Intelehealth digital health expert app

Majority the population in the selected area, especially vulnerable sectors, suffers from severe access gap in health services, particularly in the availability of physicians and inaccesible services. In addition, health services in the Philippines are decentralized and are provided by local governments resulting in a disparity in health service delivery to the poor. Midwives or local community health volunteers provide majority of the care but they are limited in the scope of services they can provide due to inadequate training. What PBSP and Intelehealth is proposing is a free & open source digital health platform that can be used by midwives and community health volunteers to provide basic health services on their own and can also be used to do tele-consultation for complex cases. The solution will specifically focus on addressing the lack of access of women and girls in remote areas to primary maternal and neonatal health services

WHO reports that in 2017, there has been a decline in the maternal mortality ratios in most regions, particularly in Southeast Asia. While the Philippines is on our way to reducing the maternal deaths, the decline have not been as fast as expected. According to the Philippine Department of Health, there were 57 maternal deaths per 100,000 livebirths in 2018. This is slightly higher than the previous year and about 46.19% lower than the target.As in most of our health problems, figures vary across the country due mainly to lack of access to quality health care.  Bukidnon, located in the southern part of the Philippines is one ofthe provinces who have both high poverty incidence (27 of 100 families are poor) and poor health outcomes. Maternal deaths were at 54 per 100,000 livebirths in 2018 while there were 4 infant deaths per 1,000 livebirths. The poor health outcomes are due to the fact that the province has one of the largest land area so that many remain unserved. Most of the municipalities remain rural and have low access to medical care. The recent COVID crisis has further affected the health seeking behavior of the people in the area. 

Intelehealth is an open source digital health & tele-medicine platform that empowers front line health providers in rural communities. It’s a cloud-based platform which can be used by hospitals, community health programs & governments to expand the reach of health services to ensure that vital primary care reaches remote, hard-to-reach and rural populations. It can work offline and in very low bandwidth environments with a simple user interface.At the heart of the Intelehealth software platform is an evidence-based intelligent clinical decision support system called the HxGuide, which helps task shift healthcare processes, that are normally done by doctors or nurses, to front line health providers.Using these software protocols and some very basic medical devices any one with a high school education can be trained to provide community-based affordable healthcare. Health organizations can contribute to HxGuide by building their own protocols to suit the needs of their programs. The platform also supports the health workers to perform tele-consultations with remote doctors for additional support & diagnosis. 

The solution will address the needs of women and girls as well as their children in remote communities in Bukidnon province, Philippines. These vulnerable sectors face many challenges in accessing health care. One, they live far from health facilities, so transport cost or availability is a problem. When they are able to go to government clinics, there is lack of manpower and supplies that they are not given proper care. They do not  have the resources to afford the services of private facilities. One of PBSP's flagship programs is safe motherhood, which aims to contribute to the reduction of maternal deaths. PBSP has mobilized resources from the corporate sector and international donors to implement both short-term and long term solutions to maternal deaths. Bukidnon has been one of the provinces that have been an active partner of PBSP in implementing such solutions.  

PBSP hopes to address the problem of access to health care by providing a tool for front line health workers to connect the women and girls to the proper health care they need, virtually. The solution will also address the problem with health-seeking behavior brought about by the COVID pandemic by bringing the services to the people. 

The solution will focus mainly on ensuring that the women and girls, and their children in Bukidnon are able to access free health services from the government. However, the solution will also help in decreasing the risk of diseases between mothers and newborns. The technology will empower frontline health providers in rural communities and link the patients to hospitals, community health programs and other government facilities. This will ensure that vital primary care reaches remote populations. It can work offline and in very low bandwidth environments with a simple user interface. 

