Luvelo

The Luke Commission Swaziland (TLC) is a health care nonprofit operating in Eswatini (formerly Swaziland), one of the poorest and most vulnerable countries from a healthcare perspective worldwide. Eswatini has the highest HIV prevalence rates worldwide and ranks as having the highest TB (co-morbidity with HIV), and cervical cancer rates. 70% of children are orphans or vulnerable children as a result of the HIV pandemic. Delivering high quality healthcare in a nation with such a high rate of disease, and such a high rate of poverty (7th highest Gini Index of 54.6 worldwide) presents unique challenges.

 Key challenges:

o   Insufficient numbers of trained healthcare professionals (doctors, nurses, aids, laboratory, radiology, biomedical technicians, etc.)

o   The most rural patients are often the poorest and most isolated from quality healthcare, with local clinics that could not provide needed care.

o   Over 50% of patients do not present with or possess a national id, and continuity of care is critical to minimizing ART drug resistance and preventing duplicated patients who appear as lost to follow up

o   Eswatini’s data charges are among the highest in the world, equivalent to $1,000 USD per month for a 10 Mbps internet connection

o   Many patients report feeling unloved or stigmatized during health care interactions

o   Most health facilities operate with a mix of paper and digital records, complicating record keeping

o   Receiving and dispatch of pharmaceuticals and medical supplies is not closely monitored, increasing the risk of corruption

o   No off-the-shelf electronic medical records system was found to be robust or adaptable enough for field conditions

o   Intractable personnel challenges at some health facilities detract from overall service delivery

The Luvelo platform empowers complete digital transformation of health networks with fully integrated modules in personnel management, supply chain, logistics, electronic health records, and more. It utilizes modern progressive web app technology alongside native iOS and Android to support any device and minimize the impact of unstable or low bandwidth connections. While many other regional health record systems design for laptop-based screen sizes, Luvelo is built mobile-first with significantly reduced training times (compared to a laptop) and improved data entry speeds on mobile devices due to limited exposure to laptop keyboarding.

 Every employee interaction is coordinated from initial application, recruitment, interview, onboarding, skills development, certification renewals, routine scheduling, time and attendance, payroll hours, and provides high touch feedback mechanisms to counsel and unlock the potential of every staff member, often presenting with deep woundedness from the loss of one or more parents or complex family dynamics.

 An integrated scheduling system links medical outreach events, vaccinations, and fixed site service offerings with multi-disciplinary teams in counseling, healthcare, and critical support functions such as biomed, supply chain management, finance, procurement, ICT and specialized trades. With nearly 700 staff, the system ensures every staff member is assigned to meaningful work each day and that trainees are paired with trainers for practical, on-site skills development.

 Tablet based clock-in and clock-out terminals leverage facial recognition to provide high accountability and enable regular communication with staff through announcements, assignments, job descriptions, and feedback forms. On the same tablets, all employees are able to report maintenance issues, ask a question, ask to speak with a counselor, or report challenges to senior management if uncomfortable raising with an immediate manager. The framework is critical to maintaining team unity and addressing even the smallest miscommunications or interpersonal tensions with crucial conversations before they disrupt compassionate care to patients. Many of the ideas for the Luvelo platform have originated from this all-staff feedback portal where team members regularly suggest new ideas and features to best align the digital ecosystem with the healthcare challenges in Eswatini.

 The supply chain module facilitates transactions from requisition, quotation, purchase order, item receipt, transfer, restock, and dispatch to provide end-to-end supply chain accountability from purchase to patient distribution, tightly coordinating with electronic health records to minimize warehouse and pharmaceutical shrinkage. The application structure allows users to begin inventory transactions, lose network connection, and pick up where they left off. All inventory transactions can be completed on a phone including barcode scanning and Bluetooth integration with Zebra label printers for one-click item and bin printing.

 Other logistics support includes fleet management of over 100 vehicles, task management, help ticketing support, work orders, and distribution of oxygen cylinders to healthcare facilities. The comprehensive electronic health record system currently supports almost 500,000 patients and permits online registration, self check-in, medical history, demographic info, real-time phone number validation, over 40 medical services, labs and diagnostics, and full inpatient and outpatient care. The system employs a layered biometrics approach with facial recognition, phone numbers, names, birthdates, and IDs to suggest the most likely patient match and minimize duplicate patient records. This solution is particularly important due to the frequency with which patients present without a national ID or known birthdate. To rapidly respond to critical vitals out of range, the system sends alerts to senior team members any time a vitals record is submitted outside of acceptable range, and all inpatient care is coordinated through digital orders that show priority, status, and completion notes to healthcare workers.

