Modernizing Healthcare in Yemen through Portable Ultrasound

Yemen is facing the most complex humanitarian crisis of our time, with an estimated 19.7million people in need of access to essential healthcare. Diagnostic capacity in Yemen is low and access to imaging is rare, placing enormous strain on the healthcare system. As a consequence, numerous unnecessary surgeries have been performed, as well as patients kept untreated for longer, or given the wrong treatment entirely. COVID-19 caused further disruptions, adding even more pressure on the healthcare system.

It is in this context we launched our pilot project to enhance the capacity of local HCPs to quickly identify and respond to certain health complications detectable through innovative portable ultrasound technology. Our results are remarkable, with compelling evidence that the innovation has greatly improved HCP diagnostic capacity, enhanced chances of patient survival and led to cost-savings within the two hospitals we are working. At scale, the impact could be much bigger.

In terms of the scale of the problem, World Health Organization (WHO) data indicates increased incidences of pneumonia, internal trauma and complications of pregnancy resulting in loss of life in the decade since the conflict began in Yemen. Although accurate data has been difficult to obtain, in 2019, WHO estimated that there were approximately 357,000 cases of pneumonia among children and over 17,000 conflict-related incidents resulting in internal injuries since 2015. Pregnancy complications are also a major concern due to the lack of diagnostic imaging in the country. Maternal mortality rates in Yemen among the highest in the world, estimated at 329 deaths per 100,000 live births (WHO).

Our pilot responded to these three health concerns through extensive training of local HPCs over two years. As part of our trial, 620 patients received scans and were reassured with normal scans or referred for care. In over 400 cases, we improved patient care, saving 222 lives, particularly when patients with internal trauma were re-admitted following their scan after having been discharged. Additionally, we established satellite internet for the first time at the hospital, giving our trainees access to support outside Yemen. We are proud that a majority of our trainees were women, challenging gender stereotypes and providing new career opportunities for everyone in the program. 

We are using point-of-care ultrasound (POCUS) in Yemen to enhance the diagnostic capacity of healthcare providers, specifically for pediatric pneumonia, trauma, and OB/GYN (pregnancy check ups, complications of pregnancy and deliveries). POCUS is an innovative tool that allows for quick and accurate ultrasound scans at the bedside. It is a handheld device that can connect wirelessly to a smartphone or tablet, making it a portable and accessible tool for healthcare workers in remote or resource-limited settings. 

POCUS technology is particularly useful in remote and crisis settings due to its portability and accessibility. As we saw in our pilot, the introduction of POCUS has already greatly improved the healthcare system and diagnostic capacity of the two hospitals we are working. However, POCUS alone is insufficient without proper training that will ultimately determine the effectiveness of this versatile diagnostic tool. This is why we offer remote and in-person training with ongoing mentorship in a train-the-trainer model that allows us to quickly build capacity in multiple locations, while allowing for local leadership with support internationally from recognized ultrasound experts.

The POCUS technology by Butterfly Network has embedded in-app training modules, and allows providers to easily send images for review and feedback using cloud-based technology. Furthermore, the Butterfly device is exceptionally affordable and durable, as compared to similar products on the market. When Butterfly is paired with remote mentorship and training provided by organizations such as Bridge to Health Medical and Dental and Med Global, healthcare providers in Yemen are empowered to access support and expertise from outside the country, overcoming the limitations of the ongoing conflict and humanitarian crisis.

Additionally, the focus on women's health through the obstetrics/gynecology cohort addresses the underserved healthcare needs of women in Yemen, who  face cultural and logistical barriers to accessing healthcare services. By pairing Butterfly technology with teaching and training, this program empowers clinicians to not only improve care delivery but also supports the community and country to achieve the WHO recommendations for antenatal scanning in pregnancy and support pursuit of achieving the Sustainable development goals 3.1 (maternal morbidity/mortality), 3.4 (non-communicable diseases) and 3.d (strengthen ability of front-line workers to better diagnose pneumonia/respiratory illness to enhance pandemic preparedness).

