The Community Health Toolkit

One billion people alive today will never see a doctor in their lifetime.

Health systems, as they currently exist, exclude people from care. For half of the world’s population, the nearest doctor or nurse can be hours, or even days away, and the health facilities that are reachable are unaffordable, understaffed, and under-resourced. System strengthening and system reform are needed at unprecedented scale to ensure people can access the care they need and deserve.

Gaps in health systems are bridged by millions of Community Health Workers (CHWs) – committed and trusted members of the communities where they live and work, and the first point of care for most families in remote, rural, and underserved communities. Unfortunately, most CHWs are disconnected from the formal health system and are largely unsupported after a few days of pre-service training. While extensive research shows that CHWs have immense potential to improve health outcomes, inadequately trained, equipped, or supervised CHWs may have little or no impact at all.

Technology could serve a key role in health system reform, but it is unclear whether this potential will be realized. Despite the rapid development of technology and communication infrastructure in these same parts of the world, the available technology is underutilized or ineffectively applied to support healthcare where it is most needed.

We cannot take it for granted that the right technology will exist, it will work for all people equitably, it will not unfairly extract resources or data from poor countries, it will reach those who have been marginalized, or that it will be used effectively to improve the lives of the poorest.

Medic serves as the steward of the Community Health Toolkit (CHT) – a leading open-source, digital public good serving more than 41,000 health workers across 15 countries in Africa and Asia. The CHT includes a collection of open-source software frameworks and applications, with resources to help partners design and deploy digital tools (“apps”) for care teams. To date, health workers using digital health apps created with the CHT, have performed over 70 million caring activities, including household registrations and screenings, pre- and post- pregnancy care, individual child assessments, family planning services, COVID-19 response, and more.  

The Core Framework of the CHT, developed and maintained by Medic, is a software platform designed and built to support an exceptional range of primary health programs, including the work of CHWs, frontline supervisors, facility-based nurses, health system managers, and even patients and caregivers. The Core Framework supports extensive customization, and makes it easier and faster to build more reliable, interoperable, and secure digital health apps than coding from scratch. Digital health apps built using the Core Framework can support many languages, run offline-first, work with basic phones (via SMS), smartphones (via Android Apps), tablets, and computers, and are integrated with complementary apps and health information systems such as DHIS2, OpenMRS, and RapidPro.

App developers can define health system roles, permissions, and reporting hierarchies, and leverage five highly configurable areas of functionality: in-app messaging, task and schedule management, decision support workflows, longitudinal person profiles, and analytics. 

As steward, Medic partners with local and national governments, implementers, technology partners, researchers, and local communities to develop people-centered, sustainable solutions that meet health, wellbeing, and development needs. We are committed to open-source resources so that any organization around the world can access free tools to support health workers and community health systems effectively.

We believe that we must design and deliver systems that reach those who have been marginalized within local health systems and communities. Therefore, our operating definition of “underserved” includes individuals who are marginalized in terms of wealth (both relative and absolute), distance (e.g. people living over five kilometers from a facility), gender, education, intellectual and physical (dis)abilities, racial and ethnic groups, religion, language groups, at-risk patients based on biology and disease transmission (e.g. people living with HIV/AIDS), specific vulnerable groups (e.g. refugees and orphans), or previous access to and experiences of care.

Medic and our partners are focused on frontline health workers as a means of reaching and positively impacting these underserved communities. We work in solidarity alongside communities experiencing extreme poverty, lacking infrastructure such as roads and reliable electricity, and facing other adverse social determinants of health and vulnerabilities.

Key user groups of digital health apps built with the CHT include CHWs, frontline supervisors, facility-based nurses, health system managers, and patients and caregivers. While frontline teams use apps for doorstep care coordination, managers and decision-makers use tools for performance management of CHWs, continuous program impact monitoring and evaluation, and data-driven resource planning and population health management.

