Digitally Enabled CHWs Combat COVID-19

Living Goods’ vision is for families to easily access healthcare they need to survive and thrive. Due to COVID-19, health systems are overburdened and risks to vulnerable communities from existing health threats are rising. CHWs play a critical role in maintaining essential health services and are uniquely positioned to provide education and frontline support to communities. Living Goods’ innovation is a network of digitally-empowered CHWs delivering dramatically improved health outcomes. CHWs are equipped with the diagnostic mobile SmartHealth app to provide basic essential healthcare. We are integrating COVID-19-appropriate workflows into the app to help CHWs educate about and identify COVID-19 cases in their communities. We aim to strengthen the pandemic response abilities of national health systems in the long-term using these digital tools. Living Goods already partners with governments to support over 10,000 CHWs, and we plan to scale our innovation by spreading to additional government and implementing partners.

In Africa, a region carrying 25% of the world’s disease burden, there are only 2.3 healthcare workers per 1,000 people. Health systems are chronically underfunded, understocked, understaffed, and under-managed. Due to these shortcomings, CHWs are often the only link to healthcare for millions of people globally.

Over 5.6 million cases and 350,000 deaths from COVID-19 have been reported worldwide as of May 27, 2020, including a steadily increasing 119,391 confirmed cases and 3,589 deaths in the African Region. Testing is severely limited, and health infrastructure is resource-constrained in communities already struggling to maintain basic healthcare. A recent study by Johns Hopkins University found that up to 1.16 million additional child deaths could occur in low- and middle-income countries if routine healthcare is disrupted by COVID-19. CHWs can help provide continued access to healthcare, during the pandemic and the ensuing recovery period. The role of CHWs during the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. If properly implemented and funded, experts estimate strong CHW programs could save millions of lives annually and generate an economic return of up to 10:1.

Living Goods supports governments and partners to model and cascade exemplar community health programs. With over a decade of experience, we believe effective CHW programs must include digital technology, reliable supplies of medicine, effective performance management, and compensation for CHWs’ work. Our network currently supports over 10,000 CHWs across Kenya and Uganda.

Our SmartHealth app guides CHWs going door-to-door to diagnose and treat life-threatening childhood illnesses (like malaria, pneumonia, and diarrhea), support maternal and newborn care, and counsel on immunization and family planning. CHWs log services provided into the app, which syncs to cloud-based performance management dashboards. Living Goods and government partners can therefore closely monitor, optimize, and verify CHW results in real time, driving informed decision-making.

In the rapidly changing circumstances of the COVID-19 pandemic, mHealth tools can provide remote and no-touch ways to keep CHWs and communities safe, help governments track the disease’s spread, and allow continuity of care for essential health services. Living Goods is technology agnostic and has experience supporting configuring mHealth applications on a variety of platforms. We will use our existing expertise in digital health, data management and integration to support CHWs and government partners in managing this challenging time.

Living Goods serves pregnant women and families with children under age five who lack access to reliable, quality healthcare. 70% of our clients live over five kilometers from the nearest health facility and struggle to travel while supporting their families on less than $1 per day. A survey of our Kenya program showed that over 40% of clients are in the lowest two wealth quintiles. This project also impacts the lives of CHWs themselves. Most CHWs are women wanting to proactively address the health needs of their neighbors. CHWs are trusted advisors who improve the health and livelihood of their family while serving their community and gaining valuable skills, enabling them to get another job, start a small business, or run for political office. CHWs earn a supplementary income that could support sending children to school, saving up for life’s unforeseen shocks, or adding a tin roof to their home. Living Goods incorporates CHW and client perspectives and needs into our technology development process through a human-centered design approach. When new features are added, they undergo user requirements gathering, user acceptance testing, and other iterative processes to ensure CHWs’ and families’ feedback is integrated so it suits their needs.

Lack of universal access to healthcare is an ongoing problem that Living Goods seeks to address, and one that is exacerbated by the COVID-19 pandemic. Long-term, sustainable health impacts can only be achieved with strong health systems in place, supported by governments and cooperating across sectors. Technology and innovation allow Living Goods to create impactful, scalable, low-cost solutions for community health systems to provide reliable access to healthcare to families living at the last mile. Our approach to tech-enabled CHW networks presents a unique, multifaceted solution that contributes to pandemic prevention, accurate detection, and rapid response efforts.

