Dawa Mobile Health

A study conducted in the Torrock area for the purpose of writing a doctoral thesis in medicine has revealed that over 50% of children aged 1 to 14 in the sample suffer from urinary problems, of which 75% were able to be consulted. The urine test results showed that 27.8% of the sample are affected by schistosomiasis, a disease caused by contaminated stagnant water.

There is no national program dedicated to addressing schistosomiasis, despite it being the second major public health issue in Chad after malaria. There are health centers in the three cantons of the sub-prefecture, but they lack qualified personnel, and the only laboratory is located at the district hospital.

The population is poorly informed about the disease, its mode of transmission, its consequences, and the vectors involved. Children with blood in their urine are either not taken to the health center or do not have the opportunity to receive proper consultation and treatment.

Finally, schistosomiasis is the leading cause of bladder cancer in Chad, and it is this disease that our project targets as a rare but dangerous condition that affects family life in rural areas. Other major complications include inflammation of the genital organs, anemia, infertility, and bladder cancer, which is the specific disease targeted by our project.

We can summarise our solution with this expression: THE MAN ON THE BIKE.

Our project is a system that we have already experimented with, which reduces the prevalence of schistosomiasis. We have published an article on this matter (https://pubmed.ncbi.nlm.nih.gov/34398817/). It involves a mobile unit for the management of schistosomiasis through the use of a laboratory for urine testing. Urine samples are collected at home by a bicycle agent, and SMS messaging is used to establish communication between the personnel and the parents. Medications are delivered to the home by the same bicycle agent. Therefore, we would like to replicate this model in Gouin, which is in the same region and shares similar environmental and demographic characteristics as Torrock. The goal of this process is to treat schistosomiasis at the grassroots level, before the feared complication of bladder cancer occurs, for which there are no treatment centers in Chad. This applies to all cancers in general.

The chain of the system:

1. Liaison Agent:

• Receives messages from parents or guardians, collects samples from the sites, and brings them to the lab.

• Weighs the child, records their name and a code, and is responsible for delivering medications.

Laboratory Technician:

• Performs urine analyses and informs the doctor of positive cases.

Doctor:

• Receives urine test results via SMS from the lab.

• Calculates medication doses and sends the number of tablets to be taken to the pharmacist.

Pharmacist:

• Sends a message to the liaison agent, who is responsible for delivering the treatment to the families.

This system combines care and awareness, so knowledge, attitudes, and practices regarding schistosomiasis, as well as other diseases in general, will change, leading to increased trust in healthcare facilities. A study revealed that 89.57% of those affected by schistosomiasis spend an average of 0 to 15 days away from their workplace. By reducing the disease burden, we can increase workdays and productivity in this area, where agriculture is the main pillar.

The goal is to break the cycle of transmission, and its impact on the environment is as follows: less polluted water, which means more water sources for livestock and irrigation.

The target population of our project consists of individuals living in regions where schistosomiasis is prevalent, particularly children aged 1 to 14 years old. We focus on areas with similar environmental and demographic characteristics as Torrock, where we have already experimented with our system.

To understand the needs of this population, we conducted research and studies, such as the article we published. We also worked closely with community members, parents, and representatives to gather their feedback and understand their concerns.

During the development of our solution, we actively involved the target population by consulting them, listening to their needs, and considering their suggestions. The system was designed to directly address their needs by providing free healthcare, urine testing, and home delivery of medications. We utilize bicycle liaison agents to collect urine samples and deliver medications while establishing communication with parents via SMS.

By providing accessible and convenient care, our solution aims to treat schistosomiasis early on, before the onset of serious complications such as bladder cancer. This is particularly crucial in regions where there are no treatment centers for this disease. By doing so, we hope to improve community members' trust in healthcare facilities and promote positive changes in knowledge, attitudes, and practices related to schistosomiasis and other diseases.

By reducing the prevalence of schistosomiasis, our solution also has a beneficial impact on the environment. Less polluted water translates to improved water quality, benefiting water supply for livestock and irrigation, thereby supporting agriculture and regional productivity.

Project Manager: Dr. Didier Lalaye is a physician specializing in e-medicine at Utrecht University in the Netherlands. He founded Dawa Mobile Health, which has become the subject of his research and has received more than 5 distinctions. He is also a project manager at Tchad Plus and has initiated and led several projects combining research and art for the popularization of science.

