Increasing medicine availability and safety in Senegal through digital platforms

In sub-Saharan Africa, prescription drug costs are high and health coverage is low. JokkoSanté’s innovative digital payments platform optimises medicine use and access through a system for sharing and cross-financing drugs that amplifies household medicine chests to community chests.

 

 

What do you do with unused medicines in your house? After feeling better and discontinuing treatment, many households in Africa retain unused prescription medicines for future use. Accumulation of medicines in these “home chests” creates risk of improper or accidental use as several developing nations have no clear policies or guidelines regarding the safe disposal of unused medicines in the home. A Senegalese entrepreneur saw opportunity in these home chests towards making medicines more affordable for achievement of universal health coverage.

 

In the Senegalese language of Wolof, Jokkolante means exchange or to give and receive. This became the inspiration behind JokkoSanté, an innovative health financing platform that allows members to purchase medicines with points accumulated on an account linked to their mobile phones. Members accrue points on JokkoSanté by donating unused medicine which are then redeemed at the purchasing of new medicines at a discounted price.

 

Instead of keeping unused (and not expired) medicines at home, members of JokkoSanté drop them off at affiliated medical facilities and pharmacies where they receive points on their mobile phone equivalent to the financial value of the medicines they donate.

 

Through cross-financing, JokkoSanté members can directly purchase points for themselves or for family members. This helps to ensure that money intended for health purposes is not misused and that medicines are obtained from licensed facilities avoiding fake drugs from informal street vendors.

 

In 2015, JokkoSanté first conducted a pilot in a rural community in Senegal. Within a year the platform had registered 750 members covering 600 households and securing the support of Senegal’s largest telecommunications company.

 

“We welcome technologic innovations such as JokkoSanté and thank CSR efforts such as the one by Sonatel,” said Mr Pape Adama Cisse, then Mayor of Passy speaking on the JokkoSanté pilot conducted in Passy.

 

JokkoSanté partners with corporates to allow direct and traceable funding of medicines for targeted population segments as part of their corporate social responsibility initiatives. In 2017, over 150 children at Diamniadio Pediatric Hospital benefited from medication funded by Sonatel Orange through JokkoSanté.

 

French multinational, Bel Group began rewarding street vendors of its Laughing Cow cheese with JokkoSanté points as an incentive to boost sales performance. This doubled the number of top street vendors in three months as 200 users in Bel Group’s street vendor network joined.

 

Initially self-funded, JokkoSanté won a US$150,000 award from the BMCE Bank of Morocco. It generates revenues from commissions of between five and seven per cent on points purchased through corporate sector donation, credit card remittances and mobile money payments. JokkoSanté works well with Senegal’s Ministry of Health having enrolled 27 hospitals, medical centres and pharmacies, and 100 health professionals into the programme.

 

Key lesson:
● Digital technologies can be leveraged in innovative financing mechanisms for increased affordability of healthcare services

 

References:

1. Marwa KJ, Mcharo G, Mwita S, Katabalo D, Ruganuza D, Kapesa A (2021) Disposal practices of expired and unused medications among households in Mwanza, Tanzania. PLoS ONE 16(2): e0246418. https://doi.org/10.1371/journal.pone.0246418

2. MO Okonkwo Ihebe; Disposal of unused medicines from households in Cape Town: https://etd.uwc.ac.za/xmlui/bitstream/handle/11394/7935/oluchi_m_nsc_2019.pdf

3. https://sn.jokkosante.org/Contents/Details/8) [accessed 06 October 2021]

4. https://www.usaid.gov/sites/default/files/documents/1864/JokkoSante.pdf [accessed 06 October 2021]

5. https://www.odess.io/initiative-detail/jokkosante.html [accessed 06 October 2021]

6. https://www.makingmorehealth.org/sites/default/files/Adama-Kane.pdf [accessed 06 October 2021]
7. https://medium.com/change-maker/the-app-to-make-medicine-affordable-3cd2db8167f [accessed 06 October 2021]

8. https://peoplecentered.net/community-update-congratulations-jokko-sante/[accessed 06 October 2021]

9. https://edition.cnn.com/2017/05/03/health/jokkosante-medicine-app-senegal/index.html [accessed 06 October 2021]

10. https://www.youtube.com/watch?v=8EoA-OoCOFA (direct quote) [accessed 06 October 2021]

11. https://disrupt-africa.com/2015/12/16/jokkosante-medicinal-cooperative..[accessed 06 October 2021]

Virtual doctors: Overcoming the health workforce shortage in Zambia and Malawi through telemedicine

Zambia is aiming to achieve universal health coverage (UHC) through strengthening primary health care. The Government embarked on a massive health infrastructure development project aimed at improving the equitable distribution of primary health care. However, this effort is challenged by a shortage in human resources for health.

 

 

An analysis on staffing levels conducted in 2016 revealed a 51 per cent gap in the number of doctors in Zambia. This is further compounded by the unequal distribution of health workers, with a skew towards urban areas. Public facilities in rural and remote areas have the lowest number of health workers compared with urban areas.

 

Virtual Doctors—a UK-based charity with a Zambian operation—stepped in to bridge this gap through telemedicine. Through a simple smartphone App they connect rural health centres in Zambia where there are no doctors to over 200 volunteer doctors, based predominantly in the UK. Virtual Doctors provides clinical officers working in remote clinics with a smart phone preloaded with their telemedicine app. When they encounter a patient who needs a doctor’s advice, the Clinical Officers create a patient file with examination notes and photos. This is uploaded to a cloud platform from which a doctor in the UK can review it and offer diagnostic and treatment advice.

 

The Virtual Doctors service is in use in more than 200 health facilities across 37 districts and 6 provinces in Zambia. These are places where people regularly walk or cycle long distances to their nearest clinic or referral hospital. Through the telemedicine service patients can get a quicker diagnosis and are often spared the long and costly journey to the distant referral hospitals.

