HERA Digital Health: Connecting refugees to healthcare

There are an estimated 89.3 million people displaced globally today and the global refugee crisis is expected to rise to at least 200 million by 2050 due to climate crisis and conflicts. (UNCHR) Access to healthcare is a fundamental human right regardless of where you are coming from. However, current health systems are not ready to respond to the needs of forcibly displaced. We are currently in the field working with Syrian refugee women and children in Turkey. There are 2.6 million Syrian women and children refugees in Turkey, who have been exposed to the debilitating effects of forced migration and remain at risk for severe health consequences. Approximately 47% of these refugees are children under age 17, and 46% are women between ages 18-59 (UNWomen) Syrian refugees resettled in Turkey have huge barriers in accessing consistent ,high quality maternal and pediatric healthcare. This takes a drastic toll on the health of women and children, who are already some of society’s most marginalized people. Discrimination towards refugee groups is on the rise globally, refugees face xenophobic lead violence,exclusion and prevention of resource access, deportation, and marginalization which leads to poverty and descending healthcare outcomes.  Due to these barriers, on average a refugee woman only receives one pregnancy check-up when the WHO recommends eight, and only 20 percent of refugee children are fully vaccinated (UN Women). This puts them at risk of not only preventable diseases, but with traumatic outcomes such as stillbirths.

HERA (which stands for Health Records App) is an open-sourced mobile health (mhealth) platform that aims at increasing the uptake of preventive health services for pregnant women, and immunization for children under two years of age. Through a mobile app, the platform enables users to receive healthcare appointment reminders, receive health information, store centralized medical records, contact emergency services, and navigate the healthcare system of the host country in multiple languages. The app is currently available in Arabic, Turkish, English, and Dari and Peshto. 

HERA relies on a modular architecture, which benefits the application by subdividing it into several modules and components, with the ability to replace or add any module without affecting the rest of the system. This architecture design provides the app with a high degree of reliability, maintainability and scalability while maintaining low costs. Anyone without knowledge of coding can  edit the information. 

Watch a short video about our app. 

We serve refugee women and children, regardless of race, religion, creed and/or politics. Currently we are based out of Turkey, working with the Syrian refugee population on the path to resettlement within Turkey’s border provinces. According to the UNHCR, women are targeted during conflict regardless of refugee status. The addition of displacement put women at an even higher risk for gender based violence and gender based discrimination. Women make up 50% of all refugees and those who are pregnant or unaccompanied are within the top percentage of gender based violence(UNHCR).  Every task a woman or child has to take once displaced is shown to be met with greater adversity. Our solution, the HERA app, helps remove a significant barrier for this specific population. By making healthcare more accessible, women and children refugees can eliminate a barrier in their journey to resettlement. Our app provides pertinent healthcare for women, pregnant women (prenatal care) and children. Items such as the WHO recommended prenatal visits for all mothers and vaccinations for both women and children. These are two top priorities of the UN and WHO, who have set ambitious goals for 2023, in order to compensate for time lost during the pandemic.  By closing this healthcare gap we can ensure a better future for a refugee.

HERA's approach to the global health issue is People-Centered. At the heart of this approach are the importance of health education and health support needed for communities to make decisions and participate in their own health care. This approach ensures that health needs and community expectations are met, rather than focusing on the negative impact of diseases affecting individuals' livelihoods. This approach is also directly linked to the United Nations Sustainable Development Goals (SDGs) 1 (No Poverty), 3 (Good Health and Well-Being), and SDG 10 (Reduced Inequality).

Local Engagement and project sustainability will be guaranteed by harnessing the power of local communities through local partnerships. In investing in local businesses and networks, HERA commits to creating a network of social and economic opportunities for the refugees, marginalized groups, and women, promoting community engagement and health for all. As a result, local communities can concretely structure local efforts to engage in developing their communities, strengthening local ownership actively. This is not only a viable method to ensure sustainable representation and inclusion in the project lifecycle, but also directly contributes to SDG 8 (Decent work and economic growth), SDG 10 (Reduced inequalities), and SDG 11 (Sustainable cities and communities).

Finally, openness, transparency, and clear communication on the project scope's achievements will ensure that refugees are involved not only as information providers but as partners in different stages of the project and decision-making process at all levels. This enables ensuring responsive, inclusive, participatory, and representative decision-making.

Currently we have 5K users in our application. 

