mHealth for CMMB

Community health systems already have a strong reach into remote communities, with frontline workers screening for and treating symptoms and reporting household-level health information. These community health workers (CHWs) are in the best position to identify concerns, but health systems are often limited by paper-based systems that must be hand-recorded, which slows preventative responses.

By putting disease surveillance tools into the hands of CHWs, health facilities will access real-time data, enabling early identification and response to trends and outbreaks. This enables more targeted responses to pandemics like COVID-19 as well as common childhood killers, like diarrhea and malaria.

At scale, mHealth enables health systems to respond effectively to needs for healthier, more resilient communities. Linking mHealth with disease surveillance in community health systems that work to target the greatest threats to maternal and child health will address both emerging and longstanding threats to public health among the most marginalized populations.

Across the low- and middle-income countries in which CMMB works, between 30 to 60% of rural communities cannot readily access basic health services—in Kenya, families walk up to six hours to access basic services, with specialized care even less accessible. If care is offered, available patient data is neither comprehensive nor accessible in real-time, so emerging public health developments are not immediately visible. Community-based health systems bring health services to hard-to-reach areas and with mHealth’s real-time data can help inform priorities to ensure the health system is effectively responding to the health needs of underserved populations.

Currently, household data is recorded by CHWs using paper-based registers before supervisors aggregate manually during monthly meetings. Facility-based clerks enter it into the health management information system (HMIS) where it can finally be analyzed for decision-making. In low-resource contexts, the slow transfer of data contributes to preventable deaths from diarrhea, unsafe childbirth, malaria, pneumonia etc. Real-time surveillance systems can be used to track and manage common morbidities and also identify and mitigate pandemics like COVID-19. Where resources are constrained, efficiency is key to saving lives, and mHealth helps direct limited health resources where they are needed most.

Designed to improve healthcare in hard-to-reach areas, Medic’s Community Health Toolkit operates through a mobile phone app to enable frontline healthcare workers to monitor family health and symptoms and provide quality care. Supporting multiple languages, the software runs on basic phones, smartphones, tablets, and computers, and works even when offline. The user-friendly functions support messaging, task schedules, care protocols, individual profiles, and analytics.

When integrated into health systems, mHealth data can be used to inform health facilities and local ministries of health of emerging and longstanding health needs to drive an appropriate response. The platform allows managers to monitor health indicators and compare performance across months, goals, and workers. Managers can also review submitted forms, track trends, and monitor key impact metrics.

This platform helps improve the quality of care delivered by CHWs at household level. In-app prompts help CHWs know how to provide preventative and frontline care and when to refer a patient for advanced treatment. The system can also host virtual consultation with specialists, has built-in follow-up reminders, and supports data sharing to help supervisors coach and mentor CHWs. By making CHW visits more productive, mHealth helps improve the coverage, quality, speed, and equity of health service delivery.

CMMB is committed to bringing quality health services to marginalized populations. Far too many women and children are dying needlessly as a result of poverty and illness. Despite significant progress in global health, marginalized communities are being left behind—5.4 million children under five still die every year from preventable, treatable diseases. The low-resource community health systems CMMB supports in Kenya, Zambia, and Haiti would greatly benefit from this mHealth initiative. In these underserved areas, CMMB is committed to developing informed health solutions and best practices at community level through constant dialogue with communities under its flagship CHAMPS (Children and Mothers Partnerships) program. Through CHAMPS, we engage local communities and health systems to ensure our interventions are locally-led, locally-appropriate, and aligned with local priorities. CHAMPS brings health services to the household level, eliminating barriers to care for populations that otherwise would struggle to access services.

Where CMMB works in Kenya, Zambia, Haiti, South Sudan, and Peru, far too many women and children are dying needlessly as a result of poverty, illness, and isolation. Despite global progress on health priorities—such as strides in childhood vaccination—disparities remain, especially in the hard-to-reach areas where CMMB focuses its work. There are great health disparities, with rural communities much worse off than the national averages. In these remote regions, CMMB supports community-based health systems with a focus on maternal and child health programs that address high maternal, newborn, and child mortality rates. Because primary health care facilities are few and communities are so widely dispersed, it is difficult for people to access the critical health services they need.

