HERA App

Today there are 80 million displaced people, more than at any other time in recorded human history, including World War II. This number is growing rapidly due to armed conflict, climate crises and other profound challenges facing humanity. Refugees encounter every kind of human crisis and challenge imaginable. For those refugees who manage to survive the trip to their host country, severe challenges and barriers remain to living a healthy, fulfilled life. Refugees have the same needs for shelter, warmth, water, food, community, access to adequate healthcare, and the other foundational tenets of basic and universal human rights ascribed to anyone else. Yet healthcare is often found far down the list of needs for refugees; though they are some of the world’s most medically vulnerable people, refugees frequently lack access to vital healthcare services due to linguistic, cultural and other barriers to care. Women and children, already more marginalized members of the population, are particularly affected by the gap between demand for healthcare services and supply of such services. 

For example, at present, Turkey hosts over 4 million refugees and, due to high mobility, refugees miss out on the vital continuum of care, including pregnancy check-ups during pregnancy and vaccinations in the first two or more years of life. Studies show that such disruption in the continuum of care increases the chance of death and disease, sometimes by as much as sixty times, compared to that of the host community.

Health Recording App (HERA) is an open-sourced mobile health (mHealth) platform that aims at increasing the uptake of preventive health services for pregnant women, and immunization for children under two years of age. The platform, through a mobile app, enables users to receive healthcare appointment reminders as well as health information, store centralized medical records, contact emergency services, and navigate what may appear to refugees to be a complex healthcare system in the host country. All of these features are available in multiple languages to overcome linguistic barriers to care, as refugees frequently do not speak the language of the host country. The app is currently available in Arabic, Turkish, English, and Dari and Pashto, and is available both for smartphones and non-smartphones. 

Considering that more than 80% of refugees have access to a mobile phone, HERA is a modern, mobile, easy-to-use, and language-accessible app where refugees can store their medical records and locate nearby medical clinics or emergency services. Unlike paper health records that may have been destroyed or left behind in their country of origin, refugees can bring the HERA app with them on their phones wherever they go. Given that refugees are frequently on the move, having a centralized and digitized place to store health records is a vital service; more often than not, physical records are missing, or even if refugees have hospital access, records are not transferred on the refugees’ behalf from one healthcare provider to another. In addition, the app helps refugees new to, or unfamiliar with, the host country, locate nearby healthcare providers through a geolocation feature.  

The HERA app also assists users in attending medical appointments such as prenatal care and routine childhood vaccinations by sending push notifications or SMS messages. HERA's push notifications do not require a consistent data network connection. In combination, these features can save lives and significantly impact the quality of life within one of the world's most vulnerable populations. HERA currently focuses on vaccinations and pregnancy care because maternal and child mortality is, sadly, exceptionally high in refugee populations.

To date since the beginning of the Syrian Civil War in 2011, millions of Syrians have fled their homeland, the majority relocating in Turkey. As of the beginning of 2022, Turkey recorded 3.7 million Syrian refugees within its borders, though this number may be undercounted. Turkey hosts more refugees by far than any other country. Approximately 47 percent of these refugees are children under the age of 17, and 23.2 percent are women between the ages of 18-59, according to United Nations High Commissioner on Refugees (UNHCR). Therefore, an overwhelming 2.6 million Syrian women and children refugees, or 70 percent of the total Syrian refugee population, have been exposed to the debilitating effects of forced migration, and therefore remain at risk for severe health consequences. 

HERA Digital Health is an organization that provides a mobile health platform via the HERA app, to ensure women have adequate pregnancy care and that children have access to basic recommended vaccinations. Our solution addresses the needs of refugee women and children by incorporating digital technologies to connect them with vital healthcare services. The vast majority of humanitarian aid interventions focus on providing a supply of medical services, leaving a gap in services for the demand side. Traditionally this mismatch has meant that even though medical services are available locally where refugees have relocated, refugees are unsure of how to access these services, and where to even begin looking for healthcare services. HERA focuses instead on increasing demand among refugee populations, namely for maternal and child health. HERA empowers refugees to take ownership of their health decisions, while also affecting behavior change in their healthcare seeking.

Users of HERA download the app to their phone, fill out basic demographic information including name and date of birth, number of children, basic child demographic information per child, and pregnancy status, and HERA safely stores user information in a privacy controlled and encrypted app environment. Users are then directed to a dashboard where they can access services depending on their current healthcare needs including push notifications for healthcare appointment reminders, targeted health information via a blog accessible in refugees’ native languages, access to centralized medical records, option to contact emergency services, access to pregnancy care, and more. HERA is designed for a low literacy and low health literate population, with simple user interfaces and a basic health literacy reading level. HERA is available in five languages, English, Turkish, Arabic, Dari, and Pashto, so users of the app can use it in their preferred language.

