Health AIM

10 million Ugandans have poor access to healthcare. These rural citizens live in healthcare “black holes”, far from government or private health facilities. Uganda also suffers from gaping inequalities in healthcare distribution with density of healthcare facilities ranging from a meagre 0.4 facilities per 10,000 population in remote Yumbe district to 8.4 facilities per 10,000 population in the capital Kampala.

Despite efforts to correct these inequalities, both Governmental and non-governmental health providers lack the knowledge, tools and easily digestible data to identify which areas are most underserved and in urgent need of health services. Providers therefore focus their healthcare efforts on areas which are easier to access such as larger towns and rural centers, neglecting the remote rural communities which need their help the most. Even when rural communities are fortunate enough to receive healthcare, services are usually provided in village centers leaving the most remote and underserved areas neglected. If healthcare providers cannot easily identify where the most underserved communities are, they will not serve them.

This Inadequate and inequitable health care coverage in poorly served regions such as Northern Uganda is associated with poor health outcomes. Northern Uganda has the highest regional infant and under- five mortality rate and 43% of women report that their family planning needs are not being met. In Nwoya, Gulu and Pader districts in Northern Uganda, high maternal and newborn mortality rates have been attributed to inadequate health care services including poor access to skilled birth attendants during childbirth.

To address inequalities and achieve universal healthcare in Uganda, there is an urgent need to accurately locate communities with poor access to health care in order to inform resource allocation and improve surveillance, prevention, and treatment of disease. New tools are needed to identify which communities are most underserved and to understand what services are needed in those communities

Health AIM is an interactive mapping tool which identifies remote rural communities with poor access to healthcare and illustrates specific health needs of those communities. Government, private and international health partners can use Health AIM to target underserved remote communities they  previously neglected, and tailor appropriate interventions to the specific needs of those communities. Health Aim empowers providers to prioritise healthcare to neglected communities, and allocate resources where they are most needed.

Health AIM’s user-friendly interface, versatility, and low cost make it an efficient tool for all providers to target healthcare interventions appropriately, improve health outcomes for neglected rural communities, reduce inequalities, and ultimately advance efforts to achieve universal health coverage first in Uganda, and potentially in other countries as well.

 Health AIM uses a grid map display, which can provides health accessibility data for any selected community. The area selected can be as small as  100 square meters or as large as 10 square kilometers. Health AIM displays important easy to understand health accessibility information about the selected area which includes

1.    A pooled overall healthcare accessibility score for each area, incorporating a range of health accessibility measures.

2.    Specific accessibility measures including distance to primary care services, distance to maternal delivery facilities and vaccination coverage.

3.    Overall healthcare accessibility score is also visualised as a colour gradient on a heatmap, with red areas demonstrating poor accessibility, and green areas better coverage.

Our current pilot has not yet reached this level of functionality, but currently uses two platforms to map healthcare accessibility in Northern Uganda – First we use the publicly available GPS co-ordinates of government health centers plotted on Google’s My-maps to identify areas geographically isolated from healthcare, and second we have coded a bespoke app with Python which displays Ugandan healthcare related census data down to the parish level. We are in the process of combining these two interactive maps, and integrating population counts sourced from the open source WorldPop dataset to produce a one platform, fully integrated Health AIM for all of Uganda

The Ugandan remote rural citizens Health AIM serves are among the most underserved people not only in Uganda, but worldwide. And not only with healthcare. We recently surveyed 160 community members who live in remote rural healthcare “black holes” to explore both their general life experience, and their challenges accessing health care. 95% of these rural citizens lived in a grass thatched hut, while 85% of the community were subsistance farmers, with the rest operating small business such as as selling produce or operating motorcycle taxies. Only half of the houesholds had all their children between 6 and 12 attending school, and only 1 in 5 households had access to a covered pit latrine.

In addition to this obvious marks of low socioeconomic status, access to healthcare is an enormous challenge. The most pressing need community members often express is access to basic primary healthcare when sickness strikes. When a child falls sick with a potentially deadly condition such as malaria or pneumonia parents have impossible decisions to make. Should they spend most of their available money on transport to distant health facilities, or wait and hope the illness gets better? Other essential healthcare services such as antenatal care, vaccination and deworming are available at distant government health facilities, but also require long walks so are often not prioritised.

Health AIM draws attention to these communities and makes these needs impossible to ignore. When governmental and non-governmental actors see the need and health disparities visualised on the Health AIM display in front of them, like us at OneDay Health they will be compelled to prioritise these communities. When funding is available for health centers, community health workers or vaccination campaigns, these communities will be considered first rather than the current situation where they are considered last or not at all.