 The Eswatini Ministry of Health approached TLC to develop a solution to coordinate the national COVID-19 vaccination program, and the electronic health record system was expanded to track the full vaccine supply chain, coordinate all vaccinating teams in country, and digitally register and vaccinate in real-time. To date, 99.9% of Eswatini’s vaccinations have taken place in Luvelo’s ESWAVAX platform, and all digital certificates used at national border posts and for international travel originate from this system. The “MyHealth” app allows patients to view their vaccination history, digital certificate, and background information, facilitating natural data cleaning driven by the patient. Millions of SMS messages have been sent to educate patients throughout all stages of the COVID-19 pandemic and notify patients of vaccine eligibility, doses due, and critical health appointment visit reminders allowing transit to healthcare facilities during COVID lockdowns.

 All data captured in the system automatically feeds into Tableau analytics reports that consolidate program metrics and generate a daily PDF reports sent to all senior team members for to continuously improve all programs and health interventions to maximize resources and extend the highest quality of care to every patient.

 WHO recognized Eswatini’s vaccination efforts as resulting in the highest rate of vaccine utilization in Africa in the first round of vaccines delivered in Eswatini and elimination of any corruption through increased efficiency, transparency, and accountability.

TLC provides free comprehensive compassionate healthcare to all patients, with a special focus on the most vulnerable populations. TLC’s conviction is to treat every patient as a father, mother, sister, brother or child. TLC also commits to ‘reach every last one,’ meaning we don’t leave a mobile outreach in a community until every patient has been treated and we never stop focusing on the barriers to healthcare and how to fix them.

 The target population is improved through the provision of more than 5 million free medical services since 2006 to more than 1 million patients in a country with a population of 1.2 million. But the key is how care is delivered. TLC’s patient-centered approach serves as a center of excellence for the rest of the nation. And TLC’s organizational and operational excellence eliminates corruption, promotes transparency, and efficiency and fills current gaps in the Eswatini healthcare system, especially for ICU/critical care. This year alone, TLC will treat as many as 200,000 patients through mobile outreaches and facility-based care. The TLC platform allows TLC to serve more and more patients with a high level of efficiency and excellence, with TLC increasing from 130,000 in 2021 to 200,000 in 2022 with close to the same level of staffing.

 TLC has played a unique role in Eswatini in helping the country to become the first of two countries to achieve the global 2030 HIV/AIDS target of 95-95-95 wherein 95% of the population is tested, 95% of those tested know their HIV status and 95% of those who test positive are on treatment and have their viral load suppressed. By reaching the most underserved patients and the hardest to retain in treatment, TLC has helped Eswatini achieve this remarkable outcome for the nation with the highest HIV prevalence rate worldwide.

 TLC uses this technology-based platform to fully track all patient medical records, send SMS messages as reminders, consult international experts, follow up with patients who do not show up for appointments, and receive patient feedback to improve the ongoing provision of healthcare through TLC’s many healthcare platforms.

The TLC DNA organizational culture is as critical as the high tech/high touch interoperable data management platform that we developed to reinforce and support the culture of learning, problem-solving, supervision/coaching and mentoring, task shifting, and leadership development of the staff. TLC now has a staff of 665 that carries out a wide range of critical care services, including the only operating oxygen plant in Eswatini (built by TLC in 2021 in response to COVID), providing 95% of ICU/critical care beds in the country (138) by turning the entire facility into an ICU facility using the same level of staffing as before the COVID pandemic hit. TLC reduced the mortality rate for COVID from 4.4% in the second wave to 2% in the third wave. TLC currently treats over 1,300 patients a day through a wide range of facility-based and outreach models.

 TLC staffing is 98% Emaswati, making up the vast majority of the TLC team. More than 90% of the management team is also from Eswatini. This gives TLC a direct link to the most vulnerable populations with many of the TLC team being adult survivors of the HIV pandemic as orphans and vulnerable children. TLC visits rural communities nationwide to conduct mobile hospital outreaches in isolated areas. TLC has now been in these communities on a regular basis since 2006, reaching every inkhundla (subregion) and more than 600 communities.

 TLC seeks feedback from patients on an ongoing basis, through a 24/7 hotline, SMS messaging, and in person feedback during visits. TLC seeks feedback from staff who observe and participate in service delivery to identify system barriers that need to be addressed. TLC also works closely with the Ministry of Health, USAID/PEPFAR partners, faith-based and business partners to identify gaps in service, barriers to care and treatment, and opportunities for innovation.

 TLC was recognized in 2021 by Claris (an Apple company) with the Global Community Development Award for the high impact implementation of the original software platform now expanded upon with Luvelo. TLC is re-platforming much of the code base in 2022 to allow the scale up and replication of the Luvelo model to other users, sectors, and countries.