Field Coordinator: Dr. Marius Madjissem, a physician who has worked in remote areas of Lake Chad (an endemic area).

Laboratory Consultant: Josué Lodoum, a senior laboratory technician. Josué has experience in purchasing medical equipment and has established relationships with several suppliers.

Manager: Mouanodji Mbonan, an accountant for Tchad Plus for over 8 years. He has managed all Tchad Plus grants, internal accounting procedures, financial reporting, audits, and grant closures.

Monitoring and Evaluation Manager: Natalie Engdahl, an organizational advisor. Natalie has over 10 years of experience in impact monitoring, support for social entrepreneurship, and organizational development in challenging markets across Africa. She has worked with streamlined organizational and M&E tools for continuous learning and impact reporting. Natalie holds a master's degree in child rights and has specifically worked with the participation of marginalized groups in service development and evaluation.

Research Coach: Prof. Mirjam de Bruijn, an anthropologist at the African Studies Centre in Leiden, Netherlands, and the Centre for Anthropological and Humanities Research in N'Djamena, Chad.

Pediatric Urology Specialist: Prof. Tom de Jong from Utrecht University.

The field team comes from or resides in the operational region. DAWA has been developed based on this intimate knowledge of the issues and habits, which allows it to leverage existing resources and skills (bicycles, SMS technology, etc.). DAWA works in collaboration with the target group, with the goal of promoting well-being. The team prioritizes relationships based on trust, attentiveness to problems or concerns, and respect for confidentiality. Continuous evaluations help develop services according to the needs. DAWA ensures to establish relationships with community leaders, ensuring community engagement and participation.

DAWA works with public health stakeholders in Torrock and plans to do the same in the Gouin region. This allows DAWA to connect with the public healthcare system and initiatives related to bilharzia at the regional and national levels.

DAWA collaborates with the academic sector, currently working with universities and professors in the Netherlands in the fields of anthropology and medicine.

DAWA is currently in talks to expand these partnerships to work with researchers who use drones to map and monitor climate change. The idea is to track changes in water bodies in Chad in order to monitor the risk levels of bilharzia.

DAWA MOBILE HEALTH OR THE MAN ON THE BIKE

DAWA Mobile Health is a service tailored to rural areas, facilitating the collection of samples, laboratory testing, and treatment of schistosomiasis for individuals who currently lack access to these services. DAWA sets up a regional laboratory with basic equipment. A liaison officer travels to villages by bicycle (the most commonly used means of transportation) for contacts and awareness campaigns. Later, parents or patients can call DAWA when they recognize symptoms of schistosomiasis, and the agent returns to the village by bicycle to collect samples. These samples are tested in the laboratory, with results sent by the lab technician to a doctor who prescribes treatment. The technician can then return to the village by bicycle with the medications. DAWA has been operating in Torrock since 2015, a region with a high prevalence of schistosomiasis. Due to climate change, conditions for schistosomiasis are now present in regions that had never experienced it before. Therefore, DAWA aims to test its concept in a new region, Lake Chad, while enhancing awareness and behavior change efforts for populations with low awareness. Apart from schistosomiasis, Dawa Mobile Health also addresses all neglected tropical diseases, primary laboratory tests for prenatal consultations, and the distribution of tuberculosis and ARV treatments in these remote areas in collaboration with district hospitals.

SUSTAINABILITY FORECAST

Once established, local laboratory services generate sufficient revenue to cover operational costs. This concept has already proven successful at the first DAWA site in Torrock.

The Lab Bus:

In 2018, a lab van was introduced into the project to reach more villages without laboratories. This report concerns the operation of the mobile lab from November 2018 to April 2020, when the project temporarily stopped functioning due to Covid-19.

For this current operation, the bus is equipped with the necessary equipment for the examination and treatment of schistosomiasis and for basic prenatal consultation tests.

During this period, six villages were scheduled with a rotation of one visit every 10 days for each village; a 2-day break is observed on weekends and two more after each rotation. These villages are Torrock urbain, Gouin, Balani, Mabassiackré, Zamagouin, and Goïgoudoum.

