Afya-One

A collaboration between Government and mHealth Kenya which is a Private not for Profit Organization

Diabetes is a major global health issue, and it is crucial to manage it effectively for an improved quality of life. Efficient management involves exercise, diet, regular glucose monitoring, oral hypoglycaemics (for T2D) and insulin therapy. However, diabetes clients in low- and middle-income countries (LMICs) face significant barriers in managing type 1 diabetes (T1D), and type 2 diabetes (T2D) such as high treatment costs and limited access to care. According to Karungungu et al. (2023), the total cost of managing (T2D) in Kenya was estimated to be US$ 635 million (KES 74,521 million) in 2021 using the bottom-up costing approach.  In a comparative analysis of adolescents and adults in Kenya, 5-10% of adolescents have T1D, and three out of every four of them struggle with managing it. The prevalence of diabetes among adults is about 40% even though majority of them have not been diagnosed.  Stigma and systemic barriers aggravate the economic, social and health burden of diabetes management in many low-to middle income countries.

Many diabetes patients are diagnosed late. Some studies have shown that in serious cases, late diagnosis results to heart attacks and strokes due to increased clot formation in the blood. Kidney disease and even kidney failure if blood vessels in the organ become blocked. Many patients are treated for other conditions putting them at the danger of developing anti-microbial resistance. Anecdotal data on the DHIS-2 shows that there is a rapidly growing number of diabetes patients who are presenting with high blood pressure at health facilities in Kenya. Diabetes is a serious wide spread killer disease in Kenya compared even to HIV whose prevalence now stands at 4.15 yet there is no formal and streamlined support available for patients who under go the hardship of monitoring their sugars from time to time, balancing their diets and activities as well as the pain of self-injecting which sometimes creates stigma especially among the adolescents suffering from T1D while still in school. On one hand, access to care and the medicines remains expensive and mainly funded through out of pockets by the patients. On the other hand, the service providers in facilities are not able to track their patients on care. This results in treatment interruption, decline of treatment, co-morbidities and finally the deaths of the patients which remain unaccountable. There are currently no robust technological interventions that can enable the patients set goals, monitor their progress to controlling sugars as well link the patients to the service providers by providing data in real time in an effort to enhance timely clinical decisions for improved health status of the diabetes patients.

Smart mHealth solutions can help overcome healthcare challenges. In Kenya, for example, more than 90% of the population own mobile phones with over 100% having access to mobile phones. The proliferation of mobile phone technology continues to provide an exciting opportunity for digital health. Research in high-income countries shows that self-care through mobile technologies can significantly improve outcomes for chronic conditions. However, there is a lack of data on innovative mobile solutions for diabetes care particularly in Sub-Saharan Africa. The proposed solution will incorporate two key aspects from previous applications developed and successfully implemented by mHealth Kenya Limited.  mHealth Kenya developed the 'Jitenge app', a mobile app that was initially designed for COVID-19 self-management. Jitenge showed promising results by managing COVID-19 data and remotely monitoring suspected and confirmed cases. The innovation was critical in supporting the ministry of health in kenya design tracing strategies for Covid-19 patients and managing the patients from home settings in isolation. Secondly, mHealth kenya developed the “Ushauri Application” for HIV/AIDS care. The application includes an electronic diary that facilitates reminders and clinical appointment messages, as well as a follow-up outcome feature for clients lost to follow-up at facilities.

To enhance diabetes self-care and treatment not only in Kenya but globally through this grant, we propose to leverage on the expertise and experience on the aforementioned innovations to develop the “Afya-One” application which will be client-centred, featuring tailored text messages, and will integrate with the Kenyan electronic health record system (EHR). This solution will enable patients/members of the community to download, register, assess their diabetes status using a set of questions based on algorithms, refer the patient to a nearby accredited health facility with a diabetes program, set their own sugar levels, monitor the performance via the continuous glucose monitoring module, and connect to other applications for data sharing. Overall, the solution will be an interactive and exciting e-diary for the patients to set their goals and achieve. Further, the solution will provide both a push and pull system for automated text messaging to the patients providing informative, appointment and wellness health messages. The app will have an automated real-time dashboard that will enable health service providers to track and monitor the patients. The dashboard will provide both population level and aggregate data at facility level for proper management of diabetes clinics. Some of the other additional functionalities envisioned include a module on meal logging, social groups, private messaging, sharing of data with friends or service providers on consent (encourager module) and e-directory to health facilities providing care to diabetes patients. Afya-One will be a game changer in how diabetes is managed. It will utilize a combination of technologies to help users take better care of themselves, optimize treatment plans, and promote a proactive approach to healthcare. To ensure accessibility for patients, the proposed solution will also use USSD technology. This will enable basic phone users to access the app and receive alerts from CGM technology even in low connective areas. 