HERA is envisioned and designed by physicians and public health professionals who, collectively, possess more than 20 years of experience working with dislocated populations. Aral, founder and CEO has been serving the refugee community in Turkey since the beginning of the Syrian crisis. Prior to the Syrian refugee crisis, Aral worked with marginalized migrant farm workers living in extreme poverty. Though he is not a refugee, his family are internally displaced minorities (Alewite). Our team is made up of professionals both in-country (Turkey) and in the US. To better represent the target population, we prioritize hiring refugees in our field work. Currently the team in Turkey (4 staff members) is entirely composed of women, two of whom are refugees. Both of the staff members who are refugees come from the community of Syrian refugees with whom we work. All field staff members speak Arabic, Turkish and English. 

HERA’s pilot was designed and implemented with Syrian refugee mothers and refugee doctors, who fled their country yet continued serving their communities in Turkey. All of the features of the HERA app, and even the decision to create ‘an app’ versus a lower-tech solution, have been devised and planned with the target population themselves. HERA Digital Health leadership and staff did not create the solution first; HERA was born directly out of the needs of the field, created and developed with the community and the healthcare workers serving the community. In addition, HERA’s current IT coding professional working on the app is a Syrian refugee, who enlisted to be part of the solution to his community’s healthcare challenges.

The leadership and developers of HERA Digital Health and the HERA app have been intentional about receiving feedback from the community to ensure that their ideas and input are constantly utilized, so that HERA may better serve them. We keep close contact with initial users, Syrian refugee group from the pilot study, and implement formal and informal user experience and feedback, such as additional features or simplifying the user onboarding process. Since HERA is an end user solution, user buy-in is the single most important factor in our success, therefore, refugee user input and collaborative improvements remain central to our work.

Thanks to the initial success of our proof-of-concept and pilot project helping women and children refugees access healthcare, the HERA app is a viable solution, and scaling it to meet the critical challenge of multiple, and growing, global refugee crises is imperative at this time. 

Currently, the HERA app serves 3,000 refugees in Turkey as part of the expansion of the pilot project. The expansion has shown positive results on several fronts, and multiple peer-reviewed papers have been published on HERA's work. Based on this initial success, ambitious goals for the next four years have been set. Objectives for 2022 to 2025 include increasing the user base within Turkey to 30,000 users and scaling up support for other refugee populations worldwide, as well as creating sustainable partnerships with governments and international organizations interested in using the HERA app to support their refugee crisis response and humanitarian aid projects globally.

In addition to expansion in Turkey, HERA Digital Health is targeting piloting in several other contexts where it would be possible to work with local partners, including a just-launched partnership implementing the app with multiple refugee populations in Nebraska in March 2022. At scale, people will have multiple ways to utilize the HERA app. It is vital to keep HERA open-sourced and free in order to reach 80 million people who are forcibly displaced. 

We are seeking technical, financial, and other support in order to achieve these ambitious, and needed, programmatic and operational goals. HERA Digital Health also welcomes the opportunity to participate and learn with a cohort of other Solvers and receive mentoring, coaching, and strategic advice from experts, including the SOLVE and MIT network. We are ready, willing and able to actively engage in the 9-month SOLVE program to learn, grow, and scale our solution, and become part of a community of Solvers.

Unlike most interventions that focus on providing a supply of medical services, HERA focuses instead on increasing demand among refugee populations, namely for maternal and child health. Refugee women and children are some of the most medically vulnerable populations on the planet, therefore HERA empowers refugees to take ownership of their health decisions, while also effecting behavior change in their healthcare seeking. The HERA app does not multiply or duplicate existing health interventions, rather, it increases the effectiveness of existing health services by focusing on the gap between healthcare access and refugees. HERA helps refugees proactively manage their health care, thus reducing the ill effects of disease and other health issues. Currently, HERA is the only service of its kind for refugees on the market. 

HERA absolutely may serve as a catalyst and driver of change in the market. As open-source software, at scale, HERA may enable thousands if not millions of refugees access to vital primary care services, including pregnancy services and basic childhood vaccinations. As mentioned previously, there are 80 million refugees globally and counting, so the implications of a software that enables refugees to access healthcare services through their mobile phones, which four out of five refugees today own, are vast. It is critical that HERA remain open-sourced and free, in order to reach 80 million people who are forcibly displaced. In order to scale HERA, HERA Digital Health is spreading the word both with community and government partners alike who work with refugees. We work with said partners in Turkey who support the Syrian refugee population, of which there are four million in the country, and most recently, have begun work introducing HERA to refugees through community partners in the US. 

