App YoPromotor (YP).

Primary Health Care (PHC) is an effective strategy to improve access to health care for the population who live far from the health centers. This strategy considers the organization of comprehensive and continuous responses to the health needs of the beneficiary population, the implementation of coordinated actions at the sectoral and inter-sectoral level; and the empowerment, mobilization as well as social and community participation (1). As part of this social and community participation, Community Health Workers (CHWs) play an important role in ensuring that health care reaches the most vulnerable; they are community advocates and workers of social change.

CHWs are persons chosen or recognized by their community, who work as a network of neighbors who support the delivery of primary health care by carrying out health promotion and disease prevention activities. CHWs operate in peri-urban areas of greatest poverty. Their work is almost always voluntary, motivated by service and solidarity with their neighbors because they identify the urgent health needs of their community members, they help to close health access gaps, reaching the poorest, most neglected and excluded groups. The Peruvian State recognizes CHWs as fundamental actors in the implementation of the primary health care strategy in their communities (2). The World Health Organization (WHO) has highlighted the importance of CHWs in strengthening PHC in order to achieve universal health coverage (3).

Peru has approximately 35,000 CHWs who, although playing a fundamental role in supporting more than 7,500 health centers in the development of healthy communities, they work are not sufficiently recognized by the State. Therefore, they do not have sufficient material and economic resources for the execution of their community activities, their work is not visible in health human resources statistics, and they are not adequately accompanied or supervised in their work in favor of PHC services.

One of the main problems CHWs face is the lack of information and communication technologies (ICT) to record their community activities, such as adequate cell phone applications for the electronic recording of home visits and follow-up activities with individuals and families in the community. Also, this lack of ICTs does not allow them to share valuable information with their peers so as not to duplicate efforts or generate care synergy, to be able to refer urgent cases to their health network and to receive the continuous training necessary to improve their performance.

Currently, more than 95% of the CHWs' consultations are recorded manually on a few paper forms; therefore, the few data recorded have many inconsistencies, considerable losses, delays of days in entering information, problems in verifying the quality of data and slow processing of their work metrics. As a result, since they are not timely, there is poor visibility of the work of the HCW with inaccurate indicators of its work in PHC.

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[1] Pincay et al, 2020. Importance of primary health care in the community. Viewed at https://reciamuc.com/index.php/RECIAMUC/article/view/535

[2] El Peruano 2018. LAW No. 30825 that strengthens the work of Community Health Workers.

[3] PAHO, 2018. The role of community health workers and primary health care in achieving universal health. Viewed at https://www3.paho.org/hq/index.php?option=com_content&view=article&id=14365:el-papel-de-los-agentes-de-salud-comunitarios-y-la-atencion-primaria-en-salud-para-alcanzar-la-salud-universal&Itemid=135&lang=es

Our solution is called YoPromotor (hereafter YP), a cell phone application in its pr, which will connect CHWs with each other, and will also connect them with the health system to improve PHC; and will collect information that allows generating metrics that will evaluate the performance of their work and their support to improve the gaps in access to health care.

YP will be useful in recording data for case identification, case follow-up, registration of care in health campaigns, and population surveys, among others, which are important activities of the CHWs when carrying out the PHC.

Depending on the type of support provided by the CHW, YP will assist in the recording of data in easily accessible forms. Since the main function of the CHWs is related to preventive care, most of the data to be recorded are early diagnosis of cases, data for the identification of health risks, data generated in health campaigns and data from community surveys.

YP will have a human-centered design, with close collaboration between CHWs and health network workers. When a CHW requires the support of another CHW for solving health care problems, such as immediately referring a patient to a health facility, he or she will be able to identify which colleagues are geographically closest because we will use geofencing and localization by the GPS function of the Smartphone.

Among other functions of YP is the interoperability with other systems, YP will be able to receive the scheduling of visits directly or in fixed XML schemes so that a patient's visits can be scheduled in such a way that a CHW can follow up the patient's treatment until the end of the treatment.