We are a small start-up with limited staffing and resources trying to compensate for healthcare needs for millions of refugees, with ambitious plans to expand. As of this application, Turkey has been struck by two earthquakes, displacing more individuals in the border region. This is putting the country at its limit, leaving multiple organizations , such as HERA, to respond to an evolving crisis. As we take on a greater challenge and expand our apps capabilities to cover not only refugees but all displaced people, we will need to branch as far as we can with resources. We hope MIT Solve will allow us a broader network of emergency-refugee response leaders who can help us cover our evolving population. We are looking for experts on monitoring and evolving impact over the next five years, allowing us to develop and strengthen our story and metics.

As a free app, HERA leverages a digital health platform to increase the access of preventative health services for pregnant women and immunizations for children under two years of age. HERA application reduces demand-side barriers to accessing care by sending medical checkup and vaccination appointment reminders, centralizing medical records, and guiding users in navigating their local healthcare systems.

Refugees are an increasingly vulnerable population that traditionally have been overlooked by digital health technology developers. Despite global efforts, there is still a lack of data explaining refugee outcomes.Therefore, there aren't many data-driven applications on the market for refugees. 

The majority of refugees today have access to smartphones as well as non-smartphones. These smartphones frequently serve as a lifeline to communicating with their families, connecting with communities, and understanding better the context of their host countries (finding services). Unlike most interventions that focus on providing a supply of medical services, HERA focuses on the increasing health demands among refugee populations, namely for maternal and child health. Refugee women and children are some of the most medically vulnerable populations on the planet. In turn, HERA empowers refugees to take ownership of their health decisions, while also affecting behavior change when seeking health services. The HERA solution does not multiply existing health interventions but instead increases the effectiveness of existing health services by focusing on the gap between healthcare access and refugees. HERA helps refugees proactively manage their healthcare and vital appointments, thus reducing the ill effects of disease and other health issues. Currently, no other equivalent to this type of service exists on the market.

The target population goal for 2023-2027 is to reach 150,000 users within the next five years in Turkey through field expansion,workshops and online campaigns. 

To start, our primary goal is to reach 30,000 refugee women. This goal  will roughly lead to 90,000 vaccines facilitated by  HERA and 60,000 pregnancy check-up appointments completed. In addition,  we are using an outcome and output-oriented logical framework to create activities and key milestones (outputs) in order to achieve this goal. 

• Outcome 1: Within one year, increase by 20%, with the uptake of preventative health services for pregnant women and immunizations for children under two years of age among refugees in Turkey. 

• Output 1.1: 30,000 Syrian refugees enrolled in HERA by the end of 2022.

• Output 1.2: 50,000 downloads of HERA by the end of 2022.

• Output 1.3: At least 80,000 women were made aware of HERA.

• Output 1.4: At least 10,000 men/heads of families were made aware of HERA

• Outcome 2: By late 2023, scale up the HERA platform to be piloted in at least two countries that host refugees.

• Output 2.1: To register HERA for use in at least two countries.

• Output 2.2: To enroll 5,000 refugees to use HERA in at least two countries.

• Outcome 3: By mid-2024, create a sustainable partnership with at least three international organizations (e.g WHO, UNICEF, MSF, UNHCR, IOM) willing to use the HERA app to support their humanitarian aid projects in Turkey and globally.

• Output 3.1: Create long-term relationships / active organization level users (at least two).

• Output 3.2: Receive sustainable funding with a runway of 1.5 years at any time.

• Output 3.3: Create and maintain tech infrastructure and team.

We would like to expand our tech team to include more refugee developers as they understand refugees and the challenges in the field. They will have the best understanding of the challenges refugees go through and suggest suitable technological solutions and features. The partner we currently work with to identify quality refugee developers is Techfugees and kodluyoruz.org.tr (a Turkish nonprofit training low income individuals for tech industry jobs).

Once we reach a critical mass (approximately 30K users) and have documented substantial  impact (number of additional vaccines, pregnancy check ups, etc.), we will begin negotiating with large healthcare providers such as MoHs in refugee hosting countries and/or UNHCR. We will offer HERA as a tool to (1) increase the effectiveness of their healthcare supply, (2) improve  maternal and child health outcomes in refugee groups, and (3) decrease health care costs. Our projected RoI of HERA (based on  similar programs’ results) is 334%. HERA will act as a consultant to the healthcare provider when implementing and integrating our HERA app into their healthcare system.

