E-Heza Data Solutions

Primary health care is widely perceived as the pathway to Universal Health Coverage (UHC) and achievement of the United Nations’ Sustainable Development Goals for health. Realizing the promise of primary health care and UHC around the globe, however, depends upon the ability of primary health care delivery systems to respond to the changing needs of frontline healthcare workers and the communities they serve. Successful primary care delivery systems require proactive frontline health workers who actively encourage their community members to invest in the future through preventative actions today, and community members who must engage with the system and adopt new behaviors despite struggling to meet immediate needs. When systems fail to recognize and support the facilitators of effective primary care delivery, healthcare workers develop burnout, quality of care diminishes, women avoid care, and health outcomes suffer. There is a global shortfall of 18 million frontline health workers, and rates of burnout- characterized as depersonalization, emotional exhaustion, and lack of sense of accomplishment- among existing health workers is as high as 70% in Low- & Middle-Income countries. Not only does this negatively affect recruitment and retention of the health workforce, but burnout has been proven to have a negative impact on the quality of care that is provided. Poor quality of care has been shown to decrease patient engagement in care and adoption of care recommendations. Poor adherence to care recommendations is known to lead poor health outcomes. To realize the promise of primary care and achieve the Sustainable Development Goals for health, it will be critical that health systems facilitate an effective and resilient health workforce that delivers high quality care to families in a way that inspires engagement in care and adoption of care recommendations.

TIP Global Health’s technology-enabled model of primary care delivery builds effective relationships between frontline health workers and community members to strengthen local health care delivery systems and achieve lasting improvements in health outcomes. We listen to communities to understand the barriers to providing and receiving high quality care, and co-design processes to overcome these barriers while aligning with government partners and priorities for ease of national scale-up. Our model promotes a health workforce motivated to provide high quality care and families who are engaged in care and inspired to adopt care recommendations, ultimately leading to sustained improvements in health outcomes.

E-Heza is a software technology created by TIP Global Health alongside frontline health workers and the Rwanda Ministry of Health to enable the rapid expansion of our approach for effective primary care delivery. E-Heza is the first point-of-care digital tool designed alongside frontline health workers to optimize high quality care for families across the entire spectrum of primary care from villages to health centers and hospitals, while building community trust and utilizing collected clinical information to track key indicators and identify emerging outbreaks. E-Heza incentivizes data quality by utilizing data trends to provide personalized care, improve engagement in care, celebrate successes, and identify emerging challenges; all while preventing health worker burnout by decreasing workloads, supporting workflows, and maximizing opportunities for meaningful interactions with patients.

E-Heza was originally developed to strengthen the effectiveness of Childhood Growth Monitoring Programs in rural Rwanda by facilitating group health assessments to promote screening, early diagnosis, treatment, and referral for cases of childhood undernutrition, and by utilizing growth trends to provide personalized health education to mothers. Now serving the entire spectrum of primary health care- including maternal and child health, common infectious diseases, and non-communicable diseases- E-Heza provides real-time decision support that is fully aligned with World Health Organization best practice clinical protocols. Personalized family progress reports are sent to pregnant women and mothers with young children via WhatsApp, providing tools to advocate for family health needs with other family members in the home. E-Heza utilizes FHIR standards, and has demonstrated interoperability with both OpenMRS and DHIS2. By ensuring quality data collection at the point of care, national governments and international institutions have access to reliable and real-time data to effectively drive public health decisions.

TIP Global Health believes that the only truly effective solution to the urgent need for quality healthcare is to build strong community-driven health systems with thriving frontline health workers at the center.  We do this by prioritizing and advocating for the needs of frontline health workers- primarily nurses, midwives, and community health workers- who serve the most socioeconomically vulnerable communities in East Africa while supporting their own mental and physical health. As such, frontline health workers are the target population for our work. While our interventions are designed for frontline health workers, the ultimate beneficiaries are community members who benefit from the increased quality of care provided by frontline health workers.

TIP Global Health currently serves a total population of 450,000 people in four districts in Rwanda. More than 110,000 women, children, and men are registered on E-Heza and have been seen by a trained frontline health worker through 299,151 care visits. TIP has trained more than 2,000 frontline health workers in our primary care toolkit, with over 650 of these providing direct care utilizing E-Heza Data Solutions.

TIP Global Health is a leading authority in developing lasting solutions on the frontlines of health. TIP’s transformative approach to collaborating with frontline health workers, alignment of its work with government priorities, and rigorous data-gathering, enables the scale-up of highly-effective solutions to extend access to life-saving quality care.