The CHT enables more proactive and timely CHW supervision – a critical link to ensuring faster, better, and more equitable care. In addition to messaging functionality so CHWs can communicate with their supervisors and troubleshoot issues as they are traveling door-to-door, dashboards and data analytics allow supervisors and administrators to monitor CHW activities, their work outputs and progress against goals – and ensure all households are receiving health services. 

Through task and schedule management features, health workers can easily review who needs care, when, why, and where. Once a health worker arrives at the patient’s home, care guidelines – built into the app – guide the health worker through evidence-based, basic health care protocols, vetted through international global health standards. Additionally, apps built with the CHT record health data as a byproduct of care provision, allowing for a patient’s health record and profile to be created and continually updated over time.  

The CHT leverages technology to keep health workers engaged, equip them with evidence-based resources, support continual training and capacity-building, and provide proactive supervision to ensure optimal community care. As an additional benefit to the larger health system, health data generated through the apps can be used by national health systems and Ministries of Health to understand health challenges in a given region and apply the appropriate resources to develop innovative and meaningful solutions to improve health outcomes and well-being.

When Medic was founded over ten years ago, our product was simple, free software to send SMS messages on basic feature phones. Today, we are a team of 90+ full-time software developers, engineers, technical leads, designers, project managers, data scientists, operations experts, and researchers distributed across six continents – with hubs in Dakar, Kampala, Kathmandu, and Nairobi. We work together to create and champion a robust open-source software toolkit with global reach. Our interdisciplinary team builds the right tools and implements high-impact projects alongside partners, health workers, and patients in pursuit of a more just world where universal health coverage is a reality, and health is secured human right. 

We have a deep focus on people-centered design. To understand the needs of those we serve, our service designers design systems, workflows, and apps alongside CHWs and other users, directly at the community level. This approach makes us uniquely equipped to design solutions for complex use cases and health systems with the voice of the end user included throughout the process. 

We approach all partnerships as accompaniment, working closely with implementers to design systems that can deliver health to all. Our non-profit mission and approach to technology have helped us partner with over 75 local and national NGOs, local and national governments, and academic institutions that are improving models of care, uncovering new insights, and maintaining health systems for millions. We have a decade of experience collaborating with a diverse set of partners, across more than 100 health systems and more than 25 countries.

Medic is committed to building the CHT as a robust digital public good, nurturing a thriving community, helping the community and early adopters deploy and leverage the CHT to its fullest potential, and advancing R&D for health equity.

Over the last decade, Medic has contributed to a growing evidence base demonstrating how digital tools can support care in community health systems. With informed and empowered leadership, the implementation of global standards, and a focus on interoperability, the “right” technologies have great potential to address inequity for the people and places where it is needed most. 

We see an unprecedented opportunity to support and scale the shared, open-source CHT that addresses challenges faced by health workers. To do this, we must equip a growing community of implementers to build, own, and scale digital tools themselves. The demand for optimized digital tools far outweighs global technical capacity to build them. This causes leading health systems to attempt to develop solutions from scratch leading to duplication and resource wastage, or delay implementing digital health at the community level altogether. To close this technical gap, and grow the reach of the CHT community, Medic will identify and bolster NGOs, proximate technical organizations, and social enterprises to increase the global capacity for building on the CHT.

With support from Solve and its MIT-backed network, we can change the way digital tools for community health are built and deployed by creating and fostering a global network of independent, technically-savvy teams, collectively building on a common open-source platform. By doing so, implementers of last mile health delivery will have a proven, economically viable, digital foundation for improving the quality, speed, access, and equity of care delivery on a path to universal health coverage.

Investing in public goods and their technical stewards (e.g the CHT and Medic) is an important opportunity to scale digital health around the world, and it is an essential path to local ownership and financial sustainability in Low- and Middle- Income Countries (LMICs). Leadership from public, private, and funding organizations can contribute to this ongoing transformation, ensuring technology will be used efficiently to improve the health and well-being of the most marginalized communities.