Most standard CHW systems, including the government CHW networks in Uganda and Kenya where we work, do not currently use mobile tools; CHWs are also often unpaid and can lack access to reliable supplies and effective supervision. Living Goods is one of the only organizations supporting CHWs to use the power of mobile tools on a large scale. Mobile tools have a competitive advantage – they are far more efficient and accurate compared to traditional paper-based systems and have greater adaptability for adding features customizable to the specific needs of each diverse community. The SmartHealth platform can be readily adapted to focus on different health interventions and products, easily adding new workflows and customizing analytical data dashboards. 

Living Goods uses data-driven approaches to care, including layering in machine learning and AI approaches for predictive analytics for CHWs to better target high-need households. We have a dedicated innovation network, based in Kenya, that is devoted to surfacing and refining new mobile-based CHW tech solutions. Everything in Living Goods’ approach is open-sourced, and we aim to create solutions that can be shared and adapted by other partners. We are tech agnostic and are not tied to a single mHealth solution for partners to adopt.

The SmartHealth app is a comprehensive mHealth tool for registering, tracking, and following up with patients; accurately diagnosing life-threatening, easily treatable illnesses like malaria, diarrhea and pneumonia; ensuring effective data-driven performance management protocols; and more. Each CHW supported by Living Goods receives a smartphone already loaded with the powerful diagnostic app. The SmartHealth platform was codeveloped by Living Goods with our technology partner, Medic Mobile. Our team now independently manages all our data and internally develops customizations to the SmartHealth platform independent of Medic Mobile, including incorporating predictive algorithms to better target the highest-need households.

We are pivoting our tech approaches to address the COVID-19 pandemic so CHWs can safely continue their core work and support response efforts. We are adapting the SmartHealth app with COVID-19 assessment workflows to accommodate low- and no-touch scenarios and challenges presented by providing remote diagnoses. As COVID-19 spreads, collecting and visualizing data will be critically important for governments to control outbreaks. We will also support governments, both in existing and new regions,  to integrate COVID-19 data into their existing health databases (including DHIS2 and other systems)and to develop dashboards to effectively analyze their data to inform response efforts.

As we enter new partnerships, Living Goods is open to supporting governments to configure any solid mHealth solution they prefer; we are tech agnostic and not wed to the SmartHealth platform if an alternate mHealth solution effectively meets the health system’s needs.

In 2014, researchers from the University of Stockholm, J-Pal, and IPA completed a randomized controlled trial (RCT) – the gold standard in evaluation – of Living Goods’ model in Uganda. The RCT proved that the model produces a 27% reduction in under-five child mortality, with similar findings for neonatal and infant mortality. These results are outstanding in community health and provide rare evidence of impact that few other community health organizations possess. The results are available in the published RCT working paper. Living Goods is now conducting a second RCT in Uganda to ensure that Living Goods continues to maintain our health impacts as we scale. 

Additional links:

• https://livinggoods.org/what-we-do/results-evidence-and-research/research-initiatives/
• https://www.aeaweb.org/articles?id=10.1257/app.20170201&&from=f
• https://www.poverty-action.org/study/entrepreneurial-model-community-health-delivery-uganda

As of Q1 2020, Living Goods supports over 10,000 CHWs serving 7.79 million people. During COVID-19 we are doubling down on supporting the communities we already serve rather than focusing on expansion, so our goal is to maintain this level of coverage in the next year. Due to lockdowns and social distancing, travel and large group gatherings for recruitment, training, and graduation will not be possible. We also may not be able to hold replacement classes for natural attrition, so these numbers may go down if CHWs begin to fall ill.

In five years, we hope to reach 9.47 million people, while expanding to two new countries beyond Kenya and Uganda. We currently have staff embedded in Sierra Leone and Burkina Faso and are exploring the opportunity to expand our support in these countries.

Each CHW impacts and benefits a catchment area of about 800 people, as measured by our 2014 RCT results, so Living Goods calculates our population served as the number of active CHWs multiplied by 800. While a CHW may not regularly provide direct services to 800 people, the RCT showed indirect community benefits from the presence of and access to a CHW (including reduction in counterfeit goods sold in the community, reduction in community spread, and increase in community-wide health knowledge). We therefore do not limit population served strictly as services provided once to an individual, but to include these wholistic, meaningful health impacts in the community and across health systems.