Haiti

Malaria— In 2017, only 31% of households had at least one insecticide-treated net (ITN), and only 41% of individuals in those homes slept under an ITN the night before the interview. Only 16% of all pregnant women and approximately 18% of all children under five slept under an ITN the night before the survey. 32% of children under five had fever in the two weeks before the survey. Advice or treatment was sought for only 40% of them. (IHE, 2018)

Diarrhea—In 2017, 21% of children under five nationally had diarrhea in the two weeks prior to survey. Prevalence of diarrhea is higher for children in households without any type of toilet (24%) than those with (17%); of the children with diarrhea, only 32% sought treatment. (IHE, 2018)

Immunization— In 2018, 41% of children aged 12-23 months had received all basic vaccines while 10% have not received any vaccine. In the Sud-Est region where CHAMPS programming is, vaccination is even lower, at 27%. (IHE, 2018)

Pregnancy— As of 2017 Haiti had the highest maternal mortality rate in the Western Hemisphere estimated at 529 deaths per 100,000 live births. From 2016-2017 the estimated neonatal mortality rate was 32 deaths per 1000 live births. Overall, 91% of pregnant women attended ANC1, while only 67% received ANC4. In 2020 where the CHAMPS program is implemented in Haiti, about 41% of all pregnant women received ANC4. (IHE, 2018)

Kenya

Malaria— In 2014, 37% of households did not have at least one ITN. 51% of all pregnant women and 54% of all children under 5 slept under an ITN the night before the survey. 24% of children under five had fever in the two weeks before the survey. Advice or treatment was sought for only 72% of them. (KNBS, 2014)

Diarrhea—In 2014 prevalence of diarrhea in children under five (in the two weeks prior to survey) was 15% nationally and 14.3% in eastern region. Country-wide, only 58% sought advice or treatment with a skilled health provider for treatment of diarrhea. (KNBS, 2014)

Immunization— In 2014, 79% of children aged 12-23 months had received all basic vaccinations, and only 1.6% had received no vaccination. (KNBS, 2014)

Pregnancy— In 2014 the maternal mortality ratio (MMR) was 362 per 100,000 live births, while the neonatal mortality rate was 39 deaths per 1000 live births. While 96% of pregnant women receive ANC visits, only 58% attended the WHO recommended ANC4 visits.  In 2020 where the CHAMPS program is implemented in Kenya, about 54% of all pregnant women received ANC4. (KNBS, 2014)

Zambia

Malaria— In 2018, 78% of households had at least 1 ITN. 49% of all pregnant women and 52% of all children under five slept under an ITN the night before the survey. A total of 16% of children under five had fever in the past two weeks before the survey and 77% of these children were taken for advice or treatment. (ZamStats, 2018)

Diarrhea—In 2018, the prevalence of diarrhea in children under five (in the two weeks prior to survey) was 15% nationally, with prevalence highest in Western province at 23% where Mwandi District is located. Prevalence of diarrhea is higher for children in households with an unimproved drinking water source (17%), and higher among children whose households engage in open defecation (17%) or use an unimproved facility (16%) than those who use improved toilet facilities (14%). Of children under age five with diarrhea, 62% were taken were taken for advice or treatment within 2 days of the onset of the diarrhea. (ZamStats, 2018)

Immunization— In 2018, 75% of children aged 12-23 months had received all vaccinations. In the Western Province where CHAMPS programming is, vaccination coverage is even lower, at 68%. (ZamStats, 2018)

Pregnancy— In 2018, Zambia’s MMR was 252 per 100,000 live births, and neonatal mortality was at 27 deaths per 1000 live births. Only 64% of pregnant women attended the WHO recommended ANC4 visits, while only 37% received ANC1 within the recommended first trimester of pregnancy. In 2020 where the CHAMPS program is implemented in Zambia, about 81% of all pregnant women received ANC4. (ZamStats, 2018)

In response to the plight of the most marginalized, CMMB has become a strong, committed partner in improving healthcare and strengthening health systems, including hospitals and local clinics. We have also built solid partnerships with ministries of health, especially at the county level. CMMB has worked to help county governments obligate increased resources to meet population health needs and reflect competing health priorities.

