The S+ eHealth platform

Health systems are increasingly dependent on the use of digital technology to connect patients, providers, policy makers and policy enablers. This technology however, has biases and failures that do not allow for equitable and sustainable use of digital solutions - financially, operationally and environmentally. When digital solutions cannot be used at a point of service as intended, it negatively impacts the service provision and health outcomes downstream and prevents insights and hinders planning by those upstream. S+ has built a universal health ledger that can be accessed in real-time, connecting all system patients, users and stakeholders, no matter where they are.  S+ provides the relevant low-cost hardware and hardware-enabled network to ensure all processes are digitized and shared through the network, even without cellular connectivity. When scaled, no patient, provider or policy maker will be left out of the health system.

Millions of health workers, especially in Developing Countries, are still using paper-based tools and are unable to use digital solutions in their contexts because the available technology has too many points of failure.  Over $150 billion spent annually on ICT hardware in Developing Countries; mostly due to short lifespan, theft, damage. Meanwhile, in Africa, 73% of rural users cannot access electricity and 84% cannot access internet.

This impacts the health sector because the ‘last mile’ of provision is routinely ‘offline’. Over $25 billion worth of medicines is wasted in the global supply chain while $30 billion is spent on counterfeit medicine every year. Meanwhile, more than 3 million people in Africa die every year due to treatable diseases and chronic medicine stockouts are common in many places. The economic and social costs are staggering.

In 2014, 93% of Health Centres in Uganda’s Eastern Region were stocked out of more than half of their essential medicines. The situation has not changed much today. Today in Uganda, we know over 90% of health facilities are digitally excluded due to prohibitively expensive hardware and inaccessibility of power sources and connectivity.

The S+ Platform is a low-cost, unified technology platform that connects all stakeholders in health systems to each other through Distributed Ledger Technology designed to work in contexts of no or limited available infrastructure. It is extensible and adaptable. 

The hardware consists of terminals (tablets modified as appliances) and microservers. Terminals host digital tools and connect to the microservers locally through wifi. Microservers are small, robust computers in an untamperable box that provide 100% uptime due to uninterrupted power supply (solar or mains) and interrupted connectivity to other microservers in the network via cell network when available and digital radio for edge cases. The terminals are appliances and will only run apps that are loaded.  A Software Development Kit (SDK) has been developed that allows for new or existing digital tools to be modified and run on the S+ system. Multiple apps can run on a terminal.

Our first S+ tool is an eStock Inventory application that has been co-designed over 300+ hours with health providers and store managers in Uganda. It was built specifically around workflows and leverages existing training protocols around medicine inventory procedures to reduce need for training.

The ledger can store infinite data types, ensuring interoperability.

The initiative began as a collaboration between the District Health Office of Mbale District (Eastern Uganda) and SIGNALYTIC in early 2017. The original aim was to explore and define the factors contributing to shortages of medicines in the District’s health centres. The study spent over 300 hours in design sessions with health workers and administrators, and went to over 40 health facilities. The study concluded with a facilitated exercise called the “Future State”, where health workers came up with the ideal features of a system which would assist them in handling the problems faced while performing stock management tasks. The requirements were simple: a tool which would always work, despite electricity and internet availability, which would be free to use, would allow health workers to communicate needs across facilities, and would eliminate reporting. Subsequent meetings with stakeholders at the Ministry of Health, USAID, the National Medical Stores and others, provided other critical inputs in design and architecture, seeing value in having front line digital tools that work, while aggregating all relevant information into a singular ledger, confronting their challenge of data sharing and interoperability. By engaging all stakeholders and tackling all problems, the solution will serve everyone individually and collectively.

