Mobile Digital Platforms for Community Health Workers and Frontline Healthcare Staff: Deployment of COVID-19 Training and Education in Sierra Leone

PJ Wall, Lucy Hederman, Tochukwu Ikwunne (Trinity College Dublin), Saffa Andrew Koroma, Fredrick F Kamara, and Christian Boombu-Johnson (World Vision Sierra Leone) discuss the Mobile Training Services (MOTS) platform, an mHealth initiative taken in Sierra Leone to provide training to community health workers during COVID-19.

According to The Lancet (2020) the COVID-19 virus was expected to result in high numbers of deaths in Africa. This is because of under-resourced and fragile public health systems, lack of access to preventative measures, barriers to testing and lack of training of health staff. However, this high death rate has not materialised as yet and mortality rates in Africa have been lower than many countries in the Global North. There are a variety of reasons put forward to explain this including Africa’s relatively young population, lower rates of obesity, and familiarity of dealing with previous infectious disease outbreaks. Sierra Leone is one example of a country whose public health systems have had to deal with infectious disease outbreaks over the last decade. These include the most widespread Ebola virus outbreak in history between May 2014 and March 2016 which resulted in a total death toll of 3,955 with 11,308 deaths across West Africa and Africa’s biggest cholera outbreak in 2012 with 22,885 reported cases and 298 confirmed deaths.

Sierra Leone has also placed significant emphasis on using technology as a key weapon in the fight against disease outbreaks. In particular, mobile technologies are viewed by the Ministry of Health and Sanitation (MoHS) as an integral part of healthcare projects with many mobile health (mHealth) initiatives being launched over the past few years by a variety of non-governmental organisation (NGOs). Taken together, this would seem to make Sierra Leone uniquely qualified to deal with the current COVID-19 pandemic. Thus, it should not be surprising that the Sierra Leonean Government in collaboration with NGOs operating in the country are using their vast experience to prevent the spread of COVID-19 by leveraging technology and mHealth.

The MOTS Training Platform

One mHealth-based COVID-19 initiative of note is the result of a collaboration between the MoHS, World Vision and Grameen Foundation. The initiative is designed to provide community health workers (CHWs) and other frontline health care delivery staff with remote training on the COVID-19 pandemic through the mobile training services (MOTS) platform. The MOTS platform was successfully used in the battle against Ebola throughout 2015 and 2016. It is now planned to use this platform to train CHWs and other frontline staff about COVID-19 and safe practices around the virus. One important objective is to use the MOTS platform to reach CHWs as physical face-to-face engagement creates serious risks under the current circumstances. The digital platform will ensure that CHWs and frontline workers are not physically mobilized and assembled together for training and hence the chances of contracting and transmitting the coronavirus are reduced. A further objective is to provide training to CHWs based in remote parts of the country that may be particularly vulnerable to COVID-19 as a result of limited access to information about the virus and associated safe practices such as hand washing and social distancing. This approach also reduces the cost of training since CHWs do not have to converge in a central location. 

The deployment of COVID-19 and non-COVID-19 training and education on the MOTS system will be guided by the MoHS and managed overall by World Vision. The processes and content will be informed by 3 key technical working groups within the MoHS – the CHW hub, the health education hub, and the eHealth coordination hub – with all content being reviewed and approved by both the MoHS and World Vision before airing to the CHWs. The training will then be facilitated through modules using interactive voice responses (IVRs). The rationale of facilitating training via IVR is to enhance conceptualization and interpretation of the module content.  To achieve this, IVR content developed will be translated and recorded into the local languages used by the CHWs. This approach is to combat issues around literacy as the majority of CHWs cannot read or write.

CHWs training on the MOTS platform

The COVID-19 MOTS initiative includes online monitoring of CHWs to ensure they complete the training modules, with the CHWs being monitored and supervised by their respective in-charges during training to ensure completion of the training and to enhance ownership of the process. Households engaged in training can also be monitored online in an attempt to improve on the mother and child health indicators which could be adversely affected by the outbreak. Inclusion of CHWs into the MOTS deployment is voluntarily and each CHW will need to have access to a functional mobile phone. CHWs who participate in the programme will not receive any additional financial reward but will be provided with non-financial incentives such as infection prevention and control materials as motivation to participate in the programme.  The COVID-19 MOTS initiative will run between June and November 2020, with training already provided to 1150 CHWs in the Bo and Kambia districts via their mobile phones.  The rationale is to make implementation of MOTS sustainable and cost effective with the overall plan being to scale this initiative to all World Vision area development programmes in Sierra Leone over the Summer of 2020.  Discussions are also ongoing to deploy MOTS directly onto individuals phones at community and household level in addition to using CHWs to pass information to the community.  The belief is that this programme will facilitate CHWs to feel more empowered to engage positively and knowledgably with their communities to provide life saving information and education about COVID-19 confidently, correctly and in a timely manner.  If they can do this the current low death rates from COVID-19 in Africa and Sierra Leone will have a far better chance of being maintained into the future.

Is Digital Technology Doing Enough during the COVID-19 Outbreak? A South African Perspective

Caroline Khene (De Montfort University) reflects on the South African government’s response to COVID-19, and on the role of digital technology within it. How should public participation complement technology uptake?

