Antenatal Rural Remote Monitoring Program (ARRMP)

Developing countries continue to be plagued with serious deficiencies in healthcare provision. While collaborations with bilateral and multilateral agencies have led to progress in combating such diseases like malaria, tuberculosis and HIV/AIDS, some resource limited countries have seen the weakening of their primary healthcare sector. As attention has been placed on global health needs, the diverse health needs of local communities appear to have been neglected. This unfortunate fact highlights the need for effective ways to measure and track primary healthcare performance in low and middle income countries.

 According to the United Nations Economic Commission for Africa, one in seven global maternal deaths occur in Nigeria. That is more than 50,000 women dying per year in Nigeria. It was also noted that in many cases these deaths were preventable. Also, according to data from the United Nations- World Population Prospects, the current infant mortality rate for Nigeria in 2022 is 56.22 deaths per 1000 live births. This figure represents a 2.57% decline from 2021 but still firmly places Nigeria among the ranks of the worst performing countries on infant mortality.

 Most of the maternal deaths and infant deaths occur in rural areas, where in many cases the patients did not access proper antenatal healthcare. According to the 2018 Nigerian Demographic and health survey 61% of live births do not take place in a health facility.

 In 2001, UN member states agreed to the millennium Development Goals (MDGs) which included a call for the number of maternal deaths to be cut by three-quarters by 2015. While efforts were boosted, the goal was not met in the countries with highest rates including Nigeria. Despite the resources invested into overcoming Nigeria’s position as the second largest contributor to maternal mortality worldwide, the figures are still very worrisome.

It is therefore critical to have a way to consistently appraise current antenatal service delivery platforms to track performance across different components. This will enable more informed decision making towards achieving better outcomes in antenatal care, which would directly translate to saving countless number of lives of pregnant women and new-born babies.

The Antenatal Rural Remote Monitoring Programme (ARRMP) leverages on the SandsClinic telehealth platform to drive innovation in the antenatal healthcare space by improving antenatal care (ANC) contact among pregnant women and new mothers (patients), especially those resident in rural Nigeria.

 It is a data collection and analysis system that enables operators to collect and analyse data on key antenatal and immunization indices from healthcare facilities and from patients themselves. A two-pronged approach will be adopted for the data collection. Data will be collected directly from the Primary Healthcare Center (PHC) and at the same time the data will also be sourced directly from the pregnant women and nursing mothers. 

ARRMP would connect with patients on a weekly basis with appointments booked in with Doctors.The method used for collecting data will be via telephone calls made through the widely available GSM networks. The data acquisition process would come at no cost to both the PHC and patients.

 A template on key performance indices on antenatal and immunization coverage will be strictly adhered to in data capture. The data will then be processed to analyse trends and track performance across different categories of interest. In addition, the data collected from the PHC and that collected from the patients will be cross refenced to check for aberrations and ensure greater reliability of data. Data will be collected SandsClinic operators and analysed by SandsClinic  data analysts

 Data will be collected on the following Key indices

• Number of prenatal care contacts
• Number of postnatal care contacts
• In facility births
• Births at home
• Adherence to prenatal blood work-ups and scans
• Adherence to midwife appointments
• Adherence to child immunizations (from birth to 12 months)
• Drugs being dispensed at the PHCs
• Patients’ adherence to prescribed medication
• Patients’ knowledge of key parts of their healthcare needs
• General concerns during pregnancy
• Community support provided during pregnany

This list is not exhaustive and would be improved as needed.

The Antenatal Rural Remote Monitoring Program is designed to serve the following;

• Pregnant women resident in rural areas: All pregnant women from the first trimester to birth
• New Mothers in rural areas: Mothers with new borns from 1day- 12 months
• New born babies in rural areas: infants from 1day to 12 months

  The target population listed above currently rely on the government owned primary healthcare facilities located closest to them. But there are just not enough of these primary healthcare facilities and some residents still live far away from the closest facility.

 Another major issue is the problem of staffing.Nigeria currently has one of the lowest doctors to population in the world. In 2020 the government officially stated that the doctor to patient ratio is 1:2753, as against the WHO recommendation of 1:600. Due to the shortage of qualified doctors most Nigerians find it difficult accessing a doctor for their medical needs. Furthermore, most people living in the rural communities have become disenfranchised from receiving quality healthcare because of the unwillingness of doctors to reside in remote areas. Considering the continued emigration of medical personnel and high population growth, the situation is not expected to improve soon.

