Kassai - A cost-effective and scalable LPM approach

Achieving UHC in low and middle-income countries (LMIC) requires the provision of high-quality health services, delivered via competent health workers, and deployed equitably across all levels of the health system. A recent Lancet study estimated that 8.6 million preventable excess deaths occurred in LMICs in 2016.1 Nearly 60% of these deaths were due to receipt of poor-quality or sub-standard primary health care. Poor quality of care was an important driver of preventable mortality across health conditions, including 84% of cardiovascular mortality; 81% of vaccine preventable diseases; and half of deaths from maternal causes, road injury, and infectious diseases.  

UHC could avert millions of deaths each year but only if expansion of service coverage is accompanied by investments into high-quality health systems. After several decades of health gains in infectious diseases and child health, the mortality in LMICs is now comprised of more complex and multimorbid conditions. Even in settings where progress has been made on UHC, deaths due to poor quality services, including health workforce capacity, represent a substantial challenge. Reducing preventable morbidity and mortality will require a health workforce that is trained with the skills to achieve clinical competency in their practice area(s), provided with adequate support and supervision, and deployed equitably in facilities and communities.  

Capacity-building approaches have historically relied on in-person interventions, including supportive supervision visits and training. In the past decade, digital education has emerged as an important tool for ministries of health (MOHs) and implementing partners (IPs) to improve the capacity of the health workforce in a sustainable way, either on its own, or by complementing in-person activities. World Health Organization (WHO) developed the “Conceptual Framework for the Use of e-Learning for Building Health Workforce Capacity in Improving Health System Outcomes.”2 The framework expands the focus of capacity-building interventions from learners to the health system as a whole. It identifies e-learning as an effective approach to sustain capacity-building and states that capacity-building needs should be addressed in a targeted, cost-effective, scalable, sustainable, and integrated way. 

Because e-learning has proven to be effective in improving the capacity of the health workforce in a measurable way, several organizations have developed and/or deployed Learning and Performance Management (LPM) solutions to support capacity-building interventions using digital technologies. In most cases, these efforts have been successful in developing health worker capacity cost-effectively and at scale. However, the Principles for Digital Development published in 2017 pose questions about to what extent the public health community can rely on LPM initiatives that (1) use open standards, open data, open source, and open innovation solutions; (2) are designed with the user and (3) are interoperable with the existing ecosystem.3 

Although countries aspire to UHC, many are not building the professional education and supervisory systems that are necessary to prepare health workers for the demands placed on them. Equipping trainees with clinical skills is not sufficient. Building and improving the capacity of the health workforce entails several factors to successfully deliver, measure, and maintain an optimized health workforce that contributes to sustainable health systems for equitable access to primary health care. Furthermore, it entails improving the management of the health workforce by providing health system officers with timely information on providers’ knowledge, service delivery quality and health outcomes that results in data-driven responses. 

1 https://pubmed.ncbi.nlm.nih.go...  

2 https://apps.who.int/iris/rest...  

3 https://digitalprinciples.org/  

With funding from the U.S. Agency for International Development (USAID) and the U.S. President’s Malaria Initiative (PMI), Population Services International (PSI) designed and successfully deployed an LPM ecosystem in Angola called Kassai, which sustainably builds, maintains, and measures the capacity of the health workforce.1 Kassai takes into account the Principles for Digital Development and responds to the needs of both the public and private sectors of the mixed health system. 

Kassai provides quality knowledge for better health care — everywhere, anytime. Its vision of success is to strengthen the capacity of the workforce at all levels of the health system, in both the public and private sectors, by improving the access and targeting of evidence-based cost-effective capacity-building approaches through a wide range of quality health care content through the health workforce’s preferred digital channels.  

