Premier Mobile Healthcare Manager (Premier mHealth)

Healthy living and the promotion of well-being for all ages are key in the delivery of Sustainable Development Goal number three (SDG3). Inequality in access to healthcare remains one of the primary challenges in achieving this goal and more so for Zimbabwe whose key healthcare delivery indicators continue to deteriorate. Zimbabwe is currently battling with the challenges of access to healthcare and the cost thereto, that have been magnified by the poorly performing economy and the effects of the COVID pandemic. This problem is more pronounced in rural and urban high-density communities. Resultantly, many have and are living with chronic and indeed other acute conditions that otherwise could be better managed with better access to both healthcare management information, primary healthcare centers and practitioners. Specifically, the problem can be further split as follows;

• While a number of healthcare providers collect diseases management data, the data does not flow freely among providers as Zimbabwe lacks a centralized and standardized information/data repository for healthcare management. This has resulted in poor management and tracking of key primary healthcare performance measures in Zimbabwe.
• Access to healthcare is generally defined as the ability, or perceived ability, to reach health services or health facilities in terms of location, timeliness, and ease of approach. Infrastructural deficiencies, limited access to medical care, and shortage of healthcare workers are just a few of the many hindrances to access to healthcare facing our country. Zimbabwe has 2 doctors per 10 000 inhabitants (World Bank,2018). The last survey was done in 2015 which is a clear demonstration of the lack of healthcare data to inform policy and strategic healthcare decisions. People in rural areas have to walk between 10 km and 50 km to access the nearest health facility. In high density urban centers, the facilities are ill equipped and mostly lack qualified skilled personnel.
• In Zimbabwe, Non-Communicable Diseases (NCDs) are estimated to account for 31% (WHO, 2018) of total annual deaths, with diabetes, hypertension and asthma as the main killers.  Managing chronic conditions is critical, especially now when countries are battling global health emergencies such as Covid-19 and monkey pox. During these historic pandemic times, people with chronic diseases are at an increased risk of death as focus has shifted to pandemics management. It is for this reason that PSMI, which currently has a chronic diseases patient register, wants to be more inclusive and offer similar and even better services to chronic diseases patients in rural areas and high-density communities in Zimbabwe.

Our solution is a more inclusive platform for chronic disease management and treatment in Zimbabwe through a digital chronic monitoring and mobile clinic support. This solution therefore seeks to bridge the poverty driven inequality gap in accessing primary healthcare with particular focus on chronic diseases management and the subsequent data collection, sharing and management.

The solution utilizes wearable devices to monitor and manage chronic diseases and is  supported by digitally automated dashboards that give real time insights on patient chronic management. Mobile clinics in the form of vans/trucks will offer community based support through periodic visits to otherwise medically less accessible communities. During such data driven visits, the mobile clinics will be offering primary healthcare to patients with both communicable and non-communicable diseases. The mobile clinics will be equipped with state-of-the-art healthcare and diagnostic equipment. Healthcare teams are able to collect data and develop insights through cloud linked information dashboards focusing on diabetes, hypertension, asthma, heart failure, chronic kidney, HIV and cancer diseases. The collected data is further integrated into an Electronic Health Record (EHR) to add more enriched insights at the point of care. Continued care especially for drug management will be complimented by drug delivery systems that include both motor bikes (for short distances) and unmanned aerial vehicles (for long distances).

Using evidence-based interventions, digital health solutions like Premier mHealth can help improve healthcare outcomes for patients and track key primary healthcare performance measures. Unbiased data is collected and is made available in real time allowing healthcare practitioners to remotely, but accurately monitor patients. Furthermore, the data assist policy makers, funders and indeed other stakeholders to identify areas requiring a particular type of intervention at the appropriate time. Among other benefits, Premier mhealth will reduce hospitalizations and/or adverse disease progressions as it allows proactive approaches to healthcare management unlike the traditional reactive approaches. The data collected through the Premier mhealth devices and the mobile clinic outreaches allows us to measure primary healthcare performances through proxies such as increase or decline in the number of patients on chronic medication, referrals to specialists for further attention, hospitalization statistics and the overall patients enrolled on the platform in comparison to the population.

Premier mHealth is in its infancy and currently serves a limited number of patients through its one mobile clinic that goes onto expositions that are wide and far apart due to lack of funding. In urban centres however, Premier mHealth does deliver chronic medication to PSMI patients who have registered onto a drug home delivery platform through its pharmacies. The Premier mHealth mobile van has also been used in remote areas and this has largely been in PSMI Community Social Responsibility activities. It is our informed view therefore that this solution, with adequate funding and material resources, is able to serve remote rural communities and the urban poor who have no ready access to medical attention. The program will not only offer accessibility but also reliability at a lower cost. Mobile Health Clinics (MHC) in general have the potential to overcome most of the challenges Zimbabwe is facing in chronic disease management especially when dealing with the remote and marginalized communities. MHCs are particularly impactful in offering urgent care, providing preventative health screenings, initiating chronic disease management and gathering of healthcare data for insights and developing personalized care solutions. Specifically our solution will provide the following benefits;

Improved access

Greater reach of healthcare delivery as services are delivered to chronic patients (and managed) via mobile technology for remote disease monitoring and management. This will be followed through by mobile clinics’ periodic visits across different districts to offer diagnosis and treatment, drug dispensing and counseling services. Wider and faster patient access to health and wellness information is delivered via mobile gadgets and wearable devices. This is key for patients living in remote and high-density suburbs where healthcare facilities are limited or are without enough equipment including human capital.