 In the 2022 federal budget a sum of about $1.7 billion, roughly 4% of the entire budget, was allocated to healthcare. This translates to $8.5 for the healthcare of each Nigerian for the whole year. This amount is insufficient to close the existing gaps in healthcare sector, which also means a poorly funded primary healthcare sector.

The government is just not able to raise enough revenue to provide the needed funding for healthcare, making it critical for the available funding to be used in the most optimal way. Our solution enables a monitoring and appraisal system that can be used to check wastes, corruption, and inefficiency in primary healthcare delivery to women resident in rural areas in Nigeria. It creates a way of reliably and consistently collecting data to scrutinize performance and get up to date information to guide decision making. This appraisal system will inevitably raise the performance level of service delivery to the target population, and lead to an improvement in their overall healthcare indices

Our core team is made up of 5 Nigerian doctors (including the founders) and a business/ finance manager. The doctors have all practiced in Nigeria at different levels, including at the community medicine level. The team therefore has the necessary experience in Primary healthcare service delivery at the local community level. In addition, we are all passionate about contributing towards the socioeconomic development of Nigeria. It is our belief that the challenges of the country can be solved by innovations driven by Nigerians who not only have firsthand experience of the unique challenges facing the country, but who also have the requisite understanding of the culture of the people.

SandsClinic has also partnered with local governments and non-governmental organizations (NGOs) in carrying out female health empowerment outreach programs in rural areas in Nigeria. These female empowerment programs consisted of medical outreach activities and health education campaigns among women resident in rural areas Nigeria. Through these outreach programs the team has been able to witness firsthand the healthcare challenges being faced by vast majority of women in the rural and remote parts of Nigeria. By working closely with the local health authorities we have also become well acquainted with the PHC structure and the current deficiencies that exists in the structure.

A key takeaway from our interactions with women in these rural communities is that antenatal care contact remains a daunting problem in the rural communities in Nigeria. Accessebility still remains a major challenge as PHCs are thinly spread out in most regions. Also, in many cases the PHCs are poorly funded not having the required staffing or the required level of drug inventory. There are also other reasons why women find it difficult visiting the PHCs, these include cases of women having physical disabilities, women facing stigma due to their HIV status or due to social taboos associated with conditions of their pregnancy and other socio-cultural hindrances. We find that some of these factors limiting antenatal care, appear to be mostly glossed over despite their significant negative effects. We are confident that with the implementation of the Antenatal and Immunization Remote Monitoring Program, we would be able to present empirical evidence properly highlighting the material impact of the different contributing factors. 

Our major reason for applying for this challenge is to secure the necessary funding to execute a seven months pilot run of the Antenatal Rural Remote Monitoring Program in Nasarawa State, Nigeria. We also hope that winning this challenge would avail us an endorsement that will enable us overcome market barriers to the solution, and ensure wider adoption of the program.

We intend to deploy in the north- central state of Nasarawa. The selected local government area is Karu, one of the more remote local government area in the state. According to the Nigerian Health Facilities registry, Karu has 169 Primary healthcare facilities (PHCs). We would need to interface with all of the PHCs to secure the necessary approvals to develop a working partnership regarding obtaining the required data. We will also need to reach out to as many pregnant women that have registered or reported once to any of these facilities. We will need to sign on operations staff who would make the necessary calls and send out SMS to the PHCs and patients alike to acquire the necessary data. We consider 30 phone operations staff to be adequate. A data analyst will also be signed on. Toll free GSM lines will also be purchased and will serve as the main means of interface. A successful pilot run that achieves the stated objective will attract the support of the states and federal government and possibly some multilateral institutions to not only maintain the project but expand it nationwide. A key feature of this innovation is that scaling up is technically easier and cheaper compared to other alternative models.

The key innovation associated by our solution is that it provides for remote monitoring and tracking of performance in primary healthcare service delivery. Existing models of appraising performance involves physical onsite audits at the different primary healthcare facilities. A major drawback of this model is that it is very expensive to sustain such onsite audits, meaning such onsite appraisals occur sparingly and far in between. Another major drawback of this traditional model is that data is sourced only from the PHC, making it very difficult to carry out any form of independent query on the validity of the presented data.

A significant feature of our proposed solution is it’s simplicity, which also makes it very cheap to implement. The reliance on the GSM phones as the main technology that powers the model makes it possible for this solution to be rolled out in virtually every location in Nigeria, even in areas with low internet penetration. Furthermore, a large segment of the target population fall in the lower cadres of the socio-economic ladder and will most likely not have smart phones or access to internet; but they will most likely have the simple phones that can be used for making and receiving calls and sending SMS. The solution is also very simple to use and can be easily adaptable to different peculiar situations in different locations. We will take great care in signing on call operators that can speak the local indigenous language and understand the pervading cultural sensitivities. This is to ensure seamless communication and accurate data gathering. 