CMMB improves health in last-mile communities by preventing health emergencies, both on the household level and in the broader community. By integrating mHealth into the health systems reaching remote areas, CHWs are able to address the greatest health threats before they escalate. Using Medic’s Community Health Toolkit on their cell phone, last-mile healthcare providers are better able to detect disease outbreaks and respond, as well as address the greatest contributors to maternal and child morbidity and mortality. Because CHWs are trusted members of their own communities, they are key players in; information campaigns, encouraging healthy behaviors, combatting isolation, and preventing the spread of misinformation, especially around things like vaccinations. In addition, mHealth technology has the ability to virtually connect rural communities with specialists, removing the need for families to travel for hours on foot to access care. CMMB also builds the capacity of local health committees to provide community oversight of the demand for and supply of quality health service and reinforce healthy preventative behaviors.  

Sources

Institut Haïtien de l’Enfance (IHE) and ICF. Enquête Mortalité, Morbidité et Utilisation des Services. EMMUS-VI 2016-2017. (Pétion-Ville, Haïti, et Rockville, Maryland, USA : IHE et ICF. 2018) Pg. 167. https://www.unicef.org/haiti/m...

Kenya National Bureau of Statistics (KNBS), Ministry of Health/Kenya, National AIDS Control Council/Kenya, Kenya Medical Research Institute, National Council for Population and Development/Kenya, and ICF International. Kenya Demographic and Health Survey  (Rockville, MD, USA: Kenya National Bureau of Statistics, Ministry of Health/Kenya, National AIDS Control Council/Kenya, Kenya Medical Research Institute, National Council for Population and Development/Kenya, and ICF International. 2014). Pg. 150. https://dhsprogram.com/pubs/pdf/FR308/FR308.pdf

Zambia Statistics Agency (ZamStats), Ministry of Health (MOH) Zambia, and ICF. Zambia Demographic and Health Survey. (Lusaka, Zambia, and Rockville, Maryland, USA: Zambia Statistics Agency, Ministry of Health, and ICF, 2018). Pg. 159-160. https://dhsprogram.com/pubs/pdf/FR361/FR361.pdf.

CMMB’s CHAMPS program is strongly aligned with all four dimensions of the Challenge; something which will be strengthened by equipping last-mile healthcare workers, CHWs, with mHealth technology and training. We support local health authorities to better use data systems for decision making, which will enable early detection and prevention of future outbreaks. Our CHWs regularly carry out information campaigns and drive behavior change for health at community and household level. COVID-19 has intensified ongoing conversations about integrating mental health into our work. Each facet of the Challenge will be supported through the integration of mHealth into CMMB-supported community health systems.

In FY17, CMMB piloted Medic’s Digital Health SMS platform with 82 CHWs across six facilities in Kenya, to track ANC visits and facility deliveries. 78% of pregnant women in Medic’s system had skilled deliveries—against a national average of <50%. SMS facilitated real-time CHW–supervisor communications, strengthening the connections between last-mile communities and health facilities.

In FY18 we scaled up to 341 CHWs across 32 health facilities (we equipped facilities with tablets), and expanding tracking to include ANC, skilled deliveries, PNC, and immunizations. 85% of enrolled women delivered in facilities. A change of government in FY19 forced CMMB to rehire/retrain its entire CHV cohort. During FY20/21 all CHVs were retrained on Medic’s app-based platform and equipped with smartphones so they could undertake indicator tracking at household level.

Building on this experience, CMMB is well-positioned for a continued scale-up in Kenya and a rollout in our Zambia and Haiti programs.

Integrating disease surveillance via mHealth technology into maternal, newborn, and child health tracking that is already reaching remote communities is an innovative use of the technology and will significantly increase the reach of preventive public health protocols into the most remote communities. This is an opportunity to launch a new disease surveillance effort that builds on the foundation and learnings of successful community health tracking, and it is a natural next step, especially given learnings from the COVID-19 pandemic. This technology provides the opportunity to further catalyze enhanced community resilience through expanded health-seeking behaviors and strengthening preparedness against disease outbreaks. As CMMB works to integrate data for decision-making into these health systems, scaling up this technology will support these efforts and enable health authorities to respond effectively to emerging health threats.

