Digital safety net app for Community Health Workers

The World Economic Forum estimates that 3.5 billion people live in last mile rural areas and face difficulty in accessing healthcare. Of these, 500 million are found in Africa. Such a big number of people ideally should not be having difficulty in accessing the healthcare that they need whenever need arises but that just is not the case.

According to UNICEF, 18 mothers die every day in Uganda while 1 in 11 children die before their fifth birthday. Most deaths of mothers and children under 5 in Uganda are from preventable causes. In turn Communicable diseases such as malaria, HIV/AIDS, tuberculosis etc. contribute to mortality which mortality is preventable. It is important to note that 80% of people in Uganda reside in rural areas where the greatest healthcare access burden exists. Healthcare access in rural areas is made difficult due to factors such as poverty, low levels of education, long distances to the nearest health facilities and poor service delivery in health facilities. A person in a rural area has to travel a distance of over 12 km to reach the nearest health center, a journey that takes 2 hours on average. Without the presence of strong community health systems, many people in rural areas opt out of accessing health care and often resort to other means which do not yield good health outcomes. 

The MobiKlinic Digital Health Safety Net is a digital community health app, used by community health workers to deliver basic health services, including maternal and child healthcare, routine non-communicable disease care, routine and campaign immunization, accurately collect associated data, promptly consult remote healthcare professionals, and refer complicated cases in their communities to advanced health centers. 

Our innovation unlocks the possibilities of community health services and the abilities of frontline CHWs by enabling the following: 

1.Authentic digital beneficiary records collection and retrieval through the use of SimprintsR‘ ethical mobile biometrics technology during registration, and subsequent identification of beneficiaries. 

2. Remote, real-time medical professional support to CHWs on the line of duty by MobiKlinic doctors. This expands the scope of care given under routine community health services. 

3. Consultation support through an in-house AI chatbot that guides CHWs on vaccines and basic health service provision and recommends referral or further consultation where required. 

4. Referral support through geolocating nearby health facilities and ambulances, and availing contact details for such services. 

CHWs use the MobiKlinic App to enroll last mile beneficiaries for services including vaccination, maternal and child health and family planning among others. Beneficiaries are enrolled with the Simprints mobile biometrics technology through facial or fingerprint scanning. A digital biometrics linked, unique beneficiary ID is created as an identification and verification standard upon which subsequent patient data including the vaccination records are attached as they happen. 

Armed with this technology, CHWs are able to know which community members received or didn’t receive which vaccine or service. Aggregation of service provision data enables us to pin-point vaccination and other service gaps and devise specific community outreach intervention. 

Our vaccination solution has already been piloted through a Makerere University School of Health Sciences Research Ethics Committee (MakSHSREC) approved pilot project where it was used by CHWs to reach over 2500 beneficiaries, deliver Covid-19 vaccines to 465 zero-dose and partially vaccinated beneficiaries. Through the pilot, our solution was associated with shorter average registration and verification times (1.5 minutes and 0.2 minutes) compared to plain digital (2.9 and 3.3 minutes) and paper forms (2.4 and 2 minutes) respectively, a 252% increment in number of vaccines inoculated at the intervention facility, and a higher proportionate vaccination coverage (6.69%) compared to the 2 control facilities (2.02% and 1.76%). 

MobiKlinic through a network of community health workers, and other support structures has been providing community based services through routine door to door home visits and routine community outreaches mostly in rural, and urban slum communities. Starting in the rural communities of Buikwe, Mobiklinic has since expanded to Kampala and Mukono in Uganda, and Kisumu in Western Kenya. Our target are underserved communities, some lacking even the most basic healthcare, the majority(79%) being women and children.  

Mobiklinic offers a variety of free or affordable health solutions to underserved communities, through an extensive network of CHWs, that are supported by a handful of readily available remote healthcare professionals and other assistive health technologies including an A.I chatbot. This healthtech ecosystem significantly reduces operational costs, and enables highly subsidized costing for services. For example, in our routine NCD care program, beneficiaries pay $0.3 instead of $1.2 for subsequent blood pressure monitoring, $0.6 instead of $1.5 for any random blood sugar screening, $0.6 instead of $3 for urinalysis using the urinalysis dipstick, and $1 instead of $10 for remote consultation with doctors while receiving their drugs are subsidized up to 50%. We offer our free services in concert with the government and other partners. 