Overall, POCUS technology is a game-changer for healthcare providers and patients in Yemen. It addresses the challenges of the ongoing humanitarian crisis by providing a portable and accessible diagnostic tool that enhances the capacity of the healthcare system. It also allows for more efficient and effective use of healthcare resources, and improved referral of high risk patients, potentially reducing healthcare costs and improving patient outcomes. With the support of organizations such as Bridge to Health Medical and Dental and Med Global, and through partnerships with the Yemeni Government and local hospitals, POCUS technology introduced at scale has the potential to transform healthcare in Yemen and improve the lives of millions of people.

Here is a link to a video demonstrating the use of POCUS technology:https://www.youtube.com/watch?v=vXHf7lPsuxg

Our solution is focused on serving local healthcare providers, however, it also directly serves the communities within which we are working in Yemen who are direct beneficiaries and are currently underserved. The patient population visiting our two hospital sites primarily consist of low-income Yemenis who are disproportionately affected by the crisis and who are in need of improved healthcare services. Our pilot responded to requests from two regional hospitals for support in training local healthcare providers (HPCs) in POCUS to manage the huge influx of patients with pregnancy complications, internal trauma and pneumonia, as well as minimizing the unnecessary surgeries that have been performed on suspected cases, or antibiotics wrongly prescribed. The HPCs we work with have been nearly entirely cut off from the rest of the world with major electricity shortages (80% of the country remains off-grid) and no internet. The satellite internet we set up has enabled the trainees to have access to new resources and support. 

Our trainees in the pilot have an affiliation with the two hospitals and are all local. Over 50% of the trainees are women who plan to use their skill to launch businesses or to advance their careers. We also found an increase in community confidence in public hospitals following the trial, potentially linked to the new technology and hospital connectivity abroad.

In addition to improving the diagnostic capacity of local healthcare providers, our solution directly benefits the patients in Yemen by providing faster and more accurate diagnoses, leading to better health outcomes and quality of life. We are also specifically targeting women's health needs through our obstetrics cohort, which directly addresses the underserved healthcare needs of women in Yemen who may face cultural and logistical barriers to accessing healthcare services.

We are a team of three organizations: Bridge to Health Medical and Dental (project design and clinical leadership), MedGlobal (strong local team in Yemen and national networks) and Butterfly Network (the manufacturers of the Butterfly devices) and together are very well placed to lead this solution to the target population in Yemen. As recipients of a Humanitarian Grand Challenges grant for the pilot, we have spent the past two years building strong relationships with the communities we serve, the local healthcare providers and government officials to facilitate our work. Butterfly’s technology is also specifically designed for use in austere environments, and their dedicated global health team has experience in large-scale deployments working with over 400 global health partners in over 100 countries.

Our Yemeni Project Coordinator, Dr. Abdulla Bagahizel, is intimately familiar with the cultural and healthcare landscape of the country. He has been instrumental in engaging local healthcare providers, building relationships with the Ministry of Public Health and Population, and advocating for the importance of POCUS technology in improving healthcare outcomes. Dr Bagahizel leads our local team, composed of clinical experts and development practitioners. 

Yemen’s healthcare system is both public and private, with huge discrepancies between the quality of care in each. Our support is primarily aimed at the public hospital and strong cooperation between the district health authorities is critical. Throughout the pilot phase of our project, we engaged both the public and health sectors to ensure the success of our initiative. We took steps to ensure all training modules were led by local experts and have acted as facilitators for the pilot, empowering our local team to lead and implement. Our training program and outreach campaign have been positive steps towards engaging the local community and raising awareness about the importance of obstetric ultrasound and antenatal care.

We also take great care to ensure that the design and implementation of our solution is guided by the communities' input, ideas, and agendas. We received feedback from local healthcare providers and patients throughout the implementation process and have incorporated their suggestions and needs into the development of our training program and outreach campaign. Additionally, we worked with local hospital administrators to identify areas where POCUS technology can have the greatest impact, such as trauma, pneumonia, and complications of pregnancy.

In summary, our team's proximity to the communities we serve, our strong relationships with local healthcare providers and government officials, and our experience in implementing healthcare initiatives in challenging settings make us well-positioned to design and deliver this solution to the target population in Yemen. Our initiative is meaningfully guided by the communities' needs, and we are committed to ensuring its sustainability and impact on the healthcare outcomes of the local population.