We empower frontline health workers to take the lead in creating lasting solutions, and we work to strengthen health worker capacity, resilience, and hopefulness. TIP never forgets the undue burdens and stressors placed on under-resourced and too few frontline health workers. The well-being of frontline health workers and the relationship between health care provider and patient is key to every step of our problem-solving process.

Early on, we align with government partners and priorities for ease of scale-up. TIP works in true partnership with government officials from the start to align with their priorities, protocols, and existing structures, by sharing information with all who need it, and by developing solutions on the frontlines that are self-sustaining and easily replicable. To ensure effective implementation strategies and scale-up policies, TIP designs a mechanism for communities and frontline health workers to provide feedback to government officials. TIP serves as a go-to resource for government officials and implementing organizations on how to get things done and in the right way.

TIP Global Health is a longstanding partner of the Rwanda Ministry of Health, and recently signed an MOU with the Rwanda National Child Development Agency- a newly formed collaboration between several national ministries and supervised by the Ministry of Gender and Family. Our team members serve on the national technical working groups for E-Health, Community Health, Reproductive Maternal Newborn & Child Health, Behavior Change, Mental Health, and Non-Communicable Diseases.

TIP’s local on-the-ground expertise and community-driven solutions are key to lasting improvements and quality of care.  All of TIP in-country staff come from the communities we serve. We know that local leadership is crucial to the design, implementation, and effectiveness of our programs for the betterment of people’s lives. TIP’s experienced team apply and adapt the best thinking and most transformative approaches to solving persistent health challenges. TIP builds strong relationships with community stakeholders by listening, learning, and co-designing for successful solutions. 

TIP Global Health co-designed E-Heza Data Solutions alongside frontline health workers and mothers to serve the primary care needs for all women and children. Our team gathers continual feedback from frontline health workers, mothers, and the Rwanda Ministry of Health to ensure a relevant tool for all stakeholders. An integral component of E-Heza’s success is rooted in the expertise of our team and the frontline health workers with whom we have worked for over a decade. Our clinical team understands the type of data being collected, the flow of this data, and the most efficient and effective ways to collect and analyze this data at an individual, community, and national level.

Since 2012, TIP Global Health has worked alongside frontline health workers and the Rwanda Ministry of Health to co-create, test, refine, and expand our model using E-Heza to drive quality improvements in health care throughout Gakenke District. Over a ten-year period, our work together in Gakenke District led to a 42% decrease in stunting, 51% decrease in underweight, and 46% decrease in <5 child mortality among a population of over 338,000 people: significantly higher than the national rates of decline in these indicators during this same period. We believe that TIP Global Health played a role in these dramatic reductions. As part of our success and our Ministry of Health partnerships, TIP Global Health now serves a total population of 450,000 people in four districts in Rwanda. TIP will be expanding E-Heza to ten additional districts serving a total population of 3.2 million people through a national government partnership beginning in October 2022.  

Over the next two years, TIP Global Health will reach 3.5 million people via E-Heza implementation in all provinces of Rwanda and expansion into Burundi via our implementation partners. During this time, TIP will conduct a randomized controlled trial to rigorously prove our ability to facilitate higher quality care in a way that leads to increased engagement in care and adoption of care recommendations as the mechanism by which we will achieve Sustainable Development Goals for health. 

We are applying to this challenge to support three key aspects of our growth:

1. Financial resources to support the organizational infrastructure growth to support E-Heza's expansion.

2. Technical support as we refine our business model.

3. Visibility as we demonstrate the impact of our model.

TIP Global Health is deeply committed to influencing the design, policy, and investment practices of national and international actors to ensure effective and resilient local primary health care delivery systems that achieve sustained improvements in health outcomes. We believe that this challenge would provide the financial means, technical support and influential platform to achieve our goals.