The COVID-19 pandemic hit Global South contexts generating severe uncertainty in relation to the impact of this virus on our population and communities. This uncertainty and fear pushed governments and societies into action, but also interestingly revealed the many gaps that exist in our current health, education, and basic service delivery systems. We already knew our local population was confronted with huge challenges ahead, as we observed what was happening in Europe and the United States of America. The government in South Africa did not waste time in imposing one of the strictest lockdown measures in the world, to combat what they foresaw as a huge disaster on its way, resulting in President Cyril Ramaphosa declaring a National State of Disaster in South Africa on 15 March 2020.

The National State of Disaster launched the national lockdown in South Africa, aimed at containing the virus, and buying some time for the government to prepare its health system and population. However, many came to realise we were battling many more problems even before COVID-19 – the complexity of these challenges only just began to unravel. As a researcher, living and working in one of the poorest provinces in South Africa, the Eastern Cape – these challenges are all too familiar. The key news headlines that recently emerged in June 2020, painted a true picture of what the province was faced with: “Eastern Cape hospitals in crisis as health workers stay away”; “Eastern Cape’s biggest emergency unit shuts down over shortage of staff and PPE”. How were things allowed to get this bad? Where was the voice of the citizens here, in engaging government with evidence of the dire circumstances of the province’s health facilities – which were far from ready to tackle a pandemic effectively; even before COVID-19.

Government has worked closely with NGOs like Praekelt to introduce a mobile WhatsApp based application called HealthConnect, allowing for communication of health information between government, citizens and health workers. In collaboration with the National Department of Health, Praekelt launched 3 key services through HealthConnect, each targeting a specific aspect of the crisis (source):

  • COVID-19 HealthAlert – disseminates accurate, timely information to the public via WhatsApp.
  • COVID-19 HealthCheck – helps assessing risk, allowing early detection, mapping and efficient management of health cases and resources.
  • HealthWorkerAlert – provides psychosocial support and up to date information for health workers on the frontline.

These services have proven vital in supporting citizens through information dissemination and clarification around facts about the virus. This HealthAlert programme has been so successful that a similar initiative was also launched for the World Health Organisation (WHO).

However, has this been enough for the South African context?

When we consider digital citizen engagement, we take into account the dimensions of ICT enabled citizen engagement, adopted from Arnstein’s ladder of citizen participation.  As illustrated by the Dimensions of ICT enabled citizen engagement, citizen engagement is facilitated by ICTs along the four dimensions of Information, Participation, Collaboration, and Empowerment. Traditionally, the view is that ICTs are a platform to provide information to citizens – this process is mainly characterised by the one-way flow of information from government to citizens (and vice versa), which is the first dimension of ‘Information’.

This is what is observed in the HealthConnect service. As valuable as information on COVID-19 is, and continues to be so, citizen engagement needs to progress further than the dissemination of information, from participation all the way through to empowerment. This is fundamental to tackling the major gaps and realities of marginalised and resource constrained health facilities in the Eastern Cape, and many similar regions in South Africa and the global south, confronted with challenging circumstances. Providing an ICT platform that allows citizens and/or local frontline health workers to report on COVID-19 service delivery challenges and gaps in the health system remains fundamental – yet it may not be sufficient alone. This should not only be seen (though rightfully so) as a platform to hold government accountable for the lack of service delivery, but rather as a platform to support evidence-based engagement in such urgent times. Essential decisions need to be made, but can only be made with a clear portrayal of what citizens and local frontline health workers are experiencing at grassroots level.

We have applied the dimensions of ICT enabled citizen engagement in the MobiSAM and MobiSAfAIDS projects, which have different focus areas on service delivery, i.e. basic service delivery, and adolescent sexual reproductive health services. Nonetheless, we can learn from these projects in addressing the crisis using technology – as COVID-19 seems to be a virus that may be around for some time. What we have observed over many years is that moving up to a position of empowerment is not a straightforward process – however, circumstances may differ for government during times of a crisis like COVID-19. There has never been a time like now, when feedback from citizens is fundamental in understanding the realities of contexts, and devising localised solutions to contain and address hotspots in the country. The process calls into question issues around technology access, capacity to use the technology (digital literacy, comprising civic and responsiveness literacy), and motivation to use the technology for its intended purpose (given the power dynamics between government and citizens are progressive).

Bridging Socio-Economic Inequities in Healthcare Access: A Mobile Health Based Approach

Sajda Qureshi (University of Nebraska) presents an app-based solution for clinicians in Nebraska (USA) to offer socio-economic resources based on patient needs. The app has been piloted in a context of urban poverty where inequalities in access to healthcare increase the importance of readily accessible digital tools. This project gathers data on the distribution of healthcare facilities in Nebraska and identifies the inequalities (pattern, neighborhood effects) in this distribution. This project began in July 2019 and the observations contained here are from March to April 27 2020.

Background: Urban Poverty in South and North Omaha

As our observations revealed, in South Omaha Hispanic communities are close-knit and widely supportive of each other, cash-on-hand keeps institutional banks largely out of the community. Many supply chains are encapsulated among the businesses within the area. As we have observed, communities have built their own economic systems and internally adjust pricing that is manageable for members of the community, sometimes transactions for goods are conducted as favors. This key factor extends outward to the rest of the community economically, often leaving the remainder of funds as assistance to their families. Another accelerant in this region is the presence of industry. While these industrial complexes are owned external to the community, they provide a large source of economic support and income for new immigrants entering the area; immigrants often seek these types of manual labor jobs to support their family as they settle.

