Scaling Open-Source Technology for Community Event-Based Surveillance

Building, scaling, and sharing open-source digital health tools for community event-based surveillance systems, rapid response, and data-driven decision making.

• Jacqueline Edwards, Chief Executive Officer, Medic
• Dr. Lyndah Makayotto, Head Division of Disease Surveillance and Response, Ministry of Health Kenya

COVID-19 left nations scrambling to adapt their public health surveillance systems to rapidly detect and meet the virus’ pace. Due to these systems’ reliance on information collected by health facilities when patients seek treatment, this surveillance method misses those who do not seek treatment at a facility, or face barriers to treatment – circumstances common in hard-to-reach populations. 

According to the WHO, half of the world’s population cannot obtain essential health services, with facilities either inaccessible, unaffordable, or under-resourced. These gaps in health systems are bridged by millions of community health workers (CHWs) who provide basic care to local residents and link them to the broader healthcare system. Engaging CHWs to participate in event-based surveillance supported by digital-tools is one approach to mitigate these gaps in care and disease detection, providing systematic pathways for CHWs to collect and report health information from their communities. (WHO, 2018)

An exemplar community event-based surveillance (CEBS) system, m-Dharura, has been developed and deployed in Kenya through collaboration between Medic and the Ministry of Health. There is an urgent need to scale this system nationally and to share best practices through the Community Health Toolkit, the open-source platform upon which m-Dharura is built.

m-Dharura supports frontline health workers in securing the health status of their communities, reinforces surveillance teams as they investigate and respond to events, and provides national-level access to reliable data around events and response to inform evidence-based decision-making. This model for linking communities to national health systems can empower people and governments to use real-time data and analytics to improve health, increase access to care for everyone, and mitigate emerging health events that impact disadvantaged communities disproportionately.

Medic and our partners, like MOH Kenya, work to strengthen health systems to ensure equitable care for all, including the most marginalized communities. We acknowledge that the poorest members of society are more likely to be exposed to disease and harm and less likely to access working health systems or robust software tools. 

Medic focuses on frontline health workers as a means of reaching and positively impacting underserved communities around the world, linking them to their local and national health systems. We work in solidarity alongside communities experiencing extreme poverty, leveraging a deep focus on human-centered design, with our service designers working at the community-level, side-by-side with app users. This skillset makes us uniquely equipped to design high-impact solutions for health systems.

m-Dharura is powered by the CHT, a digital global good and a free, open-source software toolkit used to manage, analyze, or transmit health-related data, with proven utility in several settings. It is adaptable to different countries, communities, and contexts. Emerging user needs addressed through development of features by other CHT implementers are publicly available. 

The CHT is released under an open license approved by the Open Source Initiative, specifically, under the Affero General Public License (AGPL) 3.0., with adherence to open data principles. Any organization is welcome to access and utilize the technology and resources within the CHT under the terms of this open-source license.

COVID-19 is unlikely to be the only pandemic in our lifetimes. There is a crucial need to establish sensitive early warning systems capable of identifying existing and emerging conditions to avert health emergencies. Owing to its simplicity and use of real-time data and analytics, m-Dharura is an extremely viable template and solution. 

1. It is scalable across different contexts, leveraging existing infrastructure and human resources from the communities where health events are identified and response is coordinated. 

2. It is designed to solve fragmentation in surveillance across different government departments, including human and animal health, creating a unified approach to evidence-based response, policy-making, and timely use of reliable data. 

3. It can be integrated with a national reporting system (DHIS2), combining routine public health and surveillance data, leading to better identification of clusters and high risk populations or geographies to target interventions, assessment of impact of public health interventions, and advocacy for government resource investments to enhance surveillance in communities.

The CHT is continuously enhanced as a public good. Digital health knowledge is shared freely, and more organizations have the opportunity to adopt and scale this proven technology for their community needs – focused on cost-efficient, equitable, timely, and quality care at scale.

m-Dharura is currently scaled in two counties in Kenya with a planned expansion to four additional counties over the next year through direct support, and five additional counties through bilateral and multilateral partnerships. Over the next three years, we expect to reach a total of 20 counties and an estimated 20,000 CHWs across all implementation partners. As surveillance is a national function, MOH Kenya will provide technical support to counties, enabling them to set up and operationalize CEBS as a foundation to scaling m-Dharura. Jointly, we will build capacity on m-Dharura for counties and partners to scale organically.