PBSP will partner with Intelehealth to implement this innovative solution to increase access to maternal and neonatal health services. Intelehealth  is a free & open source digital health platform that empowers front line health workers (FHWs) to provide a suite of essential primary health services in hard-to-reach areas. It has a chat-based digital assistant called Ayu (like Alexa for FHWs) to guide FHWs in providing basic health services autonomously. For complex cases it can connect them over low bandwidth networks with on-demand remote doctors for a tele-consultation. Ayu (previously called HxGuide) is a programmable rules-based engine with protocols developed at Johns Hopkins University. Intelehealth has partnered with health organizations in tribal areas in India and conflict affected communities in Philippines & Syria to deploy our tech through their FHWs. Intelehealth will provide technical support,training and implementation support while the PBSP provides staff, local expertise and community reach. This novel telemedicine platform with a digital assistant greatly augments the scope & quality of health services as compared to traditional community health programs delivering better patient outcomes.

There are a number of electronic-based systems being used by the public health sector in the Philippines. However, the systems are limited to recording of patient or client record or SMS alerts or health messages. There is no single system that would be able to provide the front liners with a simple diagnostic tool that can guide them in providing health teachings or referral services for quality care.  

The platform consists of a mobile app for health workers and a cloud based electronic health record system as a backend (OpenMRS). 

The platform contains modules for:

• Healthcare provider decision support using a knowledge enabled digital assistant - Ayu
• Telemedicine to facilitate transmission of medical data to remote doctors and set up audio or video teleconsultations in a low bandwidth environment
• Point of care diagnostic tests using low cost devices
• Prescription and Medication forwarding
• Referral co-ordination by guiding patients to the right next level of care
• Patient education and counselling through video resources
• Longitudinal patient management using electronic health records
• Data reporting

Ayu is a digital expert system to enable task-shifting of complex care processes such a history-taking, physical examination and disease management. Ayu (previously known as HxGuide) has over 20 protocols for preventative and curative care to support health workers to manage cases autonomously. When a case is beyond the level of training of a health worker they can start a teleconsultation with a remote doctor.

Ayu's history-taking protocols cover over 67 conditions and 143 basic physical exams that provide data collection for a number of primary care conditions. The protocols task-shift early history-taking and physical exam steps, reducing the time spent in data gathering and enabling the capture of structured data for analysis. The output is a concise history note that serves as a starting point for the remote doctor to develop a management plan with the health worker and the patient.

Here is a copy of the case study of the pilot implementation that was conducted in Bukidnon: 

https://static1.squarespace.com/static/5b68c433ee1759e7db0f382b/t/5de889c64f096d70f8e6d7ab/1575520720244/Philppines+-+info+about+the+project.pdf  

The solution will contribute to the reduction of maternal and infant deaths by ensuring that women and girls have access to health care services ranging from sexual and reproductive health, safe motherhood (pre, intra and post partum), child care and nutrition. This continuum of services is being offered in government facilities but most women and girls who reside in Geographically Isolated and Disadvantaged Areas (GIDA) are not able to access the services. To increase the access, the project will be training and equipping health personnel and front liners on Intelehealth to provide basic health services to GIDA areas. Health personnel (doctors, nurses, midwives and nutritionist) and one hundred (100) Community Volunteer Workers will be trained on the system and provided with IT equipment as necessary. The system as well as IT equipment (as necessary) will be installed at the government health facilities (hospitals, health centers, clinics) and selected private facilities. Major activities include training of health personnel and community health volunteers to use the system in providing health services. The project will also establish a referral system among both the public and private health service providers to have a pool of medical personnel and facilities that can provide services for complex cases. The government health facilities at the municipal, city or provincial level will also be equipped to manage the implementation of the telemedecine approach and manage the data that will be produced.  Regular sharing sessions will be conducted to serve as a venue for the health officials and front liners to discuss cases, monitor the implementation of the system/ solution and provide mentoring and coaching to the midwives and community health volunteers. The project may need to provide IT equipment for both the front liners and the government facilities as needed. If equipment are present, the project will consider just updating the equipment so that the system would be operable. The solution will be turned over to Local Government Unit and the Department of Health national and sub-national offices for maintenance and sustainability at the end of the implementation. 