The target population for this solution are type 1 and type 2 diabetes mellitus patients who will have access to mobile phones. Generally, diabetes patients are underserved in the following manner: i) late diagnosis ii) poor linkage to care iii) incurring the cost of accessing services and purchasing medicines iv) stigma associated with monthly clinics and injections. v) lack of knowledge and ability to monitor sugar levels. The other group that will benefit from this solution are the healthcare service providers who lack ability to track and monitor how the clients are performing. 

  The proposed solution will: i) provide an easy to use app that will enable screening for diabetes based on algorithm built on lead questions ii)will quickly notify a service provider and community health volunteer within a geofenced area and refer the patient diagnosis based on the outcome of screening for individuals who will not be already on care iii) reduce the cost of accessing health care facilities by providing remote monitoring of sugars and only go to the facility when the sugars are above or below required levels. iv) the business model of this innovation will allow users of the innovation to redeem Bonga points and use them to pay for health commodities and products such as glucometers v) by linking the patients remotely to other patients, service providers and social groups/networks through the encourager module, the solution will demystify stigma and empower the patients. vi) the solution will provide a resource module through which patients and the general population will access reliable information about diabetes  

The design and implementation of this solution will take a human centered approach. The research team will provide guidance based on pre-design system document and protocols but significantly allow the diabetes patients (adolescents and adults), their guardians and service providers in diabetes clinics to take lead in the design and continuum of implementation. The three key lead members of this project will be:

1. Collins Mukanya Mudogo: A seasoned project manager, researcher and innovator who has worked in the private for-profit sector, for Non-Governmental Organizations and currently, works for Government of Kenya as the Head of Digital Health and Research development. Mr. Mudogo will successfully lead this project given his strategic positioning at County leadership and in the community coordinating digital innovations in the community and at facility levels and generating evidence to enhance such solutions. He is critical for conceptualizing, implementation, and sustainability by advocating for its uptake and use through policy and budget allocation. 

2. Mike Olonyo is a registered community nurse working with communities of patients living with diabetes in Kenya. He is the coordinator of diabetes program in Vihiga County thus the main link to the national diabetes program in Kenya. Mike will be critical in linking the project to community members and service providers in facilities across the country. 

3. Dr. Vanessa Kithyoma is a Medical Doctor and the Current CEO of mHealth Kenya. She will bring on board the technical expertise in designing and enhancing the technological solutions. She led the design and implementation of both Jitenge and Ushauri which the prototypes of the proposed Afya-One application. She has networks at national government and partners in health. 

Already mHealth Kenya developed and successfully implemented Jitenge and Ushauri applications. Jitenge was able to serve over 150,000 unique COVID-19 user/patients/clients between 2019 and 2021. The solution was critical in enhancing safety and tracing of exposed individuals at all airports, health facilities and isolation centers in Kenya. For the first time, this innovation enabled home-based care for the COVID-19 patients. 

Ushauri is operated on an interoperability layer which has other systems such as Kenya EMR and Antiretroviral Web tool for management of HIV/AIDS clients. The system is critical in providing care and treatment to over 1.2 million Kenyans living with HIV/AIDS. 

This proposal suggests the need to use the lessons learnt to grow the impact of both Jitenge and Ushauri through the "Afya-One" application in order to enhance diabetes management globally. Afya-one will be a hybrid system bringing together the technologies employed in designing both Ushauri and Jitenge.

Technical support: we are interested in being linked to industry movers, innovators, partners who can generally help and work with us to enhance diabetes management and care in low and middle resource settings. Creating such networks and links will be critical to realization of the dreams of this project.

The second critical reasons which still touches on technical support is on how we can build a robust business model to sustain, scale and ensure the project is impactful thus enabling populations to live fulfilling lives and achieving the SDG 3.  