ne of HERA's goals is to decrease death and disease among refugee populations by providing a mobile health platform that connects refugee populations with existing healthcare worldwide. Two metrics measurements come from our user data, calendar completeness based off the WHO health recommendations for prenatal check-ups and vaccinations, completed by each refugee user enrolled. Then the cost savings through our ROI analysis, the more we invest in HERA the more cost saving preventative care can be provided.  Here are three metrics we use when looking for this in our data: 

Metric 1: Measuring vaccine calendar completeness percentage: Vaccination completeness is a universal health priority within refugee groups, as timely vaccination is a key component in reducing childhood mortality from vaccine-preventable diseases. Refugee children are at the highest risk of developing these diseases due to living conditions and barriers when accessing health resources (i.e. finding a physician, transportation, language). HERA helps plan and remind mothers (or caretakers) of appointments and helps them navigate to the hospital. Our goal is to increase vaccine completeness level using the Turkish Vaccine Calendar (that refugees can get free of charge). 

Metric 2: Completeness of four recommended prenatal care appointments during pregnancy. Pregnant refugee women receive a delay in prenatal care, ending in fewer prenatal visits during pregnancy due to barriers (e.g. language, transportation) in their host country. Delay or absence of this type of care results in poorer pregnancy-related outcomes (e.g. preterm birth, lower infant weight, labor inductions). Similarly to vaccine appointments, prenatal appointment completeness increases the chances of healthy natal and maternal outcomes. HERA helps refugee mothers find and schedule these pertinent appointments with a community provider through the one app, where a mother can track her appointments, schedule, set reminders, and find transportation to these providers. Currently, the levels of uptake are one appointment per pregnancy. Our aim is to increase it to at least three or four. 

Metric 3.) Healthcare costs are saved through prevention. Vaccine immunity decreases the risk of outbreaks of preventable diseases, for not only refugees but the host country's population. Therefore they are highly cost-effective. Our estimates are that for every $1 invested in HERA, it would save $3.37 in healthcare costs. This metric is using a projected Return on Investment Analysis (ROI), at a baseline of 10 years, using the current literature. This metric will be continually calculated through additional vaccines and prenatal care uptake for refugees using HERA. This metric also includes prevented mortality and morbidity rates (calculated as disability-adjusted life years - DALYs).

HERA helps refugees access healthcare in their host countries by increasing the demand for healthcare and facilitating navigation through the health system to save lives. In scope of this overarching goal: 1. We  improve the user experience, security and overall usability of HERA App and 2. Getting more users enrolled and using the functionality of the mobile intervention through community outreach and partnerships. The first activity’s specific outputs are user friendly, scalable and replicable mobile health products (data collection platform, mobile app) and ongoing improvements. These outputs are measured through technical evaluation using (currently) Google Analytics, Firebase etc. Metrics of focus here are number of downloads, daily active users, number of reminders sent and responded and similar quantitative measures such as the number of users that made a call to emergency services. 

The second activity is planning and executing community outreach, key person (or organization) buy in and creating long lasting relationships with stakeholders. Output of this activity is increased usage of our solution in the target population and integration of HERA to existing supply side digital interventions (electronic medical records, immunization surveillance systems etc.). Metrics that are of highest priority here are number of people using HERA, number of countries it is being used, level of integration to host country’s health system. These outputs also include metrics about usage of the health system, increase in the number of vaccines or pregnancy check ups done. 

Outcome of these activities is to decrease death and disability due to vaccine preventable diseases and pregnancy related risks via better utilization of preventive health services.

Health Recording App (HERA) is an open-sourced mobile health (mHealth) platform that aims at increasing the uptake of preventive health services for pregnant refugee women, and immunization for refugee children under two years of age. It is accessible to users through a mobile app which is available in smart phone and non-smartphone versions, which is useful for refugees as 80% or more of refugees today own mobile phones. 

We currently have 2 mobile applications live on the Apple App Store and Google Play Store. They are separate mobile applications for 2 separate markets:

1) Refugees in the US, namely in the Nebraska refugee camp

2) Refugees in Turkey

Users of HERA can simply download the app to their phone, fill out basic demographic information including name and date of birth, number of children, basic child demographic information per child, and pregnancy status, and HERA safely stores user information in a privacy controlled and encrypted app environment. Users are then directed to a dashboard where they can access services depending on their current healthcare needs including push notifications for healthcare appointment reminders, targeted health information via a blog, access to centralized medical records, contact emergency services, access to pregnancy care, and more. 

Our mobile application has a Health Records module that allows users to store images of their own health reports and medical records.

• This is stored and recorded fully locally on the user’s mobile device.

