CAST: A pillar of clubfoot care

Every three minutes, a child is born with clubfoot—a birth defect which affects 1 in 800 babies (200,000 each year) globally and causes one or both feet to turn inward and upward, making it difficult and painful to walk. This disability carries stigma and puts children at greater risk of discrimination, social exclusion, physical and sexual abuse, and neglect. Children with disabilities are also 49% more likely to never attend school and 41% more likely to feel discriminated against compared to their peers. In adulthood, untreated clubfoot perpetuates unemployment and poverty, with 80-90% of people with disabilities of working age in low- and middle-income countries (LMICs) being under- or unemployed.

Although clubfoot is one of the most common congenital causes of physical disability in the world, it has historically been excluded from global health and development agendas because the traditional, surgical treatment method was not well-suited to low-resource settings. Fortunately, about 15 years ago, the low-cost, nonsurgical Ponseti method became the gold-standard treatment due to its superior long-term outcomes—and it became possible to address clubfoot in LMICs. But this simple, effective treatment remains out of reach for many: 90% of babies born with clubfoot live in LMICs where there is limited or no access to treatment, despite clubfoot care being widely available in wealthy countries. Healthcare providers seldom know how to identify or treat the condition, and systems and supplies (such as clubfoot braces and data collection systems) are rarely in place or available to manage the treatment process. As a result, 85% of children with clubfoot slip through the cracks, forced to live with the condition’s devastating lifelong consequences and ingrained limits on their potential. Up to 8 million people globally are living with clubfoot disability today—including 1.6 million children who could still be treated. 

 MiracleFeet is strengthening local public health systems in LMICs to address inequitable access to comprehensive clubfoot care, a status quo which has left millions of children behind for decades. We are dedicated to one specific, targeted issue for which a simple, proven solution exists—giving us laser focus on our mission to realize a world free from clubfoot disability. We currently work in 37 LMICs (and enter new ones each year) across Africa, Asia, and Latin America where over 57,000 children are born with clubfoot annually. Every month, an average of 1,200 new children begin clubfoot treatment across MiracleFeet’s network of 433 clinics globally. 

MiracleFeet's solution to untreated clubfoot in LMICs is strengthening the capacity of local health systems to provide high-quality, comprehensive clubfoot care. Treatment, known as the Ponseti method, is a simple, effective, low-cost, and innovative medical intervention that restores full functionality and mobility in 95% of cases. It involves a series of weekly casts to gently reposition the feet and a simple outpatient procedure to release the Achilles tendon (known as tenotomy), followed by use of a foot abduction brace, worn while sleeping up to age four to prevent relapse. When the Ponseti method is initiated during infancy, correction is usually achieved within six to eight weeks. Because the Ponseti method is non-surgical and only requires basic medical supplies, treatment is inexpensive and well-suited for low-resource settings. MiracleFeet’s average cost to provide full treatment is $500 per child (at no cost to the family), making this an incredibly low-cost, high-return intervention.

Technology is at the forefront of our solution to eliminate untreated clubfoot. We use CAST, a mobile app developed by MiracleFeet with a grant from Google.org in 2016 to track patient data, enrollments, clinic activity, treatment quality, and patient dropout. By tracking these metrics at the clinic, country, regional, and global levels, MiracleFeet and its partners can implement data-driven interventions to address the needs of each country’s health system, deploy resources to address areas for improvement, target patient outreach strategies to areas with high unmet need, and measure impact. Additionally, since local partners and clinic teams are the primary program implementers, CAST gives MiracleFeet greater visibility to what is happening in each country, allowing us to provide continuous technical support, guidance, and clinical expertise.

In addition to ensuring that babies born with clubfoot today can access the care they need to thrive, MiracleFeet’s solution also establishes long-term access to care that will serve future generations. We develop networks of local clubfoot providers and Ponseti trainers and establish supply chains for the MiracleFeet clubfoot brace, a critical part of the treatment process. Population-level clubfoot data, collected and stored within CAST, is shared with Ministry of Health officials to encourage governments to mainstream clubfoot care as a routine newborn and infant health service within public health systems, establish standardized guidelines for clubfoot treatment, and integrate Ponseti method training into nursing and medical schools. These efforts ensure that, for years to come, babies born with clubfoot will systematically be identified and referred to care at birth—just as they are in wealthy countries.