E-Heza’s design facilitates adherence to clinical care protocols, accelerates effective communication between levels of care within the health system, and provides real-time data trends for personalized health education and for ongoing quality improvement activities. E-Heza is the first point-of-care digital health platform designed to optimize high quality care for families across the entire ecosystem of primary health care from villages to health centers and hospitals while serving as an early warning system for emerging outbreaks. Data quality is critical for effective individual care and for successful public health interventions. E-Heza was designed to inspire high quality data by utilizing data trends to provide personalized care, improve maternal engagement in care, celebrate successes and identify challenges before they become emergencies, while preventing frontline health worker burnout by decreasing workloads, supporting workflows and maximizing opportunities for meaningful interactions with their patients. This data is aggregated to provide community ‘primary care’ through dashboards that describe the community’s progress towards key health indicators and emerging trends in symptoms and clinical findings such as fevers or diarrhea. By ensuring quality data collection at the point of care, national and international governments have access to reliable and real-time data to provide early warning and to drive decisions. By prioritizing high quality individual care as a path by which we can achieve successful public health measures, we build equity into the system and ensure inclusive and successful public health responses.

TIP Global Health considers our impact in terms of reach, quality of care, engagement in care, and health outcomes.

Reach: Our ambition is to directly improve the health of 3.5 million people across Rwanda and East Africa by 2024 through the scale-up of our technology-enabled model of effective primary health care. We will do this through the expansion of E-Heza and our primary care toolkit throughout all fourteen districts where we work in Rwanda, while collaborating with partners to bring E-Heza to Burundi in 2022-23 and laying the foundation to expand into two additional countries in 2024-25. Expanding through trusted partners who are committed to the fidelity of our model ensures a cost-effective approach to dramatically increasing our reach and impact.

Quality: TIP Global Health utilizes our 5 Pillars of Quality framework that evaluates clinical skills, patient-centeredness, health education, data management, and logistics to support meaningful implementation of standards based on guidelines and evidence from across WHO technical programs that support and reinforce efforts to improve quality of care. TIP created our 5 Pillars of Quality observational check list (OCL) to evaluate these quality metrics at the point-of-care. On average, the quality of care increases by 85% six months post-implementation of E-Heza. Our goal is to achieve a consistent quality score of >90% across all sites where E-Heza is in use.

Access and Engagement in Care: Early and ongoing engagement in care is a core aspect of effective primary health care, particularly for pregnant women and children under five. Currently, we utilize engagement in care for pregnant women as proxy indicators for engagement in all primary care activities. Below describes key indicators and impact goals. 

• Percentage of women who have their first ANC visit in the first trimester of pregnancies (increase from 63% to 75%) 
• Percentage of women who receive at least 4 ANC visits throughout their pregnancies (increase from 50% to 75%)
• Percentage of deliveries performed by a skilled attendant (>95%)
• Percentage of women who receive a post-partum assessment within 48 hours of delivery (increase to 90%)

Hope: The Herth Hope Index-Kinyarwanda is a cross-cultural adaptation of the Herth Hope Index. It measures hope and its three psychometric properties- interconnectedness, readiness for change, and future-oriented mindsets. The validation and reliability process, as well as evaluation of its psychometric properties, can be found in our published manuscript.  Because TIP believes that hope is a critical precursor to behavior change and resilience, baseline and yearly HHI-K survey are conducted with frontline health workers and a statistically significant number of patients. 

Health Outcomes: Maternal and child health outcomes have been our primary area of impact measurement. This includes health outcomes that are demonstrated to improve with increased engagement in care- maternal anemia, low birth weight, and child undernutrition- as well as outcomes that are known to improve when these metrics improve, such as maternal, neonatal, and under-5 child mortality. Goals for sites using E-Heza are listed below:

• Maternal Anemia- decrease by 30% from baseline over 3 years
• Low Birth Weight- decrease to <6% over 3 years
• Stunting- decrease by 15% from baseline over 3 years
• Wasting- decrease to <1% over 3 years
• Underweight- decrease by 10% or to <5% over 3 years

Indicators are described in more detail in previous answer. The following indicators are aligned with the UN SDGs. Each of the metrics are tracked from data collected by E-Heza.

• Stunting (2.2.1)
• Wasting (2.2.2)
• Maternal Anemia (2.2.3)
• Maternal Mortality (3.1.1)
• Mortality Rate for Children Under 5 (3.2.1)
• Mortality Rate for Newborns (3.2.2)
• Universal Health Coverage (3.8)
  • % of women with 4 antenatal care visits per pregnancy
  • Family planning needs met
  • Child Immunization Rates (DTP)
  • Health Seeking Behavior
    • Time of symptom onset (fever) to engagement in care

TIP Global Health was founded on the premise that achieving Sustainable Development Goals for health will require an effective and resilient health workforce that delivers high quality care to families in a way that inspires engagement in care and adoption of care recommendations. We have used our vast experience in community-led health solutions in Rwanda to establish a comprehensive primary care model that facilitates frontline health workers’ ability to effectively integrate national policies into existing local health systems while working within the reality of resource constraints. This model supports the integration of new clinical guidance and protocols into existing care provision workflows, provides the rationale behind the new clinical  guidelines, builds strong clinical skills, promotes effective communication strategies for delivery of personalized health education, institutes continuous quality improvement processes, and provides a framework for problem-solving barriers to high quality care. TIP Global Health created a digital health platform called E-Heza Data Solutions to rapidly accelerate our effective model of primary care delivery. 