The two hospitals we are currently working with in Yemen see approximately 500,000 patients yearly each, although the next phase of our solution seeks to expand to communities and into other regions which would significantly scale our solution.

The public health sector in Yemen has been severely impacted by the ongoing conflict and humanitarian crisis, with many hospitals and clinics damaged or destroyed, and healthcare workers facing significant challenges in accessing essential medicines and supplies. Hospitals in Yemen are often overcrowded, with long wait times for patients due to a shortage of healthcare providers and limited resources. This potential impact of this solution is significant with compelling data already available indicating we have saved lives through our trial. 

We are operating within the context of a complex humanitarian emergency. It is an exceptionally hard-to-reach location and mostly cut-off from the outside world. The political, social and economic environment is highly volatile and the on-going threat of conflict creates additional pressure on our team’s ability to deliver. On several occasions throughout our innovation, our efforts were interrupted by conflict and our staff were instructed to seek shelter. During the time we have been operating, however, the region we are working in has largely stabilized, and we have seen positive signs of progress. We have a unique opportunity to expand our support to local healthcare providers to build comprehensive healthcare systems and connect with knowledge and learning from other countries through enhanced connectivity (satellite internet).

However, despite having successfully piloted our program, we still face significant challenges in expanding the reach and impact of our solution. In a country like Yemen that has been crippled by a decade of war, famine and other hardships, where around 1.2 million health workers and other government employees work without pay and private health facilities struggle to maintain salaries, the ability to raise internal capital from a tax-funded public healthcare system has been exceptionally difficult, creating no local buyer for technology and/or training. 

Given the incredible poverty of the communities in Yemen, funding healthcare by out- of-pocket means, is not a viable option. We have nonetheless worked tirelessly to find external donors who see value in the program and wish to see it continue and grow and we have built several meaningful partnerships with similar organizations that have supported our expansion. We believe that Solve's extensive network of partners and collaborators can help us overcome these barriers and continue to grow our pilot and expand into other hard-to-reach areas.

Through Solve, we hope to connect with partners who can provide us with both monetary and non-monetary support, including technical expertise, access to new technologies, and assistance in developing sustainable business models. We are also eager to engage with Solve's community of innovators and experts to share knowledge, insights, and best practices that can help us further develop and refine our program.

In summary, while funding is certainly an important consideration, our primary goal in applying to Solve is to connect with like-minded partners who share our vision and can help us overcome the many challenges we face in delivering high-quality healthcare to underserved communities in Yemen and other hard-to-reach areas around the world. We believe that Solve can play a vital role in helping us achieve these goals, and we are excited to explore the many opportunities that the program has to offer.

The introduction of portable ultrasound technology in Yemen's healthcare system has the potential to revolutionize the market by improving the quality and accessibility of healthcare in an extremely complex setting. While the benefits in Yemen are clear, the market potential is likely outside Yemen. This solution could increase the demand for portable ultrasound devices in low-resource settings, leading to greater innovation and competition in the market.

It may also lead to increased investment in healthcare technologies specifically designed for use in austere environments. As the solution is designed with a train-the-trainer model, it could also create a new market for training programs focused on building local capacity in low-resource settings as we have seen through our experiences working with Butterfly Network.

Overall, the success of this solution could pave the way for similar innovations to be implemented in other low-resource settings, ultimately transforming the global healthcare market.

We have great aspirations for this program. Over the next year, we will continue to develop our train-the-trainer model to contribute to building a stronger healthcare system and advance gender equality and economic opportunity for women in Yemen. In the immediate future, our team will continue to review and provide guidance on scans sent to us from Yemen and we will continue to deliver internet to the hospital using funds co-raised independently by Bridge to Health and MedGlobal. By mid 2024, we aim to expand our reach through expansion into three new sites, including local healthcare centers in the same region.

Looking ahead, we plan to further scale our innovation through additional sites in new regions and our train-the-trainer model focusing on women’s health and female economic empowerment, where we saw the most enthusiasm and demand from the communities we visited outside the hospital training sites.

To plan for our expansion into new locations, including rural rotating clinics, we have confirmed support from local NGOs, hospitals, clinics, and the Ministry of Public Health and Population. Additionally, we are planning to introduce a south-by-south learning model where our trainees in other locations (Uganda, Kenya, Peru and other countries) share data and scans globally, providing feedback and insights from multiple locations. 

