A Whats-App-based integrated surveillance platform for AMR stewardship

A WhatsApp-based integrated surveillance platform that will enable health practitioners to easily collect real-time data specific to AMR, including stock levels of therapeutics and diagnostic consumables; diagnostics as performed; diagnoses as made; prescriptions as written; and dispensing as undertaken, enabling real-time analytics to dramatically improve how Botswana addresses AMR.

Angus O'Shea, founder, Aranda Group

Robert Kabera, CEO, Arebak

The Aranda model for AMR involves creating an unlimited-volume, fixed-price portfolio of all the antimicrobials and diagnostic consumables that a country needs, available at all levels of a health system as defined by a country’s treatment guidelines. It can only be supplied if appropriate real-time surveillance, stewardship, and controlled use systems are in place. 

No LMIC country has such a system. Our app will become the foundation of a platform on which such a system can be built and scaled.

In Botswana, even with over twenty software solutions to track their supply chain, practitioners waste enormous time filling out forms. Their current IT solutions are not conducive to their lack of infrastructure. However, they all have WhatsApp, and used systems based on it during Covid-19. Using our AMR app, the core data flows from supply chain to practitioners and patients will then provide a robust database for our AI/ML data modeling, which then provides accurate prediction and proactive reduction of AMR.

We do not seek to replace existing processes; rather, our app will increase their efficiency. By deploying our solution on something they all use, we believe it will achieve strong product/market fit: namely, high adoption, usage and retention rates.

Our app will serve the people of Botswana through the Ministry of Health. Botswana is facing a rapidly expanding crisis of antimicrobial resistance, but the detail and spread of resistance patterns and prevalence are only currently emerging. Botswana’s existing surveillance system only provides data with lag times of at least three years after occurrence, and its integrity is compromised by the use of paper records which may or may not be accurately recorded. This clearly does not enable rapid or even targeted decision-making to take place. 

For any comprehensive antimicrobial stewardship programme to be effective, health system leaders require real-time understanding of pathogen prevalence (driven by diagnoses made), therapeutic stock levels to address them (driven by stock control systems that do not currently exist), and decisions made by clinicians. 

From the intensive analytic work Aranda has undertaken in Botswana over the last year, we know resistance is spread widely; indeed, community acquired resistance is potentially a much greater threat than hospital acquired infections. Our app will enable Aranda and the Ministry of Health to understand – in real time – the nature and spread of AMR, and consequentially jointly to design and implement interventions to reduce the rate of resistance.

Aranda will provide a comprehensive data set of real-time analytics on the nature and extent of the AMR epidemic in Botswana, which will enable evidence-informed clinical and policy decisions that will improve population health outcomes in a significant way.

Data collected by our app are governed by Botswana’s Data Protection Act 2018, and will be harvested under the terms of an agreement between Aranda, our implementing partner ACHAP, and the Ministry of Health. While this means that data collected are not immediately available publicly, we expect and intend to make them available as and how the government allows us to. For example surveillance data collected will be of extreme importance to the WHO's GLASS system, enabling Botswana to provide more regular updates than it currently does. 

Data will also be made available to various researchers working in partnership with government at the University of Botswana, Princess Marina Hospital and the U.S.’s CDC, as examples. 

Finally we do expect to use sanitised versions of these data as sources for white papers or peer reviewed publications over time, as and when the government allows this to take place. 

The eight core ways our solution will create tangible impact are as follows: 

1. Improved approaches for prescribing antimicrobials: by centralizing information on the pathogenicity of disease, clinicians may confidently prescribe the most appropriate therapeutics
2. Improved data collection and analysis: creating the opportunity to find AMR hotspots and trends, and therefore implement focused interventions
3. Improved administration of resources: minimising waste, avoiding stock outs, and monitoring antimicrobial efficacy.
4. Empowered healthcare practitioners: facilitating accurate data collection, increasing adherence to antimicrobial stewardship guidelines, and increased job satisfaction and motivation from better decision making.
5. User-friendliness for those inputting data, conducting analytics, and relying on it for decision-making
6. Better treatments and health outcomes for patients through providing more targeted and effective treatments, ensuring faster recovery times, reduced risks of complications, earlier identification of resistant infections, and improved trust in the healthcare system.
7. Increased cost-effectiveness for the Ministry of Health, through a wholesale reduction in the total cost of care by treating patients earlier and more accurately, avoiding complications. 
8. Security of data through end-to-end encryption

Overall, our solution will significantly improve AMR management in Africa. It targets the root causes of antimicrobial misuse, ultimately benefiting patients, providers, and society as a whole.