Currently, CMMB’s rollout of Medic’s platform is serving 47,909 people in Kenya. In one year, with funding, CMMB plans to rollout the platform to the rest of our Kenya program (a total reach of 169,000) and half of our Zambia program (18,500), serving a total of 187,500 by the end of the next year. In five years, CMMB plans to have the platform fully rolled out and functional across our Kenya programs (169,000), Zambia programs (37,000), and Haiti programs (477,000), serving a total of 683,000 people.

Beyond CMMB’s programs, our ongoing partnerships with local and national ministries of health includes support for data-driven decision making. We believe that Medic’s Community Health Toolkit has the potential to transform national health systems’ disease surveillance and community health tracking.

CMMB has a robust monitoring, evaluation, and learning system, built on the LogAlto platform, with skilled staff overseeing these efforts in each country where we operate and at CMMB’s New York headquarters office. The indicators that CMMB uses provide:

• -A deeper understanding of how our projects contribute to the desired outcomes, as aligned with our CMMB impact pathways
• -Internationally recognized metrics with which to measure our programs
• -Global aggregation of projects’ progress
• -The ability to compare progress year to year and improve performance management

The CMMB global indicators have standardized definitions and measurements, ensuring consistency and correct calculations for our projects that will be recognized externally as valid. These are incorporated into the outcomes of our project logframes and monitoring, helping our country offices, and CMMB globally, to see progress on organizational outcomes and impact. These indicators align with CMMB’s Theory of Change, which is rooted in best practices and targets the greatest health threats to women and children where we work. Pertaining to the mHealth rollout, CMMB tracks the number of CHWs and health facilities operational on the platform, the number of pregnant women registered, the number of skilled deliveries, ANC and PNC services provided, immunizations, and more. Ongoing data analysis is facilitated by the platform’s tools, facilitating CMMB’s work with local health facilities and ministries of health to support quality data management and usage. CMMB headquarters conducts quarterly and annual data reviews and ensures quality monitoring and evaluation of project goals using LogAlto’s platform.

CMMB’s solution team includes the staff of CMMB Kenya, CMMB Zambia, and CMMB Haiti, with support from the headquarters office. Together, this is a team of 250 that each play a role in scaling up this solution.

CMMB has deep experience strengthening community health systems and implementing projects that bring quality health services to the last mile. We foster a culture of transparency and inclusion, focused on continuous learning and quality improvement. Weekly supervisory meetings anticipate and troubleshoot challenges before they become problems. Monthly financial reviews highlight budget-versus-actual execution. Quarterly program quality reviews for each country portfolio assess what works and has potential for replication or scale-up and identify activities needing remediation.

In line with our commitment to build local capacity, CMMB is actively engaged in discussions about localizing our work and supporting country-office staff to guide program priorities. Nearly all CMMB staff are residents and citizens of the countries they are working in, and CMMB-supported CHWs hail from the same communities where they serve in their role. CMMB is committed to meeting the greatest health needs of the communities where we work, as defined by data, our local teams, and best practices in global health.

CMMB’s headquarters’ technical team that provides support for our global programs. Technical director Yombo Tankoano, MA, advises on community health initiatives. Claudia Llantén, MD, MPH, MBA is CMMB’s maternal and child health and nutrition specialist, and she actively mentors and educates staff on health interventions and trends. Steve Power, MSc, is CMMB’s senior field adviser, who supports daily project management and reporting. Julia King, MA, manages CMMB’s global monitoring, evaluation, and learning systems. Julia is engaged in ongoing mentorship with staff to support data-driven decision-making.

CMMB is pursuing localization efforts across our country programs, in support of diverse, equitable, and inclusive leadership. Our Haiti, Zambia and Kenya country offices are at various stages of the localization process. The vast majority of CMMB staff are from the countries where they work, and CMMB is dedicated to strengthening the skills and leadership of these teams. CMMB values diverse perspectives throughout our programs and trains staff annually on diversity and bias to facilitate an inclusive environment. In our projects, CMMB builds the capacity of local stakeholders to ensure the project’s impact will sustain in the long term under local management and will support gender-sensitive health interventions.