Most importantly, our partners on the ground will be critical to the future success of scaling-up. Local Yemeni NGOs, Nahd Development Foundation and Selah Foundation for Development, who both operate in a public health outreach capacity in the Hadhramaut Governate, have submitted letters of support for our scale-up grant and demonstrated interest in getting involved with the project.

We expect that these relationships will help establish a stronger foothold in the community as well as additional sites and trainees for the program. We will continue to seek out meaningful partnerships with other NGOs, local suppliers, and government officials in addition to strengthening our ties with existing contacts at healthcare technology manufacturers as well as Apple, Google and other potential corporate partners. 

With our continued investment in the Yemen POCUS training program through building an online community of support for our graduates, to providing graduates with the tools and knowledge necessary to become future trainers, and scaling the program up to more clinics and hospitals, we are making significant efforts to the impact of this project is as widespread, affordable, and sustainable as possible. We are developing an online community of support supported by international POCUS expert volunteers to support our recent graduates, featuring accessible resources related to POCUS such as academic articles, presentations, and more. We ensured our trainees would feel confident in supporting their peers' journey to become POCUS experts at our training sites as well through Train the Trainer sessions at the tail end of our program, with the majority of trainees reporting that they feel confident in training their peers.

Finally, we are aiming to scale the program up to additional sites through our partnerships with MedGlobal and Butterfly Network, local partners, and new partners we’ve already begun working with to meet the needs across Yemen as well as expand our program to include midwives and other midlevel providers.

Our team is measuring progress towards our impact goals through several specific indicators. We are tracking the number of trainees who complete the program, their test scores, gender balance, level of education and the number of trainers who are trained. We are also measuring the number of scans performed using POCUS technology, as well as the number of successful diagnoses made using the tool.

We are monitoring the impact of the program on maternal and infant mortality rates at the two hospitals within which we are working, as well as the impact on economic opportunities for women in the community (specifically the female graduates). We plan to collect data on the number of women who receive antenatal care and the number of safe deliveries with the use of POCUS.

In addition to these indicators, we are also tracking the number of partnerships established with local NGOs, hospitals, clinics, and the Ministry of Public Health and Population, as well as the number of sites where the program is expanded. Once we have developed the online community of support, we will track the engagement and participation of our trainees.

Overall, our team is using a combination of quantitative and qualitative measures to evaluate the success of our innovation. We plan to use this data to continuously improve and refine the program as we work towards achieving our impact goals.

Our theory of change is that by providing POCUS training and mentorship to local healthcare providers in Yemen, we can enhance their diagnostic capacity and improve patient outcomes for conditions such as trauma, pneumonia, and complications of pregnancy. Our solution also aims to address the limited availability of imaging technology, shortage of healthcare personnel, and inadequate medical supplies and equipment that currently exist in Yemen's healthcare system.

The immediate output of our solution is that local healthcare providers will have improved diagnostic skills and the ability to make more informed decisions about patient care, resulting in faster and more accurate diagnoses. The longer-term outcomes we expect to see are improved health outcomes and quality of life for patients in Yemen, as well as increased capacity and sustainability of the healthcare system in the region. Additionally, our focus on women's health through our obstetrics cohort aims to directly address the underserved healthcare needs of women in Yemen.

We have developed this theory of change based on our extensive experience in the region, our collaboration with local healthcare providers and authorities, and the feedback we have received from trainees and patients. We have also conducted research and evaluations to assess the impact of our solution, which have provided evidence to support the strength of the links between our activities, outputs, and outcomes.

We believe that our solution has the potential to make a significant impact on the healthcare system in Yemen, addressing critical gaps in diagnostic capacity and healthcare access. By empowering local healthcare providers with the skills and tools they need to improve patient outcomes, we can contribute to building a more sustainable and effective healthcare system in the region.

Our solution is powered by point-of-care ultrasound (POCUS) technology, specifically the Butterfly iQ+ device developed by Butterfly Network. POCUS technology is a non-invasive diagnostic tool that utilizes ultrasound waves to create real-time images of internal organs and structures, allowing healthcare providers to quickly and accurately diagnose a range of health conditions.