Designed with the Principles for Digital Development in mind, Kassai is based on the following building blocks: 

o   Agnostic on the front end: Health providers access e-learning content across the Internet and WhatsApp. The technology infrastructure also allows for expansion to Facebook Messenger, unstructured supplementary service data (USSD) and Interactive Voice Response (IVR)-based solutions, among others. The content is created with a user-centered approach, delivering an interactive learning experience that includes bite-sized learning, activities, videos, and quizzes. Offline capabilities allow for low bandwidth settings or lack of access to smartphones and the Internet. 

o   Interoperability: Breaking heath system silos, Kassai supports interoperability solutions with other digital health interventions already in place at country level, such as supportive supervision tools and DHIS2-based solutions. This allows application programming interface (API)-based import of data coming from the national DHIS2 instance for better monitoring of primary health outcomes and to inform the decision-making process of health system managers. 

o   Built-in dashboards support health managers at all levels to target capacity-building activities based on health providers’ knowledge, their quality assurance scores, and health outcomes of their facilities. Kassai leverages three data sources: (i) health providers’ interactions with e-learning courses  (knowledge scores, pre-test scores, and post-test scores), without any additional burden of data collection from frontline health workers; (ii) supportive supervision data collected by health officers during in-person supervision visits at the facility level through DHIS2-based quality assurance tools; and (iii) health outcomes data reported by health providers at the facility level to the national DHIS2-based Health Management Information System (HMIS). Kassai reports are broken down by health area and geography, to the provider level. Built-in bulletins are sent to individual health facilities and health system managers to analyze potential gaps at facility and provider levels, suggest actions for improvement, monitor primary health care outcomes, and track improvement over time. Kassai reports support planning of capacity building and quality improvement efforts through better targeting of interventions, e.g., facilities with higher mortality/morbidity rates and higher caseloads and with lower service delivery and knowledge scores will be prioritized first. Kassai analysis of knowledge and supportive supervision scores further inform the exact areas that require intervention (e.g., gaps in diagnosis, treatment or counseling).

o   Open source: Kassai is a Moodle-based LPM solution accessible online through computers and tablets, and both on and offline through Internet-enabled mobile phones. It relies on the support of a Moodle community, which has thousands of developers, system administrators, educators, and learners that have participated on moodle.org, fixing bugs, writing new features, updating documentation, sharing tips, helping new users, sharing resources, and debating new ideas. 

o   Design for scale: Kassai is a fit-for-purpose tool that can easily be scaled for national or international LPM interventions. 

o   Locally led development: Developed by the Angola-based tech company, Appy People, and supported by PSI’s Global Services Hub in Nairobi, Kenya, Kassai is one of the many digital health solutions developed in the African continent and being scaled to other regions of the world. 

Building on the experience and the lessons learned on the use of Kassai in Angola, PSI is now looking for funding opportunities to expand the use of this novel LPM approach to other countries, starting with Mozambique. Mozambique recently adopted a new National Health Strategy, which prioritizes improving and maintaining capacity building of public health care providers and community health workers as a fundamental approach to ensuring the quality of primary health care. However, the Mozambique MOH currently faces challenges monitoring the capacity of its health workforce, particularly in more remote provinces, and is interested in exploring innovative ways to effectively manage health worker learning and performance. Thanks to the promising results we have demonstrated using the Kassai platform in Angola, the Mozambique MOH has expressed interest in adapting Kassai to meet their LPM needs.  

1 https://kassai.ao  

By creating solutions to support the Ministry of Health (MOH) of Mozambique to ensure the delivery of quality and sustainable primate care, we will improve the health of the people of Mozambique. The MOH, implementing partners (IPs), and professional associations who oversee the work and capacity-building of frontline workers will also directly benefit from the outputs of the Kassai LPM platform. 

Frontline health workers need training and capacity-building activities that fit their busy schedules. By providing tailored learning available on several digital channels (i.e., Internet and WhatsApp), they can learn at their own pace using their preferred digital channel and electronic device. They can also stay up to date on the latest guidelines and resources from the MOH, which can be disseminated easily and quickly through messaging and notification features. We engaged health providers in the development of Kassai from the very beginning to account for their learning needs and learning pace. We tested the usability of the platform with several cohorts of health providers before the platform launch; feedback was solicited via focus groups, observational sessions, and phone calls. Kassai allows frontline health workers to improve their knowledge and skills on primary health care in a user-friendly way utilizing the technology they already use. 