North Omaha, though similar in low economic development, is dissimilar in the community-supporting factors that South Omaha exhibited. The neighborhoods in this region were lacking evident forms of financial support; this was noted by directly observing the conditions of the infrastructure and of the community in general. The roads are not maintained to the extent that the rest of Omaha is, buildings have been repurposed many times over, and enterprises are sparse to non-existent. In the past, there were districts drawn based on ethnic prevalence, barring opportunity in pseudo-rational form by limiting city and state funding for infrastructure, schooling, and various community support programs. This districting additionally inhibited the residents from attaining financials from banks making the investment opportunities little to none. Today, the health status of North Omaha residents and lack of viable infrastructure are assumed byproducts of redlined districting, with the opportunity costs affecting generations of residents.

Intervention

In order to offer clinicians with the ability to address the socio-economic needs of their patients, a series of interventions comprising of technology and training solutions were carried out at the Free Student Clinic, which was started in 1997 to provide primary health care to multi-ethnic underserved populations in North and South Omaha. Patients who qualify for care at this clinic do not have health insurance and have, on average, an annual household income of 138% below the federal poverty level (Caucutt, 2019). The clinic is located in the middle of North and South Omaha, and it serves primarily the African American and Latino communities in the area.

Addressing the needs of marginalized communities requires interventions that are culturally sensitive while understanding the socio-economic causes of the patient’s malaise. As the clinic was pressed for funding, a free solution was implemented in March 2019 that fulfilled the need to offer a growing body of services. A mobile application with the community resource-related information was required so that the clinicians could find relevant socio-economic information for their patients.

Diagnosis of problems and needs assessments

While clinicians are able to address the symptoms that patients come in with, the longer term health of their patients need to be addressed through the social and economic causes of their illness. In order to assist patients in this way, clinicians need the relevant information on community resources. The researchers came up with an application with appropriate resources listed, and aims to benefit both the clinicians and patients. An app can save clinicians time as they can instantly look at their phones and get community-resources related information.

Mobile health (mHealth) technology has expanded access to healthcare in the researched context. Mobile health is much more than just accessing healthcare applications on a mobile phone as it can involve sensors and wireless networks in monitoring various conditions, mobile devices to access a variety of healthcare services, healthcare professionals to make decisions and provide emergency care, and support the elderly to manage their daily activities. The clinicians/physicians working in Free Student Led Clinics can get the right information at the right time about the right patient and in the right place quickly. In summary, the purpose of the app is to: 1) allow clinicians to look up appropriate community resources based on patient needs, 2) allow patients to leave the clinic with a plan for further support, and 3) allow clinics to more meaningfully help patients navigate bio-psycho-social barriers.

Development and Implementation of an IT solution           

To implement the free service, we put together a Google Sites application that fulfilled the community resources requirements. As the service is free, it solves the challenge of meeting financial requirements. Researchers and Clinicians sat down and walked through a prototype of the app. This is available as a website for clinicians who are at their desks as well as a mobile application that can be accessed through their phones.

Preliminary results

In order to achieve sustainability of the technology and training intervention, clinicians need to be able to use the app to support the socioeconomic needs of their patients. Following the initial implementation of the app, researchers visited the student-led free clinic on four separate occasions to observe how the app was being used by clinicians. Specifically, the researchers sought to analyse how the app was being used to address patient needs, how the app affected patient access to resources, and how the app could be improved to ensure the relevancy of its resource list and ensure that it was considered user friendly among clinicians.

As we were collecting additional data on socio-economic outcomes of the usage of these community resources by clinicians and their patients, COVID-19 started spreading through the communities. While the infection rate in Omaha is barely 2%, the unintended effects of the virus have been devastating. People who were barely surviving on minimum wage, are now experiencing homelessness, food insecurity and domestic violence as a result for the virus.

In order to address this situation, we retooled and updated our app so that individuals in need and or their caregivers can access needed resources. The updated version can be found at: https://sites.google.com/unomaha.edu/communityresource/home. While it is early to assess the specific socio-economic impact of this app, recent data suggests that among the effects of the COVID-19 shutdown have been increases in domestic violence, homelessness and food insecurity. In particular, there has been a sudden rise in the cost of prescription drugs. We expect that with the resources made available through this app, such hardship can at least to a certain extent be alleviated for those who are able to access the resources.

For more information contact: Prof. Sajda Qureshi, University of Nebraska, squreshi@unomaha.edu

The role of a gig-worker during crisis: Consequences of COVID19 on food delivery workers in south India

Drawing on self-ethnographic research as a food delivery worker in south India, Shyam Krishna (Royal Holloway University of London) explores the consequences of the COVID-19 crisis on gig workers in a Global South context. His insights highlight the heightened risk borne by food delivery workers, the continuation of algorithmic control in spite of the emergency, and the protection gap resulting from a problematic nexus between the state and platforms.

As the COVID19 crisis unfolds in India, it is clear the country’s largely informal workforce is facing the brunt of the impact. The workers in the growing Indian gig-economy, particularly the food-delivery workers are heavily affected. With severely lowered income they also face the danger of possible exposure to infection during their daily work. In the early part of this year as the impact of COVID19 was barely surfacing globally, I was working as a food delivery worker in south India conducting a self-ethnographic research project. Based on both my experience working in food delivery and a continuing engagement with those workers who are currently active, I explore here the impact on the gig-workers and some of the consequences of the crisis.

