SHE+ Digital Hub & Dashboard

Equipping frontline-health entrepreneurs to collect data from vulnerable households, continue quality life-saving service delivery during pandemics, and thrive in their business. 

Dr. Ahsanul Islam (Coordinator-Health Systems Strengthening) has 15+years of management and leadership experience in health programming in Bangladesh. He will oversee operational aspects of the TTC programme.

During pandemics, health-workers, women and rural populations are worst affected(1). In remote areas of Bangladesh like Netrokona and Sunamganj, many low-income vulnerable people have suffered economically, whilst significant reduction in coverage of already limited and fragile healthcare systems due to COVID-19 has compounded health risks. Women are particularly endangered; uptake of critical Reproductive Maternal Neonatal and Child Health (RMNCH) services Nationwide dropped by 50% after COVID-19(2), risking massive increases in already high child and maternal mortality(3).

Skilled private community-health-workers (CHWs) are essential to plug formal healthcare gaps, especially for RMNCH, but limited capacity, support and tools restrict their ability deliver quality services and protect their livelihoods as entrepreneurs. These challenges are amplified during pandemics. 

Lack of data to understand the impacts of pandemics or policy responses on vulnerable populations- especially women and children- has left local authorities unable to monitor and respond effectively. Private CHWs are well-positioned to collect and submit data from remote patients to local health authorities, but without digital tools they currently use inefficient and error-prone paper-based collection. Whilst technology solutions exist, few organisations have end-to-end, flexible CHW solutions that can be customised to meet the needs of local health contexts and individual entrepreneurs.

Our solution supports two primary audiences:          

1) Underserved vulnerable communities

These communities are poor, remote, and the worst performing nationally on RMNCH indicators(5), relying mostly on SHEs for their health services. Supporting SHEs to professionalise and deliver improved healthcare during COVID-19 and beyond, greatly benefits all community members, particularly women, adolescent girls of reproductive age, pregnant or lactating mothers and children under 5 years, ensuring they have consistent access to accurate information, appropriate services, and risk messaging.

Our solution also increases the visibility of these populations to policymakers by filling significant data gaps and providing evidence to push for better resource allocation and service provision. 

2) Skilled Health Entrepreneurs (SHEs)

SHEs are local women health entrepreneurs, aged 25-35, each responsible for serving around 7,500 people. These women have few alternative livelihoods opportunities, with limited access to financial services and insurance; being a SHE provides essential income for themselves and their households.

Working with SHEs through a Human-centred design approach, our solutions will provide them improved routine data collection workflow, access to remote personal and professional support and training and medical networks (uninterrupted by pandemics) and linkages to protect and strengthen their incomes as entrepreneurs and address workplace safety.

CARE’s solution offers four direct types of public good:

1. Equitable healthcare services: Healthcare should be a basic right available to all regardless of income, geography, or other characteristic. The SHE model provides continued critical services that would otherwise cease during pandemics.  
2. Data: SHE’s collection of health data in rural marginalised populations will fill a data gap that leads to poor understanding of the needs and impacts of health policies on these groups. This data will be made freely available to local health authorities and integrated with the open source DHIS-2 platform. Additional dashboard reports and datasets will be made available to by CARE periodically or on-demand where possible.
3. Products: Where possible, technology software platforms, code, databases developed or adapted through this project will be shared with CARE and other partners to be assessed for feasibility of replication in other contexts.
4. Knowledge: Learnings from the SHE model and its technology application will be shared with CHW social enterprises within CARE, and other CHW global networks such as the Frontline Healthworker Coalition. CARE will circulate methodologies, findings and toolkits periodically and hold learning events. 

Our solution provides tangible impact for SHEs and vulnerable communities by:

• Reducing SHEs’ workload. Mobile based CHW-facing data collection and analytics tools will professionalise SHE’s data collection, making it more comprehensive, timely and less burdensome. Better data also allows SHEs to respond in a more targeted way to the needs of their communities.
• Protecting SHEs’ livelihoods by building professional capacity remotely. The mobile-based learning hub gives SHEs remote access to formal and informal learning (course modules, peer and expert networks and forums). This increases flexibility and access to professional development resources, information, and support, during pandemics and beyond, enabling sustained information flow and training even when mobility and gatherings are restricted, or personal safety is a concern for SHEs. 
• Ensuring sustained and improved health services to vulnerable communities: With deficient public health systems, CHWs are vital for vulnerable populations. Communities will benefit from more professional and supported SHEs, who are enabled to sustain high quality healthcare provision during pandemics. Better data for visibility of community needs and impacts during pandemics, also means more targeted public health services leading to faster response times, increased service contact and resource allocation from local authorities to affected communities during outbreaks.

CARE strategically seeks to develop and scale, health solutions that address urgent gaps in healthcare for the poor and impact millions. CARE’s CHW SE models (SHE being one) have been tested and evidenced impact and scalability. The intention is that these models (each at varying stages of growth, operating in multiple LMIC countries) reach millions through:

• CARE’s own funded programmes
• Self-sustaining, financially-viable, market-based approaches
• Replication by other agencies.