MiracleFeet primarily serves children born with clubfoot in LMICs. We target the highest-need geographies according to population and income-level, work primarily in public hospitals (in both rural and urban regions) where the lowest-income families seek treatment, and expand treatment access deep within countries—ensuring we reach typically underserved populations. Because clubfoot has historically been overlooked and fallen through the cracks of global development, there are few resources outside of MiracleFeet’s programs for children with clubfoot to access high-quality care, and they often grow up in the shadows, hidden away because of their condition.

Early treatment radically changes the trajectory of a child’s life, unlocking mobility, independence, access to education, and employment opportunities for the rest of their life. In addition to being able to walk—an already invaluable outcome—children treated for clubfoot can attend school, socialize and play with their peers, and participate fully in their families and communities—experiences that are critical for healthy childhood development—without experiencing the pain, burden, and discrimination caused by living with a physical disability. Later in life, those treated for clubfoot are more likely to secure meaningful employment, with estimates showing that a child who receives clubfoot treatment will earn an average of US$120,000 in additional lifetime earnings. These earnings reduce economic hardship for them and their families, contribute to the global economy, and break cycles of intergenerational poverty—an incredible return on investment for a treatment that costs, on average, US$500.

Because of the social and economic consequences of living with a disability in LMICs, parents and siblings of children treated are also indirect beneficiaries of our work. Caretakers in many contexts suffer from discrimination and shame—especially mothers who are often blamed or estranged for having a child with a disability—while entire families are negatively affected by stigma and diminished opportunities for education, jobs, and participation in community life.

Finally, because MiracleFeet’s solution strengthens capacity of local health systems, we also serve local healthcare providers and frontline health workers (including physiotherapists, orthopedic surgeons, midwives, and nurses) by providing training for identifying and treating clubfoot. Annual provider surveys, conducted with 330 providers across 27 countries to date, evaluate the impact and efficacy of the Ponseti method training we provide. Nearly all (99%) providers report that their ability to treat clubfoot has improved as a result of MiracleFeet’s support, and nearly 90% said they learned most or everything they needed to know about clubfoot treatment at MiracleFeet trainings. Because CAST and the data within it is available to clinic teams, MiracleFeet also strengthens their capacity to interpret the information, make data-driven decisions, and respond to challenges in a timely manner rather than waiting for advice from MiracleFeet.

MiracleFeet delivers its solution through a powerful network of global partnerships with 46 local (often grassroots) NGOs working in the fields of children’s health and disability. We also work closely with public hospitals, Ministries of Health, and local medical champions (typically leading physiotherapists or orthopedic surgeons). This allows us to build upon each country’s existing health infrastructure, scale effectively, and ensure that each program is shaped to meet local needs. Our in-country partners bring a deep understanding of local health systems, have relationships with Ministries of Health and external stakeholders, and provide strong knowledge of what works in each region to ensure babies are identified early and referred to clinics. In addition to customizing our programs to best address local conditions, our partnership model also allows us to scale efficiently by adding new partners in new countries and/or regions of large countries with existing programs. Our regionally based Programs Team works closely with each partner to provide technical expertise and strategic guidance and oversight, while the local NGO partner implements and expands the program in each country. This approach enables local customization and efficient scaling and strengthens local capacity in program management, strategic planning, and the clinical aspects of clubfoot care. Patients have benefitted from this approach throughout many global challenges, including the pandemic, natural disasters, and periods of political instability, as local teams quickly adapt and continue delivering treatment despite travel restrictions and lockdowns.

MiracleFeet currently employs 40 staff based in 18 countries. Over half the team is based in or near the countries in which we work, bringing responsiveness, cultural acuity, and local expertise to program implementation. Ten of eleven members of MiracleFeet’s Programs team, including the Director, are people of color and most are based in and/or from the countries in which we work, and 60% of our Leadership team, including our CEO, are women. Additionally, MiracleFeet’s Associate Director of Digital Systems (who oversees the CAST app) is based in South Africa, and our three Application Support Analysts (who help our partners with issues and challenges with CAST) are based in the regions in which we work.

