Simple

An estimated 1.4 billion people worldwide have high blood pressure, but less than 40% are treated for hypertension and only about 14% have it controlled. Hypertension is the leading preventable cause of premature death worldwide, accounting for 10.7 million deaths per year, with most deaths in low- and middle-income countries (LMICs). Hypertension kills more people every year than all infectious diseases before Covid, and more than Covid at its worst. Large-scale hypertension programs in low-resource settings face many challenges, including understaffed health systems with overworked clinical staff. In many countries, patients typically see a healthcare worker for less than three minutes per visit. In countries like Bangladesh and Ethiopia, hypertension services remain concentrated with medical doctors at higher-level health care facilities, and even stably controlled patients are not referred for follow up in health care facilities based nearer to the patient’s home. Our recent study in Ethiopia found that patients living >1 hour from their primary health center were three times less likely to be retained in hypertension care.

Many primary care clinics manage hypertension care using paper-based information systems that are cumbersome and delay patient care.  What is more, when hypertension program data are gathered it is usually of limited utility and does not result in improved performance that is based on actual data. Even where digital health information systems are available, they are often not deployed to the last mile: by the non-physician health workers staffing community-based clinics associated with primary health care centers.

Without a robust health information system and decentralization of this information system to non-physician health workers managing hypertension care at the community level, the quality and scale of hypertension service delivery will be constrained and the world will never reach the Sustainable Development Goal target.

In addition to supporting health care workers to improve patient care, the Simple App enables health administrators to monitor the progress of a hypertension program in a country/state/region/facility. Our dashboard provides information such as the number of patients registered, the number of follow-up visits, and the percentage of patients with controlled blood pressures. Our application enables health workers to see more patients, more efficiently, and provide better care, reducing from minutes to seconds the time needed to register a new patient (73 seconds) and record a follow up visit (14 seconds).

Simple is designed to support large-scale hypertension and diabetes management programs. The Simple app is actively used in 10,310 public health facilities in India, Bangladesh, Ethiopia, and Sri Lanka to manage 2,337,383 patients with hypertension and/or diabetes.  Simple features an offline-first design, so patients can be registered and managed in facilities lacking internet service, then uploaded later.

Healthcare workers record every patient's visit using the Simple app on their smartphone or tablet, managers receive daily reports using dashboard visualizations to monitor progress, and patients can chart their own blood pressures and blood sugars. Simple also allows for secure calls between health workers and patients, and telemedicine communication between health care providers. In order to sustainably integrate Simple app data with national surveillance systems, Simple data has been integrated into the national District Health Information System (DHIS)-2 platform, a system in use in more than 70 countries, in Bangladesh, Ethiopia, and the Maharashtra state of India.

Our solution is composed of 3 parts:

i. Simple App: An easy-to-use mobile app for healthcare workers to register new patients, record blood pressures, blood sugars, and medicines at every patient visit in about 14 seconds.

ii. Simple Dashboard: A web-based dashboard for officials and health system managers to monitor hypertension control across facilities and regions. 

iii. BP passport: An app for patients and caregivers to record BPs and blood sugars that has daily medication reminders.

Resolve to Save Lives helps countries implement the World Health Organization HEARTS hypertension control program. These programs deliver state-of-the-art care on a massive, sustainable basis. All adults aged 18 and above attending participating primary health care facilities can participate. Currently in most low- and middle-income countries, only half of people living with hypertension are aware of their diagnosis and only one in ten has their blood pressure controlled (14% control). The WHO HEARTS package is designed to deliver hypertension care at the primary care level and improve global hypertension control to >50% overall, which would prevent millions of hospitalisations and deaths from heart attacks, strokes and kidney disease. For many patients, crowded primary care facilities, long wait times, and drug stockouts are a disincentive complicating chronic care.

In Bangladesh, the HEARTS program has so far enrolled over 100,000 patients, representing about 10% coverage of the catchment hypertension population. Within enrolled patients, hypertension control has improved from a baseline 13% to 59%. HEARTS hypertension care is available to all patients enrolled, free of charge.

In Ethiopia, the HEARTS program has so far enrolled over 12,000 patients, representing about 8% coverage of the catchment hypertension population.  Within enrolled patients, hypertension control has improved from a baseline 15% to 47%.  Only about half of enrolled hypertension patients have hypertension services fully covered by national community-based insurance coverage; the remaining half must pay for medicines and other hypertension services out-of-pocket.  Currently, almost all of the program’s hypertension care is delivered at primary health care centers (PHCs), relatively centralized primary care facilities that sometimes require substantial travel to reach routine follow up appointments.  Currently there is a plan to pilot delivery of hypertension services to health posts staffed by community health extension workers.  There is potential for these workers to deliver medicines to the homes of patients enrolled in the national health insurance plan.  Currently the community health care providers staffing community clinics are not engaged with existing quality improvement teams that are based in the PHCs.