Ministry of Health wants to train the health workforce cost-efficiently and at scale. It wants to monitor training progress and Continuing Medical Education (CME) progression by geography, by health institution, and by health area, and wants to rely on a feedback mechanism to health providers to address recurring gaps and weaknesses. The MOH also wants to triangulate capacity-building data with other existing data sources from supportive supervision tools (like the DHIS2-based Health Network Quality Improvement System – HNQIS) or DHIS2 for better planning and management of supervision and training activities.1 Thanks to Kassai, by using open-source technology and ensuring that it is interoperable with such solutions as Fast Healthcare Interoperability Resources (FHIR) and DHIS2, the MOH can rely on an integrated approach to capacity-building that fits in the current health system. 

Implementing Partners want to support MOHs to strengthen and maintain the quality of primary health care. They also want to capacitate MOHs in making state-of-the-art capacity-building materials available online. The Kassai LPM platform allows them to standardize the way that MOHs deploy capacity-building for a country’s health workforce at the national level in a user-friendly way. 

Professional associations want to make the latest available guidelines and resources to their members. They also want to tie their license renewal to quality benchmarks. Thanks to Kassai, they can do this in a cost-effective way. 

In Mozambique, PSI has worked closely with the MOH to improve the quality of primary health care by using the DHIS2-based supportive supervision tool HNQIS and by committing to introducing e-learning e-learning as a cost-effective approach to build and maintain the capacity of the country’s health workforce. If successful in this Challenge, the MOH will build on current capacity building activities with 700 health providers at 350 public health facilities in 3 provinces and will introduce Kassai to strengthen, maintain, and measure primary health care.  

1 https://www.psi.org/2021/09/ho...  

PSI is an international non-governmental organization with a presence in 54 LMICs.1 PSI’s approach to designing and delivering digital health interventions uses a rigorous human-centered approach that involves the communities we serve from the very first phase. Thanks to our presence in country and to our Social Franchise networks, we work closely with frontline health workers and health system officers to understand their challenges and co-design solutions that fit their context and needs. Through a prototyping and piloting process, we jointly test solutions before scaling. We continue monitoring accessibility, desirability, and feasibility of proposed solutions to better respond to the target audience’s needs. 

For each implementation, we engaged health providers in every stage of the development of the Kassai platform to account for their learning needs and differing learning paces. Similarly, for the DHIS2-based quality assurance tool HNQIS, we involved health system officers in all phases of the tool development, which currently enable them to send feedback and seek support directly through the platform. Since 2015, PSI has built extensive experience in using HNQIS for quality improvement through its roll-out in over 20 countries, which has enabled over 4,000 health system officers to conduct 122,000 assessments with HNQIS across 13,000 health facilities. 

PSI has worked in Mozambique since 1995, and we have developed close partnerships and collaborations with the MOH and other implementing partners. We ensure that our proposed solutions work well within the national HMIS and support health system officers’ needs at province, district, and central level. The Mozambican MOH is already familiar with HNQIS and has been using it to assess sexual and reproductive health skills in public health facilities. Since 2018, the MOH health system officers have conducted a total of 1,613 HNQIS assessments at 164 public health facilities.2 

At PSI’s Global Services Hub in Nairobi, Kenya, the Digital Health and Monitoring team brings a diverse set of skills to ensure a smooth implementation of digital health solutions. Experts on monitoring, data science, chatbots, PowerBI, DHIS2, business processes, quality assurance, and program management will work together with the PSI/Mozambique country team to deliver a state-of-the-art LPM solution in line with the latest digital health guidelines.  

Lastly, PSI has formed strategic partnerships with private sector companies who are at the cutting edge of developing digital health solutions for LMICs, like Appy People, KTT and Solidlines to deliver a technically solid product.  