 

Mercy, a Clinical Officer stationed at Makeni Rural Health Centre said this about the service:

 

“The Virtual Doctors has changed the way I work. I can treat patients here in the clinic saving them time, transport costs and the stress of being away from their family.”

 

Since its inception in 2010, Virtual Doctors has become the largest non-commercial telemedicine provider in Zambia, serving a population of over 3.5 million people. In 2018, they expanded their reach to neighbouring Malawi, where a partnership with the largest telecommunications provider in the country has helped to widen their reach. Virtual Doctors operates through MOUs signed with the Ministry of Health of each country.

 

As a charitable organisation, Virtual Doctors relies solely on donations with no government funding. Clients cannot afford to pay for the services as poverty is predominant in the rural areas where 76.6 per cent live below the poverty line in Zambia. This presents a great challenge to the initiative’s sustainability especially with funding towards the non-profit sector having reduced due to the COVID-19 pandemic.

 

Key lessons:
● Telemedicine is a way to strengthen primary health care as a strategy towards achieving universal health coverage.

 

● Telemedicine contributes towards health equity by leveraging on the existing health workforce to provide care to people in rural and remote areas overcoming the distance barrier.

 

● Telemedicine will not fully address the shortage of local trained health workers. However, it can bridge the gap by breaking down borders to allow people to benefit from professional expertise in other countries.

 

● Telemedicine needs to be supported by funding mechanisms or reimbursement models for sustainable roll out.

 

References:

1. Zambia National Health Strategic Plan 2017-2021; Ministry of Health; Government of Zambia; 2017
2. https://www.virtualdoctors.org/whatwedo accessed 04/10/2021
3. Chirombo W; TNM, Virtual Doctors form telemedicine partnership; The Nation; 21/04/2020; page 7
4. https://www.virtualdoctors.org/clinicalofficers accessed 04/10/2021 (direct quote, and image)

Using technology to improve access to medicines in Ghana

Out-of-pocket payments are the main method of health care financing in low-income countries with out-of-pocket payment being the main means of accessing medicines in African countries. Consequently, availability and affordability of medicines need to be significantly improved for the achievement of Universal Health Coverage.

 

 

Constrained access to affordable, quality, safe and effective medicines is leading to the proliferation of substandard and falsified medical products. Frequent stock outs interrupt medicine supply forcing people to opt for low-grade alternatives which are often cheaper. According to the WHO, the African region reported the highest cases of substandard and falsified medical products.

 

Founded in 2013, Ghana-based mPharma is using technology to improve access to medicines by providing innovative financing and inventory management solutions to hospitals, pharmacies, and patients.

 

Through a digital prescription and inventory management system deployed over a network of pharmacies, mPharma knows in real-time the exact location and availability of any medicine of interest. With this analytical data, mPharma aggregates and predicts demand across its network of pharmacies. Through group purchasing, mPharma then negotiates lower prices with pharmaceutical manufacturers on behalf of its network, allowing the company to distribute genuine quality medicines at or below market prices.

 

mPharma has a disruptive business model whereby it stocks pharmacy shelves on a consignment basis. Instead of pharmacies buying stock, mPharma gives it to them and implements a revenue sharing model based on actual sales. Empowered by predictive data models, mPharma can absorb the financial risk, manage expiry dates, and prevent stock outs through a stock transfer tool that enables pharmacy managers to transfer stock between pharmacies in its network.

 

This lowers the price of medicines for patients through preventing fluctuations in the supply: demand dynamics of medicines caused by stock outs. mPharma also built a proprietary credit assessment system into their pharmacy operating software to offer patients interest-free payment plans at the point of sale. This offers patients an option to pay flexibly over the course of their treatment even through mobile money.

 

With the fuel of funding from foreign investors, mPharma’s proprietary vendor management inventory system is being used in a network of over 850 pharmacies spanning across Ghana, Nigeria, Kenya, Zambia, Zimbabwe, Malawi and Ethiopia. According to mPharma they have helped 2 million patients make savings on high quality medicines through medium sized clinics and community pharmacies achieving price reductions of up to 30 per cent.

 

In addition to collecting anonymised analytical data for supply chain purposes, mPharma supplies drug companies and health ministries with data to improve pharmacovigilance and patient adherence to medication.

 

Key lessons:
● Data technology can be deployed to meet the crucial need for affordable, accessible and quality medicines across Africa through improving medicine supply chain efficiency.

 

● Digital data can disrupt the pharmaceutical industry with new business models that offer patients access to medicines at lower prices.

 

● Digital health technology effectively deployed over a wide network can counterthe rise of counterfeit medicines.

 

References:

1. WHO Global Surveillance and Monitoring System for substandard and falsified medical products. Geneva: World Health Organization; 2017

2. https://mpharma.com [accessed 04 November 2021]

3. https://www.forbes.com/profile/mpharma/?sh=d65d104194a7 [accessed 10 October 2021]

4. https://qz.com/africa/1860227/ghanas-mpharma-raises-17m-appoints-ex-cvs-boss-to-board/ [accessed 10 October 2021]

5. https://www.cdcgroup.com/en/news-insight/news/cdc-group-announces…[accessed 10 October 2021]

Use of open source applications in strengthening the health system and improving universal coverage in Bangladesh

Bangladesh’s approach of digitising the healthcare system using free-to-use open-source software and applications is a valuable example for low-and-middle-income countries with budget constraints for developing and expanding digital health programmes.

 

Bangladesh is a young nation formed in 1971. Driven by ‘Vision 2021’, an articulation of where the country needs to be by its 50th anniversary, Bangladesh has achieved remarkable health care improvements in the last two decades. With the goal of transforming Bangladesh into a middle-income country devoid of poverty, Vision 2021 (conceptualised in 2008) also imbibes the goals of providing universal access to healthcare and digitising the country through the motivating idea of ‘Digital Bangladesh by 2021’ – a call to action to mainstream information technology in all areas of the society including health care.