• No APIs are called or data from the Health Records module uploaded onto our servers. This is done intentionally to respect a user’s privacy. We strictly do not collect any data on what health records are added or deleted.

As we expand to more refugee camps worldwide, it is pivotal we can easily and quickly add new translations into our mobile application and push notifications.

We have built a few custom modules to allow administrators and external translators to easily add translations for new languages we support.

     1. Admin Panel notifications module (HERA Staff)

• This is the module that controls what push notifications and in-app notifications are sent to users. Modules can be scheduled in different languages according to the user’s local timezone

  2. Admin Panel surveys module (HERA Staff)

• This is the module that controls the pop ups that appear in-app to check if a user/user’s family has gone for a scheduled vaccination or pre-natal check-up

• Administrators can schedule these surveys in different languages according to the user’s local timezone

Our leadership team is comprised as 50% women and 50% men. Our team, is global, meaning we have representation from multiple countries. We have  refugees on our team ,both as volunteers and as employees. No matter how much effort we put into diversity and inclusion at HERA there is always room to grow. 

HERA stands for the following core values:

• We aim at saving lives

• We are driven by the needs of refugees

• We are committed to equality for all 

The following principles guide HERA's work:

• Empowering refugees, especially women and children

• Promoting preventive healthcare that saves lives

• Providing an open-source platform, free for the end-users

• Promoting diversity and inclusion

• Upholding the humanitarian principles of humanity, neutrality, impartiality, and operational independence 

• Ensuring results and quality, promoting transparency and accountability

While global health grants are still the primary source of income for HERA, we are working to implement a business model in which we partner with healthcare providers to distribute the HERA app to refugee end users (primary population). 

Access to proper, continual healthcare services is next to clean water and shelter. The services our app provides are life saving and preventative services for women and children during a pertinent and crucial transition. This specific population exists in all crises, women and children will continue to be the most vulnerable. Inaction on behalf of this population during a crisis will create a bigger gap on the global scale of morbidity and mortality. There is a direct , continual need for healthcare services between population growth and resource decline. 

HERA's social enterprise model includes offering HERA as a tool to healthcare providers of refugee-hosting countries and helping them integrate HERA into the existing healthcare system, as our value proposition depends on cost-saving and increased efficiency of existing interventions. This will also allow us to continue to provide HERA free of charge to the end-users. We estimate the levels of grant-based funding will decrease from 100% to 50% over the next five years with the addition of two other countries which harbor refugees.

HERA has previously been supported by accelerators, global health donors, research grants and social impact funds such as Google.org, Grand Challenges Canada, European Investment Bank and American Beirut University and Harvard Innovation Labs. We believe the grant funds will stay our largest financial resources until we reach a large enough user base and show long term health impact (deaths averted due to vaccines etc.). We have applied to +500K $ funding for the next 12 months, $55K have already been confirmed for the next 4 months. However our long term sustainability goal is to work with healthcare providers to incorporate HERA to existing healthcare systems. 

Our most immediate axis is the distribution of the application to populations in Turkey and expansion to new locations. With the global population of refugees on the rise, we are scaling up to take on new populations. When conflict, epidemics, and climate crises occur, new populations of refugees form. This is clearly seen in Ukraine, a country with a formable healthcare system, but the conflict of war removed the population from healthcare access. Ukraine is one of many crises where HERA can increase the efficiency of a refugee centered response. 

Once we reach a critical mass (approximately 30K users) and have documented substantial  impact (number of additional vaccines, pregnancy check ups, etc.), we will begin negotiating with large healthcare providers such as MoHs in refugee hosting countries and/or UNHCR. We will offer HERA as a tool to (1) increase the effectiveness of their healthcare supply, (2) improve  maternal and child health outcomes in refugee groups, and (3) decrease health care costs. Our projected RoI of HERA (based on  similar programs’ results) is 334%. HERA will act as a consultant to the healthcare provider when implementing and integrating our HERA app into their healthcare system.

To date this is our grant breakdown:

• Roddenberry: ($15KUSD)

• Twilio.org ($98KUSD) (TBA)

• UPS Foundation & FFWD.org ($5KUSD)

• Turn.io ($25KUSD)

• Box.org ($25KUSD)

• Turkey Mozaik Foundation (UK) ($7K£)

• Monday.com, Digital Lift Software Grant ($600USD) 

• European Investment Bank - Sitolarship (5K EU)

Earthquake Response specific grants and donations: 

• IPPF 30K (Earthquake response)

• Private donors 35K (Earthquake response)