1 https://www.psi.org/  

2 https://www.psi.org/wp-content...

PSI is pursuing funding opportunities that support the expansion of Kassai Learning and Performance Management (LPM) platform to other countries. Currently, PSI is supporting LPM activities outside of the Kassai LPM platform in 3 countries (Kenya, Nigeria and Vietnam) where over 7,000 health providers have accessed e-learning courses on their preferred communication channels, and these include web-browser, WhatsApp, Facebook Messenger, Zalo, and IVR-based solutions. Health system managers have accessed reports that triangulate data from e-learning, supportive supervision visits and health outcomes to better monitor and improve indicators on primary health care. Overall, across all countries, the percentage of frontline health workers who meet knowledge benchmarks has improved from 28% to 54% and the percentage of health facilities who meet quality standards has improved from 47% to 73%.  

PSI is seeing a duplication of efforts in addressing and solving similar challenges and needs in the areas of LPM. Our experience in Angola has indicated that the Kassai platform offers unique solutions to better manage the learning and performance of frontline health workers and measure health outcomes. Through this initiative, PSI offers health systems a more cost-effective and streamlined way to improve knowledge and performance of the health workforce without reinventing the wheel. From a technology point of view, we centralize technology development as much as possible, while from a deployment point of view, we customize country implementation as much as possible in response to contextual needs (e.g., validation of e-learning post-test marks by a Local Government Area (LGA) supervisor in Nigeria, overlay of availability of COVID-19 vaccines at provider level in Kenya, etc.). 

If successful, this Challenge will allow PSI to expand the use of the Kassai LPM platform in Mozambique over the next 18 months. The Mozambique MOH, in partnership with PSI, has expressed interest in adapting Kassai e-learning courses to the local context, starting with the existing content that coversCOVID-19 vaccines, FP Counseling, Emergency Contraception, and FP methods (including Progesterone-based pills and Sayana-Press). Currently, in Mozambique,  PSI is supporting capacity building activities in 43 districts in 3 provinces and supports quality improvement in 350 public health facilities. After delivery of a solid proof of concept of the use of Kassai in the public health care sector, the MOH can expand this approach by enrolling a capillary health workforce of 6,673 Community Health Workers (CHWs), improving the reach of quality, primary care. With the expansion of Kassai in Mozambique, the MOH can use remote capacity building interventions to efficiently target the current supportive supervision visits that take place at public health facilities, thereby creating efficiencies within the system. PSI is uniquely positioned to support this expansion, bringing together our multi-country experience implementing both Kassai (for knowledge improvement) and HNQIS (for quality assurance). 

In the spirit of Digital Public Goods, MOHs and implementing partners will be able to inform the development of features that meet their needs and make Kassai core technology solutions available to any country or Kassai user worldwide.   

Kassai supports capacity building and performance improvement to improve access to quality primary care, and offers the MOH a user-friendly way to manage frontline health workers’ performance by combining data from e-learning with data already available at country level, like supportive supervision and health outcomes data.  

Kassai uses existing open-source software and technology, including DHIS2 and Moodle, in an innovative way by combining the two to enhance Learning and Performance Management (LPM) of frontline health workers. Health providers access e-learning content on Moodle-based courses and health system officers fill in data from supportive supervision visits in the DHIS2-based quality assurance tool HNQIS. In the back end, a master list of health providers and health facilities allows for technology integration and also accommodates other data sources coming from the national HMIS in DHIS2, like mortality and morbidity data at facility level. This results in integrated reports and dashboards that offer health system managers the possibility to plan LPM interventions such as training, refreshments, supportive supervision visits, and others, based on where these are most needed. Furthermore, the Kassai LPM platform allows for tracking measurements in quality improvement at provider and facility level and identifying the most effective interventions to improve quality.  