Health systems are becoming more digital and more integrated, however the technology available is creating burdens, breakdowns, inefficiencies and failures across the board. Systems need to be inclusive and accessible however the tools, platforms and models available, simply aren’t working for everyone. Our solution provides the right technology, to every stakeholder, and is extensible to build out new functionalities and reach new users. Our solution provides enterprise, user and system-wide value propositions that are required to meet day to day health needs, in addition to being better equipped to respond to future pandemics and challenges brought on by climate change

While other digital solutions have engaged users and stakeholders to design their products, they have been limited to relying on conventional hardware and infrastructure. Signalytic engaged stakeholders to identify all factors contributing to medicine stockouts, and as such, included built-in functionalities to address factors such as loss, theft, viruses, mis-use, lack of connectivity and power. The solution is cheaper and more sustainable, focusing on local repair and modular improvements, not requiring big capital costs after installation.  Marginal cost is often not factored into technology solutions, however we strive to drive down marginal cost to ensure sustainability. We also deploy a distributed ledger for information management in low-resource, often offline environments. The properties of this technology are perfect to produce a closed-supply chain, however the current digital tools and inputs are inadequate to enable this powerful technology. While competitors deploy aspects of our technology, Signalytic integrates them in a configuration not seen before. The platform is extensible to create digital access points of service across sectors and geographies.    

The core technology of the Signalytic platform is a DLT (Digital Ledger Technology), called a blockgraph. This DLT resembles in some respects existing blockchains and uses hash functions to connect blocks of data in a directed acyclic graph (DAG). The data blocks in the blockgraph store transactions. These transactions can take on any form and their meanings are determined by the client application generating the data. The blockgraph is designed for private, closed networks.

A microserver manages multiple separate blockgraphs. These blockgraphs can be thought of as separate databases that otherwise do not communicate with each other. Access control within the platform determines which client applications have access to which blockgraph. Access can be read-write or read-only, and can be restricted to one or multiple “client interfaces” or applications.

Each microserver adds data to a local “block” which, when completed is added to the blockgraph and shared with the network. Redundant storage between microservers, combined with cryptographic hashes linking up data blocks, provides very robust data security. If a microserver is lost, it can be replaced with a new one and its data will be restored. 

The hardware to access the applications, the terminals and the microservers are all built for energy-efficiency, meaning they can be reliably solar powered and connect to the network via cellular or digital radio technology. The blockgraph similarly is designed to work in low-resource settings with intermittent connectivity and limited power consumption and needs.

Our platform is built to bring digital tools and workflows to points of service in health systems, most critically in the medicine supply chain, and especially in areas with poor availability of power and cellular connectivity. The user interface/app is determined by the appropriate stakeholder or desired customer, since they know their users and the systems best. Once the app is configured using our SDK, the software is installed to the microservers for deployment. After microservers are installed and terminals are distributed to the end users, the accountable stakeholder (digital solution provider) will ensure the required training and workflows are conducted. The platform allows users to access digital tools with no barriers or point of failure, allowing users to perform digital processes, real time information to be generated and made available relevant permissioned stakeholders.  

We work within health ecosystems to fill the gaps and provide the front-end tools and back-end accessibility of information that will move the digital front-line, bringing it closer to the patient than ever before.  

Installation of the platform at a point of service supports the entire point of service for the first client app, while also providing an architecture for future apps designed for its users, as well as connectivity to the ledger, through the network. Once the eStock app is installed at facility, pharmacy and community levels, the next steps are to complete other digital functionalities like EMR's, logistics services, tokenization of commodities, etc around it. 

Our solution currently serves 2 customers. Together, they support over 6000 health facilities through logistics, medicine inventory and ICT services to supply chain stakeholders leading up to, and at those facilities. Our solution is currently being piloted with these customers. 

In the next year, over 1 million people will be served through these facilities as well as additional differentiated points of care enabled through the S+ platform. 

 Over 96 million people will benefit in the next 5 years from a full end-to-end digital medicine supply chain and through inclusive, integrated digital health systems.

We work directly with Ministries of Health, relevant technical working groups and relevant stakeholders in countries.