Even in normal times food delivery workers assume enormous risk on behalf of both the restaurants and the customers due to a near constant exposure to risks such as dangerous road traffic and harsh weather conditions. These risks have been compounded by the current crisis where some measures taken to protect the general public affect the workers adversely. Under the isolation efforts safety is paramount with ‘contactless’ deliveries becoming the norm within digital platforms. But this means that the workers themselves continue to take ownership of risk during this crisis and are seen to be a potential solution for delivering help to those affected. In these extraordinary times the government has also encouraged the ‘citizen’ use of food delivery platforms. Both as a rhetoric and a policy this is a problematic nexus between the state and digital platforms without due support to workers. The unfortunate counter intuitive impact of governmental controls such as lowering the number of operating hours for restaurants and shops is that without due protection, it forces the food delivery workers to queue up in the short time the busy locations operate. This clearly heightens the workers risk of social contact and infections even while customers avoid the risk. One of the workers that I interviewed over phone sums this up by saying that this crisis highlights to him clearly the absence of actual care and accountability towards the workers that was expected of digital platforms and the state. They report that even efforts taken to provide personal protective equipment to workers are inadequate. Many they report continue to purchase their own masks and gloves. Such efforts towards worker safety have also not been made mandatory or provisioned by the state, and similar stories are emerging from cities across India.

Sign indicating food delivery workers the designated area to queue

Food delivery workers also report that their income has greatly reduced given the 60% reduction in volume of orders has been reported on food delivery platforms. On top of unfair work conditions that have been reported in normal times, the workers report that the platforms continue algorithmic control such as imposed daily targets with lowered rewards, and this forces the fewer active workers also on longer delivery trips. These trips may now be of more than 10 kms, making it twice the distance during normal times. But now, riding across the city on a scooter also means navigating road blockades and encountering police – many of these interactions can be very risky. Further in responding the current crisis the digital platforms have taken to introducing or ramping up delivery of medicines and groceries using the same set of workers, encouraged by the government. These newer services are both untested and take a lot more efforts on behalf of the worker. But they continue to be compensated only at the same level as they would for food delivery. As one worker mentions, queuing up and picking up groceries can take 2 hours while they are paid the same as a food order which can take as little as 15 minutes. This, especially in a crisis is a situation ripe for necessary state intervention to impose the digital platforms to guarantee a ‘per hour pay’ structure for these workers and with mandated perks for additional risk efforts like queueing up and long-distance rides.

While a structured response that guarantee pay and protection to workers is still yet to be announced, digital platforms (and in ostensible support by the state) have resorted to donation or charity driven responses even as they seek governmental bailout. The largesse of the platforms is performed in asking the customers to provided tips or donations to affected workers. Funds are also collected by platforms which are raised by future facing subscriptions that lock customers to platforms. In either case the commercial nature of the platform and the relationship of these worker to the platforms does not see any intervention. In fact, the workers feel efforts such as ramping up subscription services, introducing grocery deliveries without changing the pay and even efforts of charity meant for workers will only ensure the commercial future of the platforms and not the future of the workers themselves. They point to evidence that digital platforms and their pay structure continue to be extractive including actions such as the platforms still deducting money for loan repayments even amidst these extraordinary times. As these loans are governed by private sector partnership contracts they fall under a regulatory void. The response to COVID19 by the Indian government only mandates deferment being granted on repayments schedules for loans given by many public entities.

Ultimately, the absence of regulation within the gig-economy particularly its labour practices during the COVID19 crisis is compounded by efforts of the state and digital platforms that do not go far enough to help the workers. This leaves the gig-worker to be treated as a much-needed solution for supporting the wider community even when their own livelihood is left to be governed by extractive terms set by digital platforms and their marketisation efforts. In the absence of any state mandated social safety in terms of employment protection or guaranteed wages gig-­workers face an unfortunate choice of either depending on charity or putting themselves through risky work. The state though continues to engage with digital platforms as either as a utility provider for last-mile logistics or as if they are a charity in this time of need. But this leaves out the actual responsibility of the platforms as employers signalling strong need to question the underlying assumptions of the gig-economy and the way it treats an already vulnerable workforce who have now become key to responding to the COVID19 crisis.

Author’s website: https://researching.technology/ 

Contact: shyamkrishna.r@gmail.com, Twitter: @digiflaneur 

CALL FOR TRACK PROPOSALS IFIP9.4 2021 – CONFERENCE THEME: FREEDOM AND SOCIAL INCLUSION IN A CONNECTED WORLD

Deadline 30 May 2020

The 16th International Conference on Social Implications of Computers in Developing Countries, Lima, Peru, 26-28 May 2021

We send out this call for tracks at this unusual time amid the coronavirus global pandemic. A lot of us are currently in more or less a lockdown situation. Some may be experiencing health problems themselves or of their family members, and possibly all are trying to cope with a shared anxiety when the world is in emergency mode. Sending out this call for tracks for the next IFIP 9.4 conference is an effort to maintain a degree of normalcy, as well as an invite to the community to collectively reflect on the implication of digital technologies in these highly unsettling times.