PBSP was involved in the piloting of the solution in the Philippines (Bukidnon) which was funded by VSO Philippines and implemented by Intelehealth. The pilot was done in one municipality with a population of  53,000. The pilot project was able to directly serve 406 while 10,000 were covered indirectly by the frontline health workers. With the basic Solver grant, we estimate that we would be able to reach out to 500 mothers and 5,000 individuals (indirectly) in one city in Bukidnon in one year. With additional funding from the Innnovation for Women Prize, or other  we would be able to expand the implementation to another municipality to reach about 2,000 more mothers and their children, while about 80,000 individuals will be potentially be served by the frontliners in two municipalities. However, if fully funded and expanded to all municipalities (33 municipalities) in the Bukidnon and its neighboring province, the solution will be able to serve  1,700,000 individuals or about 283,000 families.

With the Solver funding, we would be able to replicate our solution in one of the cities in Bukidnon that has a high incidence of maternal and infant mortality. We will provide training on the use of the telemedecine app to the health personnel in the city as well as the community health workers. We will enhance the health information system of the city and the province and incorporate the telemedicine system into the system of the Department of Health so that its operation/ implementation costs  would be included in the annual budget of the department.  

If we would also be granted with more funding, then we would be able to implement the solution in one more municipality, train more health personnel and increase our reach to 2,500 mothers in one year. The front line workers would be able to reach out to other members of the population, which will bring our indirect beneficiaries to an estimated 80,000 individuals. With full funding for 5 years, we could reach as much as 1, 700,000 individuals. Sustainability measures, will still be implemented. 
Since the solution will also be able to respond to the need for implementing measures to prevent the spread of COVID such as social distancing and virtual transactions, we see this model replicated in high risk areas where we operate. The solution has the potential to be the "new norm" in providing primary health care. 

The COVID pandemic might be the greatest barrier yet in achieving the kind of impact that we want as far as the solution is concerned. The effect of the pandemic is on our capacity as an organization to cope with the sudden changes in the way things have to be done.

Another  major barrier would be the poor communications infrastructure in the area and in the country as a whole. Some of the functions on the system is dependent on internet connectivity and right now, connectivity is poor in the project site.

On the political front, the national elections are two years away and the accomplishments of implementing our solution might not be sustained if the new administration (especially local) do not support the project. The local government units are also responsible for appointing and maintaining Community Health Volunteer Workers, so if there is a change in administration, the ones that the project trained might not be rehired or reappointed, and we have to train new ones

We might also lose the medical personnel that we trained to more lucrative jobs locally or abroad. It is not uncommon to find government health personnel, particularly nurses looking for better opportunities. This affects the continuity of the project and we might have to train new personnel at additional cost. 

PBSP, just like most development organizations is restrategizing its project implementation strategies to ensure that we are not contributing to the spread of the pandemic. , PBSP has recently drafted long-term solutions in response to the need for adjusting the organization's "way of doing things" to the new normal brought about by the COVID pandemic. Along with PBSP's new strategic direction of generating new or added value to our customers and ensuring sustainability by prudent fiscal management, PBSP will implement new strategies to ensure the continued survival of the organization. One, PBSP will continue and enhance poverty reduction work but develop new solution for COVID 19 recovery, redesign projects to be "COVID-proof" and strengthen community partnerships to implement projects following strict social distancing and other related measures. PBSP will immediately pursue organizational strengthening measures to withstand pandemics or similar events that would compromise our capacities and resources.  

To minimize the effects of changes in the leadership at the national and local level, we will ensure that policies and systems are in place in the Local Government Unit. This means advocating to the current administration to enacted policies that would ensure the continuity of the program and incorporating the strategies of the project into the plans of the health sector. 

The solution team will be composed of personnel from two organizations. The lead organization is the Philippine Business for Social Progress (PBSP), a non profit organization based in the Philippines. Our partner, Intelehealth, which created the telemedicine app, is a social enterprise based in India and Baltimore, USA. PBSP has partnered with Intelehealth before when a pilot was implemented in Bukidnon, with funding from VSO Philippines. PBSP handled the social preparations in the community while Intelehealth handled the technical assistance and training aspect of the pilot project. The arrangements will be the same for this project. 

