Digital SMART Guidelines for Resilient Community Child Health Systems

Strengthen and improve health systems resilience to protect essential health services during pandemics and enhance community child health and well-being (CCH) through digitally enabled community health workers in Sub-Saharan Africa, including enhancing the content, timing, and frequency of essential health and nutrition services for children and families.

Professor Debra Jackson, Takeda Chair in Global Child Health and Deputy Director of the Maternal, Adolescent, Reproductive, Child Health (MARCH) Centre at London School of Hygiene and Tropical Medicine.

The United Nations Inter-Agency Group for Child Mortality Estimation reported that the COVID-19 pandemic resulted in major disruptions to health services, threatening to undo decades of hard-won progress for women and children. The survey across 77 countries, found 68% of countries reported  some disruption in health checks for children and immunization services. In addition, 63% reported disruptions in antenatal checkups and 59% in post-natal care. Roberton et. al. (Lancet GH 2020) modeled that a 45% reduction in coverage of essential MCH services for 6 months would result in 1,157,000 additional child deaths and 56,700 additional maternal deaths. This model has been confirmed by primary data. Ashish et.al. (LGH 2020) reported primary data from Nepal showing institutional childbirth halved during lockdown, with neonatal mortality up three times, stillbirth rates up 1.5 times, and breastfeeding and QoC reduced. Pattinson et.al. (O&G Forum 2020) reported reduction is maternity services use leading to a 30% increase in maternal mortality in South Africa. UNICEF Data reported reductions in MCH services coverage in our target region (West Africa) ranging from 25-49% (data.unicef.org).  Lockdowns, misinformation and confusion have been seen across countries, leading to fear and reduced use of health services.  

The target audience is children, and community and primary health care services health care workers, primarily CHWs and other frontline health workers who support them.  An additional target audience is MCH programme managers, health information systems managers, and policy-makers. The project will be located in a selected country in the UNICEF West & Central Africa region (e.g. Togo, Guinea, Liberia) which has been developing a Child-Friendly Communities programme, including a real-time data component (CFC-RTM). Key principles of this solution include: Community ownership and accountability; Individualized follow-up of every child; Interoperability across digital systems; Using existing Open-source and public good products; Scale-up through partnerships; and a Strong learning/research agenda for timely programme adjustments. The project aims to have four key functionalities: Data capture, Data Management, Data Use, Data Sharing. The solution will build on this existing UNICEF programme to examine how to strengthen and improve health systems for children living in LMICs through the delivery of evidence-based interventions using Digital Health for Community Child Health (CCH). Existing tools will be adapted based on recommendations emanating from local virtual and in-person workshops using a Human-Centred Design approach [https://www.unicef.org/innovation/reports/designing-digital-interventions-lasting-impact] and implementation research (mixed-methods focusing on acceptability, appropriateness and feasibility).

The solution will ultimately yield open-source WHO-UNICEF recommended CCH SMART Guidelines which can be taken up for adoption in parts or in its entirety for use by CHWs throughout Sub-Saharan Africa and elsewhere globally. The CCH SMART Guideline development follows the approach WHO is currently using for other RMNCH ‘Smart’ Guidelines (see supplementary material and weblinks). 

By working with UNICEF in the development, implementation, and evaluation of the CCH SMART Guideline, we aim to extend the current WHO efforts with ANC to include CCH to ensure widespread uptake. By working with well-established cadres of CHWs, we seek to capitalize on existing government supported systems. Project activities are anticipated to lead to enhanced CCH services provision by CHWs in selected countries. 

Efforts to validate the decision-support content imbedded onto the device are anticipated to promote a higher standard for evaluating and screening content proposed for inclusion on digital tools and recognize that CHWs cadres within and across countries are not homogenous. 

The development of a ‘menu’ of broader CCH services, including pandemic preparedness, as part of the CCH SMART Guidelines aim to recognize that CHW packages can evolve over time as program’s mature and population needs change.

SMART Guidelines aim to transform how evidence-based guidelines are applied for child health service delivery to improve clinical care and health systems. [https://www.who.int/teams/digital-health-and-innovation/smart-guidelines/] using evidence-based digital technology [https://www.who.int/publications/i/item/9789241550505].

 Activities to develop CCH SMART Guidelines:

• 1.Desk Review – identify global CCH guidelines, including pandemic preparedness/response
• 2.Global Consultations – review and recommend relevant CCH guidelines and final SMART Guideline
• 3.Local Human-Centred Design Workshops – Annually with iterative inputs to design, implementation and testing
• 4.Adapt Narrative “Living” Guidelines to local context - Evidence-based guideline recommendations, implementation, data guidance
• 5.Develop DAK - “Human readable” software-neutral documentation of operational and functional requirements - personas, workflows, metadata, transparently documented algorithms, minimum data sets, priority metrics, listing of relevant health interventions, functional requirements
• 6.Develop Machine Readable Recommendations - Structured software-neutral specifications, code, terminology, interoperability standards
• 7.Develop Reference Software - Software with executable algorithms and interoperable digital components to deliver operational and functional requirements
• 8.Scale planning with Ministry of Health to integrate into national Health Information System and within health systems
• 9.Global and Regional Dissemination, presentation and training for key digital health partners.

Leading to Output: Adapted and tested Digital CCH SMART Guidelines

Resulting in Outcome: Improved community child health care, with reduced child mortality and improved well-being.