Faced with an urgent need for shared infrastructure and increased efficiency in our field, Medic chose a unique approach that moved our tools, knowledge, and skills into the public domain. In 2018, we launched the CHT as an open-source project. 

The CHT is the only people-centered, cost-effective, scalable digital solution that is designed specifically for last mile health delivery. It is flexible enough to meet the needs of local health systems as well as national digital health programs. As a free and open-source digital public good, without licensing or per-user fees, the CHT is accessible to all LMICs and serves as a long-term, financially sustainable model to leverage software to improve the delivery of health care at the last mile.

We treat CHWs as health workers, not data collectors. We believe that technology and data can help make care work visible. Making care visible is essential to the process of advocating for care providers and for the communities they serve, who are often neglected or invisible in national-level resource planning, disease surveillance, and aid distribution. Additionally, health workers are experts in their respective communities and the health concerns of their neighbors. They are best equipped to inform on the design and functionality of digital tools to ensure the technology is enabling faster and better doorstep care.

We approach partnerships as accompaniment. We are committed to helping governments and other health systems create, own, and sustain systems that are accountable to an individual and community’s vision for health and well-being. 

We focus on catalytic research and development. We partner with implementing organizations, university-based labs and impact-driven funders to test out new ideas and features in support of advancing health equity and universal health coverage. Through these experiments, we hope to continually learn, generate new evidence of impact, advance our product roadmap, and contribute a wider range of features and resources for future adoption and scale.

As a digital public good, the CHT offers a distinctive opportunity to scale and sustain digital health around the world and offer LMICs a path to local ownership and financial sustainability where there might otherwise remain a market failure. Digital public goods have the advantage of being amenable to pooling investment across smart coalitions of philanthropic organizations and governments. This is necessary because the cost of developing and maintaining a feature-rich, flexible, standards-based, and scalable platform is greater than any one nonprofit organization or LMIC could sustain in perpetuity.

Support 55,000 health workers by the end of 2022, increasing by 20% per year over the next five years.

Alongside a coalition of partners including community-based organizations, Ministries of Health, academic institutions, and proximate technical solution providers, we are expanding our efforts to equip more health workers with free and open-source technology as they deliver care in the hardest-to-reach communities. Digital health apps built with the CHT are currently deployed in 15 countries in Africa and Asia, supporting 41,000 health workers. 

Enable 20+ million caring activities per year over the next five years

From household screenings to individual child assessments to providing women with family planning services, caring activities encompass a diverse range of relationships of care supported and facilitated by the CHT. When someone uses a CHT app to support a moment of care, we add the event to our global count of caring activities – a touchstone metric for understanding our organizational impact. In addition to health systems directly supported by Medic, we also gather data from health systems that have implemented their own CHT apps and that choose to share this important information with the global open source community. The current cohort of CHT-supported health workers performed 22.7 million caring activities in 2021 and over 70 million caring activities since the first deployment of the CHT. 

Scale Digital Health Through Community: Increase National Adoption and Technical Partner Network

Medic is focused on maintaining the CHT as a robust and mature open-source project. We continue to release our technical assets into the public domain and we are bolstering the CHT for partner engagement through product enhancements, capacity-building materials, and investment in local and regional technical solution providers around the world.

Impact is measured by continual CHT product releases; enhancement of formal, structured, and well-curated training materials and resources; development that supports the WHO’s SMART Guidelines and Digital Accelerator Kits; and growth of the CHT Community Forum – both in membership and contributions. Additionally, we measure impact by the number of governments that have adopted the CHT as their national digital community health platform and the number of technical solution providers (“Technical Partners”) equipped to design, build, and maintain CHT health apps independently from Medic.

To-date, six Ministries of Health have adopted the CHT and ten Technical Partners have been onboarded. Version 3.13 of the CHT was released in Q4 2021, with version 4.0 currently in progress. The documentation site is continually updated with resources, guides, and content, and the Community Forum currently hosts 545 members, 16,000 posts per year, and 83,000 page views per year.