Driven by this goal, CARE is currently researching and developing a comprehensive investment case for SHE, providing a roadmap to scale within Bangladesh, supported by technological solutions.

In the first year in Bangladesh, we will develop and test the solution with 100 SHEs in one district (30-40 Unions)–collectively reaching up to 1million people in remote communities.

We will engage stakeholders, gather evidence, test, adapt and learn during the next 2 years – working with 2 district level health authorities and scaling to 400 SHEs, reaching 2 million of their impact population/patients.

In year 3, we will also seek opportunities to build capacity and share successful technology tools and methodologies with 1-2 additional CARE CHW SEs showing promise for large scale impact: including LiveWell in Zambia, a network of 2,000 CHWs.

Key indicators will be monitored through project MIS and regular learning sessions to review and adapt the programming, with reporting shared 6-monthly. A baseline/endline study will provide data for the Monitoring, Evaluation, Accountability and Learning (MEAL) framework, based on the following indicators already being used to assess SHE impact:

• #CHWs: 410 SHEs and 4100 community health volunteers
• #Population reached: 3,000,000
• #Skilled-service contacts: 2,200,000
• #Pregnancies registered: 262,235
• #Deliveries by SHEs and % increase 63,000;13-37% increase
• #ANC/PNC visits provided and % increase:764,877/328,920; 59-84% increase
• #Complicated maternal case referrals: 30,272
• #Family planning contraceptive distributed: 56,968
• #Government health staff trained: 1,225
• $Earned by SHEs: $1,043,736
• Top tier of SHEs getting 90% real-time data
• #Deliveries attended by SHEs at community clinics
• #IMCI services provided to children >5yrs
• #NCD services provided by SHEs
• #COVID-19 infected cases identified and referred 
• #Rapid analysis and community surveillance conducted by SHEs
• #Local officials trained and accessing the data dashboard.

We will continue to monitor and evaluate these indicators digitally, and add new indicators including:

• %SHEs effectively using the digital hub
• %SHEs completing digital training
• #SHEs accessing digital finance, expert support, insurance.

Key barriers to impact for our solution are around adoption, digital literacy, and access to digital devices and internet.

The GoB is very supportive of digital solutions and already recognises SHE as an extension workforce; the data SHEs collect already integrates into local and national datasets. We will maintain our strong relationship with GoB to ensure their continued support. To ensure CHW adoption, we will take a human-centred design approach to the Digital Hub, conducting user consultations to gather full CHW requirements and buy-in.

To overcome low digital literacy amongst SHEs and rural communities, CARE will conduct in-person training with SHEs and deploy technical support advisors in the field in the first year to build competency and confidence.

Digital tools will have offline data-entry capability to accommodate poor internet connectivity and sufficient budget will be allocated to provide SHEs access to a suitable mobile device (though we will pursue potential support from corporate partners to minimise this cost). CARE will also connect SHEs with existing Digital Information centres (at Union level) where they can use laptops and internet connection for telemedicine services for their patients and themselves. SHEs can also receive technical support from staff at these centres.

CARE is experienced in implementing multi-country, multi-million-dollar programmes, working with international and local NGOs/CBOs and service providers, academic institutions, aid agencies and corporates, trusts and foundations. We implement through local partners and CARE country offices. Existing partners and affiliates relevant to TTC include GSK, Microsoft, Maya Health App, CommCare, BMGF.   

In innovation, dearth of funding for the “missing middle” is problematic because this is often not an attractive prospect for donors or investors – but critical to the pathway to sustainability and scale.

Securing investment from TTC at this point of scaling SHE, has the potential to impact many millions and be transformative for CHW networks within CARE’s own CHW SEs and beyond.

Support from TTC to develop digital tools will facilitate this growth by allowing the model to further adapt its operations and approach to deliver effective health pandemic preparedness, response and recovery – and offers the tools and impetus for other CHW networks and SEs to do the same.

TTC and members bring together innovation thought-leaders who understand this landscape well and with whom we would love to collaborate on this journey. We would also benefit from TTCs vast networks of technology members and partners in the identification of a suitable technology partner. We also believe that CARE’s global expertise as a strategic partner for TTC going forward is an area to explore.

Microsoft: CARE is currently working with Microsoft to pilot a foundational platform and build CARE’s data architecture through a combination of Power BI, Azure Active Directory, Azure Cloud, and various Power Apps -serving as a single repository of existing and future CARE programme data to help generate insights and learning more quickly, comprehensively and sustainably. Existing and new data –including that captured through the VoiceApp and other digital tools – will be integrated and aggregated to allow comparison of diverse datasets to inform programmatic decisions in near real-time and in planning, for greater impact and influence. The data platform will be designed based on user needs and human-centered design, with the core goal of data use and rapid learning, especially with data dashboards and visualisation. We also benefit from subsidised licenses from Microsoft for several of these platforms and are exploring ways to work with Microsoft on AI, text analytics, and predictive modeling.

We would be interested to further build on this partnership with Microsoft to enhance the BI analysis capability and dashboard functionality of our proposed solution.

Mobile partner: We would be interested to explore partnerships to reduce or remove the cost of devices for SHEs in this solution.