The Health Center:

Each health center records patient requests via SMS throughout the week; on the designated day, urine collection is organized by neighborhood, and the urine samples are transported to the health center; the bus arrives and conducts the examinations, the results are communicated to the health center, and the staff is responsible for delivering Praziquantel to positive cases. It should be noted that all children and adults are registered with their gender, age, and weight (for children) as well as other variables such as the history of schistosomiasis contamination, the type of water used, the appearance of urine, symptoms, type of phone used, etc.

The Lab Bus:

It arrives in the morning at the health center, where the nurse tests the urine with a reactive strip; positive urine samples are transferred to a test tube, from which they are centrifuged and examined under a microscope for epidemiological results (number of eggs per field). The results are sent by SMS to the individuals examined. For ethical reasons, positive results are sent to the doctor via SMS, specifying the patient's age, code, and weight.

Imaging:

These are:

a digital tablet adapted for an ultrasound probe (e-ultrasound) and therefore easily transportable, which allows for stored images to be presented or sent to an expert when the technician's reading in the field is limited. This was also used to conduct a study on the effectiveness of Praziquantel in schistosomiasis lesions and to perform ultrasounds for pregnant women in these remote areas. It involves a systematic ultrasound of the urinary tract to detect visible lesions.

a magnifying glass adapted for an Android phone, which allows images of microorganisms to be taken and also presented to a specialist when the technician's reading is limited.

RESULTS OBTAINED IN THE SUB-PREFECTURE OF TORROCK

From 2015 to 2020, we received over 8000 requests in the sub-prefecture of Torrock and were able to treat over 2000 cases. In total, four articles were written, three of which were published and one under review.

We are seeking funding from Horizon Prize to support our project because we have identified a critical need in regions where bilharzia is prevalent, particularly among children aged 1 to 14 years. Our solution has been designed with consideration for the specific environmental and demographic characteristics of regions similar to Torrock and Gouin, where we have already conducted experiments.

We have conducted extensive research and studies to understand the needs of the target population. Additionally, we have worked closely with community members, parents, and local representatives to gather their feedback and address their concerns. This participatory approach has allowed us to create a solution that directly meets the needs of the population by providing healthcare services, urine biomarker tests, and home delivery of medications.

For this application, we are focusing on expanding the model to an area with similar characteristics to the region where the project was initiated. However, we also hope that apart from financial support, Horizon Prize could provide us with expertise and training in various areas such as data analysis, business planning, capacity building, and, most importantly, networking.

In the sub-prefecture of Torrock, there is a health district with a general practitioner, a midwife, and a state-registered nurse. Under the responsibility of this district, there are health centers in various villages, some more remote than others, lacking laboratory facilities and qualified personnel. Treatment, when possible, is based on probabilistic methods. Patients have difficulty traveling to the district hospital for treatment. Our system, therefore, aims to bring schistosomiasis patients closer to the hospital through a proximity service that allows them to be treated without traveling, using low technology such as GSM phones and SMS. Although the project is focused on children aged 1 to 14 and specifically addresses schistosomiasis, it's worth noting that the laboratory established in the health center of Torrock performs other paid laboratory tests, similar to an average hospital laboratory. These examinations generate revenue that contributes to the project's sustainability by covering laboratory supply expenses.

In parallel, the Dawa Mobile Health project collaborates with the health delegation, which represents the Ministry of Public Health in the Mayo-Dallah region and oversees the Torrock district. As a result, the mentioned laboratory is installed in the public health center, and the project personnel are state employees. Therefore, we plan to replicate the same model in Gouin, which has the same administrative and hierarchical system as Torrock.

Thus, sustainability operates at two levels: the revenue generated by the laboratory and the institutionalization of the project, which becomes part of the health program of the health delegation. Positive results will allow the ministry to include this project in its national program and extend it to all endemic areas. However, a preliminary baseline study is necessary for disease mapping and understanding the prevalence.

As with the pilot project in Torrock, the personnel involved in the implementation are the staff members of the health center and hospital who are paid by the state, and the facilities used are the structures of the health center. This ensures the project's autonomy and sustainability in terms of infrastructure and personnel remuneration.

