Saving lives of children in Bangladesh through eHealth

SDG (3.2) targets to end preventable death of newborn and children under 5 years of age. In Bangladesh 142,600 children under 5 die every year, many of these deaths are preventable. WHO proposed IMCI strategy provides a paper based protocol to guide health workers through a systematic clinical assessment of children with febrile illness other for improved diagnosis and treatment.  Studies suggest that adherence to the guidelines can be improved when required staff is adequately trained and supervised.

IeDA is the proposed solution, it’s a tool that digitalizes the IMCI protocol and facilitates training and supervision of primary health workers.

Health service providers in primary facilities could diagnose and provide standardized treatment through IeDA with more accuracy. This solution is a robust and evidence-based tool that facilitates real-time access to clinical data and could be linked to  health MIS for further program evaluation, policy planning and aiding in decision making.

Adherence to clinical guidelines contributes to quality of care and decreased morbidity and mortality. The Integrated e-Diagnostic Approach is designed to improve adherence by assisting FHWs during consultation of children under 5 and adhering to clinical protocols.

Information exploitation is often missed out in digital health projects and leads to inefficient data use. Understanding incentives and responsibilities of data managers and discussing what information could support decision making is key to improving data use. IeDA’s participative and iterative approach uses this route to improve data use for decision making.

In Bangladesh under five child mortality is 46 per 1000 live birth which translates into 142,600 child deaths per year. The 2017 IMCI Newsletter showed that IMCI program received data from 64 districts and 480 Upazillas of Bangladesh, however the quality of these data stays unverified. The Report stated that data collection rate was 82% but did not speak about the usage of data.

IeDA intervention is designed to improve FHWs adherence to clinical assessment and effective data use leads to better performance management. Making both of these happen at the PHC level ensures marginalized population receives quality care while critical information gets seamlessly shared across the health system.

Tdh follows an inclusive and iterative approach with an user-centric design aiming to integrate the feedback of three core groups - the beneficiaries, the different users (caregivers and care providers), and the broader group of stakeholders including persons with disabilities, minorities, indigenous people and women. As concerns the users, Tdh carried out several consultations with them during the conceptualization, piloting and further scale-up phase.

 IeDA team will directly interact with the users, collect feedback through focused discussion and interviews and incorporate stakeholder feedback to improve the tool. IeDA is also designed to collect user and community feedback through the application that can be shared instantaneously with decision makers.

The priority targets of IeDA consist of the rural population, which includes the groups that are most vulnerable due to poverty and access to services, and thus present the worst health outcomes. The specific age-group that is addressed by IeDA consists of children under five years, whose vulnerability is attested by the high incidence of childhood illnesses and high mortality numbers in Bangladesh. Since the solution is implemented in public healthcare facilities, the ill-effects of affordability of these services, which is a major cause of the further exclusion are effectively countered.

In May 2019 IeDA crossed the 5 million consultation threshold, globally. Since 2014, IeDA has been used by over 5,400 healthcare workers in Burkina Faso. Diagnosis has improved, and treatment is more adapted to the children’s medical need. With five million children consulted through IeDA, Tdh has made strides towards guaranteeing the right to health of children in Burkina Faso. With the Tiger Challenge Tdh aims to bring IeDA to Bangladesh and adapt the IeDA strategy for other diseases like tuberculosis and dengue based on the epidemiology of under-five sickness, in Bangladesh.

The android based IeDA application is being positioned also as a real-time data collection tool, providing essential information to track epidemic outbreaks. The solution includes e-learning, coaching and supervision systems, that enables improvement of healthcare workers' training, improving efficiency of diagnosing and treating patients.

London School of Hygiene and Tropical Medicine (LSHTM) has evaluated IeDA’s impact and cost in Burkina Faso. Results show a significant improvement in diagnosis, in particular for severe cases. There is a 50% improvement in adherence to IMCI protocol and when scaled up to the whole country, there would be at least USD $33 to $66 savings per center each month. Tdh aims to replicate similar results in Bangladesh and increase the IeDA assisted consultation to a million under-five children in a year.

IeDA uses the REC (French acronym for Digital Patient Records), to guide FCWs through the IMCI protocol during under-five consultations. The REC guides FCWs through the IMCI algorithm from the clinical assessment, to the classification, prescription, referral and counselling. The application is powered by Dimagi’s CommCare software platform and is designed for handheld devices to ensure interoperability.

IeDA application supports healthcare workers in primary care facilities with 4 distinct tools:

• The diagnostic support tool helps diagnose and treat children according to protocols;
• The Learning tool helps assess and train healthcare workers in care protocols and regimens;
• The associated coaching and supervision strategies improve the motivation and skills and thereby, the quality of care;
• The collected data are centralised (in DHIS2) and made available to decision-makers in the form of customized dashboards for remote monitoring, targeted supervision and tailored trainings. 