The Butterfly iQ+ device is particularly innovative as it is a portable and affordable handheld ultrasound device that can be connected to a smartphone or tablet, making it accessible in remote and resource-limited settings. The device utilizes artificial intelligence and machine learning algorithms to enhance image quality and interpretation, increasing its accuracy and reliability.

In addition to the technology itself, our solution also utilizes remote mentorship and training through telemedicine platforms, allowing healthcare providers in Yemen to access support and expertise from outside the country. This enhances their ability to utilize the POCUS technology effectively and ensures that patients receive the best possible care.

Overall, our solution combines innovative POCUS technology with remote mentorship and training to empower local healthcare providers and improve access to quality healthcare in Yemen.

We are committed to incorporating diversity, equity, and inclusivity into our work at all stages (from design to implementation) and at all levels. Our team is composed of individuals from diverse backgrounds, including gender, race, ethnicity, and nationality and are located around the world. We believe that having a diverse team not only enriches our solution but also enables us to better understand and serve the diverse communities we work with.

We recognize that there is still much work to be done to improve diversity, equity, and inclusivity in our organization, and we have set goals to ensure that we are constantly evolving and improving. One of our main goals is to increase the diversity of our Executive Board to include more individuals from the communities we serve. 

In addition to our internal goals, we are taking action to promote diversity, equity, and inclusivity in our programs. One way we are doing this is by working closely with local NGOs and community-based organizations to ensure that we are meeting the needs of the communities we work in. We are committed to listening to and incorporating the perspectives of community members in our program design and implementation.

We also strive to ensure that our programs are accessible to all members of the community, regardless of their background or identity. For example, we are working to ensure that our training programs are accessible to women and other marginalized groups who may face additional barriers to accessing healthcare education and training.

Overall, we believe that incorporating diversity, equity, and inclusivity into our work is critical to achieving our mission of building a stronger healthcare system and advancing gender equality and economic opportunity for women in Yemen. We will continue to prioritize these values in all aspects of our work, and work to constantly improve and evolve in our approach.

Our business model centers around providing accessible and affordable training and equipment to healthcare providers in Yemen and beyond, with a focus on improving the quality and accessibility of healthcare in low-resource settings. Our key customers are healthcare providers in Yemen, including physicians, nurses, and midwives, who are looking to improve the quality of care they provide to their patients. Our beneficiaries are the patients themselves, who will benefit from increased access to accurate diagnoses and treatment plans.

Our primary product is our train-the-trainer program, which equips local healthcare providers with the knowledge and skills necessary to use point-of-care ultrasound (POCUS) technology. This program is designed to be sustainable and locally led, with a focus on building local capacity to ensure long-term impact. In addition to our training program, we also provide portable POCUS devices to our trainees, which they can use to diagnose and treat patients in remote or hard-to-reach areas.

Our revenue model is primarily based on grant funding and partnerships with healthcare technology manufacturers, including MedGlobal and Butterfly Network, who provide us with discounted POCUS devices. We also plan to explore opportunities for fee-for-service models, where we would charge for our training program or for diagnostic services provided with our POCUS devices.

The introduction of portable ultrasound technology in Yemen's healthcare system has the potential to revolutionize the market by improving the quality and accessibility of healthcare in an extremely complex setting. While the benefits in Yemen are clear, the market potential is likely outside Yemen. This solution could increase the demand for portable ultrasound devices in low-resource settings, leading to greater innovation and competition in the market. It may also lead to increased investment in healthcare technologies specifically designed for use in austere environments. As the solution is designed with a train-the-trainer model, it could also create a new market for training programs focused on building local capacity in low-resource settings as we have seen through our experiences working with Butterfly Network.

Overall, our business model is centered around creating sustainable impact in the healthcare sector by providing accessible and affordable training and equipment to healthcare providers in low-resource settings. Through our partnerships and innovative approach to building local capacity, we believe our model has the potential to transform the healthcare market, both in Yemen and beyond.

As described earlier, we have just finished our pilot and are operating in an extremely challenging context. However, we are aiming to "leave no one behind" and believe that with the right support, there is significant market opportunity through this solution, if not in Yemen, in other regions that could in turn support our work in Yemen.