 

Like most low- and middle-income countries, the health system in Bangladesh is fragmented and pluralistic, and the information system was in silos. The government health system followed a paper-based system and timely data was not always available. Also, the system presented substantial data quality issues. Thus, the country presented a clear need for a routine health information system. Moreover, as the country undertook health system strengthening for universal health coverage, improved governance and evidence-based decision-making were imminent.

 

The MIS unit within the Ministry of Health and Social Welfare (MoHFW) started the groundwork for digitising healthcare in 2009. The initiative stemmed from the assessment of the Health Information System (HIS) status in Bangladesh conducted jointly by the MoHFW and WHO’s Health Metrics Network. The assessment laid the foundation for defining the need for improving HIS in the country. Also, Bangladesh launched the Health, Nutrition, and Population Sector Programme (HNPSP) in 2008, and later in the same year, the Government of Bangladesh introduced the vision of Digital Bangladesh by 2021.

 

After that, the country witnessed a sudden spurt in digital adoption in health with multiple solutions implemented at various levels. Despite the spurt, the HIS in the country remained fragmented. Combined with the country’s lack of IT infrastructure, poor IT skills among staff, high cost of developing a home-grown software solution, and limited financial resources, DHIS2, a free open source interoperable and scalable solution, was identified as the best bet for the country’s health system woes. A memorandum of understanding was signed between the Health Information System Program (HISP), India. As per the MoU, HISP India will be providing technical support in developing a national data warehouse and customising and implementing DHIS2 across the country.

 

Within two years of implementation, the honorable prime minister of Bangladesh was honored with the 2011 United Nations “Digital Health for Digital Development” award. In the next ten years, Bangladesh became the largest DHIS2 deployer globally, connecting the entire health system and ensuring that quality data is available for decision-making at levels.

 

The reporting rate from the community health level increased from 10 per cent in 2014 to 98 per cent by 2018. Over the years, multiple data sets were integrated into the national data warehouse. As of 2018, 70 data sets on information from all the health system levels have been integrated. The implementation of DHIS2 was also extended beyond the Ministry of Health to establishments and programs managed by other ministries and by NGOs and
private organisations. Thus, the ten-year progressive journey of DHIS2 implementation in the country ended with a remarkable output wherein the decision-makers at all levels have visibility to an online dashboard in one click, in real-time. In addition to the DHIS2 analytics tools, the dashboard also uses other business intelligence tools such as Tableau, Jaspersoft, Google Chart, and High-Charts for analysis and visualisation.

 

The introduction of DHIS2 also catalysed the prioritisation of data standardisation and interoperability in health care. A draft guideline on the health informatics standards and data structure for Bangladesh were developed by MIS-DGHS to define standards and interoperability procedures for existing and future database systems under MoHFW, other ministries, nongovernmental organisations, development partners, and the private sector.

 

Alongside, the country is implementing an ambitious shared health record (SHR) to create a national electronic archive for patients to access medical records anywhere, anytime. Like DHIS2, the country has chosen OpenMRS, an open-source electronic medical record (EMR) solution. The Bangladeshi version, OpenMRS+, consists of modules from OpenMRS, a national electronic medical record system, OpenELIS, an open enterprise laboratory information
system, and dcm4chee, an image manager. The OpenMRS+ is integrated into the SHR system enabling health information exchange in transporting patients’ EMR to and from the central repository where updated information is stored. Health facilities (both private and public) are encouraged to take a free copy of the software and join the national health facility automation system network.

 

In 2015, the government launched its National Telehealth Service – Shastho Batayon 16263, which is linked to the existing health system and caters to the health care needs of people anytime. Other than teleconsultation services, the platform also offers services such as reserving ambulances, providing health information, receiving and resolving complaints about public health sector facilities, and coordinating emergency health responses. A person can dial the number 16263 from any telephone connection to use the services. The service received over 10 million calls between March 2008 and August 2020, and 83 per cent were COVID-related.

 

These multiple programmes and e-initiatives are now interlinked in the country. Their performance can be verified through a real-time health information dashboard managed by the office of the Director-General of Health Services.

 

Key lesson:
● Using free-to-use open-source software/applications can enable low-and-middle-income countries with budget constraints to effectively develop and expand digital health programmes.

 

References:
1. Health System Strengthening: Transforming the health information system in Bangladesh through the implementation of DHIS2; UNICEF; https://www.unicef.org/rosa/media/3416/file/A%20Case%20Study%20Bangladesh%20Online.pdf

 

2. Muhammad Abdul Hannan Khan, Valeria de Oliveira Cruz, Abul Kalam Azad; Bangladesh’s digital health journey: reflections on a decade of quiet revolution; https://www.who-seajph.org/temp/WHOSouth-EastAsiaJPublicHealth8271-794121_021221.pdf

 

3. Bangladesh health information dashboard http://dashboard.dghs.gov.bd/webportal/pages/index.php

Role of Diagnosis Related Groups in improving efficiency, transparency and financial stability of UHC in Thailand

Thailand was among the earliest Asian countries to commit to achieving universal health coverage (UHC). It’s approach to leveraging digital technologies provides some helpful lessons for countries at different stages of UHC implementation.

 

Thailand has three UHC schemes defined for different categories of beneficiaries: the Civil Servant Medical Benefit Scheme (CSBMS) for government employees, retirees, and their dependents; Social Security Scheme (SSS) for private-sector employees; and the Universal Coverage Scheme (UCS) that covers the remaining ~75% of the country’s population.

 

A critical factor to the success of Thailand’s UHC scheme is improving total enrolment through its integration with the Civil Registration system. Every child born is enrolled for a scheme as per the eligibility by issuing a unique citizen identification. The UHC policy in Thailand, during the development stages, relied on the National Health Accounts data to determine the need for outpatient and inpatient services at different levels of care.