Tdh also has an ongoing collaboration with Cloudera (a leading enterprise data cloud solution provider, offering Artificial Intelligence led analytics solution) to include AI tools for decision making. 

IeDA is as a strategy designed by Terre des hommes aiming at supporting health care workers in primary health care facilities with mHealth tools and methodologies. The associated coaching and supervision strategies improve their motivation and the quality of service. The mobile diagnostic support tool helps health workers diagnose and treat children according to the national protocols. The collected health data is centralized and made available to decision makers for remote monitoring, targeted supervisions and tailor­ made trainings. This integrated approach makes IeDA unique and effective. IeDA also uses a real-time feedback system through which users can send in feedback to the development team for further enhancements of the tool.

IeDA combines mHealth tools and data-driven quality improvement methodologies. With IMCI, IeDA provides the implementation on a clinical protocol that targets the main illnesses responsible for the death of children. Understanding that there cannot be quality of care without on-site coaching and supervision, IeDA introduces data-driven quality improvement methodologies targeting health workers and district managers. IeDA’s on-the-job eLearning tools address the issues of traditional training strategies that are not capable of building the knowledge required to sustain lasting changes in practices. The data collected by IeDA are processed and shared to inform stakeholders about health workers performance, supervision and training needs. This specific aspect becomes critical at scale in order to efficiently manage health systems.

Context: Children die of treatable and preventable conditions due to incomplete or poor quality of care received. Internationally adopted treatment protocols exist that can reduce this burden of mortality.

Poor adherence to protocols is attributed to inadequate training, material shortage, lack of quality supervision, poor data quality and lack of systems integration

Assumptions: Change will come when the health system becomes more responsive to the health needs of the population.

-Responsiveness of the health system requires it to be better informed, with skilled and motivated providers fully adhering to internationally-adopted care protocols

-This will happen when the system is guided by a compelling evidence base.

-This evidence base can be built using a correct diagnosis pathway and a system of gap identification in the health system.

Equity and efficiency considerations dictate that the pressure point should be where the health system is weakest yet most needed – i.e. primary care in rural settings.

Evidence: Providers who adhere to the IMCI protocol produce improved health outcomes for children they treat, especially for more complex cases

Better adherence to IMCI protocol leads to reduced usage of antibiotics

Impact: Children under 5 mortality and morbidity is reduced

Intermediate results: Increased IeDA usage leads to improved skills of HCWs related to IMCI protocol; This leads to HCWs following IMCI protocol more accurately.

IeDA integrates with the national health information system; Increases usage of performance data; Identifies gaps efficiently and commissions appropriate training and remedial measure leading to overall strengthening of the health system.

In May 2019 IeDA crossed the 5 million consultation threshold. Since 2014, IeDA has been used by over 5,400 healthcare workers in 720+ facilities. This is a major achievement for the health of children, diagnosis has improved and treatment is more adapted to the children’s medical needs. With five million children consulted with the help of IeDA, Tdh has made strides towards guaranteeing the right to health of children in West Africa.With the proposed intervention in Bangladesh, Tdh now aims to bring IeDA to Asia and adapt the IeDA strategy for disease conditions like tuberculosis and dengue based on the epidemiology of under-five sickness.

The android based IeDA application will be positioned as a real-time data collection tool that provides essential information to monitor early warning for epidemic outbreaks. The solution also includes e-learning, coaching and supervision systems, that enables improvement of healthcare workers' training, making them more efficient at diagnosing and treating patients.

The specific age-group that is addressed by IeDA consists of children under five years of age, whose vulnerability is attested by the high incidence of childhood illnesses and high mortality numbers in Bangladesh. 

IeDA in the first year of deployment in Bangladesh aims to cover 50 facilities that cater to approximately 60,000 under five children in 12 months. Over a span of five years, IeDA plans to expand in 200 facilities with an annual reach of 480,000 children under five.

The London School of Hygiene and Tropical Medicine(LSHTM) evaluated IeDA’s impact and cost in Burkina Faso. Results show the high acceptance of the tool and a reduction between 6 to 15% of antibiotics over prescription. There is a 50% improvement in adherence to IMCI protocol and when scaled up to the whole country, there would be USD $33 to $66 savings per center each month. Tdh aims to replicate similar results in Bangladesh and increase the number of consultations using IeDA to a hundred thousand under-five children every month.

While the IMCI paper-form was used for 69% and 68% of the consultations at baseline and in the control arm respectively, IeDA application was used in nearly all consultations in the intervention arm (97%). Overall, the average percentage of tasks completed by the FCWs across the IMCI algorithms was 48% at baseline, 54% in the control districts and 79% in the intervention districts with strong evidence for a difference between trial arms (cluster-level mean difference = 29.9%; P-value = 0.002).