TLC is seeking to determine the best way to replicate and scale up the Luvelo model to other settings. The Ministry of Health, the Kingdom of Eswatini, and USAID/PEPFAR are interested in how to replicate the TLC model in other settings and systems, both public and private sector.

Financial resources and technical guidance are both important to fully consider the most efficient way to manage the scale up of the platform that TLC has developed, how to manage an open nonprofit platform vs. a platform that has some business applications attached to it.

The following bullets describe the Luvelo innovations:

• Offers comprehensive digital health transformation with the simplicity of a single integrated system, eliminating barriers of complex integrations and parallel systems
• Empowers real-time program strategy adjustment through summarized daily reports
• Developed at the bedside with extensive inputs from healthcare workers, supply chain technicians, support staff, and patient feedback
• Built on low code Outsystems development platform, Luvelo empowers local developers with less technical experience to evolve and adapt the solution. In our experience, the effectiveness of the solution hinges on the ecosystem's ability to leverage the ideas of local innovators with greatest context and proximity to the challenges at hand.
• Incorporates facial recognition, digital signatures, and photos to bring high levels of accountability, discipline, and visualization in the midst of limited bandwidth environments.
• Luvelo (Siswati for compassion) focuses on the strength and potential within every individual and is designed to come alongside people from underdeveloped regions to inspire innovation, operational efficiency, and a joy for bringing new solutions to every challenge and unknown situation.

1. In the next year, we aim to complete the full code rewrite of our ecosystem as we migrate from Claris FileMaker to Outsystems low-code platform to support enterprise scale. We will continue to engage users to understand what works well, what could improve, and use a robust but flexible process creating user stories, Figma design mock-ups, and development of all remaining modules in the system.
2. Onboard third-party organizations and health networks to begin expanding the compassionate reach of Luvelo to other nonprofits, businesses, governments, and health networks.
3. Within five years, support users in every country in Africa through our passion and commitment to remain teachable, humble, and forever focused on confronting every challenge with a solution. We will serve in the trenches with health care workers, businesses, and governments to identify the potential behind every challenge, opportunity in every resource, and reimagine what is possible when deep compassion, love, and effective digital systems intersect. We will incorporate additional languages, expand geographic divisional structures, and grow local developers to apply their context and ideas to challenges faced every day.

·       # patients served

·       patient feedback comments

·       # new HIV infections

·       # ART patients maintained on care

·       % inventory shrinkage

·       staff morale

Our theory of change is that by utilizing the Luvelo online interoperable platform, organizations will increase efficiency, accountability and transparency in ways that dramatically improve their capacity to deliver high quality patient-centered and staff-driven healthcare in low/medium income countries.

 Most hospitals in the region use a combination of paper medical records, desktop data entry, and digital systems developed first and foremost to analyze program implementations.

 Our solution is built in Eswatini and draws on years of interactions with patients and healthcare workers to understand how patients and staff think, feel, learn, and excel. During COVID-19, our developers brought laptops to the hospital ward, put on PPE, and deployed new code real time to help doctors and nurses carry out their work more effectively. Users engage with the system because it requires no redundant paper record keeping and is purpose-built for the challenges, they face every day. Change is actualized thru reduced operating cost and improved patient health outcomes and feedback.

 The ecosystem coordinates all organizational functions including administrative, financial, management, human resources, supply chain and healthcare service delivery. No off-the-shelf electronic medical records system was found to be robust or adaptable enough for field conditions, nor integrated with other organizational systems.

 The ‘activities’ include:

·       Utilizing a mobile-first solution that empowers complete digital transformation of health networks with fully integrated modules in personnel management, supply chain, logistics, electronic health records and more.

·       Complete a full code re-write of our ecosystem as we migrated from Claris FileMaker to Outsystems low-code platform to support enterprise scale.

Outputs will include:

·       Enterprise scale solution for the Luvelo platform tested and ready to scaleShort term outcomes include:
Easy adoption in low resource environments due to reduced training times (compared to a laptop) and improved data entry speeds on mobile devices due to limited exposure to laptop keyboarding.

 Long term outcomes include:

·       A sustainable enterprise that produces income to sustain compassionate healthcare operations of TLC in Eswatini and foster continued development of life saving interventions into the digital ecosystem

·       TLC imparts its commitment to patient-centered care as a center or excellence in both operations and healthcare service delivery to the most vulnerable and underserved populations in Africa.

·       Support for users in every country in Africa through our passion and commitment to remain teachable, humble, and forever focused on confronting every challenge with a solution.