Given the amount of high-quality data that is generated as a byproduct of our tools, we have a unique opportunity and responsibility to monitor health system performance, analyze data across use cases, understand our impact, and continually improve the tool and project. 

Medic uses a set of activity and impact metrics to understand the impact of CHT apps on health outcomes. These include primary and secondary indicators for key use cases supported by the CHT, including antenatal care, postnatal care, family planning, acute malnutrition, childhood immunizations, and integrated community case management, as well as metrics to measure the number of health workers supported by the CHT. With this data, we can accurately monitor the number of supported health workers and the number of caring activities completed by country, region or project.

Community expansion, partnerships, and national adoptions and tracked via various processes: forum metrics and website analytics, partnership agreements/contracts/MOUs, and public announcements of national adoptions.

Medic’s core areas of intervention include: (1) product, (2) community, (3) delivery, and (4) research and development (R&D). Within “product”, our indicators include, but are not limited to: the number of external integrations and the number of CHT-supported WHO digital health interventions. By prioritizing key product initiatives, expansion opportunities, and integration potential, we actively support the CHT’s Core Framework as a digital public good, and therefore users, partners, and health systems benefit from a robust, reliable, and well-supported digital tool.

Within “community,” our indicators include the number of active CHT forum members and their contributions. By building and supporting a thriving community of practice, we openly share digital health knowledge, best practices, and experiences; increase external contributions to the CHT;  improve design, technical, and implementation support; and rapidly expand and grow the community. These outputs increase confidence in and adoption of the CHT as a digital public good.

Within “delivery,” our indicators include: the global network of supported CHWs, the number of supported governments, onboarded Technical Partners, and caring activities performed by CHWs. By directly supporting delivery and scale-up of the CHT in early-adopter systems and identifying and onboarding Technical Partners who will build and deploy solutions using the CHT, we are able to sustainably deploy and scale the CHT with governments and with Ministry of Health ownership; deploy and scale the CHT with high-impact implementers to advance R&D and the product roadmap; increase capacity to independently design, deploy, and support CHT implementations in-region; and expand the global CHT community. These outputs lead to the CHT supporting a growing network of CHWs, Ministries of Health increasingly designing and managing their tools and data, a reduction in vendor lock-in, an ecosystem that fosters the right partnerships for impact, and increased funding for high-performing community health systems powered by the CHT.

Within “R&D,” by pursuing cutting-edge initiatives, we test innovations, prove them for impact, embed them into the CHT, and package them for scale. The outcome of this effort is accelerated innovation in health systems, with a focus on equity, speed, and quality of care.

The Community Health Toolkit (CHT), is a collection of free and open-source software frameworks and applications; open-access design, technical, and implementer resources; and a community of practice. The CHT is able to support care coordination for antenatal care, postnatal care, non-communicable diseases, immunizations, integrated community case management (iCCM), and nearly any infectious disease, including TB, HIV, and most recently, COVID-19. The CHT’s modular tools work together as an integrated platform for infectious disease preparedness, surveillance, and response as well as routine, essential community health services.

The Core Framework of the CHT, developed and maintained by Medic, provides a foundation on which developers can build new workflows, decreasing the time and resources required to build full-featured and ready-to-scale digital health apps – unlocking new opportunities to improve patient care. It supports extensive customization, and makes it easier and faster to build more reliable, interoperable, and secure digital health apps rather than coding from scratch. This combination of a streamlined, yet powerfully flexible app development toolkit is what makes the CHT highly useful for advanced community health programs, which often have complex task management, decision support, and performance management needs.

Apps built using the Core Framework can support many languages, run offline-first, and work with basic phones (via SMS), smartphones (via Android apps), tablets, and computers. App developers can define health system roles, permissions and reporting hierarchies, and leverage five highly configurable areas of functionality: messaging, task and schedule management, decision support workflows, longitudinal person profiles, and analytics. While frontline teams use apps built on the CHT for doorstep care coordination, managers and decision-makers use tools for performance management of CHWs, continuous program impact monitoring and evaluation, and data-driven resource planning and population health management. Additional functionality is available through integrations with complementary apps, electronic medical records, and national health information systems such as RapidPro, OpenMRS, and DHIS2 respectively. Key user groups include CHWs, frontline supervisors, facility-based nurses, health system managers, and patients and caregivers. 