The CAST app is a widely used, robust data collection tool used in 35 LMICs across Africa, Asia, and Latin America to facilitate high-quality clubfoot care. 372 clinics are currently using the application, and 527 providers/clinic staff are active users on CAST today. CAST has facilitated clubfoot treatment for over 43,000 patients around the world since it was developed in 2016.

MiracleFeet follows the software development life cycle approach to CAST, with its rollout and maintenance being an iterative process. We solicit feedback from users to understand how it’s working and what challenges they are facing, identify and design improvements, make changes to CAST, test the changes with end users, complete quality reviews, and then release the new updated version. Over the years, we have made the following improvements and iterations to CAST:

• SMS messaging, which is live in Nigeria and Uganda and provides automatic appointment reminders and informational messages to improve treatment adherence.
• Remote visit/consultation features, added during COVID to facilitate and record virtual or phone consultations.
• Photo capture, which allows clinicians to take and record photos of the feet throughout treatment to track progress and seek medical advice from other providers.
• A patient transfer feature, allowing clinicians to transfer a patient to another clinic in MiracleFeet’s network to continue treatment (in the event that a patient moves, etc.). This feature is incredibly important as it means that the medical record travels with the patient to the next clinic without loss of information.
• An ability to input “pre-MiracleFeet treatment” information, so that children who have received (unsuccessful) treatment elsewhere can begin care at a MiracleFeet-supported clinic with a full medical record.
• Easy-access patient lists, which allow providers to easily create patient lists based on key characteristics (such as who is scheduled for a visit that day).
• Missed visit codes, allowing for clinics to easily identify which patients have missed two or more appointments so they can be followed-up with to reschedule.
• A data integrity feature, which was added so that all patient records are saved for at least five years in case any follow-up visits are required for that child.

MiracleFeet’s CAST app has grown exponentially over the last eight years—from a modest app used to manage clubfoot care in 14 countries, to a global resource at the forefront of eliminating untreated clubfoot in 35 countries. MiracleFeet is applying to Solve to learn how we can harness the power of CAST even further to bring people together from different languages, cultures, and geographies—from casting technicians in Bangladesh to physiotherapists in Nigeria—to create a real global community of clubfoot providers to share best practices and knowledge.

As a Solver, MiracleFeet is interested in learning how other organizations are using mobile apps to achieve similar goals, inspiring improvements and future iterations of the CAST app. In addition, by collaborating with other organizations we would learn and strategize how CAST can be adapted to support data collection and treatment monitoring for other congenital conditions—an effort which could position CAST as the leading electronic medical record for birth defects care and treatment in LMICs.

Finally, MiracleFeet is interested in becoming a Solver to better understand how to best safeguard the data we collect. We have made it an organizational priority to learn more about data privacy, and we know that many other organizations are using apps to collect and analyze private information. We are eager to learn more about how others are coping with the different data privacy laws of each of the countries in which they work, so we can adopt similar practices as we scale the use of CAST to more LMICs. 

MiracleFeet is a trailblazer in the disability sector, forging a path to eliminate a common, preventable disability for hundreds of thousands of children every year. In addition to tackling untreated clubfoot with laser focus, there are several distinguishing factors about our solution that set us apart:

• MiracleFeet’s solution is novel because it sets us up to fully transition clubfoot care to public health systems and, eventually, exit the countries in which we currently work. There has been some success globally with mainstreaming one-time health interventions such as vaccinations, but fully mainstreaming a longer-term health service—such as clubfoot treatment—isn’t common. By achieving this goal, our solution can become a model to systematically address other conditions that cause early childhood disability in LMICs, such as cerebral palsy, orofacial clefts, and vision and hearing impairments—conditions for which access to treatment and assistive devices remains limited. In this way, our solution has the power to kickstart the first ever global movement dedicated to preventing chronic disabilities in children.
• CAST powers this work as the first and (to our knowledge) only electronic medical record designed to gather clubfoot-related treatment information and track treatment progression in LMICs. Before CAST, clinic teams captured patient information on paper forms, which were easily lost and presented issues with data privacy. CAST offers clubfoot providers a secure, reliable, and easy-to-use alternative for data collection, improving efficiency, security, and clinical outcomes. As our solution is used as a roadmap to address other conditions (as mentioned in the bullet point above), CAST can similarly be adapted to address data collection needs for other conditions, as well.
• MiracleFeet has embraced innovation and technology since the organization’s inception. We developed a suite of innovative tools that support scaling and reduce major barriers to mainstreaming clubfoot treatment. In addition to CAST, this includes the patented MiracleFeet brace—a low-cost, user-friendly alternative to foot abduction braces used in wealthy countries, which cost between $350-$1,000—as well as ACT Online, the first ever virtual Ponseti training program equipped with a virtual simulation of a clubfoot, which has helped us train more clubfoot providers than any other organization.
• MiracleFeet takes a comprehensive approach to eliminating untreated clubfoot. Unlike other organizations who focus on only one element of clubfoot treatment, MiracleFeet addresses barriers across the continuum of care—from training Ponseti providers, improving access to high-quality braces, and following up with patients who miss appointments. This approach has an unmatched return on investment. A US$500 treatment allows children to walk, play, go to school, and engage fully in their communities as both children and adults—preventing a lifetime of hardship and suffering. As noted above, an estimated US$120,000 in additional lifetime earnings for those treated for clubfoot makes this work more appealing to Ministries of Health, increasing government buy-in and the sustainability of our work to strengthen the capacity of health systems to treat clubfoot.

Implementing CAST, customized to collect detailed medical information during clinic appointments for children treated for clubfoot with the Ponseti method, improves the quality of care received and increases clinical outcomes for children through several pathways.

MiracleFeet built the CAST app on the CommCare platform, which is a widespread and respected software often used for electronic medical records (EMR) and related systems in LMICs. This stable platform, tested and supported by Dimagi, is flexible and allows customization for tailored uses, such as MiracleFeet’s implementation as the EMR and case management system for clubfoot clinics.

Following CASTs initial development, MiracleFeet continues to maintain and improve the software to respond to changes in users’ information needs, and we provide CAST training to staff at all MiracleFeet-supported clubfoot clinics as we scale and grow our global footprint. The app has been translated into several languages most suited to providers, allows providers to write notes about each visit, and it includes numerous prompts for providers to check specific details during appointments and confirm important decisions or judgments about the progress of the treatment (such as determining when a patient is ready for tenotomy). CAST also allows to see which patients miss two or more appointments, allowing providers to intervene early with a phone call or home visit. This continuously reinforces best practices among providers, while also recording meaningful data points from each visit. These records are used in aggregate and individually at clinic, country, and global levels to continuously monitor and improve treatment quality and optimize clinical outcomes for children. Many partners share aggregated information from CAST in outreach and education initiatives with government, universities, and pediatric and midwifery associations, expanding knowledge and alliances advocating for greater attention and resources for treating children born with clubfoot.

In addition, MiracleFeet uses aggregated patient records and key performance indicators to assess clinic, partner, and program quality and to plan, fund, and implement further CAST developments to increase quality. Examples include targeted training in using updated CAST versions as well as supplementary refresher trainings in the Ponseti method.  

Impact Goal #1: All children born with clubfoot access high-quality clubfoot treatment.

We measure progress by collecting data for the following indicators:

• Number of clinics using CAST. Understanding how widely CAST is used is critical to achieve this goal, as CAST allows us to track all necessary data for enrollment and treatment quality. 372 MiracleFeet-supported clinics globally are currently using CAST.
• Number of patients enrolled in treatment. To date we have enrolled over 94,000 children in clubfoot treatment, and we are reaching about 15,000/year.
• Average number of casts per child. The gold standard is for each child to receive 4-6 casts, indicating high provider skill. Currently, MiracleFeet’s global average number of casts is 4.5.
• Tenotomy rate. Based on best clinical practice, MiracleFeet’s goal is for at least 80% of patients to receive a tenotomy. MiracleFeet’s global tenotomy rate is currently 90%.
• Number of providers trained in the Ponseti method. This is a measure of the capacity of health systems in LMICs to treat clubfoot. Last year, we trained over 900 providers.
• Number of health workers trained in early detection and referral (EDR). Similarly, this is a measure of the capacity of health systems to deliver clubfoot care. Last year, MiracleFeet trained over 1,400 midwives, nurses, and primary health workers in EDR.