Our impact goals over the next year are;

1.    To generate data across behavioral patterns and health conditions of pregnant women in rural areas in Nigeria, that can be further analysed and used by  government  and other institutional stakeholders in decision making

2.    Reporting accurate appraisals on the performance of primary healthcare facilities, measuring their actual level of service delivery as against expected targets

3.    Provide intelligence that will be of immense value in the ongoing considerations regarding expanding primary healthcare services to other alternative platforms, such as telehealth

4.    Providing pregnant women with the necessary education to better position themselves in managing their healthcare needs

Impact goals for the next five years are;

1.    Providing an option for remote quality antenatal care of pregnant women through all stages of their pregnancy, enabling trained medical practitioners to spot early warning signs and then initiate timely interventions in order to reduce cases of adverse pregnancy

2.    Expand access to antenatal care to disenfranchised women, such as; women in rural and remote areas, women having physical disabilities, women facing stigma due to their HIV status or other social taboos associated with conditions of their pregnancy

We look forward to the successful rollout and subsequent wide adoption of the Antenatal and immunization Remote monitoring program to achieve the desired impact goals for the next one year.

To achieve our long term (5 years) impact goals, we have developed an affordable user-friendly telehealth platform that can enable remote patient care while linking patients to a broader healthcare ecosystem with various quality healthcare solutions. Our platform combines a web app and a mobile app compatible with both Android and IOS devices. Patients can have access to remote teleconsultations with doctors and other healthcare specialists via audio, video and text messaging, with real-time pharmacy and laboratory communication. We will still rely on toll-free GSM lines for rural and remote areas.

The clinical backbone of these digital tools is a network of Nigerian clinicians vetted for skill and passion for impact. We aim to bridge access challenges in the rural areas while leveraging existing clinical infrastructure where possible, enabling doctor to doctor consultations and electronic record management.  

Our Impact goals align with one of the stated 17 Sustainable Development Goals (SDGs), which is ‘’ Ensure healthy lives and promote Well-being for all’’ goal. By leveraging technology to increase accessibility to healthcare we are directly contributing to the strengthening of existing healthcare systems in Nigeria, plagued by a shortage of trained manpower, and an uneven distribution of healthcare facilities between rural and urban centers.

Firstly, We would rely on the amount of people who subscribe as a means of assessing adoption of services. Since the launch of our virtual clinic, which is accessed via the SandsClinic web and mobile app, we have steadily seen a growth of subscriptions to our virtual clinic, recording total subscribers of 450 subscribers within the first five months of launch. A large number of these subscribers are people with disabilities, who make up about 40% of the total subscribers.

In addition, we have key indices which we would populate with every consultation. The data will then be processed to analyse trends and track performance across different categories of interest. This would be measured against standard indices obtained from the public database. Furthermore, while working closely with the local authorities, we aimi to organise fortnightly reviews with published findings to help ensure we stay focused and are able to provide immediate inteventions when needed

Our virtual clinic consists of a core team of 20 doctors (GPs) who are online 24hrs to attend to patient’s appointment requests and 22 partner specialists responsible for handling referrals. We sincerely believe that our activities have been consistent with our mission statement, which is to make reliable healthcare easily accessible and convenient for everyone, no matter their area of location. We understand how ambitious and daring this is, but we believe that this mission is achievable with our operational model and with the collaboration of willing partners.

Nigeria currently has very poor antenatal care indicators, and has so far failed to comply with the WHO guidelines on the minimum number of antenatal care contact. A study published in 2021, carried out by Fagbamigbe A.F, Olaseinde O.F and Setlhare V focused on analysing and determining the number of antenatal care contacts in Nigeria, found that 25% of respondents had no ANC contact, 58% had at least 4 ANC contacts and 20% had 8 or more ANC contacts. Respondents with higher education and from affluent backgrounds were significantly more likely to make at least 8 ANC contacts. Among states, highest rate of ANC contact, those exceeding 8 contacts,  was Osun state with 80.2%, then Lagos had 76.8% followed by Imo 72%. The worst performing states were Kebbi with 0.2%, Zamfara 1.1% and Yobe 1.3%.

 A direct consequence of Nigeria’s poor antenatal care performance is that the country is persistently ranked as one of the countries with the most appalling maternal mortality ratio (MMR), accounting for an estimated 14% of global maternal deaths. The quest to achieve a acceptable maternal mortality level is often hampered by lack of accurate and reliable data to monitor progress.