The impact objectives of this project are focused on three areas: knowledge, behavior, and treatment. Interventions targeting knowledge and behavior are aimed at both prevention and treatment. In terms of prevention, the proof of concept will be considered successful if the indicators of schistosomiasis knowledge increase during the project. In the medium term, our goal is to reduce the prevalence in the target populations, but we anticipate that these results will take longer than this pilot project. We will monitor the prevalence within the population. Since this project is targeted towards communities experiencing an increase in schistosomiasis , the outcome may not be a decrease in prevalence but rather maintaining low levels. Therefore, prevalence will also be compared to regions already facing this issue.

In terms of treatment, the proof of concept will be deemed successful if individuals displaying symptoms of schistosomiasis seek and adhere to treatment.

As part of the prevention efforts, the knowledge indicators include knowledge of schistosomiasis as a disease and its mode of transmission. This will be measured through surveys. The expected result is that 75% of the target population will increase their knowledge about the disease and how to prevent it. Behavior change will be measured through surveys as well, although self-reported behaviors can be complicated. Therefore, prevalence in the population will be used as the key indicator. The results on this indicator depend on the baseline study, which will be identified in Phase 1, but based on experience, we anticipate a baseline prevalence of 20%. We hope that the prevalence can be reduced as part of the project and that it will be monitored, but it is not necessarily a condition for success.

For treatment interventions, the key indicator is the number of administered tests, including the percentage of positive and negative cases. In the surveys, we will also ask questions about individuals displaying symptoms of schistosomiasis to monitor if there are people with symptoms who are not seeking treatment.

The target population is approximately 20,000 in Gouin region (OCHA). We estimate that we can sample 2,000 individuals during the project period, with a 20% prevalence of schistosomiasis, resulting in 600 individuals receiving schistosomiasis treatment during the project. Additionally, we anticipate being able to offer other tests and treatments to the population.

In the long term, our targets extend to the Sahel region with a rural population of 63 million inhabitants.

Objectives for the next year:

1. Successfully establish the schistosomiasis management system in the Gouin region, using the model we have already tested in Torrock.

2. Provide home-based care and urine biological examinations for children aged 1 to 14 in the Gouin region.

3. Efficiently deliver necessary medications to schistosomiasis patients, using bicycle liaison agents to ensure distribution.

4. Establish regular communication with parents and representatives through SMS messages to strengthen trust and ensure active participation of families.

Objectives for the next five years:

1. Expand our schistosomiasis management system to other regions with similar characteristics to Torrock and Gouin, aiming for a broader impact on the disease prevalence.

2. Improve knowledge, attitudes, and practices related to schistosomiasis and other diseases among the target population by providing appropriate information and awareness.

3. Strengthen local healthcare structures by establishing partnerships with health authorities and local organizations to ensure the sustainability and continuity of healthcare services in the targeted regions.

4. Measure the effectiveness of our solution in terms of reducing schistosomiasis prevalence by conducting regular assessments and collecting epidemiological data.

Measurements progress toward  impact goals:

During the grant period: Result 1: 2,812 children sampled. Indicator 1: Number of children  sampled, disaggregated by age groups, gender, locality, and education level. Result 2: 700 positive cases detected and successfully treated. Indicator 2: Number of children successfully treated, disaggregated by age groups, gender, locality, and education level. Result 3: Approximately 50% reduction in prevalence.

For all three results, data is collected via SMS, transcribed into an Excel database, and analyzed using SPSS for descriptive statistics. Qualitative data collection will be conducted through an interview guide administered to parents and/or children, as well as healthcare personnel, followed by transcription and archiving.

Indicator 3: Baseline prevalence, midterm prevalence, and end-of-grant prevalence. Comparison of these prevalences with areas without a mobile health system.

DAWA is primarily a technological innovation as it establishes a screening and treatment system in regions lacking these services. It utilizes a combination of existing and new technologies to bring laboratory and healthcare services closer to affected populations. The innovation was created and remains focused on schistosomiasis, but it integrates other health innovations such as portable ultrasounds for prenatal care.

On the social front: The specific innovation in the iterative concept of this project combines this technological innovation with a social innovation as it applies the DAWA model to new populations with no prior experience of schistosomiasis. There is thus an additional social intervention of awareness activities. This is not a one-time activity but continuous and closely linked to healthcare services, focusing on behavior change.

Commercial/sustainability: Finally, DAWA, at its initial site, discovered an innovative business model. The site became self-sufficient once launched, leading to a business model innovation. The concept is that other international funding finances geographical expansion and product development, while local revenues, fees paid by users themselves, cover permanent local costs.