To a great extent, most of us are giving up many aspects of our individual freedom, e.g. travelling, going to the workplace, socialisation, or even worse, employment, in order to protect our individual and collective freedom to live a healthy life in a safe environment. Democratic governments face the dilemma between respecting individual will and autonomy and depriving us of freedom of movement and social interaction through top-down disciplinary measures. Policy makers struggle to balance the long term social economic consequences of social distancing measures and tackling the imminent threat of a plague.

In the face of a crisis, freedom is clearly at stake. While there is no consensus on the definition of ‘freedom’ across or even within disciplines, Berlin’s (1969) discussion of negative freedom – to be free from interference, and positive freedom – to be one’s own master, brings forth an interesting and relevant notion of a ‘real self’ that is of a ‘higher nature’ as opposed to a ‘heteronomous self’ driven by desires and passions (Robeyns, 2017, p.100). The former is considered to transcend one individual,

 “as a social whole of which the individual is an element or aspect: a tribe, a race, a church, a state, the great society of the living and the dead and the yet unborn. This entity is then identified as being the ‘true’ self which, by imposing its collective, or ‘organic’ single will upon its recalcitrant ‘members’ achieves its own, and therefore their ‘higher freedom’ (Berlin 1969, 132, cited in Robeyns, 2017, p.100).”

This passage points to some sort of connective freedom among all individuals in the world,  similar to what John Donne says, “no man is an island entire of itself; every man is a piece of the continent, a part of the main” (1839, p. 574-5) – please replace ‘man’ with ‘individual’. While Berlin acknowledges that such a definition of ‘positive freedom’ gives space to tyranny that curtails individual freedom in the name of collective good, the global pandemic once again poses the question of how societies, communities and individuals make decisions to balance the different spaces of freedom, and how do we ensure the most vulnerable and marginalised population do not fall through the cracks in the pursuit of a “greater good”. This is relevant not only in the current case of the public health crisis, but also in the long-standing tension between privacy versus surveillance, individual rights versus national security, as well as the protection of human agency amid the rapid proliferation of artificial intelligence in the forms of smart cities, big data applications, algorithmic work and increasing automation of work.  

The importance of digital technology has become even more elevated when schools and offices are closed, and societies to a large extent shut down. The issue of digital divide suddenly becomes more prominent when face to face services are unavailable. Students without access to a device or the Internet at home are automatically left out of the opportunity to continue education. A large number of people lose their job or business as their line of work does not easily convert to online working. The elderly and vulnerable are likely to suffer, physically, and mentally from social isolation with no recourse to digital connection. Social exclusion due to class, income, age, gender, etc. may be further magnified when digitalisation becomes the only available option. On the other hand, we see a lot of community initiatives and collective action being organised online to help alleviate some of these challenges. When a large part of world is under lockdown, are we more isolated or connected? Does digital connection disguise or make visible the invisible? Whose voice gets heard? These are some of the questions that we could explore.

Reference

Berlin, Isaiah. (1969). Four Essays on Liberty. Oxford: Oxford University Press.

Donne, John. (1839). The Works of John Donne. vol III. Henry Alford, ed. London: John W. Parker

Robeyns, I. (2017). Wellbeing, Freedom and Social Justice: The Capability Approach Re-Examined. Open Book Publishers.

Track Proposals for IFIP9.4 2021

While freedom and social inclusion are long standing topics in the ICT4D community, we invite track proposals that directly or indirectly address some of these issues in this highly volatile and challenging times. Other topics are also welcome.

We welcome track proposals that support the theme of the conference and include:

1. Track title

2. Name(s), email address, affiliation of track chair(s)

3. A brief motivation of the track

4. A brief overview of the research area

5. A short description of how the track aligns with the conference theme

5. Exemplar topics and types of contributions looked-for

Please submit your track proposals to  <ifip9.4.2021@gmail.com>  by 30 May, 2020. Notification of acceptance will be given by 15 June, 2020.

We look forward to seeing your IFIP9.4 2021 track proposals!

Programme Chairs

Yingqin Zheng, Royal Holloway, University of London, UK <yingqin.zheng@rhul.ac.uk>

Jose-Antonio Robles-Flores, ESAN University, Peru <jrobles@esan.edu.pe>

Reposted from: https://dosrhul.org/2020/04/06/cftifip942021/

Re-tracing the footsteps: Thoughts on implementing guidelines for COVID-19 Surveillance in Low and Middle Income Countries

Rangarirai Matavire (ITI Nordic) discusses how guidelines of Clinical Decision Support (CDS) and Clinical Quality Measurement (CQM) can be implemented towards the monitoring of COVID-19 in low- and middle-income nations.