 In Nigeria the northern regions have the highest MMR with estimated maternal mortality of more than 1000/100,000 live births in some northern states. To counter this appalling trend the Federal Ministry of Health inaugurated the ‘’ Task Force on Accelerated Reduction of Maternal Mortality in Nigeria’’. The international community have also recognised the dire situation and there have been efforts directed at creating a positive change, with the northern states of Kebbi and Adamawa, in 2013, accessing a grant of 30 million Euros.

 Some factors obstructing the  increased  use of primary healthcare facilities by pregnant women in rural areas include low literacy levels, strong socio-cultural dictates, accessibility, communication gap and lack of awareness. However, it is important to note that the individual impact of each of these factors differ from one location to another. What can be a significant contributing factor of poor performance of primary healthcare in antenatal care in one locality might be totally absent in another locality. So it is key to be able to have a way of measuring performance across different localities. In a bid to overcome these challenges, our solution provides a sustainable system of extracting accurate data on the performance of available primary healthcare facility and the behavioural trend of the respective target populations. The processed data can then be immediately presented as evidence for policy formulation and help guide subsequent decision making processes aimed at achieving the best outcomes for the target population.

The core technology that powers our solution is the mobile phone technology based on the  GSM network. The technical operations of the solution relies on the capacity of the phone lines to make and receive calls and send SMS. Every basic mobile phone on the GSM network can carry out these basic operations, without any need for internet connectivity.

According to the Nigerian Communications Commission, total number of mobile (GSM) subscribers currently stands at 147.45 million subscribers, and a unique subscribers rate of over 60% of the entire population. A 2017 study by Pew Research found that 80% of adults in Nigeria owned some type of mobile phone, with the most common phone type being the basic mobile phone.

In addition, an already operational web app would be available to all the patients. While we have factored in some literacy concerns with the target population, patients would still have access through the app to reach out to a doctor 24/7 if there is any medical issue and not only pregany related.

Data will be collected by Operators/ Admin staff working for SandsClinic. They would work under strict supervision, with the necessary work tools put in place to ensure optimal performance.

In SandsClinic we embrace diversity and inclusivity. We also strongly adopt the principle of equity, both in our internal operations and in dealing with clients and partners. Everybody is treated equally irrespective of race, religion or gender.

As an organization having a female co-founder, we are also sensitive to the very important issue of gender equality in the workplace and we have also tried to achieve gender balance in our staffing; resulting to our current staff complement being 57% female. Fostering a non-discriminatory work environment remains a top most priority in our organization's work place culture, and we consistently review our policies seeking out ways we can always make improvements.    

Our solution is an intervention that provides improved measurement methods that are low cost and shareable across information systems. The key value being delivered is that the solution enables the monitoring and measurement of performance across key indices in antenatal care and immunization coverage in rural Nigeria.

The solution has the following key activities

1. Data acquisition from primary healthcare centers and from antenatal patients being served
2. Processing collected data to measure performance across key primary healthcare indices
3. Publish performance results and key observations, and present to relevant stakeholders in primary healthcare.

The pilot run of the solution is to take place in Karu Local Government Area (L.G.A) of Nasarawa state, in North-Central Nigeria. The target population include the following;

1. Pregnant women: All pregnant women, from first trimester to birth
2. New mothers in rural areas: Mothers with new-born babies, from a day old to 12 months old    

The channel to be used in reaching the clients are mobile phones operating on the GSM network. Key partners for the success of the intervention are the primary healthcare centers and the local government authorities.

The major area of expenditure is staffing. Call service operators will act as the primary data collectors and a data analyst will process the collected data to derive conclusive results. Other expense items include the cost of operating the toll free GSM phone lines and logistics costs.

We expect the major funding for the solutions to come from donations from willing partners and government contracts. Every available surplus will be deployed towards expanding coverage of the solution to other locations 

We are confident that a successful pilot run of our solution would present clear evidence of the workability of the solution and the intelligence generated will prove to be very valuable in guiding decision making on primary healthcare delivery. This will in turn lead to a wider adoption of the solution by local, state and federal governments, that will then fund the solution as part of primary healthcare support services.

Also multilateral and non-governmental organizations will also be willing to make donations for funding of the solution, as part of their healthcare intervention programs.  

In implementing some of our female health empowerment outreach programs, we have partnered with local governments and NGOs and they funded the direct costs of the intervention activities. The target population are among the most economically vulnerable people in the country, and are  not even able to pay for their basic healthcare. It is therefore important for the government and development partners to proffer  sustainable solutions that can ensure reliable primary healthcare delivery to this segment of the population.