WeMUNIZE

Low child immunization rates in northern Nigeria present a serious global public health concern and limits the ability of the government and external organizations to eradicate grave but preventable illnesses. With only one in 10 children successfully completing their first year of immunizations, this region contributes to Nigeria’s low immunization levels and frustrates routine immunization services attempts at sustaining polio eradication. WeMUNIZE is an automated scheduling, GPS-enabled software-as-a-service that uses mobile apps in local languages to increase retention in the Child Routine Immunization (RI) Schedules, and to attract infants with no prior immunizations to commence attendance. WeMUNIZE incorporates printed photographs of the infants, taken at each RI visit. This verifies each immunized child, provides a non-monetary incentive for parents as documentary evidence for attendance, and addresses home-based record keeping which is a likely source of under reporting in population-based surveys. It generates accurate, clean immunization data to guide decision makers.

Immunization is one of the most successful and cost-effective public health interventions of all time. However, despite sustained global efforts at integrating Routine Immunization in the past decades, an estimated 10 million infants still need to be vaccinated in 64 countries of the world, if all countries are to achieve at least 90% coverage. 4 million of these children are in Nigeria, Pakistan and Afghanistan. Nigeria accounts for about 2.8 million of this number. In Nigeria’s under-served communities, families face multiple but surmountable barriers to accessing immunization services. The main clusters of factors responsible for low immunization rate across the world are: poor immunization system, absence of timely clear communication and information, family characteristics, parental attitudes/knowledge. WeMUNIZE, an mHealth Saas immunization registry leverages significant social capital resident in local ancestral, tribal and religious leaders, institutions and relationships to solidify on-going efforts to create and institutionalize sustained high coverage for routine antigens. Communities are exposed to the basic principles of baby tracking and referral, driving community ownership. Data of actual immunizations is generated in real-time and strengthens the activities of governments and international partners. Thus securing linkage with the broader health system.

The WeMUNIZE value matrix begins with the caregiver of the child whose immunization appointment is scheduled at the nearest facility, who are reminded of the child’s appointment when it is due. Male and female influential community leaders who wish to support efforts of routine immunization in their communities are coopted to upload voice recordings that are then customized to individual children. District and state government officials involved in the effort to drive demand for routine immunization get routine updates on the performance indices of facilities and communities. The state working group, which consists of all partners working on routine immunization, benefit from the data generated from the platform to inform decision-making and impact assessment in real time.

Building for sustainability, WeMUNIZE was designed for the cultural context in rural northwestern Nigeria which is defined by traditions, gender norms, political leanings, economy, technology infrastructure and other factors that can affect an individual’s ability to access and use a technology or to participate. Robocalls in the local dialect by-pass low levels of literacy in target communities. The SMS messages are in the local Arabic script of ajami. The use of SMS gateway protocols solved low delivery rates for SMS and robocalls.

The WeMUNIZE mHealth system is designed to improve RI indices by creating an increase in demand for RI services, especially in places with the poorest numbers. WeMUNIZE enrolls children under 1 year of age and their caregivers on its platform, schedules the child’s immunization appointments and makes robocalls with call-to-action immunization messages that double as reminders for next appointments in local languages voiced over by respected and influential male and female personalities of the community (such as religious and traditional leaders). This engenders personalized engagement, familiarity and community ownership. The application also sends follow-up SMS to remind and persuade primary care givers and given relatives in the weeks leading up to the next immunization visit that the infants be taken for upcoming appointments. Once at the RI facility, as part of the process to verify and as an incentive for attendance, the photograph of the child is taken, printed and given to the caregiver. This not only serves as a part of the immunization home-based record keeping tool for data verification during immunization surveys, it pleases the caregivers to have such an anecdotal keepsake from a health facility, and often encourages repeat attendance. 

WeMUNIZE rests on telecommunications infrastructure and uses GPS technology to geo-locate households with children under 1 year of age so that households in remote areas with poor internet service also benefit, no matter their location. This also enables the monitoring and evaluation activities of enrollment volunteers and Routine Immunization service providers within client communities. Furthermore, WeMUNIZE uses RFID and barcode technology to gather Routine Immunization data as the caregivers visit the facilities. The service providers at the facility use android mobile devices with cameras and printers to print out the photograph of the child. The more technical aspect of our breakthrough was to overcome the absence of mobile broadband, and for this we created an SMS-based telecommunications protocol that allowed our RFID readers, barcode scanners and Android apps, in rural northern communities, send and receive data from remote web servers. An SMS-based Internet of things, in a low resource environment, was our actual technical breakthrough. The vast majority of children in northern Nigeria are born in the home and their births are never registered by the Government of Nigeria (GON). This program would connect a cohort of children and families to RI and other GON amenities who otherwise might never have benefited from local government services.