There has been a proliferation of advanced information system technologies in the public healthcare sectors of Low and Middle Income Countries (LMICs). Asides to a number of Web-based systems, many of these solutions are also built on mobile devices owing to the widespread use of both feature and smart phones, particularly those running on the Android operating system. Mobile devices are particularly useful for the provision of quality healthcare services to communities in remote areas, the often called next billion people. In many LMICs, local and global technology vendors, supported by international funding agencies, are active in developing public health information infrastructures for case-based surveillance, aggregated data reports and analytics. Heterogeneity in adopted technologies persists within and across LMICs, with choices made on custom or generic solutions and licensing models which range from proprietary, through open source, to copyleft. The net result of these interventions is that there is often a number of technologies developed and implemented within countries for different health programs and regions, with scarce usage of communication interfaces and limited alignment of processes between them. Information is consequently fragmented across these landscapes, with each vendor solution implementing its own approach for supporting health workers in the provision of quality care. While these systems are often adopted to encourage improved adherence to healthcare guidelines, research suggests that these systems have not lived up to expectations. The main reason is not whether individual solutions, or implementations, are aligned to guidelines, but rather if the net result of the different technologies has led to the expected improvement. In addition, in times of emergencies, such as the COVID-19 pandemic, guidelines change rapidly as new information comes in thereby exacerbating the problem. The ability of systems to share and implement the fast changing rules becomes of prime importance.

Training of nurses on a Mobile Health Information System in Zimbabwe

To understand how IT is implicated in the agenda for the strengthening of health information systems in LMICs, it is important to look at two of its envisioned roles in the provision of care, that is Clinical Decision Support (CDS) and Clinical Quality Measurement (CQM). Clinical decision support (CDS) is concerned with “reminders and alerts driven by rules” [1]. This has to do with a systems’ ability to provide recommendations to a health worker or patient during the course of care provision. On the other hand, Clinical Quality Measurement (CQM) is concerned with indicators on the quality of care based on the data collected on populations. The need for CDS and CQM is driven by a realisation that health workers do not adequately adhere to narrative clinical guidelines, and technology has been found to increase the quality of care in these contexts. In a situation where COVID-19, a highly contagious virus is concerned, CDS has to do with the ability of a system to generate alerts or reminders that recommend certain courses of action when collected data fires preconfigured triggers. For instance a patients’ travel history, alongside other symptoms, could trigger an alert when an information system recognises that the client was exposed when they visited a place with known high transmission, as has been done for the Zika Virus [2]. The system could therefore recommend that certain measures be taken with the client in question, including requesting a test or sending an alert to a regional response team. CDS is, by design, inherently linked with CQM, where the indicators on the percentage of clients who followed through with the recommended courses of action are analysed for decision making. In this context, the Fast Healthcare Interoperability Resources (FHIR) standard is being increasingly adopted to address the challenge of implementing guidelines across vendor offerings. This standard could enable for rapidly updating guidelines across compliant system systems in the event of emergencies.

Computable Care Guidelines are the standards driven executable resources which can be shared across systems to provide the logic for triggering rules when certain client data points are encountered. While health information systems have traditionally applied their own internal mechanisms to implement narrative care guidelines, there has been a risk of eroding their principles across different computer systems and thereby, increasing fragmentation [1]. Their implementation in a standard such as FHIR offers an opportunity for aligning the quality of care when different IT solutions are used at the point of care. In this context, the developer of the guideline, be it an international agency such as the World Health Organisation (WHO), or a local Ministry of Health (MoH), can publish the computable file for implementation by compliant systems [3]. In the event of an outbreak such as COVID-19, these guidelines can be rapidly changing, and therefore consumed and implemented in real-time by compliant systems. Currently, the World Health Organisation (WHO) is actively developing CCGs for Antenatal care (ANC) for LMICs which are to be implemented by a number of active vendors in these regions. It is therefore possible to see some of the ways in which this approach can be adopted for pandemic response information systems, and the benefits thereof. However, a few systems are close to, or capable of, running these executable guidelines currently. In this COVID-19 context, already compliant systems have much to offer to the response, and to improve the quality of care for clients who are able to benefit from these innovations [4]. It still remains however, that in the short to medium term, LMICs are well advised to channel investments to such infrastructural innovations as they stand to benefit during this, and in future epidemics. The capabilities of this approach are open and therefore present a fruitful direction for health IT research and development.

[1] Aziz A Boxwala, et. al., A multi-layered framework for disseminating knowledge for computer-based decision support, Journal of the American Medical Informatics Association, Volume 18, Issue Supplement_1, December 2011, Pages i132–i139

[2] Sanjeev Tandon, et. al., Emerging Infectious Diseases, Clinical Decision Support, and Electronic Health Records Meaningful Use , Healthcare Information and Management Systems Society (HIMSS), April 2017,  https://www.himssconference.org/sites/himssconference/files/pdf/39_0.pdf

[3] IHE, The Computable Care Guidelines (CCG) profile, https://wiki.ihe.net/index.php/Computable_Care_Guidelines

[4] Grahame Grieve, HL7, #FHIR, and Covid-19, http://www.healthintersections.com.au/?p=3012

DHIS2 for COVID-19 Surveillance: Sri Lankan Use Case

With the current outbreak of COVID-19, Sri Lanka needed to implement adequate precautions to prevent the disease from entering the country as a significant number of tourists from at-risk countries are traveling to Sri Lanka regularly.

One of the main preventive activities for this purpose was screening travellers at the ports of entries and carry out active surveillance until the incubation period is over in the community setting using the existing public health infrastructure.

Establishing a proper information system for surveillance of COVID-19 as a prime requirement of the Ministry of Health and as an initial stage of the surveillance system, the ministry wanted to capture information related to the tourists who enter the country from at-risk countries. To facilitate the above process, the Ministry of Health of Sri Lanka with the collaboration of HISP Sri Lanka developed a District Health Information System (DHIS2) based solution for active surveillance for COVID-19 in Sri Lanka.

