitations: Cell Coverage and Data Transfer availability

● Strengths: Many mHealth programs already implemented, pilots provide solutions to potential local problems

● CHW job aids are proven effective

● Existing CHW mHealth pilots are effective

● Existing approval of CHWs in communities will bridge any cultural diversities

Parameters Scientific Basis Environmental Context


IMPACT:mHealth can bridge delivery gaps

1. CHWs2. DATA 3. SUPERVISION4. PATIENTS5. COSTS


● Professional development ● Empowerment and Motivation● Prioritize cases: access data● Health system integration (26)● Standardize care

● M&E of performance● Transparent case mgmt● Communication ● Feedback and reporting

● Data-driven policy & programs● Resource allocation● Data analysis● Adherence to standards

● Confidentiality of information● Lower stigma● SMS decision-making support● Referral systems

DATA

PATIENTS

MA-CHWs (27,36)

SUPERVISORS


can bridge service delivery gaps

CHWs: employs best practices to improve motivation & standard of care

Low motivation of CHWs may decrease benefits of investments in CHW

programs (9,27).

Mobile tools help CHWs improve quality of care, efficiency of services,

and capacity of program monitoring (3,27)

mHealth gives CHWs new skills, increases

motivation, and improves community perceptions of CHWs

(12,27,28)


DATA: im supports data-driven policy-making, program management, & resource allocation“Programmatic efforts to strengthen service delivery focus on improving

adherence to standards and guideline. Mobile tools help CHWs

to improve the quality of care provided, efficiency of services, and capacity for program monitoring” (3).

CHWs use mHealth for collecting field-based health data, receiving

alerts, facilitating health education sessions,

and communication (1)

Review of 25 studies concluded: data

collection is one of the main functions

performed by frontline health

workers (1)


SUPERVISION: facilitates supervision and feedback mechanismsIn Tanzania, the benefits of

mHealth will be limited without addressing the

current “one-way upward flow of information” (14)

A supervision process to monitor, improve and maintain clinical skill

performance by CHWs is important in program

design and implementation to obtain

health outcomes (34)

mHealth facilitates supervision through regular and prompt

communication across different levels of

providers and easy assessment of the CHW

performance through the web-interface

dashboard (1)


PATIENTS: informs & empowers patients and increases confidentiality

“Regular access to health information via SMS or mobile-based decision-making support systems

may improve the adherence of the FHWs to treatment

algorithms” (1).

Common barriers to care in Tanzania: long distances to facilities, inappropriate care,

limited decision-making power, low financial

resources, stigma (12)

inSCALE App in Mozambique: phone-based job aid to help

CHWs with consultation steps to assess,

diagnose, treat and refer patients (25)


COSTS: = A high-impact investment

Financially sustainable mHealth programs need to transfer SMS costs to users (with lower costs negotiated through telecom partners) (15)

Investments in CHWs (1)1) Requirement for achieving UHC2) Results in positive return, as high as 10:13) Scale up has short and long-term savings4) Yields further societal benefits: women

empowerment, reduced patient costs, data collection, additional service delivery

Investments in mHealth (5,6,7,10,19,21,33):1) $100 per phone - Huawei Ascend Y 5112) Less than $5 per month for airtime*3) Dimagi Additional Implementation Package

OptionGrowth Package - $80,000

*Cheka Bombastik Plan on Vodacom: 125 minutes, 1000 SMS, 100MB Data per month


https://www.commcarehq.org/pricing/


Why should Tanzania use with the new MA-CHW cadre?

1. Global context: CHWs matter

2. Local context: current Tanzanian mHealth context needs better approach

3. HIV Public health context: MA-CHWs transform HIV/ART care


Global context: CHWs have great potential with proper support


CHWs are indispensable for the SDGs, for UHC, & for access to care in rural areas

“Volunteer CHWs have been with us over many decades and many programs owe their success to these poorly trained and equipped, least supported and unpaid volunteer workforce. They are the unsung heroes of our success whom we have been taking for granted for many years” (23)

- Tanzanian Deputy Minister of Health

“Community health is foundational to attaining many of the SDGs” (30)

115 of the 313 tasks that are essential for HIV prevention and treatment can be performed by CHWs (30)

In developing countries, frontline workers represent the main way most citizens access health services (8,35)


Gaps in CHW training = Gaps in serviceHow mHealth can bridge gaps & improve quality of care

1.