Financial Resources: To implement this project will require some financial resources. If successful we would be honored to receive some monetary support that can give us the starting point to even advocate and lobby for policy and budget allocations aimed at further strengthening and enhancing diabetes care and management.

Diabetes management is still a neglected health sector. There is limited support provided to patients or facilities operating diabetes clinics in Kenya as is the case in many resource poor settings. Most patients or rather members of the population lack access to reliable information on the danger signs as well as inability to monitor their sugar levels. The Afya-One innovation utilizes proven technologies that have worked in managing COVID-19 and HIV/AIDs to provide populations at risk with a tool to screen for diabetes, refer them to a nearby community health promoter or health facility and be able to set sugar goals and monitor the performance. Further, the innovation will provide healthcare service providers with ability to track their patients and have access to real time data trends on performance of their patients. 

Our theory of change is based on three assumptions that:

1. If we provide a digital solution that can enhance faster screening and referral of potential patients to care then most cases will be identified early and be linked to care.
2. If patients linked to care are empowered enough to set sugar goals, have access to messages, have access to an electronic diary where they can record their feelings and plans and monitor their performance they will likely have better treatment outcomes.
3. If healthcare service providers are able to track their patients using an electronic tool that provides real time data, there will be increased accountability for patients.

The innovation will define success as follows:

1. Number of people screened for diabetes: This will be measured using individuals who will have downloaded the app and used it to screen for diabetes.

2. Number of people identified to have have danger signs of diabetes: The tool will highlight individuals who will have danger signs of diabetes based on questions and responses structured using an algorithm

3. Proportion linked to a health facility: The tool will have a referral module that will refer patients from community to health facility and back to the community health promoter for support 

4. Proportion of patients adhering to appointments and treatment schedules: The innovation will track and show patients who will be adhering to treatment and appointment schedules. 

5. Proportion of patients with controlled sugar levels: At any given time, the innovation will show patients who will controlling their sugar levels in real time

6. Proportion of patents accessing messages and information: The intervention will display individuals who will have accessed the messages and information over time.

The proposed app aims to provide a comprehensive platform for managing diabetes. It will utilize a combination of technologies to help users take better care of themselves, optimize treatment plans, and promote a proactive approach to healthcare. The app will include Continuous Glucose Monitoring (CGM) technology among other features to improve diabetes management, implement predictive analysis, and enhance self-care. To ensure accessibility for patients, the proposed solution will also use USSD technology. This will enable basic phone users to access the app and receive alerts from CGM technology even in low connective areas. Data from the CGM will be directly uploaded to the study facility's web interface, including readings will be sent via text messages (USSD), creating an automated diary for diabetic patients.

Full time

1. Collins Mukanya Mudogo-Lead investigator -County Government of Vihiga

2. Mike Olonyo- Project coordinator- County Government of Vihiga

3. Joel Wekesa (lead software engineer from mHealth Kenya)

Part time

1. Dr. Vanessa Kithyoma -CEO mHealth Kenya 

2. Christine Maghagha- M&E officer at mHealth Kenya

mHealth Kenya has been developing solutions since 2012. Ushauri was conceptualized in 2015 and full implementation started in 2017. Jitenge was developed in 2019. The two technologies are mature, have been tested and proven to be effective and cost-efficient. Afya-one will only require merging of the two by consolidating key aspects of both systems.

This is a collaboration between Government and Private Sector. Whereas the private entity (mHealth Kenya) will focus on the technology, the government will focus on implementation, scaling and sustainability of the solution. This collaboration does not discriminate staff based on any social, sexual, religious, gender of disability factors.  

Afya-One has three broad business models :

Grants: We shall continue to seek financial support from well wishers and partners supporting diabetes management in the region.

Commercial: By downloading and using the Afya-One app patients will have used some bundles. We intend to have an MOU with communication companies (Safaricom and Airtel) so that the patients can redeem their Bonga points whenever they use the app to purchase health commodities.

Government funding: We shall advocate and lobby for governments (national and county) to fund diabetes management through policy and budget.

Working with government by lobbying and advocating for them to take the running costs of the innovations. this worked with Ushauri and Jitenge apps and will definitely work with Afya-one app. We intend to sensitize and create awareness among key Government agencies.