With full-funding, the team will be composed of seven (7) part-time staff and one full-time staff. For PBSP, the Executive Director, Director Grants Management and Implementation, the head of our IT team, the Manager for Grants and Implementation and a Senior Program Officer will devote a percentage of their time to manage the project. One full-time staff (Project Officer) will be hired to implement and monitor activities on the field. Three (3) staff from Intelehealth will provide a percentage of their time to be resource persons to the training, and troubleshoot systems problems as well as maintenance. 

PBSP creates sustainable solutions to societal problems in its core program areas which are Health, Education, Environment, and Livelihood and Enterprise Development. PBSP has a 49-year track record in program and grants management, capability building and multi-stakeholder engagement.  As an implementing and grant making organization, PBSP operates directly in communities, work through partners, and collaborate with the Philippine government, local government units (LGUs), private corporations and donors to implement our core programs. PBSP has three (3) field offices located in Manila (together with the Head Office), Cebu City, and Davao City, which makes the facilitation and implementation of projects nationwide with ease and efficiency. PBSP has established a good and long-standing working relationship with the Department of Health, having been the main partner and implementer of projects, funded by the Global Fund and USAID, that supported the implementation of the NTP

The Intelehealth project management is supported by a team of experts from Johns Hopkins University. Dr. Soumyadipta Acharya, Graduate Program Director, Center for Bioengineering Innovation and Design at Johns Hopkins University is our Board President and he provides evid ence based advice for program design & implementation. In addition, they have pro-bono volunteer support from Infosys, Wipro & Atlassian to build Intelesafe app features further. Intelehealth has extensive experience working with Governments and NGOs for implementing successful telemedicine and digital health programs at the primary healthcare level in India, Philippines, Kyrgyzstan and Syria. 

PBSP partners with the Department of Health for its various health projects, particularly tuberculosis. While health services are devolved, the department is the technical resources for health personnel in Local Government Units in implementing their health programs. The department provides guidelines and protocols for the various health programs, capacity-building for health personnel and technical oversight of local health facilities. PBSP's partnership with the department at the national and sub-national level is strategic in terms of policy advocacy an provision of resources for sustainability of our health projects. At the regional level, PBSP usually works with the Maternal Neonatal Child Health and Nutrition (MNCHN) technical unit so that they could provide technical inputs and supervision to health workers in terms of maternal and neonatal health services. 

We also maintain relationships the local government units.  PBSP usually work with these units to get support for effective implementation of projects. Most of our projects require the manpower under these LGUs to render man-days. In some cases also, projects need to have access to existing equipment or materials of these units. More importantly, it would be important to have a good partnership with the LGU to have access to our intended beneficiaries with less difficulty.  

We also partner with local non profit organizations or community-based organizations to assist us in implementing the projects at the community level, provide insights into community dynamics that might affect the project and also to build their capacity in implementing projects. 

PBSP is a non-profit non government organization. It was established in 1970 by 50 of the leaders of the business sectors so that the could collectively mobilize funds to implement sustainable projects to reduce poverty. PBSP has two types of revenues: unrestricted and restricted funds. Our unrestricted funds mostly come the annual contribution of our member companies, which have grown from 50 to more than 200 now. These funds are used for overhead expenses such as salaries of core employees, rents, utilities, supplies, among others. Our restricted funds comes from grants given to us by international donors or development agencies (USAID, Global Affairs Canada, AECID). We also get restricted funds from our corporate partners (ex: Coca-Cola Foundation). The restricted funds, aside from financing project implementation costs, also fund some of the salaries of our core employees and some overhead expenses. PBSP focuses its interventions on the marginalized sector - fishers, small holder farmers, women and the poorest of the poor.

On the other hand, Intelehealth is distributed free and open source – so any organization can use it and adapt it to meet their needs. We aim to be a financially self-sustaining organization. The company earns revenue through four revenue streams – software as a service (we host and manage the platform), end-user training, implementation support and licensing of the task shifting protocols. 