These communities are not homogenous, as health care needs vary greatly between communities. Health AIM identifies not only which communities are underserved, but what specific access problems they have. Some communities live next to swamps and suffer badly from malaria. Other communities have reasonable access to primary healthcare, but live 20km or more from maternity services, distances impossible on foot while in labour. Health AIM highlights these specific community needs that can be responded to with the appropriate interventions.

As workers with OneDay Health, we have personal experience in the transformational power of identifying underserved communities with Health AIM. Here are a couple of voices (translated from Acholi language to English) from a recent survey we conducted of remote rural communities which demonstrate the incredible outcomes when neglected remote rural areas are identified and reached with healthcare.

“For a long time over a period of 10 years we suffered here because there was no health center, so people died on the way to other health centers. But now at least our lives have changed, because the hospital is near us” – Mother, Nyakagoro OneDay Health Center

“We used to move a long distance, and spend a lot of money on transport yet you may not even get all the medication you need. Since you opened this health center life has become easy, we can even move on foot and we always get all the treatment that we need” – Mother, Wii Lacor Health Center

The majority of our team live and work in Gulu, Northern Uganda, and our working lives are dedicated to improving health access to remote areas. Nurse Emmanuel grew up in a remote, rural healthcare black hole and witnessed the struggles of his mother trying to access healthcare for her children, including a terrible situation when his younger brother died of malaria. This motivated Emmanuel to become a nurse and serve the kind of communities he grew up in. He spent two years working in an extremely remote are in South Sudan, before joining Nicolas and the OneDay Health team in his homeland as the Gulu Hub manager. Emmanuel has since launched 11 OneDay Health centers in the Gulu hub, as part of the network of 31 sustainable healthcare facilities across Northern Uganda which have served over 120,000 patients in remote rural areas. 

Health-AIM originally emerged organically to help us identify potential areas close to our home in Gulu which could benefit from OneDay health centers. Jeenan Kaiser is passionate about healthcare inequalities and social injustice both in her home country Canada and her parents' home country of Bangladesh. She has worked on initiatives to decolonise healthcare aid. In 2019 member Jeenan met Nicolas during their Public Health Masters course and together they developed the potential of Health AIM to serve remote communities across the whole of Uganda and potentially even beyond. At this stage however we only had the skills of healthcare workers, and did not have the technical ability on board to build a comprehensive Health AIM.

We were fortunate to meet Nick Dowhaniuk in 2020, who has made further development of Health AIM possible. Nick also lives in Gulu, and is passionate about including the community in all health research, working with the community on his Masters to produce the publication “Setting a research agenda to improve community health: An inclusive mixed-methods approach in Northern Uganda”. He also is proficient in mapping and coding, publishing the first ever comprehensive map of all registered Health facilities in Uganda. He is confident that with some extra technical support in the next few months he can improve what we have already built into a fully integrated, marketable version of Health AIM

Health AIM is a critical first step to put the spotlight on neglected communities, raising awareness and identifying needs, but our accessibility data must always be paired with the lived experience of rural communities. After we identify neglected areas through Health AIM, communities are always visited to deeper understand their needs before implementing any kind of healthcare intervention. Before launching our OneDay Health centers in remote areas identified by Health AIM, we first meet with communities to assess their felt needs, and establish whether a OneDay health center really is a good fit for their community and what services they require. Our heart is only that these remote communities we love so much get the services they need and deserve, indeed that is their right. Health AIM is just one important tool on the road to make that happen.

We believe your support could be invaluable in two areas.

1) Technical support in bringing the Health AIM tool to market, especially in refining our visual interface to make it as enaging and easy to use as possible

2) Business support, to help us develop our fledgling business plan into a viable sustainable model. We do not endeavour to make large profits from Health AIM, but still need a pathway to long term financial sustainability

Health AIM will be the first ever interactive map which displays a variety of measures of health accessibility of all communities in Uganda, down to a granular level as fine as 100m squared.

Our overall healthcare accessibility score which Pools a range of accessibility factors into a single number expressed as a heat map is also a new idea, which provides easy visualisation of neglected areas.