 

Rising medical costs and investments have constantly threatened sustainability and private sector participation in UHC schemes. Thailand has countered these by implementing Diagnosis-Related Groups (DRG)—a system of grouping of patients according to medical diagnosis for purposes of paying hospitalisation costs—under a fixed global budget. Research activities on DRG detailing implementation steps under the radical health care reforms for
UHC facilitated the exclusive capitation reform. After the first installation of DRG dealing with high-cost cases of the low-income card scheme, subsequent Thai-DRG versions played a significant role in steering the UHC implementation and shaping the country’s health financing system through higher complexities.

 

The National Health Security Office setup by law to manage the Universal Coverage Scheme was the first established governance mechanism to implement DRG according to the content in the National Health Security Act. However, the reluctance found during the first few years pointed to the need for a reliable tool and an apt information technology environment.

 

The Health Systems Research Institute (HSRI), an autonomous state agency established to achieve effective knowledge management in health system services, had first invested in developing “Thai DRG Grouper,” a software that facilitates a relative weightage system to calculate payments to hospitals. Subsequently funded by the National Health Security Office (NHSO), the software is now being used for managing DRG claims processing for the UCS in all hospitals. Recently, the development of Case-Mix Tools (including the Thai DRG Grouper) is self-funded through a minimal transaction fee levied for claims processing by the Health Information System Standard and Processing Administration (HISPA) under HSRI.

 

The DRG system made the payments attractive to hospitals and has also allowed collection of operational and financial data required to improve primary health care in the country. Processing of claims and reimbursements to hospitals is based on standard data sets and the International Classification of Diseases (ICD). The standard data set approach enables interoperability within the health system and offers flexibility for the hospitals to use any hospital information system that fits in the universally accepted interoperability standards and ability to export data in the specified standard format.

 

The outpatient and inpatient data sets are linked to evaluating the quality of the primary health care system in preventing non-communicable diseases and unnecessary hospitalisation. Further, HISPA (under the aegis of HSRI) has made extensive investments in standardising data requirements to improve the efficiency of UHC in the country. This was required as different payment methods, such as high-cost medicine, investigation, high-cost care medical devices, etc., that go beyond capitation and DRG, were implemented. A Thai Medicines Terminology (TMT) was developed not only for claim reimbursement but also for monitoring drug purchasing by hospitals. TMT is also used to track accessibility to high-cost drugs, auditing for fraud detection, and understand patients’ adherence to drug treatment.

 

The three public insurance schemes in the country have now adopted DRG for inpatient payment to hospitals; but the difference is the base rate payment for a unit of DRG relative weight. The civil servant medical benefit scheme (CSMBS) pays by hospital group rates, which are relatively higher than the universal coverage scheme (UCS) that pays by the regional global budget rates. The SSS, that originally pioneered the inclusive capitation marginally
pays by a more complex system (relative weight of 2 and higher) on a case by case basis.

 

Thus, Thailand’s DRG system inherits and facilitates complex financing mechanisms using the same harmonised tool. Further, DRGs and related interoperable software tools have also helped build an efficient UHC programme, which today stands as an example and inspiration for low-and-middle-income countries to implement efficient and effective UHC schemes within their fiscal constraints and operational complexities, yet also taking on board all the stakeholders including health care providers and hospitals.

 

Key lessons:
● Universal enrolment is critical for the success of financing schemes. Thailand has strengthened the process by linking UHC to the civil registration system, enrolling every child born in the country.

 

● While the DRG system and its criticality in containing costs are gaining traction worldwide, Thailand had instituted the system early and has successfully implemented digital solutions to enable the UHC to function efficiently even under fiscal constraints, operational complexities, and higher private sector participation. Thus, when countries are considering DRG implementation in UHC – earlier and digitised is better.

 

● Countries must invest in solutions that can extract operational health information linked with payment, so that good quality data is generated to evaluate the health care system’s performance, including primary health care.Also, it is critical to maximising the use of transactional and survey data in developing evidence-based health policies.

 

References:
1. Pannarunothai, Supasit; Health Management Information Systems for Universal Health Coverage

 

2. Official website of the National Health Security Office, Thailand (http://eng.nhso.go.th/view/1/home/Thailand-to-share-knowhow-of-DRG-payment-system/156/EN-US)

 

The authors acknowledge the support and significant contribution of Dr. Supasit Pannarunothai, Chair, Center of Health Equity Monitoring Foundation, Thailand.

How digital health is helping Zanzibar to achieve UHC

In August 2021, the Zanzibar Ministry of Health (MOH), in partnership with D-tree International, celebrated a significant milestone as Jamii ni Afya—the government’s digitally-enabled community health programme—reached full scale

 

 

Jamii ni Afya leverages government guidelines and global best practices to walk community health volunteers (CHVs) through each step of delivering high-quality, standardised services in maternal and child health; nutrition; water, sanitation and hygiene and early childhood development using digital tools. The data generated from these interactions is used to strengthen the health system by improving CHV supervision, personalising health services to
client’s needs, and supporting programmatic and policy decision-making at community, district and national levels.

 

This is an important moment for the field of global health, as Zanzibar is among the world’s first examples of a government-led digital community health programme achieving full scale. By ensuring all of its 1.6 million citizens have access to a digitally-equipped CHV at their doorsteps, Zanzibar is closer to universal health coverage than ever before.

 

Jamii ni Afya’s comprehensive digital system connects communities, health facilities, and the health system to transform how care is delivered. 2,300 CHVs are equipped with digital tools that guide them in providing care, automate data collection, and digitally link referred clients to primary health facilities. As a patient’s care needs change, CHVs receive tailored guidance to follow up and provide the most appropriate and personalised care possible. For supervisors and decision-makers, Jamii ni Afya provides valuable data, visualised on dashboards, to
monitor and improve performance of the health system. Because data is aggregated from across the system, the MOH has a real-time understanding of community health in Zanzibar for the first time.

 

Although the programme is still in its early stages, Jamii ni Afya is already making an impact:

 

● More than 1 million people (out of 1.6 million) have been registered in the programme, demonstrating strong community acceptance and buy-in.

 

● 86 per cent of pregnant women in the programme are delivering in a health facility with a skilled birth attendant—a 28 per cent increase over the national average and one of the strongest predictors of positive maternal and newborn outcomes.

