Shifo Solution based on Smart Paper Technology

Shifo Solution enables reliable data to drive continuous improvement in quality of care and health outcomes for women and children

To dramatically decrease maternal and new-born mortality and morbidity and reach Sustainable Development Goal targets, countries need strong health system that provides equal, equitable and quality health services. To do so, major data gaps need to be closed to allow for proactive decision making and accountability using reliable, relevant and timely data, as data can show the root causes of specific problems related to poor health outcomes. There is lack of actionable, disaggregate level, quality data readily available at local, sub-national and national levels from existing health management information system on effective coverage of health services, health outcomes and existing gaps based on each health facility and area, thus hindering effective planning, accountability and resource allocation at all levels of the health system.
Major data gaps need to be closed from community to national levels to allow for proactive decision making and accountability in the health sector.
Shifo's Smart Paper Technology is a solution to achieve four desired outcomes and address one of the root causes of high maternal and child mortality and morbidity: 1) to ensure all women and children receive digital identity in rural, urban, emergency and conflict areas, 2) minimise administration time of scarce health workers by more than 60%, 3) digitise every woman and child's health records with above 99% data accuracy, consistency, completeness and timeliness, 4) ensure that above 95% of health centres perform continuous quality improvement actions, in order to improve quality of care and health outcomes. 
Shifo Solution is an innovative, hybrid paper-digital solution based on Smart Paper Technology. With Shifo Solution, health workers use the Smart Paper Forms to register women and children with a unique ID number, collect clinical data within the ante, intra, postnatal and child health periods. The Smart Paper Forms, which are modelled after, and replace, the currently used health registers and tally sheets, are scanned at a district or regional level (depending on the existing processes and structures) and data is automatically digitised. After the data is digitised, the system automatically generates national MoH reports, provides real-time indicators and dashboards for action, sends SMS messages to beneficiaries reminding about their due date and generates stock request reports to prevent under or overstocking of essential medicines and supplies. Solution integrates the data with other systems, such as DHIS2, logistics management information system and civil registration and vital statistics.

In two years of implementation, 94% of work processes have been integrated into existing health system structure in Afghanistan; 84% of work processes have been integrated in Uganda. In other words, in Afghanistan, 94% of activities necessary during operations are being conducted by existing health system, without Shifo's or other partners' support. Shifo has a five year exit strategy, and during this time, 100% of all work processes are transitioned/transferred/integrated into the existing health system structures.
Scientific evaluations show that Shifo Solution minimises administration for frontline health workers by 60-73%, is cost effective, quality of generated data is 99% and above.

Shifo Solution is an application of scanning, recognition, machine learning and artificial intelligence technologies including product and process innovations. Shifo Solution has no demand on electricity at the health service point, while the data processing is done through scanning at a station with reliable electricity, network coverage and security. Evaluations showed that it does not increase the work load for health providers, as other systems using point-of-care eHealth solutions often do, as they do not integrate into the existing system and create double work. Solution is co-created with health workers based on their needs and requirements. 

Shifo Solution digitises and processes information using scanning technology as well as machine learning algorithms. Shifo developed Smart Paper Engine which  performs automatic data processing, analysis, verification and report generation based on each country’s national needs, languages, clinical and patient data safety standards. Solution is implemented covering all health facilities- public, private, non-profit.  

Scale up and evaluate the solution nationally and sub-nationally in two countries, implement on district/sub-county level in four countries. Cover the population of 250,000 beneficiaries (women and children). 

Evaluation will focus if data use actions at facility and sub-national level are leading to improved quality of care and health outcomes for newborns, children and women before, during and after pregnancy and childbirth. 
Another evaluation will focus if Shifo Solution prevents under and overstocking of essential medicines and supplies in health facilities.

To reach up to 1 million women and children we plan to scale up and integrate the solution to the existing health system. We will continue working with MoH, UN agencies, funding agencies, research institutes. When solution is implemented on a national level, it benefits women and children living today and generations to come. We will work to cover reproductive, maternal, newborn, child and adolescence health and ensure health management information system provides quality, relevant data to empower decision makers along the healthcare chain to close the identified gaps-

Shifo Solution partners with Ministries of Health, UN agencies, NGOs, research institutes, and funding agencies when introducing and scaling up the solution in respective countries. Implementation costs are co-funded by the partners and after the implementation the governments take up all the costs to maintain the intervention. 

Shifo and its partners build local capacity in key stakeholders including MoH, UN agencies, NGOs. These master trainers train stakeholders at sub-national and facility levels. 
Implementation is done gradually covering one district/region at a time and reach every health facility in the country.

Currently more than 198,000 children and 15000 women are registered and followed up by health workers in child health facilities. These families receive SMS messages to remind them about their due date to increase demand for health services. Health workers have more time to provide better quality of care including health counselling. In countries with low mobile phone coverage, children who missed their visits are followed up by health workers using automatically generated follow up list. 

Solution is implemented in more than 500 health service delivery points in Uganda, Afghanistan, The Gambia and Kenya and from September 2018 in Tanzania.

By 2021 the goal is to reach and serve up to 1million women and children by implementing the solution nationally in four countries and working totally in eight countries on scale up initiatives at sub-national level.

In The Gambia, Afghanistan and Kenya, MoH agreed to scale-up the initiative sub-nationally and after further evaluation, decide on the national scale-up. The Government of Rwanda endorsed the solution and is planning for national implementation.

Shifo has a passionate, visionary, dedicated team with a range of diverse backgrounds including public health, biomedical engineering, business administration, development cooperation, research, user experience and design, business analysis, and software and hardware development.

We work to ensure impactful results in our programmes and based on the evidence engage funding partners to scale up the solution in existing and new countries. We have 63 priority countries where the need in our solution is greatest and build partnership with the government in these countries and work together since the inception of the programmes.

Using innovative sustainability model, pioneered by Gavi, for gradual country ownership to achieve longterm sustainability, Shifo prioritises implementation in 63 low- and middle-income countries, where the need is greatest, and works with health ministries during all phases of the project to ensure sustainability and replication of the solution nationally. Gradual transition and local ownership of activities to sustain the solution is done during the 5-year implementation phase, which includes investments in necessary infrastructure, capacity building, adjustments and implementation of the solution in health service delivery points, and integration to national standards and information systems, among other activities. From the sixth year, with the exception of the Smart Paper Technology Engine, all activities are performed by local partners. The cost analysis in all countries showed that governments can sustain the costs with the existing budget since the solution replaces existing system and does not create duplicated efforts. 

The license fee is 5 EUR/registered patient per year, but, for Shifo priority countries, the fee is reduced by 98%. Countries pay 0.1 EUR/registered patient per year for utilising the Smart Paper Technology Engine. To cover the costs of the implementation, Shifo receives funding from governments, foundations and NGOs.

Shifo's strategy to achieve its vision is working together with partners to close gaps in the health sector using reliable and relevant data. We are hoping to gain following from Solve: 

1. Receive expert advice about our strategy from domain strategy and tech experts

2. Raise awareness about Shifo's work and Smart Paper Technology in the Solve community

3. Gain access to Solve's community including tech leaders, foundations, leading research and development institutes

4. Get more friends and expand our network with Solve community and at Solve Flagship event

5. Share Shifo's experience and lessons learned with other creators and innovators

We need to work with strategic partners who share our vision and can support lean scale up and evaluation initiatives. There are strategic partners with whom Shifo should work to solve the problems causing high maternal and child mortality and morbidity in low resource settings by strengthening data quality and use in the health sector. Solve can hopefully facilitate Shifo to be known among the key partners and provide strategic advice to further the impact which Shifo strives to achieve.