Internally, PBSP has instituted new ways of ensuring sustainability given the new trends in the provision of grants to non profit organizations. This is to ensure that PBSP continues to operate and mobiize resources to develop new programs or provide additional funding for projects. Using the Collective Impact approach, PBSP will convene stakeholders in the area to support the project. PBSP will enjoin its member companies located in the project site to provide assistance to the local government unit to sustain the solution.

As the solution will eventually be turned over to the local government unit, the team will work with them to develop a plan to raise revenues to cover the expenses of maintaning and operating the system. This could be in a form of minimal user's fee or annual budget allocation for the system. mainstreaming of the solution into the DOh system - budget will be allocated to the system(annual)

PBSP is always looking at innovative solutions to societal problems especially in the areas where help is needed most. The solutions, as far as we are concerned, does not have to always come from internal sources. In fact, our main approach is collective impact - meaning, we provide a platform for stakeholders to contribute, based on their expertise and resources, to addressing problems related to poverty. In our analysis, one of the most immediate problem in the health sector is the continuing lack of access to primary health services of vulnerable populations especially those that live in Geographically Isolated and Depressed Areas (GIDA). 

PBSP decided to take our partnership with Intelehealth further by mobilizing funds to expand their telemedicine app to more areas in Bukidnon. We envision the system to address the problem of accessibility of services. The piloting in the province had encouraging results and we think that the more local government units that adopt this system, the better. We would especially like to focus on providing services to mother and their children, as maternal and infant mortality has not been decreasing as much as we want it to be.  In fact, we have not reached the MDG target that we committed a few years back. 
The solution will also respond to the need for a new method of medical consultation that does not involve face-to-face transactions, given the COVID pandemic, so this is also something that would add value to the project. 

While PBSP and Intelehealth, have the expertise to set up and maintain the system during the project life, we need to also engage in partnerships to sustain the solution.  Our team needs more technical inputs on the business model with focus on sustainability, product/ service distribution, funding and revenue model and monitoring and evaluation. We are planning to expand this to other municipalites in Bukidnon so we need help in terms of looking at the operating the solution in large scale. As we will be turning over the system to the local government unit, we need to endorse a business model and a funding and revenue model that would be sustainable. 

The implementation of this solution is a partnership between PBSP and Intelehealth. We might also bring in VSO Philippines who lead the implementation of the pilot in Bukidnon to gain some insights on how to improve the solution. This tripartite partnership would be adequate to get the implementation started, but we might need to bring in the expertise of IT companies or universities when we scale up or sustain the solution.

One of the most immediate problem in the health sector is the continuing lack of access to primary health services of vulnerable populations especially those that live in Geographically Isolated and Depressed Areas (GIDA). 

PBSP decided to take our partnership with Intelehealth further by mobilizing funds to expand their telemedicine app to more areas in Bukidnon. We envision the system to address the problem of accessibility of services for women and girls. The piloting in the province had encouraging results and we think that the more local government units that adopt this system, the better. We would especially like to focus on providing services to mother and their children, as maternal and infant mortality has not been decreasing as much as we want it to be.  In fact, we have not reached the MDG target that we committed a few years back. 

The solution will also respond to the need for a new method of medical consultation that does not involve face-to-face transactions, given the COVID pandemic, so this is also something that would add value tothe project. 

Our proposed solution is focused on improving the access of women and girls, and their children to maternal and neonatal health services. The solutions seeks to improve the capacity of the local government unit to provide maternal and neonatal health services especially to those that live in geographically isolated areas. This will be achieved by training and equipping the front line health workers with a new technology that will empower them to provide primary health services where is it most needed. More importantly, the solution will also provide physicians with an opportunity to provide consultations remotely, freeing some time for them to do other work instead of traveling to remote areas where they might also be exposed to security risks. 

The solution will also respond to the need for a new method of medical consultation that does not involve face-to-face transactions, given the COVID pandemic, so this is also something that would add value to the project.