 

● Over 95 per cent of women and children who exhibit a life-threatening danger sign successfully receive care at a health facility, more than triple the rate of typical referral completion.

 

● Due to the strong digital monitoring and supervision system, more than 75 per cent of CHVs consistently meet performance targets to deliver quality, timely home-based visits to their neighbours, ensuring that everyone receives the care they need, when they need it.

 

At the policy level, the government has taken important steps to ensure long-term ownership and financing of the programme into the future. To formalise the use of digital tools within the primary health system, the government revised its National Community Health Strategy (2019-2025) to recognise digitally-enabled CHVs as part of the government’s health system and to reaffirm the MOH’s vision of an inclusive community health system for all Zanzibaris. While this alone is a tangible demonstration of the government’s commitment to Jamii ni Afya, embedding the programme in the strategy also makes it eligible to receive direct government funding from the Ministry of Finance and from multilateral donors.

 

“We are extremely proud that the Jamii ni Afya programme is now serving every community and ensuring that every Zanzibari can access high-quality health care. This represents an important milestone in our long-term partnership with D-tree, and a meaningful step toward achieving universal health coverage.

 

With Jamii ni Afya, we are creating a foundation for transforming Zanzibar’s primary health system. The Ministry is committed to leading Jamii ni Afya into the future and to continue increasing demand for health services, improving the quality of care provided, and actively involving communities in the health system.”

 

– Dr. Abdullah S. Ali, Director General, Zanzibar Ministry of Health

 

The Zanzibar government has also shown strong commitment to strengthening the enabling environment for digital health. In 2020, the government developed their first National Digital Health Strategy (2020-2025) and corresponding Digital Health Investment Roadmap, outlining plans for a coordinated digital health ecosystem. Jamii ni Afya is also integrated into Zanzibar’s health management information system (DHIS-2), positioning the
government to use this vast data set in resource planning and decision-making.

 

There is a tremendous opportunity to employ Jamii ni Afya as the foundation to transform Zanzibar’s health system. From health insurance to client registries that enable seamless care from the community to facilities; having comprehensive individual client health records, made possible by Jamii ni Afya, will be catalytic in strengthening Zanzibar’s health system and advancing its goals for universal health coverage.

 

For further information, please contact Erica Layer, D-tree International [email protected]

 

Digitally-equipped community health workers fight COVID-19 in Bangladesh

BRAC, an international non-profit organisation founded in Bangladesh, has been at the forefront of the COVID-19 response. Despite reaching more than 81 million people across Bangladesh through mobilisation activities, a more intensified approach was required to combat recurring waves of the pandemic throughout 2021.

 

 

In response, BRAC saw a unique opportunity to leverage digital technology to disseminate key information and enable data-sharing with government partners. These digital tools have enabled more efficient delivery of critical health services by community health workers (CHWs) and augmented gaps in Bangladesh’s fragmented health care system. CHWs are local women trained by BRAC to provide primary healthcare services through door-to-door household visits. Throughout the pandemic, BRAC’s network of over 50,000 CHWs have acted as trusted sources of health information by curtailing the spread of misinformation, identifying suspected COVID-19 cases, and ensuring proper adherence and follow up at the household level.

 

Despite interruptions from COVID-19, BRAC launched a new mHealth application in 2020 to digitise data collection for over 98 million people in partnership with a technical partner, mPower. The app was built using OpenSRP, an open source mobile platform endorsed by the WHO and a growing number of governments, including the Ministry of Health and Family Welfare in Bangladesh. Approximately 4,300 CHWs were deployed with an Android-based
tablet for data collection and patient tracking. This is part of a larger initiative to digitise BRAC’s data health system, which will enable longitudinal tracking of millions of patients across Bangladesh. Beyond CHWs collecting individual and household data on mobile devices, the system will digitally link BRAC health facilities to CHWs and allow for tailored messages to be sent to CHWs for routine communication and remote training.

 

BRAC leveraged its existing mHealth platform to conduct syndromic surveillance under its ‘Community Fort in Resisting COVID-19’ (CFRC) project. Digitally equipped with tablets, 2,600 CHWs were trained to identify suspected COVID-19 patients. The app’s algorithm helps CHWs identify higher-risk suspected cases who show more severe symptoms. Suspected cases are then reported to local government officials for national case identification and tracking. Over 200 officials are actively using this platform to track and monitor suspected cases and leveraging this data to inform decision-making about resource allocation as the pandemic evolves.

 

Once a suspected case is identified, the patient is connected to a telemedicine hotline managed by BRAC staff. Hotlines were primarily established in rural communities to provide telemedicine services to those without formal access to health care. An average of 800 calls are received per day—a number that has continued to climb—with 67% of suspected cases reporting symptoms through the hotline. This technology has greatly improved the speed at which CHWs identify, monitor, and follow up on suspected cases and ensures that communities receive tailored and timely medical guidance. In some areas, these hotlines have greatly reduced demand on health facilities as people can receive support from home without overburdening hospitals who are already inundated with COVID-19 cases.

 

The use of digital technology has greatly improved the speed at which communities access health information. With data-sharing becoming even more vital, BRAC is working alongside the government to improve interoperability and capacity building for more targeted and proactive response efforts. As a strategic thought partner within the digital health space, BRAC is collaborating with a variety of partners to explore how data science solutions can improve health outcomes and showcase the impact of CHWs. To transform community health systems, we will continue to invest in digital health solutions so that all can access quality, affordable care when they need it most.

 

For more information on BRAC’s response efforts in Bangladesh, please visit
https://www.brac.net/covid19/index.html.

Digital-First Integrated Care: Rwanda’s innovative digital health care service

In alignment with Rwanda’s drive to achieve the Sustainable Development Goals by 2030, the country’s Health Sector Strategic Plan (HSSP 2018-2024) reflects a commitment to achieving Universal Health Coverage. The HSSP sets the overall objective of Rwanda’s health sector as ensuring universal accessibility to quality health services in both geographical and financial terms.