Our proposed solution—adoption of the Simple app by non-physician health workers staffing last mile community clinic settings and integrating these workers into quality improvement teams—will mean transition of the Bangladesh and Ethiopia HEARTS programs to a patient-centered model that will provide hypertension services at greater patient convenience.  At the same time, improved quality of services received by patients will be driven by Simple app data and the Simple data visualization dashboard.

Resolve to Save Lives has a mission to save 100 million lives from heart attacks and strokes, and we have partnered with the health ministries in the different countries. Simple is being used to properly understand their indicators and ensure that the Simple dashboard provides the information. We have partnered with the Ministries of Health,  India council of Medical Research and World Health Organisation and  National Health Foundation Bangladesh. We always ensure that in the countries where Simple is used, our team visits a sample of the health facilities to better understand unique attributes such as patient flow, patient behaviour as well as the behaviour of the healthcare workers. We take into consideration peculiar challenges of the region and working with the health managers in that country, we design a process that is well suited. Resolve to save lives also has staff in these countries who are nationals and residents there and can provide real time feedback from the field. 

In some of the countries we operate in, there are existing National dashboards for monitoring various diseases but very few governments monitor Hypertension and Diabetes despite its prevalence. We are applying for this challenge to enable us extend the Simple App technology and data infrastructure pipeline to be able to Integrate seamlessly with these National dashboards. 

For instance, in Bangladesh, Simple Mobile app is used by healthcare workers to collect data in primary healthcare centres, however using APIs we developed, we are able to feed aggregate data from our servers into the National DHIS2 dashboard providing the ministry of health with information on the percentage of patients with Controlled or Uncontrolled blood pressure.

We fully intend to reach out to many more LMICs with this model and we would need resources (human and financial) to be able to explore integrations with the different existing systems.

In Primary Healthcare Centres, health workers have been required to spend a considerable amount of time recording data in patient treatment cards and hospital registers. Drug stock information is also typically recorded and reports written. With the Simple App, health workers are able to digitally record patient information in a shorter time and view the progress of their patients and facility with a few clicks. Thus, Simple App brings value to health workers, as well as facilitates improvement in quality of patient care.

We intend to be able to manage a high percentage of patients enrolled in Hypertension programs with a digital system to produce accurate, reliable, real-time program data for feedback loops either by Using Simple alone or by Integrating Simple with existing systems. 

2)In diseases such as Hypertension and Diabetes that are treated for life, one major challenge is patients not returning  to the clinics for follow-up visits. We intend to drastically reduce missed visit rates. This is possible using the Simple App as we are able to send SMS to patients reminding them of upcoming visits and we’re able to do this in multiple languages to cater for all categories of patients.

Ensure 80% of patients in Resolve funded/managed programs are managed using Simple or a "Simple-like" digital system. 

Ensure  70% of patients managed with Simple have a follow-up BP recorded each month. 

Build a sustainable information system for Hypertension

It is extremely difficult for ministries of Health to make policies to ensure better outcomes in Hypertension care within a populace if they are unable to make real time informed decisions based on available data. With the Simple App, we are able to provide detailed information from facilities all the way up to the National level where decision makers can make policies such as the type of medication protocol to be used.

Our solution is Open Source and uses a combination of software technology: A mobile app that works on both Android and iOS devices, SMS technology.

Nurses, community health officers and frontline healthcare workers collect the data.

Community Health Care Providers staffing community clinics will receive digital referrals of controlled patients, actively manage hypertension care (monitor blood pressure, refill medicines, counsel on adherence), and join existing quality improvement teams to propose and evaluate one performance improvement solution per 3-month quarter.

There are 2 main incentives for the Health workers to use our application: 

1)Due to our partnership with the Ministry of health, the healthcare workers are required to collect this information as part of the requirements from the government.

2) It is faster and saves time. A new patient is registered in just 73 seconds. 

3) It can be quickly learned for all these reasons, user satisfaction is very high.

Our team is a truly diverse group with individuals from different nationalities and living in different continents. Our recruitment process is without bias and independent of gender or ethnicity.we have representation from different nationalities (team members from Ethiopia, Bangladesh, Nigeria, India, Canada). Our team has 16 people; 8 males and 8 females. We work directly with the countries we work in to ensure we have local in-country support.

As a non-profit public health organization, our aim is to provide value by maximizing the output of public sector health care workers through more efficient processing of routine hypertension care, and maximizing the efficiency of the government health sector by providing timely and accurate health information to guide resource allocation.  The software package we provide complements the clinical and system design support to governments from other Resolve to Save Lives staff and partner organizations like the World Health Organization.  As an organization funded by philanthropic organizations, we are positioned to offer our software as open source and free of charge.

The solution is free to use. Resolve to Save Lives receives funding from foundations and private donors as a nonprofit organization and in the future we intend to leverage on applying for grants.

Resolve to Save Lives is primarily funded via multi-year grant commitments. After five years as an initiative of a separate entity, Resolve to Save lives became a fully independent non-profit organization in 2021. We have built upon a core group of funders and considerably expanded our base of support. This has provided both the ability to continue growing and thriving, as well as the sustainability that comes from not being dependent on any single or small pool of donors.