After an initial start-up investment in a solution, the long-term ROI from eHealth tools results from proportionate savings in costs combined with an increase in value over time.  IeDA enables such economies of scale to be achieved, through ease of configuration to modify and maintain all aspects of the system, and speed of deployment and user onboarding. With a wider geographic scope and greater reach, Tdh believes these results can be replicated for a higher number of beneficiaries. 

Slow response from the government: To deploy IeDA in PHC facilities, Tdh will seek approval from the MoH. Coordination with the government might take longer than expected which could delay implementation.

Connectivity issues: Project anticipate some support from telecom service providers to ensure internet connectivity in all facilities. We might not get adequate support from mobile operators depending on their priorities.

Security/Risk : A national digital program must ensure standards for security, maintenance and quality assurance. Regulations and standards are constantly evolving and the solution provider should continue to be aligned with them. This can be a challenge as making iterative changes has cost implications. 

Slow response from the government Mitigation Measure: Tdh will lead the federal level coordination in association with partner and share the impact data available from the LSHTM evaluation study. Moreover, Tdh will initiate coordination with government authorities at the earliest. Tdh will deploy advocacy officers to work in tandem with the government to ensure the functioning of the project is not hampered.

Connectivity issues Mitigation Measure: Tdh will advocate with internet service providers to get their interest in this innovation. Tdh will also set up some data collection measures to ensure data from PHC facilities are centralized in a common database. Tdh will deploy a mobile device management solution called Focus. Focus allows programs to see how their health workers are using their devices at a distance, provides information about the status (battery, data credit etc) in order to provide remote technical troubleshooting for devices in order to ensure that the mobile application can be used effectively.

Security/Risk Mitigation Measure: Tdh has a dedicated risk management department in HQ that support delegations in case of critical risks. The delegations will share identified risks with the risk management department in case of risks and avail support.

IeDA uses the CommCare platform and CommCare has an automated built-in features and expertise that ensure consistency across national standards. For example, the platform is fully compliant with GDPR regulations and HIPAA standards for patient data security, allows administrators to encrypt and anonymize patient data, and manage user permissions to control access to data.

IeDA has been supported by a strong learning process. The conceptual framework has been designed from experiences and has evolved throughout the project lifecycle. It integrates research findings from several evaluations and analysis of users’ practices. Thus, each component has been created and implemented using an iterative process of development, feedback and refinement.

Deployment of IeDA in Bangladesh will be in three distinct phases - Localization and development, Piloting and iterations, Scaling and expansion. Phase1 will start with the application being adapted for local context and protocols. It is then made available on tablets provided to primary facilities to guide FCWs through the IMCI protocol. A quality improvement system will be setup that encourages each district and PHC facility to use data from IeDA and find appropriate solutions to improve the functioning of health facilities.

Phase2 is where the coaching component is initiated. The coaching app is used for supervision and coaching, including a monthly supervisory visit to PHC facilities by district personnel. The district, regional and national officials are trained on the use of the available dashboards. This phase also sees that community participation is encouraged and discussions on sustainability are initiated.

For IeDA scale-up, tools are progressively integrated through top down mechanisms (integration into a national strategy) and bottom-up support (engagement of the districts). The help desk is designed to support requests from all IeDA users. The desk collects user feedback, with two-way communication between users and support agents through multiple channels.

The total team working on developing IeDA globally is 15

Full time staff is 9, part-time staff is 1 and 3 are from the contractor team.

Tdh’s vision is to substantially reduce the burden of mortality for children under five and their mothers and IeDA fits well with our vision. IeDA strengthens PHC in rural areas through innovation and provides high quality Integrated Management of Childhood Illness (IMCI) consultations with accurate diagnosis and treatment.

Key staff

Riccardo Lampariello holds an MSc in Applied Statistics and an MBA. He has almost 20 years of experience in Health: from Pharma to International Organizations. As Head of the Health Programme focusing on maternal, newborn and child health. Riccardo is known for his expertise in portfolio & programme management, monitoring & evaluation, clinical drug development and project evaluation.

Kallol has worked in development projects across three continents, including the US, Tanzania, Ghana, India, Bangladesh and Indonesia. In his role with Tdh, Kallol leads Tdh’s health portfolio in Asia. In his previous role with GE Healthcare, Kallol led the designing of technology-based solutions for maternal and child health in Africa and Asia. Kallol holds an MPH degree from the University of Michigan and a Postgraduate degree in Management from IIFM Bhopal.

Guillaume has over 10 years of IT project management experience in seven countries in Europe, USA and Africa, working for both governmental and non-governmental organizations. Guillaume leads IeDA activation in Africa and provides overall oversight on the implementation of the project, including its technical, clinical and operational developments.  Guillaume Foutry holds a Master’s Degree in European Business from École Supérieure de Commerce de Paris and a Degree in Law. 