 

 

To deliver UHC, Rwanda set up a community-based health insurance scheme called Mutuelle de Santé, a solidarity health insurance system in which members of the community pay contributions towards receiving primary medical care from a health facility anywhere in the country. It was established to help people with low incomes access medical care at affordable cost. As a result, Rwanda has a health insurance coverage of over 90 per cent. However, access to health facilities is challenged by Rwanda’s hilly terrain and inefficient transport  infrastructure which make it difficult to access health facilities, especially for the rural population that constitutes more than 80 per cent of the population.

 

To overcome this challenge, the government’s vision is to use Information Communication Technologies to transform the health sector. Thus, Rwanda’s Digital Health Strategic plan 2018-2023 set an overarching goal to improve health service delivery and accessibility through Digital Health. The Ministry of Health’s strategic plan aligns with the SmartRwanda Masterplan under the Ministry of ICT in prioritising the use of telemedicine technologies to increase accessibility to health services. Through telemedicine, Rwanda hopes to realise the
following benefits:

 

● Convenience: The ability for patients to make a virtual visit from their own homes or a nearby primary care facility with a physician at any time of the day, through video, web chat, or phone.

 

● Reduced waiting times: Telemedicine eliminates the time needed to travel to a facility and queue while waiting to see a physician.

 

● Cost-efficiency: The resources that are required to conduct a telemedicine consultation are much less. Telemedicine reduces travel expenses for patients, especially for those living in rural communities.

 

As a strategic direction for its health service delivery, Rwanda aims by 2024 to ensure accessible, quality and efficient delivery of health services using technology, towards achieving UHC. The country has thus been exemplary in Africa in implementing digital health solutions at a national scale including significant contributions from the private sector.

 

One such private sector initiative is Babyl – the largest digital health service provider in Rwanda. Through a combination of several technology platforms that include SMS, USSD, mobile money, a call centre and artificial intelligence triage system, Babyl delivers more than 5,000 virtual consultations per day. After the consultation, prescriptions and laboratory test orders are sent to patients via SMS code. These codes can then be redeemed at partnering pharmacies and laboratories for service. Since its launch in Rwanda in 2016, Babyl has registered over 2 million users and performed more than 1.3 million consultations.

 

Rwanda passed a public-private partnership (PPP) law to foster development of long-term partnerships with the private sector in digital health. This enabled the government of Rwanda to sign a 10-year contract with Babyl aimed at rolling out telemedicine services to all of Rwanda. The Babyl system uses text messages and voice calls making it easily accessible to people using phones with limited multimedia and internet capability. As Rwanda reports 98
per cent mobile network coverage, Babyl can thus afford the rural population access to a consultation with a health professional via the mobile phone.

 

The Ministry of Health signed a Memorandum Of Understanding with Babyl to develop a new healthcare delivery model called ‘Digital-First Integrated Care’, for convenient access to qualified doctors and nurses, especially for people living in remote areas. Regarding the partnership, Dr Daniel Ngamije, Minister of Health in Rwanda, said:

 

“We are delighted to have this partnership with Babyl who will work alongside all our health institutions and RSSB to deliver this innovative digital healthcare service. Increasing access to our doctors will help stop self-diagnosis and self-medication which lead to longer-term complications. With the reduced burden on health centres and other medical institutions, our medical professionals will be able to spend more time and resources on the most serious medical cases, further increasing the quality of healthcare delivery across the country.”

 

The Rwanda Social Security Board (RSSB), which is under the Ministry of Finance, administers the community based health insurance scheme. The RSSB signed an agreement with Babyl to allow members of the scheme to access prescription medications and lab tests issued via the Babyl system at approved health facilities utilising the insurance scheme. Members of the scheme are also able to process any co-pay payments using the mobile money service integrated within the service.

 

Regarding the agreement, Dr. Solange Hakiba, the Deputy Director General of RSSB said: “RSSB strives to increasingly deliver a comprehensive social security package that addresses all social security needs of all Rwandans. Digital healthcare is a significant step towards ensuring that all our members can conveniently access doctors without fear of loss of income or worry about travel to a medical institution. Early intervention with easier access to healthcare will also reduce the burden on our universal healthcare scheme.”

 

Rwanda’s National ID Agency (NIDA) partnered with Babyl allowing patients to register and access medical appointments from a shared mobile device. Prior to this, individuals without mobile numbers registered in their name, weren’t able to complete the registration process. Now using just the national ID number, Rwandans can use a shared mobile device to access the Babyl service. This change alone saw a 64 per cent increase in female registration and a 55 per cent increase in daily consultations.

 

To further grow telemedicine and digital health as a means of achieving UHC, the Ministry of Health intends to improve the legal and regulatory framework for security, confidentiality and controlled access to information. The country’s digital health strategy aims to have regulatory mechanisms and telemedicine standards in place that are conducive for public and private investors in telemedicine services while protecting the security and confidentiality of patient data.

 

Key lessons:
● Public Private Partnerships can scale up digital health services in support of government efforts towards UHC. Well defined PPP laws foster the development of such partnerships.

 

● Telemedicine is a way to support government-led health insurance schemes as it can remarkably improve access to health services and concurrently reduce the cost of service provision. This has to be supported by regulatory frameworks for setting tariffs for telemedicine services that will be covered by the major government-run health insurance schemes.

 

● Scaling up of digital health interventions to ensure reach to all citizens requires the involvement of diverse government departments and ministries contributing towards achievement of the national vision.