The blend of knowledgeable, accessible and digitized CHWs ensures that community members have universal access to basic health services, the teleconsultation with remote doctors and A.I support allows safe provision of more advanced health services while, the mobile biometrics technology ensures authentic collection and retrieval of all beneficiary records. Ultimately, the communities are able to access dignified, comprehensive and universal health coverage.

We are guided by a non-executive board led by Mrs. Bright Wandera Asiimwe (senior public health consultant with over 25 years of Public health experience), and supported by Dr. Robin Kibuuka (former chair Stanchart Uganda, UBOS and Retired senior economist IMF), Isabelle Magnin(Gelonier Innovation Hub), Pamela Steele (Pamela Steele Associates), and Paul J. Crook(of Crook Consults) among other industry leaders with a combined work experience of more than 150 years in successfully delivering diverse development solutions in diverse environments including challenging and unpredictable ones. More about our Board of directors: Mobiklinic board of directors

We have a track record of excellence in digital health strategies evidenced by awards, and backing from respected industry stakeholders like, Forbes Magazine, Global Citizen, The United States Embassy in Uganda, Emergent Ventures, UNCAP, Roddenberry Foundation, Novartis Foundation, Boehringer Ingelheim among others.

With our acquired reputation, and achievements, we were deemed fit to participate in the WHO civil society engagement commission, where strategies towards accelerated attainment of UHC2030 are discussed. Here, we represent the constituencies of digital health, and last mile service delivery. Precisely we represent digital health innovators at the WHO Civil Society Commission.

Diversity of skills and expertise:  With a blend of medical practitioners, software engineers, lawyers, M&E specialists and community health practitioners, we have a 360° view of the digital health ecosystem from technology development, regulation, and service provision. This advantage allows us to develop and implement cutting edge digital solutions that are practical and highly acceptable by community health workers and beneficiaries alike. More about our team: Mobiklinic team

Our technical team has thorough knowledge of the public health systems in Uganda and Kenya as well as corporate operations, more than 20 years of programming and technical training experience, and close to 10 years of research and material development expertise. These are critical for innovation, design, implementation, and evaluation of context specific projects.

From 2019 to date, MobiKlinic has directly served over 25,000 patients through our trained community health professionals (CHPs).

MobiKlinic developed a mobile application that was designed to be used by community health professionals as they go about their health service delivery. Most recently, we partnered with Simprints to pilot a research project that sought to test the application of biometrics facial recognition in patient identification in rural areas that has yielded success as per the project targets. 

We are therefore looking to grow our solution and move into new communities and new districts.

We have a great desire to strengthen community health systems in Uganda and Africa as a whole. Seeing as this is one of the themes of this program, we are greatly motivated to apply for Solve with the hopes of sharing our success stories so far and lessons learnt while we also learn from others who, just like us, are actively involved in improving access to health services for people in underserved communities. We strongly believe that knowledge is power and as such we expect to learn more on how we can grow MobiKlinic. We hope to learn from tutors and peers and alumni. We also expect to polish our fundraising skills as well as benefit from the funding that is available from this program.

We will therefore need support in:

1. Fine tuning our business model to be able to achieve desired sustainability.

2. Polishing skills on fundraising to be able to reach our fundraising targets as a company.

3. Guidance on how best to tell MobiKlinic’s story and marketing of the organization.

Our solution is premised on innovation in the following ways. 

Our digitalized patient data management allows flexibility in storing, retrieving and ultimately utilizing beneficiary data in community service provision, monitoring and evaluation, needs forecasting and procurement. 

Through a real time chat feature, our solution allows seamless interaction between frontline CHWs and advanced health support systems including professionals, ambulances and referral centers. This improves the scope of conditions managed by CHWs and the quality of care community members receive, extending comprehensive healthcare to their communities. 

Through the Simprints’ ethical biometrics technology, our solution offers an authentic beneficiary identification and verification modality, significantly improving the integrity and security of data stored on our databases. 

Our inbuilt A.I chatbot allows CHWs to conveniently consult about routine community health cases, significantly reducing the room for error during service provision and increasing the safety of community health services. 

With the MobiKlinic App, the CHW is confident about delivering safe and appropriate care to community members because they have options to fall back to, while we are also confident of the integrity of beneficiary data collected by CHWs given the robust beneficiary identification and verification. 

Community health workers have extensive knowledge and reach of the communities that they serve. 

Training and digitizing them optimizes their work through enabling community health information efficiency, seamless interaction with advanced patient support with resultant improvement in scope of work and comprehensive, universal health coverage. 