Health AIM will empower large and influencial healthcare provision organisations such as the Ugandan Ministry of Health, USAID and GAVI to focus on neglected areas they had never before considered, and to reach them with interventions tailored to the needs of that community. Once they undersand where healthcare is most needed, they will be compelled to act. Health AIM will be catalytic in driving healthcare to reach thousands of communities which until now have been neglected by these large health providers

In the next year, our initial goal is to develop our current pilot into a fully integrated, marketable version of Health AIM by August this year. Within the next year our further impact goals include

1) Secure at least three major commercial partners who pay monthly subscription for Health AIM. Potential customers include large international health providers and NGOs such as USAID, PEPFAR, Marie Stopes, UNICEF, Malaria Consortium and GAVI.

2) Deliver Health AIM to Ugandan Ministry of Health Providers at no cost, and trained at least 5 District Health departments in how to use Health AIM to more effectively target target their regular activities such as vaccination campaigns and Community Health Worker Placement.

3) At least 300,000 Ugandans in remote rural areas will have been reached by health services through first being identified through the Health AIM tool. This will be broken down into the nature of care provided, for example primary health care services, vaccination, maternity etc.

In the next 5 years our goals will expand to roll our Health AIM in other countries, starting in East Africa

1) Adapt health Aim for use in at least 5 other countries. The Health AIM application will be relatively easy to adapt to different contexts, as the same Health facility location Data, population data, and similar census data is freely available in those countries as well. Health systems and the nature of health facilities do vary however from country to country, so there will need to be some systematic adjustments made.

2) Secure enough commercial paying partners for Health AIM to ensure long term sustainability of the mapping tool, including paying full time staff to service our customers and hosting costs of the tool.

3) Over 2 million people in remote rural areas who have been served with healthcare through first being identified through the Health AIM tool.

These are our current two indicators we use to track the impact of the current Health AIM pilot within our organisation OneDay Health

1) Number of OneDay Health centers launched in regions identified by the current Health AIM pilot - currently 31

2) Number of patients in remote rural communities served by OneDay Health centers launched - currently around 120,000

After completing the marketable version of Health AIM in July this year, our indicators will focus on the larger organisations that will use to inform their Healthcare delivery

1) Number of organisations that have signed commercial contracts with health AIM

2) Number of Government District Health departments trained in the use of Health AIM and who are actively using it to inform their health programs

3) Number of people in remote rural areas who have been served with healthcare through first being identified through the Health AIM tool.

4) Reduction in health provision inequalities in areas Health AIM seves, as measured using our mapping tool. As well as being used to identify underserved communities, Health AIM can also track health inequalities over time on a nationwide level, as the tool is updated with new GIS and census data over time.

Despite hundreds of Dollars spent each year on healthcare provision in Uganda by both Government and non-governmental health providers, remote rural communities are neglected. This is evidenced by the 10 million Ugandans who still have no access to quality primary healthcare, and also by our own survey of those living in remote, rural healthcare black holes which demonstrate the dire situation in many remote areas.

Health providers do not reach these populations that are most in need because they do not know which populations are most underserved, and they do not understand the scale of the problem. Healthcare providers instead focus on delivering their services to easier to reach communities, ignoring the large rural communities far outside the reach of their services. 

Health AIM bridges the gap between Health providers and these neglected remote communities. Our health access mapping tool allows health providers to clearly visualise for the first time both the location of underserved communities, and the scale of the problem. Our application also suggests potential interventions which may be of most benefit to those communities. This allows Health providers to easily visit these underserved communities, and dialogue with the communities to design community centered interventions in areas which they have never before reached.

We have seen this theory of change in action through our own experiences at OneDay Health. Health AIM helped us identify communities healthcare “black holes”, dialogue with them to understand their needs and then launch 31 OneDay Health centers in remote rural areas. These communities now have access to high quality, comprehensive healthcare for the first time, and have demonstrated through their words and actions how their lives have been transformed through ready access to healthcare.

Health AIM bridges the gap between health providers and remote rural communities, empowering health providers to target their interventions to those that are most underserved, reducing healthcare inequalities and moving towards truly universal healthcare in Uganda and beyond.

Health Aim is built from scratch on Dash Plotly using Python programming language. We utilise open source data which includes GIS data with health center locations, Population data from WorldPop generated through both machine learning and manual counting, and freely available Ugandan census data.

We are a locally based solution in Gulu, Northern Uganda, and believe that in order to serve remote communities even with an online mapping tool we need to continually be in dialogue with the communities we love and endeavour to serve. Even as we grow to serve other regions of Uganda and potentially, we will prioritise local interpersonal contact between our office staff in towns and city, and remote rural communities. Basing our operations and office locally will help facilitate more hiring of local staff, and increased community dialogue.