Our current priorities:

1. Successful pilots of the various tools working on the S+ Platform, establish traction and benefit of each tool in its own right. Tools include serving of the Uganda EMR through the S+ Platform, medicine management at lower-level health facilities through the S+ Platform and native medicine management app, private pharmacy dispensing of medicines through electronic prescribing from healthcare providers.

2. Linking tools through the S+ Platform and demonstrating interoperability of processes. E.g. an electronic prescription created on an EMR at a public health facility is filled by a patient at a private pharmacy through a completely paperless process, and the patient’s record is updated in the host EMR. 

3. Enable the transition of digital functions at health facilities from the current computer and tablet-based technologies to the S+ Platform. In Uganda, adoption of S+ Platform as a technology of choice would reduce the hardware and support costs by 45% of the current expenditures on conventional hardware, while ensuring 100% uptime to each user

We aim to help our customers reach their own KPIs and metrics according to their roles and mandate in the health system. In doing so, we will also improve the coordination and access to information of the system at large, moving the needle towards national goals and targets.  Signalytic works to provide reliable and sustainable technology solutions to achieve the SDG’s together.

In the next year, we will need to secure more financial resources to ensure continue developing our product, optimizing its performance and building out new functionalities. Traditional impact investing has been affected by the Covid-19 pandemic and priorities have changed for many investors.  

Beyond this, with respect to markets, we need there to be flexibility from regulators, including openness and willingness for transparency and visibility of commodities throughout the system. Technically, our platform performs better when there are proper digital ID protocols in place (barcodes, QR codes, etc) to ensure linkages of commodities and people through the database. Finally, cultural barriers or resistance to change from paper to digital remain barriers to full implementation of any transformational solution.

In the next year, we intend to boot strap and rely on grants to fund pilots, and demonstrate to donor agencies and NGO's how our solution can provide a more sustainable systemic impact as a targeted infrastructure investment. Our platform also provides a tremendous opportunity to strengthen health systems - specifically with supply chains and enabling digital surveillance in all required points of service. The pandemic has ignited conversations and interest in health strengthening, so our fundraising efforts will prioritize individuals and entities working to that end. 

Longer term, given the proximity to and collaboration with Ministries, technical working groups and key stakeholders, there is a forum to begin discussing the longer term needs, opportunities and challenges to a successful system. These challenges are no different than what they would be without the S+ platform, however given the framework and architecture of the solution, it will become clearer how singular, unified ID systems can provide tremendous value through a Distributed Ledger. Working with implementing partners to identify competitive advantages and competencies will also help overcome specific challenges that emerge over time.

6 Full-time staff (3 Founders, 3 employees); 4 interns; 2 part-time analysts

Our skillsets, solution and working relationships in Uganda make us uniquely positioned to solve this problem.

Bryan Plummer, MIA has twelve years of experience implementing cutting edge rigorous impact evaluations on innovative social programs across low- resource contexts with MIT’s Poverty Action Lab, UNHCR and the International Rescue Committee.

Nico Christofi, MD has worked in the development of medical technologies and medical innovations focusing on the evaluation of product clinical testing, analyzing and integrating novel scientific discoveries. 

Willem Atsma, PhD Mechanical Engineering, was trained as an engineer and a scientist and has spent his professional career on the invention and development of medical devices. 

Through 3 years working to understand the user, enterprise and system wide factors contributing to the problem of medicine stock outs, we began developing the core technology, enabled through contributions by the Canadian government.

In 2019, we began collaborating with IICS, Uganda’s provider of its national EMR system. In partnership with IICS, the S+ Platform makes the IICS EMR accessible to health workers in all facilities through our network. 

After partnering with IICS, SIGNALYTIC partnered with Medical Access Uganda Ltd (MAUL) in a successful bid to pilot a joint medicine management system in private health centres in Western Uganda. This project will focus on implementations in rural health centres. This project also acts as the stepping stone to a Distributed Service Delivery model for a Remote Medicines Dispensation Module for dispensing of medicines outside of health facilities, closer to patients. 