As the CCH SMART Guideline solution will be embedded in an ongoing UNICEF regional programme, the solution should immediately scale in the selected target country as the CFC-RTM and CCH SMART Guidelines are part of joint UNICEF-Ministry of Health programmes.  The CCH SMART Guidelines would also likely be immediately relevant for the other CFC-RTM countries in West Africa.  Of the three countries being considered Liberia has just over 750,000 children under 5 year of age, Togo just over 1 million and Guinea just over 2 million.

Beyond local relevance, the CCH SMART Guideline as a global good will be made available through and supported by UNICEF, WHO and other global data collaborations for countries to use and adaptat as part of the global efforts by WHO, UNICEF and other partners to use digital health solutions to improve health systems [https://www.who.int/publications/i/item/9789241550505]. 

Outcome measures for SMART Guidelines [https://www.who.int/teams/digital-health-and-innovation/smart-guidelines/]:

Accurate Guideline Use: Accelerate adoption of clinical, public health and data interventions by leveraging digital technologies. Implementation indicators - Acceptability, Appropriateness, Feasibility, Adoption

Guideline Fidelity: Systematically encourage the consistent and accurate interpretation and adaptation of guidelines as digitization proceeds - results of Decision Support Algorithms validation (correct response, agreement); Review of routine data (appropriate referrals for at-risk children).

Improve Analytics, Monitoring & Evaluation: Strengthen data quality, metrics and reporting to accurately monitor, course correct and attribute health gains - data quality reviews, disaggregated reporting, evidence of data use by CHWs and managers for planning (data review meetings, lost to follow-up addressed).

Strengthen the evidence base: Real-time feedback loops to track guideline use and enrich evidence-base for evaluation and adjustment. Identify implementation barriers and approaches to overcome these barriers - qualitative documentation of adaptation and implementation process (key informant interviews, focus group discussions).

Coverage of Child Health Services: Descriptive time-series review of key child health coverage outcomes - children 12-23 months fully immunized; children 0-59 months screened for developmental milestones and have their birth registered; children 12-59 months received vitamin A and deworming; children live in households with a functional latrine. (Limitation no comparison group)

Potential Barriers at outcome level: Lack of ownership by national and local authorities and partners; insecurity due to conflicts, terrorism, and criminality; collapse due to outbreaks.

Mitigation Measures: Advocacy and inclusive dialogue with key actors; develop DO NO HARM strategy and partnerships with local authorities and community service organizations; emergency preparedness and systems resilience building.

Potential Barriers at activity and output level: inadequate buy-in, weak coordination, weak implementation capacity and insufficient resources; political instability and insecurity.

Mitigation Measures:  Inclusive dialogue with stakeholders, building capacity of all from the outset, leverage domestic resources.

Potential Barriers at global level: Large number of guidelines for CCH across global community which will need to be considered and harmonized to reach a consensus set to be included in the Digital SMART Guidelines. 

Mitigation Measures: Prioritise evidence-based guidelines from global leadership, such as WHO, UNICEF, World Bank, UNDP; Rely strongly on local knowledge for adaptation methodologies and consideration of context; assure a wide spectrum of consultations across experts and current digital  and child health collaboratives (e.g. Health Data Collaborative, Global Child Health Task Force, and WHO Technical Advisory Groups)

London School of Hygiene and Tropical Medicine, Maternal Adolescent Reproductive Child Health (MARCH) Centre, London, UK

Digital Health Unit, Health Section, UNICEF, New York, USA

School of Public Health and Family Medicine, Division of Public Medicine, University of Cape Town, Cape Town, South Africa

We were attracted to the Trinity Challenge based on the 3-pronged approach to pandemic response. The MCH community and local governments have been very concerned with the secondary effects of COVID-19 on essential health services (see weblinks), i.e., the Recover component.  Children while not often directly impacted by COVID-19 disease have been at most risk due to disruption of essential health services (suspension of immunization campaigns and closure of health service sites) and misinformation (such as reduced breastfeeding and fear of taking sick children for treatment). We were also attracted by the network of partners associated with Trinity Challenge as we feel the that a multi-sectoral comprehensive response will be needed to address COVID-19, the secondary impacts of the pandemic and to “Build Back Better” including attention to our most vulnerable populations. Potential Trinity partners include the Bill & Melinda Gates Foundation as they are funding the UNICEF CFC-RTM programme in several sites upon which this solution will be built, and our sister school London School of Economics and Political Science for future consideration of costing the solution and measurement of economic impacts. We also note organisations represented in the Judging Panel which are potential partners, e.g. PATH and KEMRI-Wellcome.

The current team of London School of Hygiene and Tropical Medicine, University of Cape Town, and UNICEF will partner first and for most with the local Ministry of Health and Community Health Worker Programmes. 

We will also partner with the WHO Digital Health Department and WHO Special Programme in Sexual Reproductive Health who created the SMART Guideline process and the initial ANC SMART Guideline.  Our team already has close working relationship with these WHO teams.

We will also seek to partner with digital health solutions being used in the region, for example University of Oslo/DHIS2, MedicMobile, CommCare, OpenSRP, this will be necessary as the work will adapt and expand locally used health information systems championed by the Ministry of Health to include digitally enabled community health and community health workers as a component of the overall government-led health information system.  

We will also seek to partner with global digital health collaborations such as Digital Square, WHO Health Data Collaborative Interoperability and Digital Health Working Group, OpenHIE and others to ensure the CCH SMART Guidelines aligns with other global goods in digital health and as platforms for dissemination of the CCH SMART Guideline (for example see weblinks).