A big pool of knowledgeable and digitized CHWs will improve the quality and reach of community health services and this will produce improved community health outcomes especially in fields like maternal and child health, family planning and routine immunization where CHWs are supposed to play a critical role. A CHW can reach a minimum of 100 beneficiaries per year in Buikwe District.

Inputs 

Funds, human resource, devices, technology (Mobiklinic App and Mobiklearn), support systems. 

Activities 

Baseline, Midline and Endline Primary and secondary data collection on community health indicators like immunization statistics and preventable diseases’ incidence rates. 

Baseline, Midline and Endline data collection on CHWs’ knowledge. 

Training and digitization of additional CHWs  .

User assessment tests for CHWs.

User observation. 

Routine user surveys. 

Content creation in line with user survey results for the Mobiklearn platform.

Technology adjustment (UI, and back end) in line with user survey results. 

Partnerships development with key stakeholders in the community health space.

Marketing activities for costed community services.

Cost benefit analysis 

Cost effectiveness analysis. 

Outputs

Baseline, midline and endline reports, User assessment reports, User survey reports, Knowledge assessment reports.

Peer reviewed, open access publications of new knowledge.

Cost benefit analysis report.

Cost effectiveness analysis report. 

Outcomes 

Fully trained and equipped CHWs. 

95% of villages in the districts we serve having full community health professional coverage and digitization i.e. villages having the recommended 2 community health professionals per village, each with functional smartphone.

95% of children being fully vaccinated.

100% of pregnant women receiving folate supplies.

85% of pregnant women attending 8 antenatal visits.

85% awareness of NCD status.

ART retention rate of 95% among patients living with HIV.

Impact 

Reduction in morbidity and mortality due to behavioral preventable diseases like Malaria, Bilharzia, Diarrheal ailments, HIV and STDs, and vaccine preventable diseases like Measles, Tetanus, dysentery, Hepatitis B and HPV infection and improved outcomes in NCD management.

Improvement in healthcare seeking behaviors of the communities measured through, increased hospital-based delivery, attendance to antenatal services, vaccine regimen completion and increased hospital bed occupancy rates. 

Improvement in NCD care and associated outcomes in underserved communities.

Robust, community-based response to health emergencies. 

Reduction in neonatal and under-five mortality rate, maternal mortality rate and stunting in children.

A randomized control trial carried out by Living Goods to determine the impact of community health workers empowered with digital tools established that there was a 27 percent reduction in under-five mortality at an estimated average cost of $68 per life-year saved. Infant and neonatal—under 1 month—mortality was also significantly reduced by 33 and 27 percent, respectively. The study also found out that community health programs improved other intermediate outcomes as well, including improved health access, health knowledge, and behaviors. This provides proof of the impact community health professionals can have on the health outcomes of communities.

This research coupled with our own successes since 2019 further strengthens our belief in our solution in that we not only expect it to work but we actually know that it will work. 

The MobiKlinic application is an android based application that is installed on a community health professional's (CHP's) smartphone. 

Our App is built in react native language to allow implementation of inclusive and dynamic user interface features to meet the diverse technology needs and preferences of user CHWs and the communities they serve.

Our data models are designed following the FHIR resources, and we specifically used the FHIR RESTful APIs to integrate with FHIR servers, and to allow technology flexibility in meeting prevailing user(CHW) and community needs. We used the fhirclient for JavaScript library to facilitate communication between the app and the FHIR resources and we enabled data synchronization to effect this. 

The following profiles and extensions are enabled to facilitate easy, and comprehensive analysis of CHW collected data: Observation resource, DiagnosticReport resource, questionnaire resource, CQM profiles, risk assessment profiles, data element extensions, structured data capture profiles and data provenance extensions. 

The react Asyncstorage API is enabled for asynchronous storage of data, to enable offline use, and applicability in areas with low internet bandwidth which form a big proportion of where our CHWs are based.

Full-time: 15

Intern: 1

Volunteers: 2

MobiKlinic was founded in September 2019 and from October that very same year to date, the organization has been offering basic health services in rural areas of Buikwe district, and urban slums of Kampala Metropolitan area. 

MobiKlinic was founded by 2 women and a gentleman from very different backgrounds, being brought together by the shared passion for equitable healthcare. Mr. Andrew Ddembe, Co-founder and current CEO of MobiKlinic is from the legal background and his enthusiasm for health equity through emerging technologies has landed him on the front page of the Forbes Africa Magazine as a Forbes 30 under 30. He has also won the coveted Global Citizen award among other prestigious recognitions. Ms. Barbara Nabigambo, another cofounder is an accountant and a women health advocate while Mrs. Mary Ssenyonga, the 3rd co-founder is a community nurse with over 30 years of community work. 