Impact Goal #2: Children with clubfoot obtain lasting mobility and functionality through high-quality clubfoot treatment.

• MiracleFeet measures the long-term impact of our work by talking to parents of children who underwent clubfoot treatment. Through these external evaluations, commissioned annually since 2019 by leading impact evaluator 60 Decibels, we have heard from over 2,600 parents from 11 countries at least two years after their children received treatment. Of those who responded, 97% of guardians said their children’s quality of life improved, and 88% of patients are always able to walk without difficulty or assistance.

Impact Goal #3: Clubfoot treatment becomes mainstreamed in public health systems as a routine newborn and infant health service.

To measure progress against this goal, we track:

• The percentage of patients enrolled who are <12 months old at their first visit. Clubfoot treatment being a “routine” health service means that all babies born with clubfoot will begin treatment during infancy. Our goal is for at least 75% of patients enrolled to be <12 months old at their first appointment; currently, the global average is 77%.
• National coverage. MiracleFeet’s coverage is the percent of a country’s annual clubfoot population we are reaching. Our long-term goal is to reach at least 70% coverage in each country where we work. Currently we are reaching this goal in three countries, and we are reaching at least 50% coverage in five others.
• Number of countries in which governments are beginning to mainstream clubfoot care. This looks different in all countries but can include Ponseti training being included within physiotherapy and medical school curricula, clubfoot identification being added to midwifery school curricula, and clubfoot screening being added to newborn screening tools.

CAST enables us to identify and reach more children with the high-quality healthcare they need to thrive. Situated on Dimagi’s Commcare platform, CAST is currently used by providers in 35 LMICs to track enrollments, record treatment data, and manage appointments. Providers input data in real time during patient appointments, which flows into a Salesforce database where patient records can be viewed individually or aggregated to show enrollment trends and performance against MiracleFeet’s treatment quality indicators, which are based on standards for best clinical practice. Real-time reports and dashboards are visible by local partners, the MiracleFeet team, and program managers, democratizing access to key information and empowering data-driven decision-making.

By reviewing performance against targets at the clinic and country levels (which happens at least on a monthly and quarterly basis), we can identify areas of success or concern and revise action plans to address issues through organizational support, clinical training, community awareness, and/or parent education. For instance, enrollment data stored in CAST allows partners and clinic teams to see where patients are from, so we can direct patient outreach to areas where we expect there is a high level of unmet need. By tracking the number of casts per child, we can see where clinics may be over-casting and direct additional clinic support there to ensure patients aren’t coming back to clinics for unnecessary casts. Tracking tenotomy rates provides another opportunity to intervene at a critical time in the treatment process. Tenotomies are a key element of treatment, and are needed in most cases to improve ankle flexibility and prevent relapse, so if a clinic is consistently skipping this stage, we can intervene with additional training to change course.

Another critical function of CAST is its ability to improve patient follow-up. Especially in low-income settings where resources are limited, families face many obstacles to completing a long-term intervention like clubfoot treatment, which requires periodic check-ups for up to four years.  Since patient appointments are tracked in CAST, clinic teams can see when families miss appointments and quickly reach out to reschedule or, when necessary, arrange for a home visit. A new feature recently added to CAST facilitates automatic appointment reminders, sent via SMS messaging, to parents during the treatment process to reduce the risk of dropout. 

MiracleFeet is confident that our technology works because we receive positive feedback from clinic staff about the use of the application and we are achieving our key performance indicators for treatment quality (included in our "Impact Goals" response). Overall, CAST is meeting a critical need for our programs by functioning as a tool for data collection and treatment quality analysis. 

MiracleFeet currently employs 40 staff members, which includes two part-time employees and 38 full-time employees. In addition, we partner with a network of 46 partners around the world who implement clubfoot programs in the countries in which we work. 

MiracleFeet has been maintaining and iterating the CAST app for eight years, since it was developed in 2016.