We expect this novel use of current technology to be catalytic and of interest to many Ministries of Health and implementing partners because: 

• It relies on technology widely adopted and supported by the public health community and taps into a pool of technical experts who know how to develop, maintain, and deploy the technology; 
• MOHs and implementing partners are familiar with Moodle and DHIS2 and there is no need to invest in building their capacity to use Kassai; 
• It accommodates integration and interoperability with other commonly used technologies such as PowerBI; and 
• It supports integration with a chatbot framework that can further expand into Facebook Messenger, Zalo, USSD and IVR-based solutions. 

Thee following are Kassai impact goals for the next year: 

• Improve the number of health providers who meet knowledge benchmarks in Mozambique. Target: 700 health providers in the public health sector 
• Improve the number of health facilities that meet quality standards for primary health care in Mozambique. Target: 350 health facilities in the public health sector 

Over the next 5 years, we aim to: 

• Expand the use of Kassai to 5 countries, including dedicated and customizable sub-domains in at least 2 countries (e.g., kassai.zw) 
• Ensure that 75% of health providers enrolled in Kassai meet knowledge benchmarks in available content areas within one year from enrollment 

• Ensure that 75% of health facilities meet selected quality standards for primary health care within one year from enrollment 

We plan to achieve these impact goals by deploying the Kassai LPM approach: 

• Health system officers assess health providers’ quality and knowledge through the DHIS2-based HNQIS tool. Health providers are assessed on a variety of health areas based on the services they provide, e.g., Maternal and Child Health, Malaria, HIV, Family Planning, etc.;
• Based on HNQIS quality competency scores, health providers are enrolled in a set of e-learning courses to support their learning needs;
• Health system officers track improvement in learning outcomes (pre- and post-test scores) through Kassai dashboards. Data on morbidity and mortality are overlaid in the Kassai dashboards to support health system officers in targeting next supportive supervision visits where they are most needed (e.g., facilities with higher mortality/morbidity rates and higher caseloads and with lower providers’ service delivery and knowledge scores will be prioritized first);
• Improvement of primary health care outcomes is monitored in Kassai dashboards. 

If we are successful in meeting these goals, we will have increased health workforce’s knowledge and performance, and ultimately will have contributed to improve access to quality of care.

Kassai dashboards provide a wealth of information on progress towards health outcomes. Data coming from e-learning activities, supportive supervision visits, and facility-level mortality and morbidity are analyzed in user-friendly dashboards. Benchmarks and color-coding of results support data users in identifying geographic and thematic priorities. This is a selected group of industry and customized Key Performance Indicators (KPIs): 

• Customer Satisfaction score (CSAT): 1-5 or 1-10 likert scale on health provider’s satisfaction with Kassai

• Net Promoter Score (NPS): number of users who recommend Kassai / number of users surveyed  

• Knowledge gain: percentage of users who meet benchmark at pre-test vs post-test  

• Daily active users: number of users who interact with Kassai on a daily basis  

• Conversation rate: number of users who complete an eLearning course / # of users who initiate an eLearning course  

• Customer retention rate: number of users who have been active in Kassai for 12 months  

• Total new customers by country: number of new users by country on a monthly basis  

• Knowledge base growth: number of courses added by month / number of courses in total  

• Quality of care score: number of correctly performed steps / number of steps assessed during supportive supervision visits (by health area) 

A second set of metrics and KPIs to measure the impact of Kassai in terms of health outcomes and ability to improve quality of health service provision in a cost-effective way at scale come from activity-based costing analysis that assess:  

• Number and percent of providers meeting knowledge benchmark (e.g., passing the post-training knowledge assessment) and quality standards (e.g., passing the benchmark at supportive supervision visits)  

• Cost per user meeting knowledge and quality benchmark   

• Cost of the LPM platform to capacitate a health workforce of 1,000   

• Scalability cost to enroll 1,000 new providers   

Kassai’s Theory of Change is in line with WHO’s Conceptual framework for the use of LPM approaches for building health workforce capacity to improve health system outcomes. If UHC goals are to be achieved, frontline health workers need to maintain and improve their technical capacity to deliver quality health care. LPM approaches can address this outcome by improving medical knowledge, promoting patient-centered care, communication skills, professionalism, and expanding clinical skills. 