Over the next year, Living Goods is committed to maintaining the health of our communities during the COVID-19 outbreak through our existing programs and new technologies. CHWs typically enter their neighbors’ homes to provide lifesaving care, sometimes using direct physical contact to diagnose and treat. Due to the community spread risks inherent in close contact, we are adapting our core workflows to support low-/no-touch protocols in the absence of Personal Protective Equipment (PPE). While customizing the SmartHealth app with new workflows to continue delivering essential health services, helping identify cases and preventing further community spread, we will also use our expertise to:

• Develop an e-learning platform to remotely train CHWs, our staff, and government staff in COVID-19 prevention, early case detection, reporting procedures, and personal safety measures;
• Evolve our existing SMS platform into a 2-way messaging platform to reach CHWs and families with COVID-19 information;
• Adapt existing and new technology to support national and sub-national health awareness and prevention communications; and
• Support governments to integrate core health and COVID-19 data into their existing health systems to inform data-driven pandemic tracking and responses. 

Over the next five years, Living Goods hopes to scale, reaching millions of people across six countries, increasing government ownership of CHW systems and ensuring all CHWs are armed with digital tools. We will continue to work with governments and partners to leverage smart mobile technology, rigorously strengthen performance and relentlessly innovate to reliably deliver cost-effective, high quality community health services.

Our senior leadership is 65% African and brings decades of experience with a robust combination of public- and private-sector experience, including: deep knowledge on local health systems and government relations; well-connected and respected advocacy and impact leaders from the global public health community; business, pharmaceutical, and consumer product leaders who understand how to serve target customers and scale multi-country teams; and a CFO who has managed complex multi- and bilateral funding portfolios in excess of $100 million. Our East Africa-based CEO, Liz Jarman, joined Living Goods in 2014 and was instrumental in launching and scaling our operations in Kenya, stepping into the CEO role in mid-2018. You can find biographies of our leadership staff at: https://livinggoods.org/who-we-are/our-leadership/.

In recent years, Living Goods expanded our internal tech capacity by hiring our CFO, Asif Akram, and more than tripling our dedicated tech staff, at 71 filled and planned roles for 2020. The team also increased its ability to operate on the SmartHealth platform independently from our development partner Medic Mobile. This was a huge milestone for our long-term tech vision, allowing us to more quickly generate improvements, adaptations, and new workflows – especially to adapt the platform for partners and new health services. The growth of our tech team and strategy has catapulted us forward to explore further innovations, such as developing predictive algorithms to optimize CHW care and better target high-need households, developing data interoperability with government data systems, and more nimbly improving upon the SmartHealth app and accompanying supervisor app.

Typically, when a child in Sub-Saharan Africa gets sick, her mother has two options: go to a private drug shop where prices can be 350% above market rate and there are high incidences of counterfeit drugs, or lose a day of work and incur costs to travel and wait at a public health facility for a free treatment that can likely be out of stock. CHWs expand access to healthcare and education by proactively bringing essential health services to their neighbors’ doorsteps at a fraction of the cost of facility-based care. Our approach benefits individual CHWs and the communities they serve.

CHWs that Living Goods supports are not volunteers or salaried employees; they are empowered entrepreneurs who earn a supplementary income through health product sales and incentives tied to KPIs. During COVID-19, we are providing free key health commodities (ACT, paracetamol, amoxicillin, zinc/ORS) to sick children in CHW catchment areas via our own supply chain to not overstretch the public sector. We have also increased CHWs’ compensation, reflecting the increased workload and risk they are taking on and the potential disruption of other income sources. We are also providing increased data/airtime stipends to CHWs and supervisors to support remote communication.

A rigorous 2014 RCT study of Living Goods’ model in Uganda found a 27% reduction in under-five child mortality. These results are outstanding in community health and provide rare evidence of impact that few other organizations possess, at a low cost of under $3 per person reached.

Living Goods’ long-term goal is to unlock domestic government funding for CHWs, which we see as the most sustainable path to long-term scale. We will pursue that wholeheartedly by focusing on building government capacity to manage networks, making CHW models as cost effective and high impact as possible, and producing evidence of CHW success to make community health investments more attractive, increasing the likelihood that government could become an effective payer in the long-term. However, we are not relying on domestic government resources in the short to medium-term.

We currently have a strong base of longstanding philanthropic donors, including corporate and foundation donors and high net worth individuals. We have traditionally received a substantial amount of unrestricted funding from our donor network, at around 80% of our total annual revenue. To reach the scale of our vision, Living Goods must also seek new sources of funding. To this end, we are pursuing an increase to our funding from bi- and multi-lateral donors—the largest source of funding for public health programs and a near-term bridge to government funding as they influence domestic government resource allocation to a high degree. Due to our sustainable model, Living Goods is also able to keep our costs low by covering the cost of goods sold through the wholesale of health products by CHWs.