Signalytic currently enjoys two types of partnerships:

• Funding: the National Research Council of Canada supports Signalytic’s R&D activities in-part through the Industrial Research Assistance Program

• In-country implementation: IICS Technologies, an entity of the Government of Uganda tasked with digitizing the Public Health Sector. IICS are engaged as clients using the Signalytic technology to extend the reach of their already-developed Electronic Medical Records system. In July 2020 Signalytic will be announcing further official partnerships as part of a multilateral collaboration for a 1-year pilot to be conducted in Uganda. Partners will include Development Agencies and a Private Sector Medicines Distributor.

The current business model provides value to two distinct customer segments. 

1. The first segment is the health workers and lower-level administrators who use the S+ Platform as part of their daily workflows. The value proposition to this segment is digital stock management including requisitions and authorizations, communication of needs between facilities, and elimination of paper-based reporting. This segment does not provide a revenue stream.
2. The second segment are government organizations, implementation partners, and donors. They use the S+ Platform to access data and reports from facilities. The value proposition to this segment is to extend access of their digital solutions, end-to-end supply chain visibility, and an interoperable source of data across the systems they work in. Revenues from this segment are derived from three streams: non-recurring engineering costs related to adapting current tools to the S+ Platform; sales of S+ Hardware; and recurring support fees.

 Signalytic’s business model will evolve as its business environment, stakeholders, and traction change. The goals of the model are to 

• avoid burdening stakeholders at the base of the pyramid; 
• decrease reliance on governments and donors; and 
• eventually increase market-based revenues and local private sector capacity. 

Signalytic is exploring transitioning to market-based revenue streams by engaging local private-sector customers who can provide services needed by health systems through the Platform. Examples are logistics support and distribution of medicines through private pharmacies. Revenues will be in the form of remittances made from revenues these customers receive through the Platform.

Financial sustainability will be gained by charging recurring annual fees for support and maintenance of the System. Additional sustainability will be gained by decreasing dependence on donor and government funding and transitioning to private-sector customers. This eliminates the cyclical, project-oriented funding and entrenches the Platform into the local markets. Plans to incorporate private-sector customers include expansion of the Platform to private health centres, pharmacies, and logistics providers and to allow for these entities to provide verifiable and quantifiable value to the health systems in which they function. This will reduce the Health System’s dependence on foreign aid while increasing capacity of the local private sector.

Investment capital will also drive growth of the social enterprise, in addition to project-based grants when available. Within 5 years, revenues will cover operational costs. 

We are applying to Solve to make our solution visible to a wider audience. We believe in providing the right tools to build resilient, efficient and sustainable health systems.  We believe we provide a tremendous opportunity for targeted investment that can benefit all stakeholders in the ecosystem, freeing up bandwidth and resources from technology and infrastructure towards actual service provision - such as medicines, equipment and accessibility. Given the crowded digital health landscape, it can be very challenging to get the visibility from donors and investors, especially during a pandemic. 

We hear the common thread challenges of digital inclusion, sustainability and interoperability of digital solutions. As such we Solve problems with solutions that address related problems upstream and downstream. 

We seek like minded people and entities who see the opportunity of such a solution, across geographies and sectors, and can contribute to the direction, strategy and execution of rolling out in the coming years. 

We seek partners who will be able to help us navigate the funding aspect of our social enterprise. Additionally, we seek those who understand platforms, value exchanges and possibilities of the 4th industrial revolution technologies in low resource settings. 

We would like to partner with the donors and development agencies who are interested in system-level digital infrastructure and tools beyond the traditional solutions that prevent leapfrog advancements.

We believe the Global Innovation Fund, USAID DIV, and the USAID Global Health Supply Chain program would be great to connect with for joint-financing and application of our solution to serve their needs.