According to OpenHub.net, the CHT is in the top 10% of highly-active open source projects around the globe, representing over 29,652 commits from 115 contributors, 992,268 lines of code, and an estimated 272 years of effort to build (COCOMO model).

Our work is driven by frontline health workers and community-based care teams, a large majority of whom are women. These health workers, in turn, provide care to mothers and children around the world. This keeps women and children at the center of everything we do. 

However, supporting women in technology goes beyond our users. It is also reflected in our product and team and is essential to our organizational success. While the technology sector, and the ICT4D field in particular, is characterized by significant gender disparities, we have developed and maintained a diverse team; 42% of the team, 60% of our leadership (including our CEO), and 50% of our board of directors identify as female. 

Additionally, we ensure our staff is reflective of the communities and health workers we serve – 68% of our teams are based regionally in Asia and Africa, staffed with talent that is local to the countries and contexts where we work. Over 70% of our global team and 35% of our leadership identify as persons of color.

Medic builds open-source software tools that are designed specifically for CHWs and health systems in the hardest-to-reach areas. Guided by our mission and insights from CHWs themselves, we have developed a unique delivery model focused on scale and replicability. We aim to make our tools accessible to any impact-driven health organization, regardless of their size or resources, by building capacity within partner organizations and ministries, using a free and open-source software license, and packaging our tools and learnings.

Medic has three key strategies to bolster and scale the CHT. 

1. End-to-end Support: For mission-aligned partners with established evidence and secured funding, Medic offers end-to-end support through deep partnership and accompaniment. From strategy and readiness assessment to workflow and systems design, app development and configuration, training, deployment, maintenance, technical support, and data-driven iteration, we support partners through the entire digital health journey.

2. Capacity Building: Medic works with implementing partners and Technical Partners to build internal capacity and expertise to design, develop, and implement scalable digital health apps powered by the CHT. Our onboarding process leverages tightly-scoped, curriculum-based training and workshops, as well as deeper, accompaniment-based support. Upon completion, partner teams are equipped to independently build and support CHT apps for their unique contexts.

3. CHT Stewardship: As steward, Medic’s role in the next decade is focused on five key pillars: (1) build and support the CHT as a digital public good; (2) nurture a thriving open-source community; (3) help the community deploy and use the CHT to its full potential; (4) advance R&D for care coverage, quality, speed, and health equity; and (5) set the global agenda in the digital ecosystem for community health.

While public goods are typically associated with open-source, there are many kinds of open-source business models; a defining feature of a successful public good is the presence of a community of users adapting and using the technology. As the steward of a public good, Medic has an obligation to maintain a business model that complements rather than competes with local implementers, and it means we pursue a product roadmap and onboarding programs that accelerate growth in the community of technical solution providers.

We are grateful for our incredible funders and allies over the past 10+ years, who believe in our work and have watched us grow from one pilot program in Malawi to 41,000 health workers across 15 countries. Philanthropy is Medic’s largest source of revenue. Development of the core product and our research and development efforts have been supported by philanthropic funding since our beginnings. An additional source of income is the contract revenue earned for partner services. This includes end-to-end engagement to design, implement, and support digital health programs, and capacity building services.

Medic is honored and humbled by our many incredible, long-standing funding partners who provide multi-year commitments and dedicated engagement with Medic’s work and to the CHT. Our funders include, but are not limited to: Anonymous, The Children’s Investment Fund (CIFF), Dovetail Impact Foundation, The Elma Philanthropies, Goldsmith Foundation, Google.org, Johnson & Johnson, Mulago Foundation, The Ray and Tye Noorda Foundation, Rippleworks Foundation, The Rockefeller Foundation, and Skoll Foundation.