Improved quality

Better coordination of care as digital health enables faster and secure communication and data sharing between PSMI healthcare centers, healthcare professionals, patients and other relevant stakeholders such as policy makers. Besides the improved quality of care to patients, our solution further improves the quality and professional aptitude of medical professionals as they are better equipped and can analyze greater data sets to make clinical decisions and better manage chronic disease cases.

Reduced health costs

Earlier risk detection and action is essential for chronic disease management to avoid hospitalization and death in some cases. Premier mHealth allows chronic patients to take greater responsibility for active personal healthcare management and also enables medical professionals to pre-detect risks resulting in reduced costs of healthcare.

Service access at low cost

 PSMI is a mass-market franchise with a pricing philosophy that demands that its services be the most affordable on the market with exit prices of not more than 80% of the average market price of each respective service. Premier mHealth will thus enable PSMI to extend these lower prices to the otherwise over charged and under serviced remote and marginalized communities in Zimbabwe.

Primary healthcare data availability

 Premier mHealth will ensure healthcare data is available in a secure platform and give an opportunity for PSMI and indeed all other relevant healthcare stakeholders to generate insights to drive healthcare access across Zimbabwe.

a) Experience and expansive service model

PSMI is not new in the healthcare industry after having been established in 2003 by an association of civil servants called PSMAS (Premier Service Medical Aid Society). It is one of Zimbabwe’s largest private healthcare service providers consisting of ten (10) lines of business which are; primary care medical clinics, pharmacies, small hospitals, ambulance services, physiotherapy rehabilitations clinics, dental clinics, laboratory diagnostic services, radiology diagnostic services, optometry services and renal care centers.

b) Geographical presence and reach

With physical presence in all of Zimbabwe’s 10 geo-political provinces and major cities, PSMI already has the infrastructure to complement the Premier mHealth service model. Currently, it operates from 152 service centres which can be used as support and launch platforms for the Premier mHealth mobile clinic outreaches. These centres will be used to offer continued support after the mobile clinic has moved to other sites.

c)Pool of experienced medical practitioners

PSMI already has a pool of 843 medical practitioners that are but just a phone call away to both be part of the mobile clinics and also offer continued support once the mobile clinic has moved to other sites.

d) Existing chronic diseases management scheme

Through its pharmacies, PSMI already has a chronic disease management scheme in which it does drugs home deliveries. The Premier mHealth service model is an extension of the chronic diseases management scheme to reach and provide access to the otherwise marginalized patients. PSMI therefore has capacity to manage a pool of chronic diseases patients. What it only lacks is widened reach and access to the otherwise marginalized patients.

e)Tried and tested service model

PSMI already owns a mobile van that it has been using for both commercial and CSR healthcare outreaches. Through this model PSMI has managed to reach communities that are remote and marginalized. It is this model that Premier mHealth is expanding, in the process making service data- enabled and ensuring commercial sustainability.

f) Data enabled service delivery

PSMI’s operations ride on an internally developed and managed ICT health care system called Healthcare Management system (HSMS). This system is an online, robust and secure real time platform. Premier mHealth service model rides on this system already connected to a wider and bigger information communication system.

PSMI already has the activation of the Premier mHealth service model as part of its expansion strategy. The biggest challenge has been the capital financial injections required for such a massive investment. Funding from this application will therefore act as seed capital for the expansion and operationalization of the Premier mHealth strategy

Our solution is innovative in that it creates medical access that is not bound to geographical location and also creates a digital footprint and profiling of patients in communities that would otherwise be excluded. It is a progressive mix of traditional healthcare service provision and technology-enabled-service provisions through key instruments such;

• Unmanned aerial vehicles for drugs and wearables delivery. The deployment of drones in healthcare will be a first in Zimbabwe.
• Cloud based ICT systems that are accessible from remote locations and have capacity to produce real time healthcare insights, and measurement KPIs.
• Adequately equipped mobile vans that house otherwise immobile radiology and laboratory equipment.
• Mobile gadgets and wearable devices are key in monitoring and management of  chronic patients living in remote and high-density suburbs.

a) Broader Impact Goals

Guided by our four broad areas of focus (Improved primary healthcare access, improved chronic diseases management, data harvesting, warehousing and management, and improved healthcare KPIs performance measurement) we came up with the following broad goals:

• Give regular primary healthcare access to 10% of Zimbabwe’s marginalized population by year 2025.
• Physical presence in each of Zimbabwe’s 59 districts, particularly rural and marginalized districts by end of 2025
• Grow our chronic register from the current 2300 to 270 000 by end of 2025.
• Develop an online-realtime and AI enabled digital platform by end of June 2023.
• Start delivery of drugs via drones in the remote districts of Matebeleland and Mashonaland West by end of year 2023.
• Riding on current data at PSMI and the planned improved access through Premier mHealth, develop a data repository that has capacity to attract other healthcare players by September 2023. We will then deploy business intelligence ICT tools to track and measure the performance of Healthcare KPIs.

b) Our approaches

This section elucidates how we are to achieve the above broader goals.