The global need for digital tools in the community health setting is greater than any one organization can fulfill. Medic makes our tools accessible to any impact-driven health organization, regardless of their size or resources. In Kenya, and other contexts and settings where we work, we partner with local and national governments to design and implement digital health tools as government-led programs embedded in the broader national health system. We also work alongside high-impact technical solution providers, building their technical capacity to assess community needs, design workflows, configure the CHT’s Core Framework, and deploy and maintain digital tools at scale.

Given the amount of high-quality data that is generated as a byproduct of our tools, we have a unique opportunity and responsibility to monitor health system performance, analyze data across use cases, understand our impact, and continually improve the tool and project. Nearly all activity and impact metrics for deployed CHT apps around the world are calculated automatically using Medic’s web app and dashboard platform, with data collected as part of the workflow. Data can also be aggregated and pulled into different tools for one-off analysis or visualization. 

We routinely track and measure our impact using a range of signals, processes, and tools; we are committed to using and sharing this data with our partners to better monitor systems, analyze data, improve performance and enhance impact. The data we track includes:

• Delivery (output) metrics, that provide information about the drivers of direct impact on health outcomes,

• Activity metrics, that provide granular, actionable information about program performance and people’s behavior,

• Interim impact metrics, that measure progress towards health impact on much shorter time scales, and

• Impact metrics, that measure the direct impact on health outcomes.

1. Extensive resources are required to successfully transition m-Dharura to be fully domiciled within MOH Kenya, build in-house technical capacity on the solution and data use, maintain the software, and support implementation and user feedback sessions. In addition, during the verification of suspected health events, CHW supervisors must contact their supervisees and travel on-site – both of which incur increased labor costs and workload, and contribute to financial constraints. These resources will be raised through a combination of philanthropy supported by Medic’s funding partners and partners such as CDC continue to provide technical and funding directly to support MOH Kenya’s Division of Disease Surveillance and Response to fully operationalize EBS at national and sub-national levels.
2. The current toll-free SMS shortcode for reporting signals is only supported by one mobile network operator. This barrier will be mitigated through the use of a dual shortcode that supports the two biggest operators in Kenya - Safaricom and Airtel.
3. Societal factors, including evolving disease burdens and low literacy in hardest-to-reach communities continue to be overarching challenges. We have overcome these in the past through a deeply human-centered approach to developing technology, ensuring that the tools are user-friendly, even for low-literate users.

Beehyv, BRAC, CMMB, D-Tree, East Bali Poverty Project, HealthRight International, Integrate Health, International Care Ministries, Jhpiego Indonesia, Living Goods, Médecins San Frontiérs, Ministries of Health (Kenya, Mali, Nepal, Niger, Tanzania, Togo), Muso, Palladium, Partners in Health, Rural Health Collaborative, Safari Doctors, Triggerise, and Village Health Works 

We are seeking committed partners to expand viable digital health technology at scale. m-Dharura leverages data and analytics to identify and respond to health emergencies in a way that did not exist previously. In the lens of climate change and devastating impacts on hard-to-reach communities, evolving population-level health crises due to the dual burden of disease, and the high prospect of not-yet-detectable pandemics on the horizon, it is essential to grow exemplar CEBS-principled systems such as m-Dharura. The CHT, as an open-source global good is perfectly positioned to support the scale of m-Dharura with the MOH Kenya, document best practices and app building tools for public consumption, and explore scaling opportunities with new MOHs and regional implementing partners. We must get ahead of the next health emergency to avert loss of life and avoid devastating economic impacts as seen with COVID-19.

We are particularly interested in developing or expanding relationships with:

• Patrick J. McGovern Foundation, to align on AI and data solutions being explored by our Medic Labs initiative,

• Microsoft, to expand our relationship beyond Microsoft Research and AI4H into philanthropic partnership, and

• Bill & Melinda Gates Foundation, to discuss direct-funding opportunities and navigation to their best-suited team for collaboration.