At its core, our solution is designed to remove barriers to care and empower children with disabilities who have been chronically marginalized and left behind by the status quo. As we scale, we target the highest-need geographies according to population and income-level, work primarily in public hospitals where the lowest-income families seek treatment, and expand treatment access deep within countries—ensuring we reach typically underserved populations. By, in the long-term, transferring ownership of clubfoot treatment over to Ministries of Health and public health systems in LMICs, we aim to shift traditional power dynamics by devolving MiracleFeet’s decision-making authority and advisory role to stakeholders rooted in the global South. We center the voices of patient families, community members and leaders, healthcare providers, and government agencies to ensure our work in each country is context-specific and culturally appropriate. Our partners work closely with families to identify key barriers to treatment, engage with Ministries of Social Welfare to ensure the project is aligned with national strategies for inclusive development, and combat disability stigma and misconceptions about clubfoot—which often cause children with clubfoot and their mothers to be ostracized and/or accused of witchcraft or bringing a curse on the family. MiracleFeet and its partners also abide by a Child Protection Policy, ensuring children with clubfoot—who are more susceptible to abuse than their able-bodied peers—are treated with respect at all clinics.

MiracleFeet’s model for sustainable change to end a treatable disability includes:

Empower partners and providers

MiracleFeet provides the technical and financial resources needed to create and support high-quality clubfoot clinics in LMICs. This support usually includes:

• Identifying in-country partners to deliver clubfoot programs that address local treatment barriers and challenges.
• Training healthcare workers in the Ponseti method, increasing the capacity of local health systems to deliver quality care.
• Leveraging CAST to establish systems for collecting and analyzing data at the patient, clinic, and country levels to optimize treatment adherence and clinical outcomes for patients.
• Hiring and training parent educators to support parents in navigating challenges throughout treatment, alleviating some of the burden of care on parents, improving treatment adherence, reducing dropout rates, and improving clinical outcomes for patients.
• Providing treatment supplies, including braces, also improving clinical outcomes by addressing a critical supply chain issue in many LMICs.

Expand access to services

MiracleFeet expands access to proper treatment. Strategies include:

• Creating early detection and referral processes, ensuring babies with clubfoot are identified early in life and connected to care so they can grow up disability-free.
• Executing clubfoot awareness campaigns to raise awareness of clubfoot in communities, supporting early detection and referral and helping locate older children who never received treatment.
• Adding more clinics to reduce travel time for families, increasing treatment adherence.
• Conducting basic and advanced Ponseti training to ensure clubfoot providers are highly skilled.

Mainstreaming clubfoot treatment

MiracleFeet integrates clubfoot treatment into the public health system of each country to promote lasting and sustainable change. We do this by:

• Securing increased endorsement and support from the government and/or Ministry of Health, who currently provides clinic space in public hospitals, covers the salaries of treatment providers, and supports the cost of some treatment supplies (like plaster for casting) in many countries in which MiracleFeet work.
• Embedding clubfoot management into the existing public health infrastructure to drive down treatment costs (making the solution more appealing to Ministries of Health and governments) and minimize long-term dependence on MiracleFeet and external funding.
• Collaborating closely with government agencies, NGOs, and private partners to reduce need for outside support.

Much of our funding in FY23 (our last completed FY ending June 30, 2023) came from donors inspired by MiracleFeet’s expanding capacity to reach more children and our impressive return on philanthropic investment with the average cost to fully treat a child for just $500. We raised $9.6M in cash, an increase of $1.8M over the previous year, and grew future pledges to a total of $15.4M. We were thrilled to receive a $5.8M grant from GiveWell, one of the most selective and impact-driven philanthropic donors in the global public health sector, to launch programs in Chad and Cote d’Ivoire and expand our work in the Philippines. Major renewals included several three-year multi-million-dollar commitments from high-net-worth individuals and a family foundation, as well as a three-year grant from Oak Foundation to fully fund our Zimbabwe program.

Overall, 45% of gifts come from major donors (individual and family foundation gifts of $10K+), 43% from institutional foundations, 6% from small and medium individual donors, 4% from government, and 2% from corporations.

So far in FY24 we have raised $7 million and have $15.8 million pledged for FY25-27.

We are incredibly grateful to our supporters across the globe who continue to believe in our mission and make our work possible.