This COVID-19 Surveillance System of Sri Lanka was developed by using the tracker component of DHIS2 2.33. Brief technical overview is as follows.

The system consists of one tracker program which has three program stages.

Name, DOB, gender, email, passport number, telephone number, and few other sociodemographic factors are captured at the registration as tracked entity attributes. The first programme stage is also captured at the port of entry along with information for registration. The first which is a compulsory program stage captures information related to immigration, symptoms of COVID-19 disease, possible contacts and the stay in the country.

Second program stage, follow-up (within 14 days) is a non-compulsory repeatable program stage that captures symptoms of COVID-19 disease and any action taken during the surveillance process.

Follow-up (at the end of 14 days), the third program stage is a non-repeatable, compulsory program stage and captures symptoms of COVID-19 disease and any action taken at the end of the surveillance period. This programme stage is the conclusion of the surveillance process.

Currently, contact tracing and treatment modules are not included in the system and there are discussions underway to design them if required.

System implementation was planned at National, Province, District and Medical Officer of Health areas covering the entire country with separate access and dashboards for each level. System implementation and training were reinforced with standard operating procedures and simple user guides. The system also has dashboards which facilitate national level administrators to track the progression of surveillance activities.

Also underway is a smartphone version allowing mobile access for health workers although this is not practiced in all regions.

As of now, data entry at the point of entry to the country is established and training programmes are being conducted to the provincial level staff on the use of the system. The familiarity of public health staff with the DHIS2 platform has greatly facilitated the implementation.

There were some challenges facing the implementation: firstly, limited capacity in terms of available skilled developers was overcome by volunteer developers who were enrolled to help in the software development process.  Other constraints were presented by questions over the ownership of the DHIS2 system where multiple agencies are involved with different rules on access to data.  Finally is the problem of rapidly rolling out training to users to implement the system where quick adoption is of crucial importance.

 

Contact :

 

Dr Pamod Amarakoon pamodm@gmail.com

Postgraduate Institute of Medicine (PGIM)

University of Colombo

160, Prof. Nandadasa Kodagoda Mawatha,

Colombo 07, Sri Lanka 00700

 

https://www.dhis2.org/about

The Potential of India’s Village Health Committees in Containing the Spread of Diseases

Drawing on her research in rural Karnataka, south India, Shirin Madon (London School of Economics and Political Science) discusses the importance of Village Health Committees in taking village-level measures and interventions to contain the diffusion of diseases.

In recent years, many developing countries such as India, Tanzania and Bangladesh have introduced village health committees as part of efforts to improve the functioning and effectiveness of health systems. These are committees that elicit participation from a range of frontline government health workers, local politicians and civil society representatives at the village level. There are two key rationales for this intervention. First, while governments and district agencies hold substantial decision-making power with regards to the planning and execution of health programmes, their actual implementation occurs at the village level and requires active community participation.  Second, many diseases are influenced by water, sanitation and hygiene conditions requiring the joint implementation of programmes under an overall village development agenda.

Since 2012, we have been studying the Village Health Sanitation and Nutrition Committees (VHSNCs) introduced in India by the National Health Mission in 2008 as a flagship programme aimed at promoting community-based decentralisation of primary healthcare. India has lagged behind many other developing countries in terms of improving sanitation, nutrition and hygiene indices and the prevalence of low birth weight is among the highest in the world with diarrhoea a major killer of children under the age of five years. The VHSNCs were introduced to ameliorate the situation by decentralising decisions to a 15 to 20-member sub-committee of the gram panchayat, a village council in which members are elected to serve for a 5-year term, and providing each VHSNC with an annual untied grant of Rs. 10,000 (approximately US$152) payable in three instalments which can be used at the discretion of the village committee.

Village Health Committees in Karnataka, south India

In Karnataka, a state of south India where our research has been based, after several years of building capacity within the VHSNCs, we find that in our study villages the committees serve as vital social spaces for creating awareness amongst low-income communities about the spread of diseases. In particular, since 2012 we have noticed that there has been a drastic reduction in the incidence of diarrhoeal diseases in our study villages while the occurrence of intersectoral collaboration between ex-officio VHSNC members from different line departments, non-governmental member, the gram panchayat and ordinary households has increased. Participants over the period of our study are found to develop an ability to interpret information in context and act appropriately to establish practices that improve intersectoral collaboration, for example between the health worker and the mother and child nutrition specialist, or in conjunction with the waterman and gram panchayat.  Ultimately, we have found that the development and maturity of a VHSNC is not something that can be mandated from outside by the imposition of structures but needs to be understood in terms of specific local situations, interventions and practices which can create resilience among communities in order to cope with chronic diseases and epidemics.

COVID-19: A Proposal for a Digital and Distributed Response System

Margunn Aanestad (University of Agder) proposes a health emergency response system that, with its digital and distributed natures, would allow quarantined and infected patients to stay at home as long as possible.

It is crucial to try to limit the spread of the virus through case detection, situation reporting and surveillance, as well as contact tracing. During emergencies, health authorities may experience a huge demand from the general public and from both suspected and confirmed victims which threatens to overload the health system. We see that well-resourced health system struggle to respond to the COVID19 epidemic and can only image the extreme demands on health systems with less resources.  