Since interaction between CHWs is key, YP will have basic functions such as phone call and chat with the ability to create groups of CHWs and to send attachments in predefined formats such as JPEG and PDF.

YP will actively collaborate with the referral process of patients from the community in peri-urban areas that are miles away from a health facility to the health services network. This will be possible because the CHW will be able to visualize the location of their patients but also where the nearest health center is and if they need help from a peer CHW, they will be able to use the chat tool alerting the CHW for immediate referral for example for pregnant women or emergencies with children or the elderly.

Other very important process in which YP is going to be key is the continuous training of the CHW. YP will allow CHWs to be alerted about future trainings addressed to them, about public health alerts, about recommendations from the Ministry of Health (MINSA), as well as other useful information for the sustainability of the CHWs service, such as CHW service requests for organizations related to public health and PHC.

The YP app, which will be available for the Android operating system because it is the most used by CHWs, will be primarily configured in the cloud of Socios En Salud, which will allow the necessary adjustments to be made at the beginning to provide care with pilot health programs such as the YP pilot with mental health care. At the end of this pilot, YP will be able to operate with other healthcare services and interoperate with other solutions that record healthcare data.

Because YP will use the Model-View-Controller (MVC) design pattern, we will be able to make improvements in its technological layers without affecting others, improving the efficiency of its functions at the programming level without the need to change the user interface.

YP will initially use SQL server 2014 as database engine and will be programmed in C# to better control the integrity of its functions with the Android cell phone operating system. YP will use the Google Maps interface for the management of geographic information systems.

For remote areas where the main challenge of YP lies, in case of poor or no internet connection, we will use an offline module with data upload and download with redundancy to manage several failures so that the work of CHW is saved while there is no internet connection.

We mentioned that YP is focused in its design in the CHWs, especially in the CHWs of the areas of poor network resources, this type of design will facilitate the work of the most remote CHW with the identification and monitoring of vulnerable people such as pregnant mothers, children at risk or sick, tuberculosis patients, HIV patients, alerting in real time to the health services.

YP will strengthen the existing network of CHWs in vulnerable areas with high inequality of access to health systems. YP will be the technological tool that facilitates and makes visible the hard work of the CHW, recording all the visits that the CHWs make to the homes of their neighbors who need care. The analysis of these attentions we believe will allow us to generate advocacy to dimension true impact of CHWs in primary care health.

According to the 2020 national statistics in Peru, the use of the Internet and Smartphones is high, even in low-income households. Thus 90.6% of households in Peru have at least one family member using a Smartphone connected to the Internet, and in rural areas where CHW works, it is 78% (5) with a tendency to rise as is the case in Africa (4).

The use of cell phone technology by CHWs has not been measured in Peru. Nevertheless, according to the profile of the CHW working for SES, all of them have a Smartphone and are digitally literate because they communicate without difficulty through social networks and other popular chat programs.

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[4] World Bank, blogs. Limited digital access holds back Latin America and the Caribbean. How to solve this problem? https://blogs.worldbank.org/es/latinamerica/el-escaso-acceso-digital-frena-america-latina-y-el-caribe-como-solucionar-este

[5] National Institute of Statistics and Informatics of Peru, 2017. In 90.6% of households in the country there is at least one member who has a cell phone.

https://m.inei.gob.pe/prensa/noticias/en-el-906-de-los-hogares-del-pais-existe-al-menos-un-miembro-que-tiene-telefono-celular-10412/

YP will target CHWs that attend and serve the population neglected by the Ministry of Health in peri-urban areas, especially those in extreme poverty.  The poor and extremely poor populations have the lowest access to health care services, and in Peru correspond to 25.9% and 4.1%, respectively [6]. The CHWs, this time supported with YP, will continue to identify, in these populations, children with psychomotor developmental risks, high-risk pregnant women in follow-up, respiratory symptoms of tuberculosis, mental health problems, people affected by tuberculosis in home follow-up, and children with incomplete vaccination schedules who cannot access the Peruvian State's health services network on their own and need the support of a CHW.