CMMB is deeply committed to accountability to affected populations across all our programs. Our commitment to placing the most vulnerable communities at the center of our humanitarian response informs our programmatic approach and compels us to provide accessible information to and facilitate feedback from those participating in our programs and receiving assistance.

CMMB is applying to Solve because we are excited that our application of Medic’s Community Health Toolkit has such strong alignment with what MIT Solve has identified as one of the most pressing issues of this generation – disease surveillance. The prospect of accessing funding, partnerships and networks, technical support, and expert input for our initiative is an unmatched opportunity that would accelerate the effectiveness of our mHealth efforts tremendously. Additionally, the CMMB team believes that members of the Solve community and MIT D-Lab would be able to provide valuable insights into how we are addressing the barriers to implementation and scale-up. The area of greatest opportunity for input from this community is regarding the design and iteration of this mHealth technology as we build on our learnings and adapt it to meet the needs of varying country contexts.

CMMB would benefit from support in the strategy and development of this rollout to ensure that our plans are the best fit for the context where we work and the governments we plan to hand these systems over to in the long-term. Support in this area would help us iterate our design and approach as we roll out this mHealth initiative in different contexts.

Financial partnerships are key to this rollout, and CMMB would welcome support for this effort, as well as feedback on how to improve our pitch and presentation of these plans.

The monitoring and evaluation aspects of this initiative are key to our effectiveness, and CMMB has taken strides to improve our M&E systems and processes over the past few years. Input on data analysis and research would help CMMB optimally integrate our learnings.

CMMB hopes to partner with MIT D-Lab’s team on the initial research and rollout of Medic’s Community Health Toolkit in the countries where we are seeking to implement this system. Support for research and data analysis would also significantly benefit our effectiveness and learning as we work to refine and optimize these systems.

Some team members we would like to partner with in particular include:

Laura Budzyna, MEL Manager & Associate Director for Innovation Practice, as she is highly experienced with mHealth systems in various contexts Dan Frey, Faculty Research Director Amy Smith, Founding Director

CMMB would be honored to partner with any of these individuals or the broader D-Lab team. We are certain that this mHealth rollout would benefit from their insights and expertise, especially as we iterate the design approach and pilot the initiative across three different contexts.

Guided by global health best practices and our detailed needs assessment, CMMB’s flagship program, CHAMPS (Children and Mothers Partnerships), focuses on the root causes of poor health and high mortality in women and children. CHAMPS addresses maternal, neonatal, and child health, HIV, and WASH. CMMB also undertakes significant infrastructure improvement efforts, such as building obstetric clinics and water points, and procuring ambulances.

CMMB is working to scale up our mHealth efforts. We believe that by putting Medic’s Community Health Toolkit into the hands of CHWs, data can be sent to local health facilities in real time, enabling the health systems to identify trends and disease outbreaks early and respond appropriately. This not only applies to large-scale crises like COVID-19, but also supports healthy pregnancies, and can identify and respond to outbreaks of common childhood killers, such as diarrhea and malaria.

If scaled globally, mHealth usage could enable health systems to respond effectively to needs for healthier, more resilient populations. Linking disease surveillance with mHealth into community health systems that are already working to target the greatest threats to maternal and child health would help address both emerging and longstanding threats to public health among the most marginalized women and children worldwide.

Community health systems are already designed to have a strong reach into remote communities, with frontline workers screening for and treating symptoms and reporting crucial health information as they visit individual households. These community health workers (CHWs) are in the best position to identify health concerns, but the health system is often limited by paper-based systems that must be recorded by hand, which compromises their ability to enact preventative measures.

By putting mHealth and disease surveillance tools into the hands of CHWs, data can be sent to local health facilities in real time, enabling the health systems to identify trends and disease outbreaks early and respond appropriately. This not only applies to large-scale crises like COVID-19, but also outbreaks of common childhood killers, such as diarrhea and malaria.

If scaled globally, mHealth usage could enable health systems to respond effectively to needs for healthier, more resilient populations. Linking disease surveillance with mHealth into community health systems that are already working to target the greatest threats to maternal and child health would help address both emerging and longstanding threats to public health among the most marginalized populations.