·       Serve in the trenches with healthcare workers, businesses, and governments to identify the potential behind every challenge, opportunity in every resource, and reimagine what is possible when deep compassion, love, and effective digital systems intersect.

·       Incorporate additional languages, expand geographic divisional structures, and grow local developers to apply their context and ideas to challenges faced every day.

·       Outsystems SQL low-code application

·       ReactiveWeb, Native iOS and Android apps, progressive web apps

·       Bulk SMS

·       Facial recognition

Primary healthcare data is entered by patients or collected by TLC staff in the Luvelo interoperable platform. No paper documentation occurs in the system; all data is collected via smartphones and tablets.

 This data collection process is also used as part of TLC’s quality assurance/quality improvement infrastructure. In this framework, assigned tasks are quickly reviewed by a supervisor and validated as correct. Any coaching or training that needs to be done to correct an error takes place immediately, in a positive context.

 Luvelo generates dashboards which allow managers to ensure that hour by hour, day by day, all patient care and staffing adjustments to manage workflows are informed by real-time data. The system also facilitates feedback from staff on problem identification, problem solving, supply chain needs, and other vital operational areas.

 Data analysis occurs through the day and is used to ensure the highest quality experience for the patient, both individually and collectively.

 In addition to health care data collected in patient care settings, other departments within the organization are also collecting data and documenting their work through the Luvelo platform. That data is actively used to ensure accountability, transparency and efficiency. Data is a tool to achieve excellence and an integrated part of the culture of the organization in support of the mission to deliver compassionate, patient-centered care.

TLC prioritizes diversity, equity and inclusion both for staff and for beneficiaries.

 Staffing: TLC is an equal employment opportunity employer. All qualified applicants receive consideration for employment and will not be discriminated against on the basis of race, color, sex, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, ancestry, or national or ethnic origin. Over 98% of TLC’s staff is from Eswatini; the remaining 2% are from other African countries or the US. Women make up more than 50% of the staff and 50% of the leadership/supervisor cohorts. TLC works hard to ensure that all staff work in a safe, healthy environment that provides each one an opportunity to thrive and develop new skills. TLC provides opportunities for training, professional growth and leadership development. Many of TLC’s staff are adult orphans who have experienced great loss and trauma as a result of the HIV pandemic in Eswatini. TLC provides ongoing counseling and support to all staff to help them heal from difficult life experiences and where appropriate to heal broken family relationships.

 Beneficiaries: TLC provides free comprehensive compassionate medical care to all patients with no discrimination based on any criteria. TLC seeks to be intentional about reaching the most marginalized and underserved populations, particularly rural and poor populations and those in key populations that tend to be stigmatized and isolated. TLC sees every patient as a VIP (Very Important Patient). Patient-centered compassionate, respectful care is essential to our provision of services. Reducing stigmatization and increasing access to care and retention is care is at the heart of our work.

TLC operates as a nonprofit organization focused on providing free, comprehensive compassionate healthcare to the most vulnerable populations in Eswatini. In addition to providing a panel of over 45 health services, TLC also provides emergency care, surgical service, critical care, snake bite care, specialty care, treatment of advanced disease (including HIV, TB, and COVID-19), rehabilitative services, and palliative care.

 TLC does not receive revenue from beneficiaries but from donors (institutional such as USAID and UNICEF, foundations and individual donors/churches/businesses). TLC also receives millions of dollars’ worth of gifts-in-kind to support the delivery of medical services.

 Recently, TLC expanded from solely providing medical services to supporting the health care system through the development of a digital solution—the ESWAVAX online national vaccination platform for Eswatini. TLC is preparing to expand that portion of its services by building on the learned experience and expansion of the Luvelo platform’s capacity to manage millions of users.

TLC sees the potential of applying the platform to other organizations, to other sectors, to government and to corporate users. This deployment could happen through an entirely open source/free platform or it could happen through a service subsidization model where TLC could spin off Luvelo as a for-profit service or product. That for-profit option could include the cost being paid for by government or by groups like USAID to expand access and the application to other organizations, sectors, businesses or government units.

 TLC is evaluating approaches for replication and broader dissemination of the Luvelo platform. Some funding will be necessary to move into a framework for raising capital for expansion of that is the choice made for replication. The for-profit approach would then provide ongoing sustainable funding for TLC operations in Eswatini beyond our current grant and foundation funding.

 The Kingdom of Eswatini has expressed interest in using the Luvelo platform across the public health sector and in other sectors in government.

TLC has received funding from USAID to support the ongoing development of the Luvelo platform since 2017 through a series of Fixed Award Agreements with a total of about $2 million spent since 2017 to develop and expand the platform.

USAID invested $500,000 in the new ESWAVAX national vaccination platform based on the Luvelo platform.