I here share a proposal for a response system that allows this large group of patients to be monitored without accessing hospitals or healthcare institutions. This digital and distributed response system allow quarantined and infected patients to stay at home as long as possible. Patients at home register symptom and report them through their mobile phones. This allows a form of triage (see the table below), where health personnel at a response centre responds to the incoming data. This could involve calling the patients with red alerts to assess if they need access to a doctor or hospital admission. This is a first version of a protocol that is being implemented in the region of Agder in Norway, i.e. in a well-resourced health system context. While it builds on the symptom descriptions published by the WHO (among others)[1] it is an initial version and may have to be adjusted[2].

In practice, the actual implementation of both the triage questions, threshold values and responses need to be decided on for each instance. An implementation in a developing country context would need to adjust to local conditions and resources. A web interface can work with smartphones, or the infrastructure should set up for structured SMS if the population does not generally have access to smart phones.

There may be other candidate protocols around, however, I am not aware of any. Most existing triage protocols for corona virus are made for emergency departments in well-resourced hospitals. This protocol, made for a western, affluent context is based on access to a thermometer; this may not be generally available, and a subjective assessment of no fever/fever might be an alternative. The crucial resource for putting such a system in place would be responder resources to monitor the incoming data and access to physical health care for those that require it. Healthcare staff will be difficult to mobilize in an over-stretched health system. There is the option of automate some of the job of prioritizing among reporting patients so that “red alert” patients are shown first. One might also think of solutions where non-healthcare staff might do some of the triage work and even advice patients. Access to healthcare resources for the most needy are going to be a challenge, but if implemented, such a digital, distributed triage system might alleviate the demand for service and increase the likelihood that the most needy will be able to access it.


[1] https://www.who.int/news-room/q-a-detail/q-a-coronaviruses

[2] It is implemented using the COVID19-module on the OpenTeleHealth platform (oth.io) delivered by Siemens Healthineers.

HISP at University of Oslo releases DHIS2 package for tracking of COVID-19

The Health Information Systems Programme (HISP) is a sustainable and scalable research project enabling and supporting health information systems implementation in more than 100 developing countries.

As a large-scale longitudinal international action research programme coordinated from the University of Oslo (UiO), HISP has engaged in the development and implementation of the District Health Information System (DHIS2) software for more than two decades. DHIS2 is a generic open-source software system with data warehousing functionalities and customizable modules for integrated health data management. Ministries of Health and Non-Governmental Organizations (NGO) in more than 100 developing countries are using DHIS2 covering an estimated 2.28 billion people (see www.dhis2.org/inaction).

HISP is today a global network constituted of Independent HISP groups (like HISP South Africa, HISP India and HISP Uganda), Universities (like University of Dar es Salaam and Universidade Eduardo Mondlane), Ministries of Health, NGOs, global policy makers, global donors, researchers, students, social entrepreneurs, individual consultants, and more. Together, they play different, but complementary roles, and form an organically growing ecosystem around the DHIS2 software with new roles developing and shifting between the different actors.

HISP UiO which coordinates the development of DHIS2 is now also a professionalized software development organization. Other core actors in this global ecosystem around DHIS2 implementations are the HISP groups with established and sustainable local expertise in developing countries (Bangladesh, India, Malawi, Mozambique, Nigeria, Rwanda, South Africa, Sri Lanka, Tanzania, Uganda, Vietnam, West and Central Africa region, and Colombia). They support the implementation of DHIS2 in their countries and regions based on their domain knowledge, technical and implementation expertise and experience. Their efforts include training of users at different levels, software implementation and maintenance, integration with other systems and software development of extensions and apps. They also contribute by arranging regional DHIS2 academies and share knowledge with other entities through e.g. the DHIS2 annual conference.

DHIS2 & COVID-19

In the fight against the spread of COVID-19, the Health Information Systems Programme (HISP) at the University of Oslo is actively working with its global network of partners to provide open-source technological solutions to help track and contain transmission.

The DHIS2 software platform, developed at UiO, is used as a national Health Information Management System (HMIS) in 67 countries around the world. It offers the possibility of registering and tracking suspected and confirmed cases of COVID-19, as well as tools to rapidly analyze and present data for decision making.

HISP Sri Lanka was the first group in the UiO network to deploy DHIS2 for this purpose, creating a COVID-19 surveillance system on request from their Ministry of Health to monitor travelers from high-risk countries. They shared the details of their work online with the DHIS2 community so that others could easily apply the same approach. Since then, health authorities in Fiji, Palestine, Senegal and more have begun work on their own versions of this system.

Led by UiO, a global team has developed a standardized version of the DHIS2 surveillance program according to WHO guidelines that can be easily configured to a country’s unique needs. This work has drawn heavily on the example of Sri Lanka, as well as experience from HISP Vietnam with contact tracing of TB cases among migrants in the Mekong Delta, and foundational work on DHIS2 disease surveillance with WHO, GAVI, CDC and partners in Africa.

More information about the DHIS2 COVID-19 surveillance system–including an online interactive demo and a downloadable version of the software package–is now available on the DHIS2 website: www.dhis2.org/covid-19

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For more information, contact:

Kristin Braa, Professor, University of Oslo, Informatics Department

Leader of HISP-UiO

kristin.braa@gmail.com

+4741630260

About HISP: https://www.mn.uio.no/ifi/english/research/networks/hisp/

About DHIS2: https://dhis2.org