We selected Botswana for the proof of concept given its history of innovation in public health delivery, including its approach to the HIV and COVID-19 pandemics. The government is solid but its health system is not without challenges. As we determined during discovery, it is also plagued with increasing resistance to antimicrobials both in community and hospital settings. 

This is exacerbated by significant stock-outs of appropriate therapeutics, leading, for example, to the use of azithromycin (a Watch drug) instead of amoxicillin (an Access drug), due to the latter’s unavailability. 

Our vision is to expand across LMIC countries who wish to adopt the combined portfolio & stewardship approach to AMR. In each country we will use the same process: 3-4 months of fact finding, analysis, and discovery, followed by an intensive, 6-week “Delivery Lab” problem-solving process (including over 100 key full-time stakeholders from all sectors), followed by establishing a delivery unit, which ensures the government works to implement the stewardship-related plans arising from the delivery lab. 

The result is implementation of a sustainable stewardship and controlled use program continually funded by the portfolio model. Once the POC is complete, we intend to expand to other LMIC countries.

We have established an AMR Delivery Unit under the governance of the Ministry of Health. Its secretariat is provided by ACHAP, an NGO with over 20 years’ experience in implementing innovative public health programs in Botswana. 

The delivery unit’s tasks are twofold: 

1. to monitor the implementation of the action plans of rising out of delivery lab; and 
2. to aggregate and analyse the data being harvested by our solution. 

We will track adoption, retention and daily usage measuring the following metrics: number of active users on a daily, weekly, monthly rate; average duration per visit; frequency; and actions taken within the app such as ordering supply, stock management, medical prescriptions made, etc. 

Every week, the delivery unit will create a dashboard of both implementation and health outcomes based on the data being collected. These dashboards, and the underlying analyses, will be provided to the Ministry of Health. Each month, the Ministry’s Permanent Secretary will chair a performance dialogue, during which she will review the analytics, dashboards, conclusions being drawn, and the need for interventions.

As a result, Aranda, and the government, will have continual access to real-time performance and health outcome data being generated by our solution.

Since the WhatsApp-based tech challenge is fairly simple, our main barriers to success are financial, and speed of absorption. We are currently at the end of a grant designed to fund the POC. However, that grant did not cover the costs of developing the app. We have other potential grants or investors in the pipeline, and while they are looking positive, they are not guaranteed. 

On the technology, our default plan is to develop the entire app in WhatsApp. However, if its business model and API functionality does not fully meet our needs and requirements, we will develop a standalone app, still based on WhatsApp technology, that will work off-line (given that internet connectivity is a barrier to usage for most digital solutions in Botswana).

In the meantime, we are working with the government to develop the policy changes required for them to move toward a subscription model for antimicrobials. This will create the conditions for Aranda to sustainably support stewardship and controlled use, and therefore support the app.  Other barriers we may face include workforce capacity across Botswana for them to adopt the app and begin consistently utilising its functions, though the government has a plan for this

We believe our solution is compelling, and urgently needed for surveillance of microbial infections, leading to better data around AMR. The development of our app is not happening in isolation, in the hope that a future someone will adopt it. It is part of a broader program, already sponsored by an LMIC government, and has a very clear route to impact. 

We aim to be in operation by the third quarter of 2024. 

Founders of the Trinity Challenge have provided valuable early support for the development of the Aranda model. It has taken four years of investment and then a year to test, as part of the POC. Thus far each component of the model is being proven: 

• the need for a subscription approach to antimicrobials (and industry’s appetite to join); 
• a country’s need for intensive problem-solving around how to design and implement stewardship; and 
• enabling factors necessary to make the approach perpetually sustainable, without reliance on continued grant funding. 

We look forward to working with multiple partners as we operationalize Aranda in Botswana, and expand to more countries.

We therefore believe that both our stage of development and the Trinity Challenge are uniquely matched in time, and in objectives.

Aranda’s model to address the challenge of AMR is designed to work in partnership with government. We will always be utilising the strengths of a local implementing partner in any country where we work, but our core values are that successful public health programs should be sponsored and owned by host governments to ensure sustainability.

Organisations we would like to collaborate with are therefore governments and their trusted local partners. In all cases, it is the government's decision and their political will which is the defining question for whether Aranda seeks to work with them or not. 

We also welcome the opportunity to work with all multilateral or donor organisations which seek to create early impact and support us to address the AMR challenge, and expand our collaboration with multilateral actors in the AMR space, such as GARDP, ICARS, CHAI, the Center for Global Development, etc. 

We will also seek to partner on an institutional level with institutions such as the University of Botswana, University of Cape Town, and others. Finally, we seek to expand our collaboration with others already working in AMR surveillance, such as the University of Pennsylvania, Harvard University, and their funders such as the CDC Foundation.

Knowledge of Dame Sally's efforts in AMR over the years!