Indirectly, YP will serve the poor and extremely poor population by closing the health access gap, closing inequities by enabling their connection to the health system through the CHW.

YP will also serve the health system, because with this COVID-19 pandemic, health staff has been overburdened to provide immediate care to the community. YP will allow simple care to be provided at the primary health care level without the need to go to a hospital, giving space to patients who really need more complex care.

Within the health system, YP will help public health policy makers with data on the real impact of CHWs' work in PHC, on their level of coverage beyond the limits of what the current health system can provide. We believe that these data will be an important input for incidence and advocacy in order to elaborate new technical standards that include CHW as a priority in PHC and redesign strategies and public policies in primary health care.

We know that the poor and extremely poor populations are the ones that most require support of CHWs that make up a solid, historical, and expert network in extending the arms of PHC. We believe that YP for the first time, together with the CHWs, will help to reduce the different gaps in access to the health system. Some of the gaps that we believe will benefit are the gaps in vaccination coverage, the gaps in care coverage for communicable diseases such as tuberculosis and HIV infection, and the gaps in mental health care and maternal and child health care.

The first program in which we are going to pilot YP is going to be in a mental health project that is currently being implemented in the Carabayllo district of the city of Lima, Peru, which has approximately 300,000 inhabitants. One third of this community lives in poverty and extreme poverty, about 2,000 families being followed by about 109 CHWs. The project to be carried out by the YP pilot is called Many Voices and is aimed at following up on the treatment of patients with schizophrenia and their immediate family members.

The Many Voices project currently involves 109 CHWs, who will use YP for six months, recording data on the current situation, and after the project interventions. The CHWs will be able to collect data on the results of the intervention on patients and their families. In addition, using YP, they will be able to exchange experiences with other CHWs. The data from this pilot will be useful to improve the architecture, interface, functionality, usability of YP, and above all to verify the efficiency of YP as a tool for CHWs in community interventions.

After this first pilot, we plan to extend the same experience to other SES programs in Carabayllo, such as tuberculosis, maternal and child health, HIV infection, mental health, among others.

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[6] National Institute of Statistics and Informatics of Peru, 2021. National Household Survey https://m.inei.gob.pe/media/MenuRecursivo/noticias/nota-de-prensa-no-072-2022-inei.pdf

Socios En Salud Sucursal Perú (SES) is a non-governmental organization that has been working for more than 26 years in Peru with the support of CHWs. SES belongs to Partners In Health (PIH), an organization based in Boston (USA) that has also been working with CHWs since 1987. Partners In Health, during this time, has recognized that the only way to help the few teams of technicians and professionals in our health system is with the invaluable support of CHWs. Therefore, in its 6 health programs (maternal and child health, mental health, tuberculosis, HIV infection, chronic diseases, and social protection) they have an average of 5 CHWs working permanently, being able to expand the number according to the need of each program according to the interventions to be implemented. In the Mental Health program projects, depending on each related project, starting from 2 to many CHWs.

SES has experience in developing information systems for each of its projects, and currently has its own platform for data management and teams of data managers, computer scientists, database managers and statisticians.

Being SES a health NGO that collaborates with the Ministry of Health, we believe in strengthening the Ministry of Health with YP to improve the performance of its CHWs, in the identification of cases, patient follow-up, and timely referral of patients. We believe that YP could be adopted by the Ministry of Health because we have a history of testing technological innovations that have been adopted by the Ministry of Health.

YP has a prototype, but it needs funding to complete its functionalities and its deployment with the CHWs in different programs and areas of the country. We believe that YP with the improvements in its functionalities described will be able to operate with several public health programs, such as tuberculosis, HIV, child health, maternal health, nutrition in different areas of inequity in access to health.

YP needs funding to demonstrate that it is a useful tool for CHWs, for patients, for the health system and for public health policy makers. We are confident that the YP pilot will provide the necessary advocacy with regional governments in charge of primary health care facilities, and with the Ministry of Health to establish YP as a useful tool in PHC.