Dimagi and Tdh have successfully collaborated in West Africa for the last 5 years. We jointly developed and scaled IeDA in Burkina Faso, ensuring its successful transition to the government. Dimagi’s use of full product-oriented approach to ICT in low-resource environments, allows solutions to realize faster value and better support while benefiting from all the new features deployed on the CommCare platform. Because Dimagi commercially supports CommCare for different use cases for over 2000 projects, the users can be confident in the longevity of CommCare. This is preferable to a platform that is specifically built, which incurs cost for additional features and can potentially lose IT support without a commercial model.

Dimagi’s CommCare as a platform is proven at scale, demonstrated global adoption and proven to support National Digital Health Strategies. CommCare has the most proven evidence base of any digital health platform, with over 51 completed evidence studies.

 IeDA development approaches sustainability from two distinct yet interrelated perspectives. On one hand IeDA development is focused on developing a sustainable business model, which in turn supports the long-term sustainability of the initiative, with the goal of transferring the knowledge and skills necessary for the users to self-sustain. From the perspective of the organizational sustainability, IeDA team has established a business model designed to ensure our ability to provide ongoing support and ensure our soundness as an institution. In this vein, we are looking ahead towards shifting our financial model away from donor and partner-driven funding to one that is supported by the local government. This has given good results in Burkina and we expect to emulate a similar model in Bangladesh. IeDA uses the Commcare platform this allows health systems to realize faster value and better support while simultaneously benefiting from all of the new features deployed on the CommCare platform. Because Dimagi commercially supports CommCare for different use cases for over 500 projects, the users can be confident in the longevity of CommCare and Dimagi’s continual platform support. Dimagi has developed software plans providing varying levels of support on a graduated pay scale, based on the scope of the health system and the complexity of the requested features. This graduated pay scale helps policy makers introduce the solution while saving money. The primary consumer for Tdh is the government as we believe that public health system is the route to reach the most vulnerable and provide maximum impact. 

Tdh is in the process of handing over the IeDA operations to MoH Burkina (one of the main reasons we are no longer requesting funds for Burkina). With the cost savings by deployment of the tool being higher than the maintenance of the application when calculated at the individual facility level, we foresee similar models of transformation in Bangladesh. The Bangladesh MoH will ensure sustainability of the strategy and of the tool and will leverage own funds for the replication and scale within the country, looking at the benefits IeDA produces.

The project also aims to set up a social sustainability unit that will work towards popularizing the tool and advocate with government to adopt IeDA and improve IMCI service delivery. This team will be entrusted with taking IeDA to all corners of Bangladesh and advocate using the strong evaluation base that IeDA creates.

The crux of this approach will be to have a strong cost analysis done in Bangladesh similar to the model used in Burkina. This will provide a clear value add for the government and evidence for inclusion in the national strategy. Sustainability measure for IeDA will be the inclusion of it in the government plan of action.

Tdh is dedicated to Health System Strengthening (HSS) and works jointly with MoHs to ensure its projects reach all stakeholders. As IeDA is deployed in PHC facilities open to all communities and welcoming patients with disabilities, these groups will benefit from the intervention as they benefit from all types of care provided by these facilities. Tdh’s inclusive approach is expected to offer a level playing field to all professionals to be part of the project as staff, advisor, partner and as consultants. Additionally, special efforts will be made to encourage people with disabilities to work as team members by leveraging organizations who operate specifically to support people with disabilities. Tdh stays open to receiving non-monetary resources, as in support from Tiger IT Foundation for further improving the project’s inclusiveness for people living with disabilities.

On the Barrier front, a critical area of expertise will be the provision of internet in remote locations and working with service providers to garner their support. Tdh will appreciate support on building relationship with internet service providers to assist the solution targeted to reduce deaths of children under 5 years age. 

WHO:

• Malaria: They are already involved in the data management work focusing on malaria and will provide their technical expertise for the research
• Universal Health Coverage – One of the major thrust area for WHO and will be good to have WHO assess how IeDA can fit into the UHC model of Bangladesh

Tableau Foundation: Tableau is the default data visualization software used by Tdh for IeDA. Tdh has plans to train MoH stakeholders on how to use Tableau-powered dashboard.  

Maternity Foundation: They have offered to let Tdh use their Safe Delivery application that can be embedded into the eLearning tool.

Iterative approach: All products developed in this project (i.e. Mobile applications and dashboards) will be designed and tested with the MoH Bangladesh before a release. Each first release will be done with a small number of users, enabling Tdh to quickly collect feedback on the products and modify them accordingly. Tdh expects to have at least between 2 to 3 versions of all products within the course of usage of this funding.