WeMUNIZE’s use of printed photographs of immunized children as an incentive for Routine Immunization appointment attendance and home-based record keeping for data verification during immunization surveys.

The immunization reminders are in the local languages of intervention communities. Voice recordings done bypass literacy barriers and engender caregiver positive association, as each call is personalized for each child. Voice recordings are voiced by influential male and female religious/traditional leaders. This helps penetrate layers of gender bias that might otherwise pose problems to individualistic assumptions of who RI actors and beneficiaries are.

WeMUNIZE rests on telecommunications infrastructure and services. WeMUNIZE uses embedded Global Positioning System (GPS) technology to geo-locate households with children under 1 year of age. It uses Radio Frequency Identification (RFID) and barcode technology to gather real-time RI data of attendance.

The more technical aspect of our breakthrough was to overcome the absence of mobile broadband, and for this we created an SMS-based telecommunications protocol that allowed our RFID readers, barcode scanners and Android apps, in rural northern communities, send and receive data from remote web servers. An SMS-based Internet of things, in a low resource environment, was our actual technical breakthrough.

The Web app, comprising a scheduler and a registry, generates client specific robocalls, SMS and updates client information at each contact. It also has an in-built system that verifies infant information providing data for policy makers in real-time. Design and Implementation of WeMUNIZE employs an ecosystem approach to create value for every RI stakeholder.

WeMUNIZE is an automated scheduling, GPS-enabled software-as-a-service application that uses 3 distinct mobile apps(enrolment, immunization and verification app) in local languages to increase retention in the Child Routine Immunization (RI) Schedule and to attract infants with no prior immunizations to commence the immunization cycle. The WeMUNIZE process also incorporates the printed photographs of the infants, taken at each RI visit, and given to the primary caregiver as a non-monetary incentive. The more technical aspect of our breakthrough. To overcome the absence of mobile broadband, we created an SMS-based telecommunications protocol that allowed our RFID readers, barcode scanners and Android apps, in rural Northern communities, send and receive data from remote web servers. An SMS-based Internet of things, in a low resource environment, was our actual technical breakthrough. WeMUNIZE rests on telecommunications infrastructure and services to deliver Routine Immuniztion Call-to-Action messages through robocalls and SMS. WeMUNIZE has embedded Global Positioning System (GPS) technology to geo-locate the households with children under 1 year of age and map communities covered by the point of service, while estimating the target population. It uses Radio Frequency Identification (RFID) and barcode technology to gather real-time RI data for vaccine security, cold chain and logistics as well as monitoring for action. It also uses mobile camera and printers to create incentives for Routine Immunization appointment attendance.

The project theory of change suggests that

If we reduce supply-side barriers to RI services,

If we augment the existing program, service-specific platforms for integrated primary health care (PHC) with demand-side oriented technology platforms and non-monetary incentives, and

If we scale up high-impact interventions using technology, with other partners playing their respective roles

Then we will improve access to, utilization of quality RI services in a sustainable manner, thereby reducing mortality and morbidity from preventable, treatable causes.

This theory of change will be achieved through realization of crucial outputs that respond to the priority issues and areas covered in this concept note, by supporting the implementation of the State Strategies, Priorities, Policies and Plans, and other related sectoral & cross-sectoral frameworks and policies in the state. The above actions will be accomplished via a range of core programming approaches that capitalize on Black Swan Tech’s strengths in partnerships and capabilities in leveraging resources to contribute to a more coordinated, effective, efficient and sustainable intervention in the state. 

Our pilot enrolled 4,126 infants and we were over-subscribed with a waiting list of 1,122 resourced by the government. 98% of the cohort of children who began and their immunization appointments registered on the platform completed their full immunization schedules. Of the 4,126 registered, 1,482 (39%) completed their immunization schedule (measles, yellow fever). The number of children who received their vaccination within seven days of their scheduled appointment allowing for public holidays represents 80% (3,332) of the infants enrolled.

Our initial pilot deployment was under the quadripartite MOU including USAID, Sokoto state government, Bill and Melinda Gates Foundation and Dangote Foundation. Black Swan Tech Ltd as the implementing partner  served a total of 4,200 infants under 1 year old and their communities. Scale-up plans under way see us serving 2.2 million children under 1 year of age over the next year and over 10 million children across Northern Nigeria in 5 years.

This innovation is currently reaching 4,200 infants. For the next 2 years, our tactical plan for scale is to grow the number of health facilities where we offer the technology and further reduce operational cost to $2.88 per child per year. The second component of our pathway to scale is to seek out strategic partnerships that enable us deliver this solution to over 10 million children over the next 3 years. This will further drive down our cost per infant, specifically, our cost per infant who completes RI to less than $1.10 per child per year. We are working to create synergies that will further reduce this cost by 25 percent of our current cost per infant projections, which will ultimately make our program more scalable and attractive to large donors. The project will also optimize the structure of the platform; build strong relationships with other implementing partners and enable us to scale to millions of infants in Nigeria and across Africa.