 

References:

1. Fourth Health Sector Strategic Plan July 2018 – June 2024; Ministry of Health; Government of Rwanda; 2018.

2. National digital Health strategic plan 2018-2023; Ministry of Health; Government of Rwanda; 2018.

3. Public Private Partnership Guidelines; 2018.

4. https://babyl.rw (accessed 01 October 2021)

5. https://babyl.rw/uploads/press-releases/Press-Release-MoH-babyl-VF.pdf

6. https://rdb.rw/government-of-rwanda-babyl-partner-to-provide-digital-healthcare-to-all-rwandans/ (accessed 01 October 2021)

7. https://www.rssb.rw/index.php?id=17 (accessed 01 October 2021)

8. https:/ www.babylonhealth.com/blog/business/rwanda-will-be-the-worlds…(accessed 01 October 2021)

 

Digital health accelerating progress to achieve UHC in the Philippines

From 2012 to today, telemedicine, electronic medical records, information exchange and health privacy have been part of the government’s UHC reforms to revolutionise the Philippine health system. The Philippines’ case of implementing digital health solutions to support UHC presents valuable lessons for other developing countries to emulate.

 

The Philippines’ journey towards universal health coverage (UHC) started as early as 1969 through the Philippine Medical Care Act. The Philippine Health Insurance Corporation (PhilHealth), which subsequently served as the foundation for the present-day UHC scheme, was introduced in 1995 through the National Health Insurance Act to provide social health insurance to all Filipinos.

 

There has always been a strong commitment towards UHC and considerable investments in digital health to achieve this goal. A significant political move that attempted to legislate technology to support health services was the introduction of the National Telehealth Service bill in 2009. Since then, several bills to legislate telehealth, health passports, and other eHealth services have been enacted, demonstrating the country’s progressive political commitments towards technology use in improving health services.

 

In 2012, the Department of Health (DOH) saw telemedicine as the potential solution to reach around 600 municipalities with limited health care access. It implemented the National Telehealth Service Program as part of the 10-point action plan of the Aquino Health Agenda towards Kalusugan Pangkalahatan (Universal Health Care). Furthermore, to create an enabling environment for digital technologies, the DOH and the Department of Science and Technology (DOST), with the support of the World Health Organization Regional Office for the Western Pacific, facilitated the crafting of the Philippine eHealth Strategic Framework and Plan in 2013. This plan served as the roadmap on the use of digital technologies in the health sector.

 

Improving the country’s digital health ecosystem is also a coalesced process of integrating patient care solutions, improving health care access, and promoting administrative efficiency. A critical indicator for the enhanced digital administrative system in the Philippines is the improved turn-around time for claims processing to 19 days in 2019 from 40 days in 2013.  During this time, the DOH and PhilHealth mandated the adoption of electronic medical records in health facilities and deployed projects to establish the country’s health information exchange infrastructure. Through grants, international development partners supported the country’s eHealth vision by building enterprise architecture capacities in the government. Key personnel in the DOH and PhilHealth underwent industry-based IT certification programmes for IT governance, programme management and evaluation.

 

In 2019, the signing of the Universal Health Care Act served as an impetus to shift many governance paradigms in the health system. PhilHealth expanded its coverage and automatically enrolled all Filipinos under the UHC scheme. Provincial governments are placed in greater accountability to become less dependent on the national government in managing local health systems by integrating services within health care provider networks. Provinces manage the Special Health Fund (SHF), which pools all resources intended for health. Policies and guidelines on digital health are also issued to accelerate technology and optimise the use of data for evidence-based approaches and programme planning. Technology is recognised as an accelerator in linking patient referral mechanisms at provinces and district levels, emphasising expanding access to primary care. Many investments, especially in digital health, are expected to achieve economies of scale through network contracting.

 

The COVID-19 pandemic has reinforced digital health as a mainstream solution in improving care, underscoring the importance of data privacy and the use of clinical information standards. At the onset of the pandemic, the government developed its case management and surveillance system to track the virus and designed internal and public dashboards for accountability and resource management. It launched a national hotline to address needs for
health information. It scaled telemedicine across the country through a sandbox approach, simultaneously developing regulatory controls towards quality, safety, and efficiency, in partnership with the National Privacy Commission. While the national government deployed a national contact tracing technology, several local governments have developed their own. To link the data submissions, an interoperability team connected these COVID-19 technologies in an ICT ecosystem through HL7-FHIR, a clinical information standard.

 

Like other countries, technology uptake has become very high in the Philippines during the pandemic. With this, the Department of Information and Communications Technology (DICT) released a policy on vetting and evaluating technologies proposed for nationwide use. This policy and other privacy-preserving data collection and use guidelines brought various discussions on the regulation of technologies for health and the legal and ethical use of data, especially among private companies.

 

While the above are instrumental, infrastructure and human resource limitations deter broader coverage. Internet connectivity remains a significant hurdle, especially in remote rural areas. The Free Internet Access in Public Places Act of 2017 was enacted, demonstrating the country’s seriousness to overcome poor connectivity. Also, there have been significant efforts to institutionalise digital health capacities in undergraduate and graduate degree curriculum. The Philippine Professional Regulations Commission and the Commission on Higher Education become active partners in the national eHealth expert groups, facilitating the crafting of eHealth curricula and advocacy activities towards the country’s transition from manual and paper-based systems to electronic.

 

Key lessons:
● Most digital health challenges can’t be addressed nor led to be resolved by the health sector alone. Building information technology infrastructure, regulating digital health innovations, and ensuring lawful use of health data requires joint initiatives with other government agencies.

 

● Building a cadre of digital health workforce through training within and outside the university and government institutions is a step towards managing change from paper-based reporting systems to the adoption of digital health technologies.

 

● Establishing enterprise architecture capacities in the government leverages digitisation efforts. A vetted and costed enterprise architecture plan that imbibes the country’s long-term goals can accelerate ICT services, applications, and platforms.

 

● Strong political commitments (including leadership, legislation, and funding) are quintessential for implementing digital health reforms.

 

References:
1. Universal Healthcare: Trailblazing a New Era of Quality Healthcare; Philippine Health Insurance Corporation; Annual Report 2019;

 

2. Official websites of the Philippine Health Insurance Corporation (https://www.philhealth.gov.ph) and Department of Health, Philippines (https://doh.gov.ph/uhc)

 

The authors acknowledge the significant contribution of Aliyah Lou A. Evangelista from the National eHealth Program Management Office (Knowledge Management and Information Technology Service, Health Facilities and Infrastructure Development Team), Department of Health – Philippines.