E-learning presents an exciting opportunity to expand training coverage, reduce costs to health systems, standardize and improve training quality, and ultimately increase provider confidence and job satisfaction, while allowing them to learn at their convenience, at the time and location of their choosing. Thanks to supportive supervision visits, health system managers can monitor and improve providers’ knowledge and skills on-site to target gaps and weaknesses. Taken together, an LPM platform such as Kassai also provides a wealth of real-time data for health systems leadership to track supportive supervision scores, training implementation, monitor provider outcomes (such as knowledge gains, certifications, and completion of refresher trainings), and make linkages to service delivery data, including quality measures. Pairing access to user-friendly dashboards with support to improve data use can help leaders to better plan, target, and assess their training and capacity-building investments, generating better returns on these investments.  

At a higher level, this can contribute to systems-level capacity building, stewardship, governance, change management, performance management, and strategic partnerships. Improving the quality and coverage of essential health services contributes to improved patient and population health outcomes, user satisfaction, equity, efficiency, and effectiveness, all of which move countries closer to achieving UHC.  

Kassai is a Moodle-based Learning and Performance Management (LPM) platform and hence, it relies on the open-source technology of Moodle.1 

Kassai has been made interoperable with DHIS2, an open-source Health Management Information System (HMIS) developed by the University of Oslo and currently in use in more than 30 countries.2 HNQIS is a DHIS2-based Tracker Program that runs on the DHIS2 Android Capture app and it is used on-line or offline via tablets during supportive supervision visits. Health system officers use HNQIS checklists to assess quality of service delivery, rate them based on the quality assurance scores, and provide real time feedback to providers. DHIS2 configurations are highly customizable to different health area needs in quality and clinical assurance/improvement assessments.  

Kassai integrates DHIS2 and HNQIS via Application Programming Interface (API). Data from e-learning, DHIS2 and HNQIS is analyzed and presented through Kassai dashboards. This allows managers to triangulate information on health providers’ learning scores available on Kassai (knowledge) with HNQIS supervision scores (applied knowledge and skills) and MOH DHIS2 morbidity and mortality data (health outcomes). This information is available by health facility and is used for more targeted planning of capacity building and quality improvement efforts through better prioritization of health facilities. 

Moodle and DHIS2 are in line with the Principles of Digital Development and support interoperability solutions with other software commonly used by Ministries of Health and implementing partners, like Superset, FHIR and PowerBI, allowing for further expansion of Kassai’s data model to accommodate data coming from a variety of data sources. 

1 https://moodle.org/  

2 https://dhis2.org  

Kassai relies on 3 main data sources: 

• e-learning data: When health providers enroll in Kassai courses and go through the courses, they are asked to undertake pre- and post- test assessments, complete course activities like quizzes and case scenarios, and provide feedback through surveys. During these interactions, Kassai automatically collects data, including data related to users’ average time to complete a course, drop-off points in the courses, etc. Kassai dashboards automatically analyze and reports Key Performance Indicators on e-learning like enrollment rate, completion rate, average pre- and post- test scores, percentage of providers meeting knowledge benchmarks, etc. Apart from the engaging interaction with e-learning courses, there is no additional data collection burden for health providers when they use Kassai, 
• Supportive supervision data: As part of their routine duties, health system officers conduct in-person supportive supervision visits at health facilities to assess and improve providers’ knowledge and skills to provide primary health care. Health system officers use the DHIS2-based supportive supervision tool HNQIS to go through an electronic assessment checklist and report whether health providers have correctly undertaken steps of a certain health service provision (i.e., management of fever cases in children under five) by filling in Yes/No questions. At the end of the assessment, HNQIS automatically calculates an overall quality of care score, as well as section scores and identifies critical areas that require improvements (i.e., diagnosis vs treatment of febrile illnesses). All HNQIS data is stored in DHIS2 and visualized in user-friendly and tailored dashboards to support decision-making processes. Apart from filling in the electronic assessment checklist, there is no additional burden to data collection for health system managers when they use HNQIS, 
• Health outcomes data: at facility level, health providers fill in facility registers and report data on a monthly basis to their provincial supervisors. This data is then entered into the national DHIS2-based HMIS and analyzed through user-friendly dashboards. This data collection and reporting at facility level is part of the routine HMIS flow, and it doesn’t require any additional burden to what health providers already collect on a monthly basis as per requirements by the Ministry of Health.