YP is the first health ICT that will support the work done by CHWs in Peru. YP focuses on the neediest population, which usually only has contact with the CHWs and they with the healthcare network. To the extent that the CHW can perform better, more of the needy population will have contact with health services.

YP will facilitate case registration, with an automatic alert to the health service, connect CHWs to each other, and connect the CHW to his or her health facility or health program. Thanks to data collection with timely transmission and these connections, better support and coordination with the CHW can be provided in case management.

Next year:

Impact purpose: To strengthen the capacity of primary health care in early warning, risk reduction, and case monitoring, through the intervention of CHWs using YP in the programs developed by SES with MINSA.

How will it be achieved?

The key activities for this first year are:

• Complete the YP pilot with the Many Voices project in Carabayllo to validate functionalities of the YP tool.
• Expand the use of YP to other SES programs initially in the district of Carabayllo, in the programs of tuberculosis, maternal and child health, HIV infection, and mental health with the incorporation of more Carabayllo CHWs that would use YP in approximately 6 months.
• Deploy YP in CHWs working in rural health programs with support from SES and the Ministry of Health.

For this purpose, other complementary activities will be carried out: the call and selection of the CHWs, installation of YP in the cell phones of the CHWs, training of the CHWs in the use of YP, implementation of the pilot plan in the field: data collection for the improvement of its functionalities following checklists and validation of functionalities. We will also evaluate the support and assistance in YP management in complex situations or with low connectivity.

After designing, programming, and deploying the YP demo, the CHWs will use the pilot version of YP, recording data from the Many Voices project. In this pilot, which will be conducted for 6 months, data will be collected to make improvements to the user-centered design, improvements in the connectivity modules, and improvements in the interface usability of YP.

All these data will be used to analyze the results of the work of the CHWs in the care of patients with schizophrenia, identifying the number of cases referred to the health network, the number of cases at risk or patients with co-morbidities that were referred to the health system. The data collected and reported by the YP will be useful to validate and verify its effectiveness during community-based interventions in areas with low technological coverage.

Next five years:

The impact purpose: To strengthen the capacity of primary health care in early warning, risk reduction, and case follow-up, through the intervention of CHWs using YP in PHC programs developed by MINSA.

How will it be achieved?

• Pilot the use of YP in at least 10 MINSA facilities, distributed in the three regions of the country.
• Approval of YP as an official MINSA application.
• Transfer YP to MINSA's Health Promotion Directorate (PROMSA).
• Elaboration and dissemination of the YP User's Manual through training for CHWs and MINSA managers. Monitor its national implementation, through PROMSA and with assistance from SES.

For the proposal of indicators, two UN Sustainable Development Goals (SDGs) have been taken as a reference:

• Strengthen PHC capacity, in early warning, risk reduction and national health risk management, through the CHWs: number of early detections of cases (unvaccinated persons, TB symptomatic, population at risk of HIV, malnutrition, pregnancies at risk), number of effective follow-ups, number of referrals.
• By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, and combat hepatitis, waterborne diseases, and other communicable diseases. YP collaborates with the work of community workers in the early detection of tuberculosis and HIV. In addition, it can be extended to any other public health program.

The indicators that will be used to measure progress are related to the achievement of the outputs of the intervention:

Product 1, YP version 2.0 implemented and working on SES CHWs:

• Number of improvements made by solving errors, problems, and suggestions from CHWs.
• Percentage of CHWs who rate with high satisfaction the usefulness of YP in their work.

Product 2, YP Usage Guide:

• Number of training videos on the use of the YP tool. Percentage of CHWs who have a high score of YP functions.

The following model is proposed:

YP will be a mobile phone application for the Android operating system. YP is going to be interoperable by using XML interchange formats, and it is going to be upgradable in different layers because it will use the MVC design pattern, and it will be able to use geofencing functionalities because we will use the Google Maps interface for geolocation procedures.