To scale, reduce the unit cost per child to $2.88 per child for the next 2 years the intervention requires investment that will allow it be rolled out to cover 323 health care facilities with additional savings being possible at even larger scales.

1. Our solution currently works by leasing gateway access from third party service providers and requiring an opt-in action by our recipients. At scale, the intervention will have to procure its own license and gateway technology to achieve cost savings and be excluded from the “Do Not Disturb” (DND) service of the Nigeria Communications Commission.

2. Given the time and financial constraints for deploying the pilot, we made a design decision to limit the Android devices on which the app runs to android mobile devices with Android Version 6.0 and with Android Security Patch Level no later than March 5, 2017. Android devices with new Android security features would otherwise prevent seamless operation of outbound and inbound SMS required for registrations and communication with the remote serves. We need to extend our design to all android devices which will incur technical and financial costs. 

3. We need to invest in R&D to build a ‘voice-cloning’ and ‘text-to-speech’ technology that will allow us continue to provide localized and customized routine immunization ‘call-to-action’ messages at scale based on the consent of religious and traditional male and female influential community leaders on whose leverage and standing in the communities a key aspect of the impact of the intervention depends.

Following the initial pilot, the state government has endorsed WeMUNIZE and recommended that the WeMUNIZE program be scaled up to 244 facilities in communities with the most need for an increase in demand for and access to RI services. Based on these recommendations, we are currently seeking collaborative relationships with international partners to enable our team deploy the solution at scale. We have completed internal and external, indepedent technical reviews of our platform and intervention. On the basis of the report from these reviews we will be expanding our engineering team to deliver a work plan for optimization and features extension.

Full time staff including program staff and software engineering team: 24

Volunteers: 100

WeMUNIZE is an innovation that has proven its capacity to tackle a longstanding global public health challenge. Black Swan Tech Ltd is a start-up that focuses on deploying contextually-relevant technological solutions for national and global developmental challenges. We

• Identify a situation with enormous excess capacity/ demand
• Locate users who require identified excess capacity/demand but do not know how to access it
• Build a unique platform, using contextually relevant and scalable technology, to connect users to capacity, and manage interactions.

These principles add up to a strategy that has, over the years, allowed us conceptualize and develop uniquely positioned, sustainable solutions in the development space with buy-in from crucial stakeholders in sectors like education and public health at both national and international levels. Black Swan Tech is composed of young Nigerians who have over the past 15 years been involved with software development projects of a national scope across Nigeria. Our interventions have won USAID Global Development Lab DIGIS Award 2018, National Health Innovation Challenge 2016 finalist, 2016 Future Hack awards, USAID Congressional Award 2016. The Black Swan Tech team has a proven track record of working with diverse international partners to deliver contextually relevant, innovative technology solutions to pressing developmental challenges. 

Sokoto State Primary Healthcare Development Agency: Worked with the state emergency routine immunization committee(SERRIC) which includes international partners like USAID/MCSP, WHO, CDC-NSTOP, BMGF, UNICEF, SAVE the CHILDREN, PLAN international to ensure proper deployment and use of the application and the effective tracking of RI indices in intervention communities. 

National Primary Healthcare Development Agency (NPHCDA): The WeMUNIZE platform was designed and endorsed by the Routine Immunization Working Group and the COORE group of the NPHCDA which includes international partners like USAID, WHO, CDC-NSTOP, BMGF, UNICEF, SAVE the CHILDREN, GSK.

Federal Ministry of Health (Nigeria)

WeMUNIZE takes advantage of ecomomies of scale and is increasingly cheaper at large scale deployment. As part of efforts to strengthen Routine Immunization in Sokoto State, the State Government, Bill and Melinda Gates Foundation, Dangote Foundation and the USAID signed a quadripartite Memorandum of Understanding, which sees Sokoto State dedicating funds to driving RI demand promotion and community partnership. It is under the related budget lines that the operating expenditure for WeMUNIZE is easily accommodated by states under the MOU arrangement. Furthermore, by making community mobilization and community ownership of Routine Immunization a central objective, in leveraging the voices of influential leaders, WeMUNIZE taps significant social capital for behavioral change that minimizes the role that financial incentives usually play in interventions of this nature. Conscious of the importance of gender inclusion in community projects, female leaders are some of the key influencers whose voices are used in the WeMUNIZE robocalls. It jointly mobilizes communal influencers, the extended family and the parents of the child, to penetrate any layers of gender inequality that might otherwise pose problems to individualistic assumptions of who Routine Immunization actors and beneficiaries are. We are also exploring a franchise model opportunities that will enable governments and international partners deploy the solution on a cost per child basis.