Full time: 5

Part time: 6

Contractors: 4

7

DAWA is working to bring healthcare services closer to the population. Initially, the focus was on bilharzia, but as it expands, DAWA offers other screening and treatment services. This allows women to take control of their own health. Some services can also be provided more discreetly. The nurse will be a woman with skills in gender sensitivity.

Furthermore, DAWA will work closely with the target community to develop its services, particularly women and other marginalized groups. This will give women in the target populations direct influence over their access to healthcare services.

Once established, local laboratory services generate sufficient revenue to cover the cost of operations. This concept has already been proven at the first DAWA site in Torrock. Since healthcare services are brought to the people in need, rather than requiring them to travel to cities, sometimes for days, the costs for clients are actually lower than what they currently pay, making it an affordable and sustainable option.

The service can be implemented in addition to local services, as is the case in Torrock where the laboratory is installed in a public health center. However, it can also function independently if the local health center is unable or unwilling to collaborate.

Healthcare is a heavily regulated industry, and relationships with the government are crucial. The expansion plan would focus on regions where there are good collaboration conditions and existing operating permits.

The solution does not compete with existing services but complements them, creating favorable conditions for positive collaboration as seen in Torrock.

The financial plan is to develop specific projects and strategic partnerships that fund expansion investments to launch new sites. Once established, each local site covers its costs with local revenue because clients pay for the services they use.

International research is also a potential source of revenue as this service can provide access to subjects and data that currently lack available statistics. The value of this has been observed in the founder's own doctoral research, and we also have initial interest from other individuals.

DAWA already has an established relationship with Utrecht Medical Center for medical expertise and research access. This relationship has proven mutually beneficial, and we expect to establish similar partnerships with other institutions that have research interests in the region.

Paid laboratory services: We offer a range of laboratory services that include biological tests for the screening and monitoring of bilharzia. These services are fee-based, which allows us to generate revenue to cover operational costs and ensure medium-term financial sustainability. The pricing model is similar to that of traditional health centers, providing a sense of familiarity for users.

Accessibility and affordability: Although our services are fee-based, we strive to make them affordable for vulnerable populations. We ensure reasonable pricing by adjusting our operational costs and seeking grants or partnerships to support the most disadvantaged populations. We also provide free services for children aged 1 to 14, reducing the financial barrier for low-income families.

Use of accessible technologies: We have chosen technologies that are easily accessible in the rural areas where we operate. The use of SMS as a means of communication allows families to interact with our system without requiring an internet connection or an Android phone. Additionally, sample and medication transportation is carried out by bicycles, which is convenient for poorly maintained roads and helps reduce transportation costs.

Collaboration with existing healthcare personnel: We work in collaboration with state healthcare personnel, allowing us to share resources and minimize costs associated with hiring additional staff. The laboratory personnel, doctors, and pharmacists are healthcare professionals already present in the public healthcare system, ensuring continuity of care and facilitating potential institutionalization of our project by the Ministry of Health.

Seeking external funding: We actively seek grants, external funding, and partnerships with organizations and funders who share our vision and mission. These external funding sources enable us to develop our activities, expand our reach, and improve our services while maintaining financial accessibility for disadvantaged communities.

The technologies used are accessible to rural areas, as SMS does not require an internet connection or an Android phone. The use of SMS is part of the daily life of families in this area. Sample transportation is done by bicycle, which is very convenient for poorly maintained roads and due to the scarcity of public transportation.

Dawa Mobile Health reaches out to vulnerable communities, particularly those who have no voice in deciding their access to healthcare and have limited healthcare options. Our project allows these communities to have a different perspective on healthcare and rebuild trust with healthcare services.

This is a laboratory service that operates like any hospital laboratory, despite its social nature. It offers a variety of biological tests. The services are fee-based and allow for self-financing in the medium term. The pricing model is the same as that of regular health centers. The personnel are government employees. Finally, if the effectiveness of our system is demonstrated, it will lead to institutionalization within the Ministry of Health.

During this project we have received some grants from: 

Reach for Change: 25 000 US dollars

Total Tchad: 10 000 euros

Fondation de Bruijn Scholtus: 62 000 euros

Utrecht University: 26 000 euros

Voice4thought: 81 000 euros