Ultimately, it is our vision to create sustainable partnerships with governments and international organizations interested in using the HERA app to support their refugee crises response and humanitarian aid projects, globally, because the refugee crisis is a global problem. At scale, people will have multiple ways to utilize the HERA app, including access to essential primary care services, health screenings including symptom screenings during epidemics or pandemics, and to receive health notification alerts including appointment reminders and even infectious disease outbreak alerts. 

Over the next year, HERA Digital Health has the following two main impact goals: Within one year, increase by 20% the uptake of preventative health services for pregnant women and immunizations for children under two years of age among refugees in Turkey, from 3,000 to 30,000; and pilot and modify our solution in several other country contexts. By 2025, HERA has an impact goal of enrolling 50,000 non-Syrian refugees on the app in at least two countries that host refugees. 

Over the next twelve months, the goal is to increase the current user population of 3,000, to over 30,000 unique users within Turkey through field expansion, utilizing workshops and online campaigns to spread awareness of the app. The primary goal is to reach 30,000 refugee women, or 20% of HERA’s total target population in Turkey who have vaccine-aged children or are pregnant in Turkey. In a given year this number will roughly lead to 90,000 vaccines being delivered with HERA as facilitator, and 60,000 pregnancy check-ups appointments completed. We will hire more field and coordinator staff in Turkey, are developing a marketing budget, and maintaining our partnerships with community and government partners who have in-reach with our target population to achieve this goal. 

This year we will also pilot HERA in other refugee populations to understand its effectiveness in various settings. As of March 2022 a pilot project is underway with Burmese, Afghan and Syrian refugee communities in Nebraska, a high-income setting in contrast to Turkey. HERA Digital Health staff are also in talks with local organizations in countries that include Iraq and Greece to explore pilot projects in their communities. 

Finally, HERA Digital Health’s five-year goal is to have enrolled 50,000 non-Syrian refugees on the app in at least two countries that host refugees. This goal will require registering HERA for use in at least two countries, country scoping visits, local partner identification and agreeing to and signing of memoranda of understanding (MOUs), outreach to the target population via grassroots organizations and establishing a network of partner organizations, and enrolling of at least 50,000 refugees in at least two countries with outreach and awareness raising activities, online marketing, and further translation of the app to appropriate target languages for specific refugee populations. 

We are measuring progress in empowering refugees in their healthcare seeking across several quantitative indicators, including increase in number of unique users utilizing the HERA app, and eventually, reduction in morbidity and mortality indicators. 

We are measuring progress by unique number of users actively enrolled and using the app. Currently, there are 3,000 active users, Syrian refugee women, in Turkey. That means that 3,000 more women have access to pregnancy care, vaccination appointments for their young children, safe and secure storage of medical records, and more, than before. 

Other quantitative indicators include the following, for 2021: 500 refugee women were trained in the importance of vaccines and pregnancy care; 300 refugees were informed about COVID-19, symptom screened and navigated to health services; 5000 vaccine appointments or pregnancy check-up appointments were facilitated; 3 papers on the uses of mobile health technologies in refugee crises were published; 5 additional cities were added (4 cities in Turkey, 1 city in the US) to field expansion; and, 15 additional organizations and local authority partnerships were completed. We will measure using the same or similar indicators as we scale up in 2022 and beyond. 

HERA's theory of change is based on the principle that processes, products, and services contribute to the achievement of desired results (outputs, project outcomes, and goals).

HERA's work is established on the principles of participation, which starts with ensuring that the “planning, monitoring and evaluation cycle" is participatory through the regular assessment of activities. 

HERA's work is committed to providing refugee communities with opportunities toengage with this project and directly contribute to it. HERA operates by ensuring the embedding of participatory approaches throughout the project lifecycle by building trust and aligning project goals with beneficiaries' needs. The action of continually revisiting activities, ensuring these match refugee needs, and continuously improving its monitoring and evaluation system to enhance the project's yearly performance informs the planning of HERA's activities and their implementation to meet organizational goals and objectives.

Our solution is born out of a need from the field itself, therefore, in line with our participatory emphasis, focus groups and refugee participant workshops are opportunities to solicit ongoing feedback for our solution. Additionally, we receive feedback from other organizations that serve our same population, including from field and case manager staff at grassroots organizations, as well as at key stakeholder meetings. Refugees are made aware that they are the most important stakeholders in the project and can actively inform app design and program direction, rather than being initially thought of in North America and implemented without the ownership of the refugee communities themselves. 

Part of ensuring an effective monitoring and evaluation framework is measuring the extent to

which progress has been reached for each objective, allowing HERA to further plan and report progress on a yearly basis. HERA's program manager will commit to sending monthly simplified financial reporting updates to all the investors. Board meetings are held online on a quarterly or ad-hoc basis. The board oversees financial and business updates, provides necessary best experience marketing and support, and decides on strategic development priorities. The CFO will hold corporate co-signature rights together with the Executive Director on all above-predefined threshold expenditures.