MIT Solve is a marketplace connecting innovators such as Black Swan with resources to solve global challenges. We see MIT Solve as a community that can help us connect to an ecosystem of institutional support, resources and other innovators who can join Black Swan and WeMUNIZE on the pathway to scale this innovation.  

Black Swan Tech seeks to closely collaborate with many and diverse partners including government, funding agencies and research partners in order to achieve the results and maximize impact, access important networks, meet other innovators, leverage the reach of Solve to secure more resources to enable us achieve the vision. 

Being a member of MIT Solve will enable Black Swan Tech frame, adapt and expand our understanding of WeMUNIZE’s mhealth innovation against the larger global conversation to deliver impact through entrepreneurship, innovation, and collaboration in global public healthcare. 

SOLVE provides a unique opportunity for Black Swan Tech to meet with and engage a wide-range of partners with the most experience and insight our specific area of focus, global health. 

We seek partners with whom we can collaborate and who have the reach to enable us achieve the full scale of our vision. Partners with grant giving and/or international research capabilities who will join us in taking risks, pushing for new solutions, reinterpreting old notions and harnessing the power of science and technology to bring lasting impact and change for all. Partners with a clear record of success in working with governments, private sector, communities and individuals who can help us take WeMUNIZE to scale. Partners who can help us ground our approach in evidence-based implementation.

Funding and Research partners:

United States Agency for International Development (USAID):

USAID Development Innovation Ventures. USAID's open innovation program that tests and scales creative solutions to any global development challenge. 

USAID Global Development Lab

USAID MSTAR program

Integrated Health Project 

Palladium

Department for International Development(DFID)

Bill and Melinda Gates Foundation

World Bank

Global financing facility

World Health Organization

Global Alliance for Vaccines and Immunization(GAVI)

UNICEF

United Nations

MacArthur Foundation

Rockefeller Foundation

Carnegie Foundation

Global Fund

FHI 360

Private Sector:/Technology:

Google

Microsoft

Airtel foundation

Johnson and Johnson

Procter and Gamble

Research:

Jhpeigo

Johns Hopkins University

Breakthrough Action and Research

Clinton Health Access Initiative

Centre for Disease Control (CDC)

Carnegie Foundation

Global Fund

OXFAM

Wellcome Trust

PATH

World Economic Forum

Plan International 

MIT Global Health+ Medical Humanities Initiatives

Our current iteration for a pilot involving 4,200 children sees our platform processing over 832,000 recorded audio files of over 320 individual male and female voices concatenated in 12 permutations to deliver ultra-specific, individualized robocalls in the local languages of intervention communities. These robocalls direct caregivers of infants on when, where, how and why they should attend immunization sessions.  Our vision is to digitize the process of influencing and tracking immunization attendance and frontline community engagement efforts across third world countries. Routine immunization reminder messages and calls in 100s of local languages will provide directions to caregivers of 2.3 million children of rural and migrant communities for scheduled appointments at the closest healthcare centre. This sees our platform recording, processing and concatenating 7.65 billion audio files. At scale, scheduling of appointments, selection and concatenation of audio files for messaging and routing of robocalls will be more effectively done by AI. To achieve ultrahigh-specificity, we need to invest in R&D to build a ‘voice-cloning’, and ‘text-to-speech’ technology that allows us continue to provide localized and customized routine immunization ‘call-to-action’ messages in indigenous African languages at scale based on the consent of religious and traditional male and female influential community leaders on whose leverage and standing in the communities a key aspect of the impact of the intervention depends. AI will be a key component of this module. AI will play a role in providing predictive insights derived from data analytics to help policy makers with decision-making on vaccine supply chain management.

 In order to reach and engage women and families with mobile messages from WeMUNIZE, the project undertook gender analyses prior to deployment to examine the various roles that women and men play at the family and community level, the different levels of influence they wield, their differing constraints, opportunities; and the impacts that these differences have on their ability to make decisions that affect the health of the family unit. 

Female agency is cardinal for better health outcomes in rural communities. Therefore, gender integration is central to the WeMUNIZE design and deployment, placing premium on establishing agency among female populations to influence immunization indices in the right direction. The WeMUNIZE project volunteers are intentionally women, each of whom was trained as Routine Immunization champion within their communities. These women will be equipped with an android device with which they enroll eligible children and their caregivers (usually female) on the WeMUNIZE platform. Each volunteer will use the WeMUNIZE app to digitally record immunization information and take a photo of the child, printing it as an incentive for the caregiver and storing it as a way to track the child’s development. These records will be monitored to ensure immunization schedules are followed, significantly reducing dropout rates. In the event of a default on immunization appointment, volunteers are trained to track down the defaulters and reschedule missed appointments. The prize would support ongoing efforts to equip, train and empower these female volunteers in rural communities, and will further engender local  ownership of WeMUNIZE.