Delivering digital health services to offline communities in India

Delivering UHC for a population of approximately 1.4 billion people is a significant task for the Indian government, particularly when the majority of the population use private facilities over public health providers.

 

 

The Government of India is committed to accelerating progress on universal health coverage (UHC) through its national UHC initiative Ayushman Bharat. Through Ayushman Bharat, more than 80,000 primary health centres (PHCs) have been transformed into better-resourced health and wellness centres and the national health protection scheme (PM-Jan Arogya Yojana) has expanded to cover over 100 million poor and vulnerable families.In October 2021, the government also announced the Ayushman Bharat Digital Mission to connect the digital health solutions of hospitals across the country and provide every citizen with a digital health ID.

 

However, to deliver UHC for a country with a population of approximately 1.4 billion people, there remain significant health system gaps and weaknesses to overcome. As recently as 2018, India was ranked 145th amongst 195 countries in terms of the quality and accessibility of health care. The majority of the population (about 66 percent) prefer private facilities over public health providers whilst more than 60 per cent of Indian health care is paid for out-of-pocket, and unexpected illness can mean financial ruin for too many.Digital health has the potential to overcome these barriers to affordable health care in India and across the world. Whilst the COVID-19 pandemic has accelerated the adoption of digital health services, with much fanfare about telehealth, a lot of this growth has been seen in higher income, urban areas. Many digital health solutions don’t work effectively in rural regions with lower incomes, low-to-no internet connectivity and low digital literacy. Digitally-enabled health care innovations from private sector organisations are needed to support and extend government initiatives to reach underserved populations. This is particularly the case in India, where 65 per cent of the population live in rural regions.

 

reach52 is a tech social enterprise delivering health services in the markets others don’t reach across low- and middle-income countries, currently The Philippines, Cambodia, Indonesia, Kenya and India. Their reach52 access “offline-first” healthtech platform enables a full range of health services in even low-connectivity markets. These platforms equip community health workers and members as networks of agents with offline-mobile apps to manage services, such as collecting data on health care needs, running targeted health education and screening programmes, and e-commerce for essential health products.

 

In September 2020, reach52 launched its health platform into India, specifically Karnataka where out-of-pocket health expenses comprise a high proportion of household spending and many families are unable to afford the cost of hospital treatments.Through its “growth partner” model and state government collaboration, reach52 engaged with existing community-based organisations operating in target rural districts across Karnataka, including Nucleus Trust, Myrada, and Mkyaps. These partners recruited teams to be reach52 agents (many ASHA workers and +90% women), who are equipped with reach52’s “offline-first” mobile platform to run health services for their communities. The mhealth apps are designed to be ‘offline-first’, so agents can use them to provide health support even in low connectivity regions and sync when back online. They work on basic versions of Android with simple functionality to reflect the lower digital literacy levels of the users.

 

The first priority was to enrol users onto the reach52 platform, with agents visiting households to sign them up and collect health information on their needs for health services. As of October 2021, over 500,000 users in India had been enrolled onto the reach52 platform across Karnataka and now also Gujarat. Alongside this, reach52 also partnered with Aditya Birla Health Insurance to provide affordable health insurance to low income, rural populations. Through this partnership, residents can purchase a basic (200 INR) or premium plan (325 INR), providing coverage for daily hospitalisation cash, ICU benefits, personal accident health insurance, maternity benefits and Covid-19. These simple, affordable insurance plans provide protection from catastrophic health expenditures, and motivate residents to seek treatment earlier without the fear of financial ruin. The insurance is provided by reach52 agents equipped with the reach52 access e-commerce app, supported by community-based activity such as outdoor advertising, community leader advocacy and events (where Covid-19 regulations permitted). As of October 2021, over 10,000 insurance plans have been purchased by rural residents through the digital health service. reach52 has also been piloting affordable medicines, OTCs and everyday health products through its e-commerce service in partnership with Tata 1mg.

 

Key to the success of this digital health model is the combination of trusted community-based teams alongside the use of “offline-first” mhealth technology.

 

reach52 is innovating direct-to-patient channels as well in India to support its on-the-ground access initiatives. During 2020, health chatbot services (including a COVID-19 information and symptom checker and online health check) were provided on a basic version of Facebook Messenger to support harder-to-reach communities during the pandemic. Over 100,000 rural residents used the chatbot services in India and other countries across Southeast Asia and East Africa, demonstrating that health chatbots can be part of the health system solution even in areas with poor internet connectivity. reach52 has now built a WhatsApp health service (providing health education, symptom advice and access to screening and health products), which will be launched in India by the end of 2021. WhatsApp has 64% penetration in India and many rural residents use WhatsApp for around 1 hour per day, so just as reach52 goes to where residents are on the ground with community-based health services, they also going to where they are online to provide continuous health support.

 

The progress so far of reach52 in rural India demonstrates how “offline-first” digital health platforms, community involvement and new partnerships can be used to accelerate access to health care for low-connectivity populations beyond the reach of traditional public and private sector services. reach52 is expanding into new states (most recently Gujarat) and building new public-private sector partnerships to establish sustainable access to the health education, screening and products that rural populations across India need.

 

References:

1. https://pmjay.gov.in/

2. https://www.thehindu.com/news/national/pm-modi-launches-ayushman-bharat…

3. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext

4. NSSO health survey 2017-18

5. https://news.harvard.edu/gazette/story/2021/02/whats-the-future-for-healthcare-in-india/

6. https://www.ajpmonline.org/article/S0749-3797(21)00131-8/fulltext#seccesectitle0013

7. https://bangaloremirror.indiatimes.com/bangalore/others/health-costs-a-lot-of-wealth/articleshow/56189141.cms

8. https://www.gwi.com/reports/social

For further information, please contact Rich Bryson, reach52, [email protected]