TIP Global Health theory of change is consistent with the World Health Organization's framework for quality of maternal and newborn care. We focus on the tools and processes to increase the quality of care in a way that increases engagement in care, adoption of care recommendations, celebrates short term health improvements, to achieve and sustain long term improvements in health outcomes. Below is a diagram of the WHO framework.

Our Primary Care Toolkit

1, TIP Education Model- This interactive approach, specifically designed for adult learning, encourages pre-session preparation and a realistic discussion about participants’ ability to implement the lessons learned.  The educational approach, described as See It, Say It, Do It, Teach It, Talk About It, encourages trainers to utilize at least 2 of the first 4 components of the model and then to end each education session with a brainstorming session regarding potential barriers to implementing the new information.

2. Protocols to Practice Skills Training- Health care workers are trained to understand the reasoning behind the protocols, illustrate the complimentary nature of overlapping protocols, and highlight opportunities for critical thinking within these protocols. Through interactive trainings, our team builds transferable skill sets by demonstrating the commonality of all protocols and breaks down the siloed thinking around disease states that can occur when care is protocol-driven.

3. Five Pillars of Quality- Asset-based Continuous Quality Improvement- TIP Global Health developed a unique approach to Continuous Quality Improvement established to strengthen adherence to clinical care protocols by promoting health care worker participation, skills, innovative mindset and trust that their actions will lead to improved health outcomes. In addition to health outcomes such as rates of malnutrition and HIV transmission, we focus on the key processes that lead to accurate diagnosis and treatment because this demonstrates to health care workers and patients that their actions are leading to the health outcomes they are striving for. Successes are celebrated, and challenges are identified. Small teams conduct improvement projects to address these challenges, and present their project and results at a collaborative meeting of all health centers in a hospital catchment area. These projects, also know as Plan, Do, Study, Act (PDSAs), strive to address structural barriers to the challenges to support sustained improvements.

E-Heza Data Solutions

E-Heza is a digital health platform created by TIP Global Health that enables the rapid expansion of our approach for effective primary care delivery. E-Heza’s design facilitates adherence to clinical care protocols, accelerates effective communication between levels of care, and provides real-time data trends for personalized health education and for ongoing quality improvement activities. E-Heza is the first point-of-care digital tool designed to optimize high quality care for families across the entire ecosystem of primary health care from villages to health centers and hospitals while serving as an early warning system for emerging outbreaks. Data quality is critical for effective individual care and for successful public health interventions. E-Heza was designed to inspire high quality data by utilizing data trends to provide personalized care, improve maternal engagement in care, celebrate successes and identify challenges before they become emergencies, while preventing frontline health worker burnout by decreasing workloads, supporting workflows and maximizing opportunities for meaningful interactions with their patients. This data is aggregated to provide community ‘primary care’ through dashboards that describe the community’s progress towards key health indicators and emerging trends in symptoms and clinical findings such as fevers or diarrhea. By ensuring quality data collection at the point of care, national and international governments have access to reliable and real-time data to provide early warning and to drive decisions. By prioritizing high quality individual care as a path by which we can achieve successful public health measures, we build equity into the system and ensure inclusive and successful public health responses.

E-Heza Data Solutions is a digital health application designed by and for the frontline health worker- primarily nurses, midwives, and community health workers- that can be used on a smartphone or tablet.

With a global shortfall of 18 million frontline healthcare workers and the pressure on the existing health workforce to provide more services to more people more often, it is critical that digital tools are designed to support the needs of frontline healthcare workers and their ability to provide higher quality care to the community members they serve.

E-Heza captures essential data at the point of care by providing frontline health workers with immediate insights to help personalize information and advice, and help track the well-being of families. WHO guidelines inform algorithms that suggest diagnoses, treatment recommendations, and ongoing care. Over 20 million discrete clinical data points related to symptomatology, physical exam findings, and laboratory test results have been collected- providing ample opportunity for machine learning in the future.