The current non-executive board of directors headed by Ms. Asiimwe Bright is not multidisciplinary but has a good composition of men and women from different age brackets who share over 150 years of senior management and executive leadership. 

Over the years, MobiKlinic has attracted and contributed to the growth of different professionals such as engineers, pharmacist, doctors and accountants through innovative and open recruitment, unbiased screening, and cultivation of a collaborative and highly flexible work environment including a 4-day work week, and preference to remote work where applicable. 

MobiKlinic has actively implemented staff support policies to ensure diversity protection including routine diversity training which are facilitated through the African Leadership Network, regular review of our diversity policies and maintenance of robust, whistle blowing policy. 

Our diversity approach is inbuilt into the company structures from the inception and has significantly contributed to staff wellbeing. We believe this is one of our forefront success drivers.

We build self-sustaining service delivery chains of 1 doctor, 100 CHWs, and 1500 unique beneficiaries. 

Revenue from conveniently-priced non-communicable disease services and grants supports the delivery of free PHC, vaccinations, and technology maintenance.

After the initial screening for NCDs, beneficiaries pay $0.3 instead of $1.2 for subsequent blood pressure monitoring, $0.6 instead of $1.5 for any random blood sugar screening, $0.6 instead of $3 for urinalysis using the dipstick, and $1 instead of $10 for remote consultation with doctors. 

Those enrolled in pharmacotherapy get their drugs delivered by CHWs at 80% of average retail prices, conveniently. On average, each patient returns a net revenue of $2.3 per month to MobiKlinic. A chain of 1500 patients, 100 CHWs, and 1 doctor is self-sustainable if each patient returns net revenue of at least $1.5. 

The cost of services is met by able community members through our direct B2C approach or waived by likeminded organizations such as the American Embassy and UNICEF who meet user fees for clients with very low purchase power through the B2B approach. Nonetheless, our B2B approach generates most of our current revenue, and, together with grants, meets 85% of our operational expenses, sustaining the free basic health services like maternal and child health, family planning, and routine vaccination support.

Our goal is to build a sustainable model at scale with buy-in or ownership by the Government of Uganda through the community health department and UNEPI to share implementation resources in basic community health and vaccine delivery. 

We intend to expand our technology on a build, pilot, transfer model where we shall work with governments to build and pilot our digital solutions, and then transfer them to the government while we continue offering technical assistance. To facilitate this process, we intend to make the source code open to the public and develop a guiding development and customization toolkit to allow wider, diverse and responsible interaction of different community health developers with our technology. We follow the widely used FHIR standards in development, and so technology skills transfer won’t be a tedious process given the familiarity. 

A review of our pilot project  by the Ministry of Health is currently ongoing, and will shape our prospective partnership with the following possibilities already discussed internally:. 

1. Transfer and integrate technology for non-profit operations into the ministry’s electronic community health information system (eCHIS), facilitate a technical staff to join the Digital Health Sub-committee, and continue providing technical support in technology development, supportive supervision and monitoring, evaluation, research, and learning. This will free up our resources and facilitate piloting and expansion in other regions in Uganda, Kenya, and other countries. 

1. Work on a costing partnership as a public private partnership that will involve the ministry subsidizing NCD service costs for beneficiaries with very low purchase power on top of the free basic community services, do joint supportive supervision, monitoring and evaluation. 

Any partnership with the government will strengthen us in the following ways: 

1. It will bring us closer to decision making, where we will be able to influence uptake and expansion of best practices in the community health space for vaccine delivery and monitoring. 

2. We will free up our resources, some of which are tied to CHW facilitation and free basic health service provision. A partnership will facilitate sharing, or transfer, of these costs. 

3. It will repurpose our human resources into incremental development focused activities in Uganda and other countries while ensuring sustainability of basic health services. 

4. It gives us an opportunity to leverage upcoming policy changes like the National Health Insurance Bill currently under Parliament, and the Public Health Policy Amendment Bill to advance the usage and impact of our technology. 

In the meantime, we have a variety of payable offerings, B2B and B2C offerings including the Mobiklearn training platform in digital health, the city based teleconsultation model and reselling of other digital health technologies like Clinitough in East Africa. These currently contribute 15% of our revenue and are growing. The build-pilot-transfer model will allow us to optimize resource allocation for development and expansion of these solutions.