Dynamic, easily customizable platforms

Standardized quality of service delivery + M&E tools

Portable devices: job aids for in-service practice

Mobile platforms for communication & coordination

Mobile toolkit for improved quality of service

Lack of adaptation of training to support local languages (23)

Inconsistent delivery methods and M&E practices(11)

Failure to train where CHWs practice (23)

Lack of coordination with other health providers (25)

Gap in curricula: lack of emphasis on communication skills (23)


Incorporating interactive methods

Repetitive interventions

Case-based training

Blended training (integrating technology)

Emphasizing communication skills

Improve M&E through incorporating consistent CHW feedback and transparent evaluation


Digital health can improve MA-CHWs in-practice training (2)

Lessons from CHW apps: Feedback is crucial

CommCare Escalating Reminders: SMS reminders and supervisor feedback to CHW to reduce overdue days of patient visits. Improved the timeliness of CHW-patient visits by 86% reduction in number of days an appointment was overdue, decreased from 9.7 days late to 1.4 days. When there was no feedback to the supervisor, CHW performance decreased significantly. (34)

Monitoring of performance and feedback are key in application development


Local context:mHealth in Tanzania should be collaborative

CHWs are “unsung heroes of our success whom we have been taking for granted for many years”

Tanzanian Deputy MoH


Four large MNOs, but systems are marginal

and operate below capacity(24)

Mobile Access

64% people have access to a cell phone

31.9 million mobile users(4)

Policy

National eHealth Strategy for 2012-2018 prioritizes professional development for health care workers through

mHealth(17)

mHealth

Lack of collaboration & cohesion

mHealth projects in Tanzania are often

pilots


Setting the scene: Mobile Access, mHealth, policy

Current mHealth projects in Tanzania are diverse & disjointed, not collaborative or comprehensive.

Examples: ● Mobile for Reproductive Health (m4RH): a national text-message (SMS) based health

communication service in Tanzania and Kenya that provides “simple, accurate and globally relevant information on reproductive health”. Award winning, deployed + created by FHI 360 (15).

● Management Information System (MIS) for control of Neglected Tropical Diseases (NTD): was and mHealth system piloted where village health workers were given mobile phones with web-based software to capture health data (14).

● D-Tree Safer Deliveries in Zanzibar: A collaboration between D-Tree, Tanzania Ministry of Health, JHPIEGO, and Gates Foundation to equip traditional birth attendants and MA-CHWs to register and screen pregnant/postpartum women and newborns (31)


HIV Public health context: MA-CHWs transform HIV/ART care


CHWs play a critical role in community care of PLHIV

The biggest obstacle to scaling up ART care in Sub-Saharan Africa is the lack of qualified human resources for health (10)

MA-CHWs can help fix this problem through task-shifting to community-level care

● CHWs in Zambia are shown to provide adherence counseling of equal quality to clinic counselors, with significantly less loss to follow up rates (29)

● After CHWs in Haiti were trained on HIV care, households in the intervention area increased uptake of ART and attendance at primary health care (18)


MA-CHWs can alleviate HIV Burden in Tanzania

HIV prevalence among adults in Tanzania in 2014 was 5.34% which is estimated at 1,499,400 people living with HIV/AIDS (4).

140,000 of PLHIV are children

There are only 0.03 physicians per 1,000 population (4).

Literacy: 70.6 percent of total population (75.9% M, 65.4% female) over the age of 15 can read and write Swahili, English, or Arabic (4).


MA-CHWs improve ART adherence in Tanzania● Having low perceived quality of patient-provider interaction and missing a clinic

appointment was associated with poor adherence (32). ● A study of HIV+ mothers found their motivation to take ART decreased after birth and

having prevented MTCT (21). ● Among children, poor adherence was predicted by living with a non-parent caretaker

(22).● Improving adherence counseling in clinic settings may effectively improve adherence to

ART (16). ● Mobile phone text message reminders are recommended to improve ART adherence

(13).


The time to lead is now The opportunity is NOW


The time to lead is NOWStep up as a regional leader

in mHealth standards, regulation, and systems integration

➔ Quality of close-to-community care over quantity of mHealth projects

➔ Improve the country’s community health information databases.

➔ Take ownership over the nationwide mHealth program


The opportunity is NOW

A well-developed, comprehensive smart mHealth project will have significant impact on MA-CHW performance in Tanzania and on health issues like ART adherence and ensure evidence-based, sustainable, data driven programs that empower local communities and make use of the best technology and innovation models.


Contact InformationBoston University School of Public Health

Caitlin Gillespie MPH May ‘16 [email protected] Hodsdon MPH May ‘16 [email protected] Jacobson, MSW MPH May ‘16 [email protected] Paola Peynetti V. MPH Jan ‘17 [email protected] Sanfratello MPH May ‘16 [email protected]

James Wolff (Faculty) MD, MPH [email protected]

Initiatives IncRebecca Furth Ph.D. [email protected]

mailto:[email protected]

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https://www.vodacom.co.tz/productsandservices/prepaid/cheka_bombastik

Annex I: User guide

Annex II - Dimagi Costing Tool

Dimagi Costing Tool

If link is inactive, can be found at: https://confluence.dimagi.com/download/attachments/14549044/Dimagi%20-%20CommCare%20-%20TCO_v5-cp.xlsx?version=1&modificationDate=1370536055234&api=v2

https://confluence.dimagi.com/download/attachments/14549044/Dimagi%20-%20CommCare%20-%20TCO_v5-cp.xlsx?version=1&modificationDate=1370536055234&api=v2

https://confluence.dimagi.com/download/attachments/14549044/Dimagi%20-%20CommCare%20-%20TCO_v5-cp.xlsx?version=1&modificationDate=1370536055234&api=v2

Documents

AfyaCheck_mHealth Deck