When we look in future to hire further staff, we will not discriminate on the basis of race, colour, religion tribe, gender or sexual orientation. Specifically in our Ugandan context there is risk of tribal or religious alignment, and we will actively remain free from such trappings.

We believe in the value of being both locally grounded, while also encouraging racial and cultural diversity in our team. Although team members are based in Gulu, at inception our team has an international flavour, As we grow we will focus on including and hiring local staff.

OneDay Health in its current form is a not-for profit social enterprise. Our goal for Health AIM however is to generate profits that will be invested directly into the growth and further expansion of Health AIM.

We currently use Health AIM to create value for OneDay Health, in identifying areas which are potentially suitable for OneDay Health launch. Our current beneficiaries are the communities of 120,000 people served by OneDay Health centers who now have a good option for high quality healthcare thanks to the combination of identifcation by our Health AIM tool, and healthcare provision by OneDay Health.

In future, our customers will be the Ugandan government and large non-governmental organisations which operate in Uganda. We can offer these providers enormous value, through helping them identify the communities that need their interventions the most. For example in a hypothetical project where an organisations aims to reduce unmet need for family planning by 10%, Health AIM can show them specific communities where unmet need is greatest, so the organisation has highest chance of meeting their goal. If the Ugandan's government's goal is to improve primary healthcare access, we can add value by demonstrating the best possible areas for health facilities to maximise the population reached. If organisations target their work where needs are greatest rather than convenient communities close to town, they will more readily achieve their goals.

Our beneficiaries are rural, remote communities that will benefit from healthcare interventions from our partners that would never previously have considered or reached them. The value generated through newfound access to healthcare will resonate through all aspects of their lives

Our first goal is to raise $20,000 US to bring our current tool to marketable stage, where Health AIM is integrated on one platform and encompasses all of Uganda. We will achieve this by August this year. This $20,000 will be spent towards this in these two ways.

1)    Hiring an extra code. Nick Dowhaniuk has agreed to continue to work part time at no cost to grow Health AIM, and will co-ordinate with another to expedite the work. This will begin with $5000 already set aside by OneDay Health for this purpose.

2)    Paying for the online platform which will host Health AIM.

After the fully integrated and nationwide Health AIM is brought to market, our first step will be to pitch our tool to large multinational health providers, which have the large scale programs and budgets to justify the cost of Health AIM. OneDay Health already has relationships with many of these providers, which should expedite the marketing process.

1)    We will secure 5 Health AIM partners who will each pay a US$200 monthly subscription for nationwide use of our tool. Potential partners include various USAID projects, the GAVI alliance, UNICEF, World Vision, Marie Stopes and various other  national development agencies such as DANIDA (Denmark), UKAID, (UK), JICA (Japan) and GIZ (Germany). These first 5 parters will generate enough money to sustain the ongoing operation of Health AIM in Uganda, including paying a full time local technical support person and online hosting.

2)    We will also share Health AIM freely with the ministry of Health, first training 5 District Health offices to use the tool effectively to ensure remote communities are served in their vaccination, community health worker and other provision programs. Unfortunately it is not realistic to view the Ugandan government as a paying customer at this stage as they have not yet demonstrated willingness to date to pay for innovate solutions to service provision problems. Other surrounding country governments however such as Kenya and Rwanda currently have business relationships with many social enterprises so remain potential customers.

3)    After completing this sustainability stage, we will look to expand the number of partners we work with, and expand Health AIM to other countries. This should be fairly straightforward, as the same GIS, population and census data used to build health AIM in Uganda is also freely available in other countries. There will obviously be major differences in Health provision which will need to be accounted for, so each country’s version will need to be carefully individualised.

We are in early stages of business development, so have not yet secured specific funding for Health AIM, besides that offered within our OneDay Health organisation. We recognise that our best option is to raise the $20,000 of grant funding to build a marketable version of Health AIM as quickly as possible, so we can get the tool to market and become financially sustainable. OneDay Health has a good track record of fundraising over its 4 years of existence, and we are confident we can raise this money in the coming months. 

OneDay Health has raised around US $100,000 for our programs this year, and has dedicated $5000 of this funding towards developing the marketable version of Health AIM over the next 5 months. OneDay health are also planning a crowd funding round specifically towards developing Health AIM, and we expect to raise between $3000 and $10,000 dollars based on our previous two successful crowdfunding efforts. Current or new individuals and foundations can help cover the balance needed to bring Health AIM to market.