CHWs are working on the frontlines every day to bring lifesaving care to thousands of families that lack access to reliable, quality health services and medicines. The need for basic but essential healthcare does not disappear during a pandemic, and the lifeline to care provided by CHWs cannot be interrupted without risking further, preventable loss of life. CHWs continue to serve their communities because they care deeply about their neighbors and know they can make a lifechanging difference. Their communities respect and rely on them as a valuable resource of information and care, and while they don’t have the same highly skilled training as a nurse or doctor, CHWs come from the communities they serve and can bridge cultural, geographical, and linguistic barriers to effectively address a wide range of their community’s basic and preventative health needs.

The CHWs that Living Goods supports proactively visit families to provide health education geared towards prevention; this integrated approach to community health is more important than ever to swiftly incorporate rapid changes of the latest COVID-19 best practices. CHWs will play a vital part in ensuring that communities can continue to access basic healthcare during the pandemic and the ensuing recovery period, providing relief to the already overburdened public health system. Living Goods would use this prize to increase our support to CHWs and governments in new regions and on a larger scale, to combat the effects of COVID-19 with best-in-class mHealth technology and data-driven analytics to inform response efforts.

Living Goods harnesses technology to enhance impact, reduce costs, provide better monitoring, gather patient data, and deliver low-cost behavior change communications to patients. We also explore emerging technologies that can drive a step-change in health delivery, such as machine learning. We are already applying data science and machine learning techniques to our mobile data to improve impact and care outcomes. While many organizations are exploring the use of machine learning for health, few are already operationalizing and testing them in the field with health workers and patients.

The SmartHealth app contains an Equity Tool that prompts CHWs to ask questions that help assess the household’s wealth quintile. This gives CHWs better visibility into which households in their catchment area may need more of their time and attention. Living Goods has analyzed this equity data alongside our wealth of historic mobile data to better understand which demographic factors and variables predict a household’s risk for four negative health outcomes: a child getting sick; a sick child not being diagnosed within 72hrs; a pregnant woman not delivering in a health facility; and a child being born with a danger sign according to iCCM specifications (fever, coughing, malnutrition, etc.). Living Goods has built and tested these algorithms into the SmartHealth app to alert CHWs if a household is at risk of experiencing one of these negative health outcomes and instruct them to deliver increased time and attention to that household to prevent it. Before the restrictions of COVID-19 were in place this year, Living Goods was also completing work on an immunization-specific algorithm to predict and track immunization defaulters. Over the next few years, we hope to find new ways to further incorporate AI into our ongoing work and to support COVID-19 detection and response efforts in communities where we work.

Living Goods’ model is a powerful engine for women’s empowerment and economic development, providing women with meaningful incomes, training, and status. More than 70% of CHWs supported by Living Goods in Kenya and 90% in Uganda are women. We not only empower women to dramatically improve the health of their communities, but also allow them to better their own lives outside of their role as CHW. CHWs can improve the health and livelihood of their own family through increased health knowledge while gaining valuable job skills and earning a supplementary income.

CHWs benefit from free ongoing health, sales, and business education/training provided by Living Goods as well as increased respect and status within their communities. Through their role as a CHW, these women can increase their comfort level with technology and gain valuable skills that they may not have otherwise been exposed to. Importantly, these non-financial improvements can often lead to an indirect, positive economic benefit. 95% of CHWs report that Living Goods taught them new skills that will help them get another job or start a business, and 97% report improved status in their communities. In many cases, women have used this increased status and wealth to run for political office or launch a small business. The positive impact begins with each CHW and extends far beyond them to their families and communities. With this prize, Living Goods will support our network of digitally-empowered CHWs, made up mostly of women, to safely and confidently continue their meaningful work in their communities while bettering their own lives.

Living Goods targets SDG 3.2 - eliminating preventable newborn and under-five deaths by 2030. Current estimates show that over 50 countries will fall short of this target, at a cost of ten million preventable under-five deaths between now and 2030. The key term here is “preventable.” So many under-five deaths are needless, with approximately one third occurring due to a trio of causes whose treatment is cheap and effective and can be delivered by CHWs: malaria, diarrhea, and pneumonia. An end to child deaths (SDG 3.2) and achieving universal health coverage (SDG 3.8) will not be achieved without CHWs. CHWs have been proven to effectively address a wide range of basic and preventative health needs and reach remote patients at a fraction of the cost of facility-based care. Living Goods would use this prize money to support our systems-strengthening work with ministry of health partners to ensure the system at all levels is better able to sustain impacts of pandemics/other large-scale events in future, including ensuring that access to essential health services for the leading causes of child mortality continue.