PSI is committed to working towards a more diverse, equitable and inclusive world. At PSI, we measure our organization’s progress on Diversity, Equity, and Inclusion (DEI) through our organization health dashboard.1 This ensures that we have a way to measure how well we are doing in terms of DEI and what actions we need to take to improve. For Kassai, a very diverse team based in different countries is supporting development and implementation of the LPM approach. When it comes to recruiting personnel to support the development and deployment of Kassai, PSI follows our Human Resources guidelines that are in line with DEI principles.  

When it comes to ensuring DEI in the work we do in Low- and Middle- Income Countries (LMICs), we take DEI principles into account during the design and deliver phase of our project implementation approach. For example, during the design phase, we use a human-centered design approach, and we test the proposed solution with our target audience. This allows us to make sure that our public health interventions are designed to address the diverse needs of our target audience. Furthermore, when we deploy public health interventions at country level, we offer the possibility to give us feedback, so that we hear from users, and thanks to our rigorous data use approach, we have the possibility to track if we are including a diverse group of target audiences or whether our consumers are skewed towards one group over others. This allows us to take course correction. 

1 https://www.psi.org/2022/06/di... 

In 2021, PSI conducted a Cost Effectiveness Analysis (CEA) to compare the costs of self-learning with Kassai, blended learning using a mix of Kassai and traditional classroom learning, and traditional in-classroom learning alone in Angola.1 Based on baseline data for 2020, costs, effectiveness, and cost-effectiveness were estimated for 2021–2025. Costs were estimated using the “ingredients approach” (“bottom-up costing”). Self-learning using the Kassai LPM platform is the most cost-effective of the three training methods evaluated. The estimated marginal cost of training one health worker using self-learning is 11 times more cost-effective than in-classroom training. The estimated marginal cost of training one health worker successfully using self-learning is 13 times more cost-effective than in-classroom training. The estimated marginal cost of training one health worker successfully using blended learning is almost two times more cost-effective than in-classroom training alone. 

The cost effectiveness of Kassai and its integration with national DHIS2 and with the supervision system makes it an attractive investment to both the MOH and other implementing partners, including private sector companies. 

1. https://www.psi.org/publicatio... 

Since its launch in 2020, Kassai has attracted investments from a variety of donors, including the President’s for Malaria Initiative (PMI), the United States Agency for International Development (USAID), the Bill and Melinda Gates Foundation, the Japan International Cooperation Agency (JICA), the Foreign, Commonwealth & Development Office (FCDO), and others. Private companies like Unilever and others have also supported development and use of Kassai Learning and Performance Management (LPM) approach in other countries under the name Kiira (https://kiira.com). Several implementing partners and non-governmental organizations have expressed interest in using Kassai to respond to their LPM needs in various countries, and several Ministries of Health have demonstrated interest in piloting the Kassai LPM approach in their countries.  

A demonstrated success of our Kassai LPM approach lies in the Kiira LPM platform which PSI has created to respond to countries’ needs in LPM in countries like eSwatini, Kenya, Mozambique, Nigeria and Myanmar, sustained by several funding opportunities. This diversity of funding sources and interests that support Kassai business model confirms our journey towards a community-funded product built by the community for the community. 

PSI envisions that the Kassai LPM platform will become a community-funded platform, where international organizations and donors (USAID, Global Fund, World Bank, etc.), private sector companies (telecommunication organizations, pharmaceutical companies) and the MOH will continue funding the Kassai platform, similar to what is currently happening to other community-led initiatives, as DHIS2.