Health Recording App (HERA) is an open-sourced mobile health (mHealth) platform that aims at increasing the uptake of preventive health services for pregnant women, and immunization for children under two years of age. It is accessible to users through a mobile app which is available in smart phone and non-smartphone versions, which is useful for refugees as 80% or more of refugees today own mobile phones. 

Users of HERA have only to download the app to their phone, fill out basic demographic information including name and date of birth, number of children, basic child demographic information per child, and pregnancy status, and HERA safely stores user information in a privacy controlled and encrypted app environment. Users are then directed to a dashboard where they can access services depending on their current healthcare needs including push notifications for healthcare appointment reminders, targeted health information via a blog, access to centralized medical records, contact emergency services, access to pregnancy care, and more. HERA is designed for a low literacy and health literate population, with simple user interfaces and a basic health literacy reading level. HERA is available in four languages, English, Turkish, Arabic, and Dari, so users of the app can use it in their preferred language. 

In addition, we have recently finalized version 2 of HERA, which is more streamlined and easier to use than the original version. Like the original, it remains fully open-sourced; it is imperative to our mission that HERA remains open-sourced, so that, as we continue to scale the solution, it is accessible to more refugees and organizations working on their behalf. 

Some of the world’s most marginalized people, refugees, are HERA’s key customers, and our leadership and hiring mirrors that of the community which we serve. We are committed to diversity, equity and inclusion in our work and hiring practices. Our Chief Executive Officer (CEO) and Chief Medical Officer (CMO) identify as people of color, and our CEO identifies as a member of a minority internally displaced group (Alewhite) in Turkey. Of our five-member senior leadership team, two identify as people of color and two identify as women, so the majority of our C-suite team identifies as women or minorities (60%). 

In addition, in Turkey, where our primary operations are currently based, our team is 100 percent composed of women, and two of the team members are from the community that we serve, Syrian refugees, meaning that half of our team (50%) are refugees. Given that the vast majority of the people we serve are women, and their children, and of course, refugees, we prioritize hiring from these communities for our field team. Our coding IT professional developing the HERA app is also a Syrian refugee. 

We encourage and welcome diversity, recognizing it as a key competitive advantage. The value of different backgrounds and perspectives should not be overlooked. Having a diverse workforce assists us in looking at all situations from a variety of angles and encourages the development of innovative ideas and solutions. Embracing and understanding what each employee’s background and perspective can contribute gives us a competitive edge.

HERA’s key customers and beneficiaries are the refugees we serve. Our solution helps them connect with healthcare services and providers locally where they are. We are proud to offer our solution 100 percent free to refugees and are committed to keeping the HERA app free to all. Traditionally our revenue for our work has come from global health grants, however, as our value proposition depends on cost-saving and increased efficiency of existing interventions, we plan to move to a social enterprise model, partnering with healthcare providers to distribute the app. This will also allow us to provide HERA free of charge to the end-users. We estimate the levels of grant-based funding will decrease from 100% to 50% over the next five years. 

To date, HERA Digital Health has provided its free, open-source platform, via a mobile app, to our key customers, refugees. It is vital that HERA remain free and open-sourced, so that refugees can access the app and access healthcare without barriers, as well as to scale the solution to address healthcare access for millions of refugees. Traditionally, HERA Digital Health has received funding for this work primarily from global health grants, however, we plan to move to a more sustainable financial model by transitioning our organization to a social enterprise model. As a social enterprise, HERA Digital Health will partner with healthcare providers to distribute the app to refugee end users, allowing for greater financial growth to ensure the app remains a valuable resource to refugees and provide the app to a larger population worldwide without reliance on grant donors. The most immediate axis is the distribution of the app in Turkey where 3,000 users currently use HERA, and expansion to new locations including the United States. We anticipate approximately a five-transition to this social business model. 

HERA Digital Health has received the following funding: 25K from FastForward, 87K from Grand Challenges Canada, 10K (€) from the European Investment Bank (EIB) Social Innovation Tournament; 5K (€) from EIB SITolarship Programme; 30K from FFWD Demo Day (from individual donors), 8K from the American Beirut University Research Grant; 5K (€) from Sivil Dusun EU; and approximately 5K from individual donors.  

Additionally in 2022, we are piloting working with local health authorities and integrating with existing health systems. In April 2022, we are starting an RCT with the Ministry of Health (MOH) in Turkey to distribute HERA in the obstetrics and gynecology (OBGYN) hospitals in Istanbul to increase uptake of pregnancy care services, and compare the efficacy of HERA to the hospital-based electronic health records (EHR).