We believe that YP will have a good user-centered design because SES has been working with CHWs for 26 years, and in this interaction, it identified the great need of CHWs to systematize their work with ICT tools within their reach, with low connectivity, and appropriate to their environment. Consequently, the design of YP and its improvements in the future are based on the expressed needs of the CHWs and collected by SES to register their cases, related data, schedule their visits, communicate with each other and with the health network.

Primary health care data in Peru are collected by technical and professional health staff. The CHW of the Ministry of Health's network of health facilities does not record data.

Unlike in SES, data are collected by both health staff and CHWs. Precisely because data collection in the community is manual, an easy-to-use technological tool with connectivity is needed, which is why YP was created.

Specifically for the pilot, in the CHWs mental health intervention with people living with schizophrenia, the initial registration of people is obtained from the health facilities of the Ministry of Health. With the authorization of the health teams, the CHWs initiate the follow-up of each of the patients with schizophrenia. In the event that a patient needs clinical or emotional support (medications, adverse events, emergencies, emotional support, among others), the CHWs alert the teams of the community mental health centers to provide support in the shortest possible time. Furthermore, in case the patient needs any socioeconomic support, the CHWs initiate coordination with the SES social protection team to evaluate the support and the number of times to be supported.

SES has as one of its organizational practices, the promotion of equity, diversity, and inclusion, which should be reflected at all levels of the organization. We actively seek to cultivate and nurture an organizational culture that addresses discrimination based on, but not limited to, nationality, gender, class, race, age, ability, and sexual orientation through the following strategies:

• Aligning with the context, history, and life experience of local communities by implementing equity, diversity, and inclusion strategies at each organizational location.
• Continuing to break down power dynamics and structures born of colonialism, patriarchy, and racism within and across the organization and among partners with whom we collaborate.
• Proactively recruiting, accompanying, and promoting those who are systematically excluded at all levels of the organization.

On the other hand, the organization's plan considers the following as strategic priorities:

• Promote and provide high-level training to improve health care and address social inequities.
• Strengthen our organizational system to maximize our approach to health care for the poor and vulnerable.

Following the institution's commitment to support the most neglected and ensure health equity, SES since 2013, has implemented a Community Advisory Committee that ensures maximum benefit to communities and guarantees the inclusion and differentiated care of vulnerable populations in SES interventions. In that sense, the SES Community Advisory Committee will be providing input to the YP pilot and its subsequent implementation in the field.

YP will be part of the work tools of the community network in support of health. The business model is the social support that the CHWs provide, in coordination with the health services network. The value of the service is the approach of primary care health services through the CHWs, better supported by the YP app.

The impact on the population is in the early detection, in the community, of cases, such as cases of tuberculosis, HIV, unvaccinated people, malnutrition, pregnant women at risk, etc., as well as the follow-up of cases in the community, and the investigation of risk behaviors.

YP will require funding and support for technological improvements, and to expand its deployment among CHWs. Funding will be provided through two business models.

The business models to be applied will be a mix of free-for-service and low-client-client. In this model we will offer support and follow-up services to patients of health programs with a focus on those who otherwise would not be able to afford it. This model will be based on direct agreements with the organizations that use the services of the health CHWs, such as the health NGOs registered in Peru, the Ministry of Health and the Ministry of Development and Social Inclusion, and also with agreements with the organizations that finance the services, such as multilateral organizations like the World Health Organization, the World Bank, and European cooperation.

YP is currently in its first version, thanks to limited funding from USAID during the critical epidemic of COVID-19.

YP so far has not executed its financial sustainability plan because the application is in its first versions and has not been used by the stakeholders we need. Nevertheless, our organization that makes use of the services of the CHW, has budget in each funded health program to be able to finance the first 6 months of using YP while looking to execute our financial sustainability plan, selling services to other NGOs, multilateral organizations and Ministries of the Peruvian state because we have direct contact with their leaders and responsible officials.