1. Deployment model

Our deployment model (figure 1 below) is anchored on existing national data and our own experiences. Using this data we then devised a unique combination of the traditional primary healthcare access services and digitally enabled primary healthcare management instruments such as wearables and drones. Both improved access and improved continued management of health conditions then result in better healthcare KPIs performance tracking and measurement.

Figure 1: Deployment model

2. Impact Goals

For measurable impact of our initiatives, we further split Zimbabwe along the lines of its geo-political provinces. Table 1  below captures the population split, identifies the number of the “vulnerable and marginalized” per province and then the impact of our solution over a period of five years.

Table 1 : Impact goals

3.Mobile clinics reach & deployment

We will use a targeted approach, prioritizing districts, which are remote and densely populated. For purposes of this presentation we have given full detail of our deployment approach in Manicaland province as outlined below:

Figure 2: Manicaland Province

The province is subdivided into seven rural districts and three town/councils which are:

• Buhera District
• Chimanimani District
• Chipinge District
• Makoni District
• Mutare District (in the center)
• Mutasa District
• Nyanga District (in the northeast of the province)
• Mutare City Council
• Chipinge Town Council
• Rusape Town Council

 We will target Chipinge Rural and Buhera districts as we roll out the program. The two districts constitutes 31.7% of the total province population. They are also marginalized, inaccessible and remote. In Buhera, the mobile van will target wards 28, 29, 25, 22, 23 & 14 which are densely populated. In Chipinge the mobile van will target wards 5, 6, 8, 19, 24, 26, 28 as below.

Table 2:Target districts

Each visit per ward will be for a period of 1 week (2 logistics, 3 days operations). On average we will attend 300 people per day with each patient having approximately 4 encounters by LOB (line of business).  From experience, approximately 900 people will be saved in 3 days. We will repeat the circle after every 3 months, doing reviews and enrolling new patients to the program

b.Other Provinces

Using the same model above we will deploy our initiatives in the rest of the other nine (9) provinces as follows:

Table 3: Target provinces

• Chronic drug management Strategy

Using the data that we currently have in our custody, approximately 60% of the patients who are attended to in our clinics are chronic patients. Our records also show that 73% of chronic patients have high BP. Based on these statistics, on average 180 patients attended to daily will join our chronic register. Wearable devices will be distributed to these patients to enrich our database and for continued support. It is our hope that the program will be extended to other districts in these provinces.

Figure 3: Zimbabwe provincial map

Our target is to penetrate densely populated districts in all the 10 provinces. The following table illustrates our proposed penetration approach.

Table 4:Drug delivery and chronic management strategy

We developed a framework (figure 4) to assist us in our performance tracking and measurement. The framework is premised on;

• Intended Impact
• Improved access
• Improved quality
• Reduced healthcare costs
• Service access at lower costs
• Primary healthcare data availability

The solution will depend on AI powered technology to empower the supporting systems to this solution. Artificial Intelligence will support data gathering and developing insights from primary healthcare data. The following systems and devices will be deployed;

Wearable devices

Wearable devices which utilizes low bandwidth to be deployed in rural areas will be connected to the central data repository (electronic health records).

Mobile vans

State of the art mobile vans, utilizing clean energy, connected to the electronic healthcare records to store data on real time. Mobile vans depend on low bandwidth network to communicate with central data repository, residing at PSMI.

Unmanned Aerial Vehicles(Drones)

Drones will be used to dispatch chronic drugs around remote areas

Electronic health management system

The solution depends on internally developed health management system, which has been tested and can be scaled for growth.

Business Intelligence System

The solution will utilize AI powered business intelligence system to conduct data analysis, develop insights and reporting of primary healthcare data. This will be outsourced from top and secure solutions providers like ServiceNow, Salesforce and Microsoft.

Diversity: PSMI appreciates and recognize differences across staff members and the community we serve. PSMI serves every member of the community regardless of social status, ender and / or age.

Equity: PSMI's gender policy recognizes every employee regardless of gender. PSMI directors are 60% female  against 40% men. PMSI policies which include  promotion policy, recruitment policy, ethics policy and HR policy were designed with the objective of creating opportunities for all.

Inclusion: PSMI strive to provide an environment which protects ,respects and value every employee, customer and any stakeholder. PSMI has recently introduced a mental health support system to cater for employees, employee wellness program subscriptions . PSMI healthcare solutions are spread around the ten (10 ) geo-political provinces, catering for the whole of Zimbabwe, thriving to meet healthcare needs of every patient across Zimbabwe.