E-Heza is a project of TIP Global Health and is an open source software project governed by the E-Heza Executive Committee. We welcome participation in the project through contributions of code, testing, documentation, and feature requests. E-Heza open source software is licensed under the Apache License, Version 2.0.

On the front end, E-Heza is developed in Elm, an open source and functional, statically-typed language that compiles to JavaScript. On the back end, the application is served by Drupal, an open source PHP content management system. The front and back ends communicate through a Restful API developed as a contributed module to Drupal. E-Heza adheres to all FHIR standards, ensuring interoperability with any digital platform that follows similar standards.

This is a link to the E-Heza wiki. In addition, this is a link to a series of demonstration videos that show how E-Heza is used in the community and at rural health centers in Rwanda.

Across Sub Saharan Africa, the vast majority of primary care delivery is conducted by nurses and midwives in health facilities and community health workers in villages. E-Heza is designed to facilitate their ability to provide high quality primary health care to their communities. All data is collected in E-Heza, and frontline health workers are motivated to enter accurate data because it is used to improve their ability to provide high quality care and to personalize the care their provide to families in their communities.

TIP Global Health was founded on the principle that society is at its best when each member is valued, capable, and hopeful in the future. Our vision is a world in which healthcare delivery systems are designed to foster this principle. As such, we deeply value the importance of establishing a safe environment that fosters diversity, equity and inclusion within our team and among our collaborators, beneficiaries, and stakeholders. 

TIP has established a Diversity, Equity and Inclusion policy that embraces and encourages our employees’ differences in age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.

E-Heza Data Solutions holds great potential to serve as the gold standard point-of-care digital platform for all of primary health care delivery in Sub Saharan Africa because it promotes data integrity, eases healthcare provider workloads, utilizes real-time data to facilitate personalized health education, and delivers timely and reliable data to national databases. Our primary path for scale is via government adoption, although our unique value proposition also appeals to both non-governmental and private sector direct care providers and researchers who require data collection and historical clinical data storage at the point of care.

Unlike previous electronic health records that have been designed for simplicity of technology and national data reporting requirements, E-Heza is designed for health care workers to ease their workloads, improve their interactions with families, and provide real-time data trends that facilitate individualized health education while also ensuring the accurate and timely delivery of data to the national government. Our tool supports both individual and group health assessments common in Sub Saharan Africa and promotes adherence to clinical care guidelines through positive feedback and experiential learning. Progressive web app technology allows healthcare workers to easily access the longitudinal data they need to care for their patients without requiring the internet and while maintaining data security for those who live outside of their service areas. Open source licensing provides a sustainable software solutions for government entities.  

E-Heza is designed for interoperability with any digital health platform that follows FHIR standards. This is particularly appealing to national governments who have invested in large electronic medical record systems that serve the purposes of establishing robust individual and population health records, but which have proven to be extremely difficult to implement due to poor integration of end-user work flows at the point of care. 

E-Heza is now expanding across Rwanda through a partnership with the Rwandan government. To facilitate expansion outside of Rwanda, we have conducted an extensive landscape analysis and determined both country and partner criteria. Our strategy is to identify strong implementation partners with meaningful ties both to their communities and to the national government. This allows us to test and refine E-Heza in a community-centric way that facilitates the needs of frontline health workers while building partnerships with the national government to support their longer term priorities. We have begun our first such expansion in Burundi.

In additional to grant funding, we have established a variety of earned revenue streams that support long term sustainability of E-Heza. These include:

1. Implementation Fees

• Train-the-Trainer Approach to Implementation within Local Health Systems
• Minor Modifications of Software for New Contexts
• Integration with National Database Systems

2. Maintenance of Software & Integration Fees

• Managed Hosting
• Interoperability Layers and/or API Integrations

3. Consultation Fees

• Direct Implementation
• New Modules
• New Workflows
• New Integrations
• Data Mapping to Improve Overall Data Flow

E-Heza is in the process of signing an MOU with the Rwandan government that includes payment for requested software modifications and a percentage of the implementation costs. We are in similar negotiations with two additional implementation partners outside of Rwanda. We aim to generate half of our revenue from earned income streams by the end of 2024.

This describes our projected revenue over the next three years. We aim to generate half of our revenue from earned income streams by 2024.

Below is a description of the generous funders who have provided funding to support E-Heza.