Tanzania's New MA-CHWs: A Mobile Health App for Quality Care

A Mobile Health Application for the
New MA-CHW Cadre in Tanzania
Initiatives mHealth Consulting Group
Caitlin Gillespie, Lauren Hodsdon, Sarah Jacobson,
Paola Peynetti, Natalie Sanfratello
Initiatives Liaison: Rebecca Furth
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV Conclusions

Slide deck purpose: Product, impact, why now?
1. To present and explain the logic, processes, and prototype of
2. To outline the impact that can have on policy-making, supervision, patient
satisfaction, and MA-CHWs quality care.
3. To provide the context and evidence that drive the Tanzanian government the
opportunity to be a leader in the implementation of a comprehensive mHealth tool for
frontline health workers.
PRODUCT:
Application
IMPACT:
Standardized,
Quality Care &
Performance
Feedback
WHY NOW?
An Opportunity for
Tanzanian
leadership in
mHealth

Identifying the problem: No standardization of mHealth
Current rural health system relies heavily on voluntary Medical Attendant
Community Health Workers (MA-CHWs). Government has begun transitioning
to hiring and training MA-CHWs as paid state employees.
Primary Problem:
Lack of coordination of
MA-CHW performance,
no standardized
monitoring or feedback
system.
Secondary Problem:
Current mHealth context is
diverse & widespread, but
not collaborative or
comprehensive

A comprehensive mobile
health application for
MA-CHW home visits

New MA-CHW program: A response to a disjointed system
A single, national, cadre of MA-CHWs:
● to standardize care,
● ensure sustainability, and
● promote community health
Which includes:
● Standardized training
● Salary - half minimum gov’t wage
● Supplies - transport, health kit, & a job
aid
● 1 MA-CHW per 25 people after
program completes (34)
To establish:
● Appropriate supervision and support
systems,
● Incentive structures, and
● Linkages between health facilities and
health management information systems
(HMIS)

Involves MA-CHWs,
supervisors, patients, & government
MA-CHW receives
patient visit list from
local clinic via SMS
MA-CHW takes
phone to home
visits
MA-CHW
registers
patient if
unregistered
MA-CHW
completes
necessary
modules
eg. ART Adherence
Counseling
MA-CHW
Uploads data
once a week
Supervisor reviews
data on patients and
MA-CHW performance
Supervisor
provides feedback
to MA-CHW via
SMS or in person
Supervisor uploads
data to Tanzanian
government monthly
Tanzanian
Government uses
data to inform policy
& practice
START
END

The logic
behind

: A checklist to improve quality of care
Objectives:
● To provide a streamlined checklist for MA-CHW home visits that is:
○ For all components of Tanzanian MA-CHW visit SOP
○ Interactive and collects patient data
○ Able to flag and prioritize patients
● To improve and standardize quality of care to provide comprehensive quality services.

will address all components of MA-CHW visit (34)
Reproductive
Health & Family
Planning
Nutrition
Healthy Behaviors
& Disease
Prevention
Linkages to the
Health System
HIV Counseling
Prototype addresses:
ART Counseling

The logic behind
ART counseling
module prototype

ART counseling module prototype:
A checklist to improve ART adherence & provide referrals
ART Counseling module: Situated within larger application of all MA-CHW visit
components to showcase application use:
○ Reference tool for MA-CHW professional development
○ Ensure data captured is high quality
○ Feedback & data analysis for MA-CHW supervisors
○ Decision-making support at all levels
● User Guide in Annex

: A reference tool for quality care
Promotes decision-
making skills and
prioritization of patients
according to immediate
need
Overview of patient
case load and needs -
case management
Recording tool of visits
completed and needed
to complete

application will ensure high quality data
Through Data Control:
● Display and validation logic
● Case management
● Monitoring data

Sample dashboards: improved quality care
CLINIC SUPERVISOR DASHBOARD NATIONAL STAKEHOLDER DASHBOARD
# Patients
Reporting
ART
Stockouts
% Patient
Visits within 30
Days of
Previous Visit

a. Data: Visit data collected and aggregated in background on
■ MA-CHW performance data (supervisor sees MA-CHWs as cases)
■ Patient consultation data (confidentiality)
b. Supervision: Quality care and performance feedback
c. Patients:
■ Empowers patients to feel informed and provide feedback
■ Facilitates Confidentiality
: Feedback mechanisms between supervisors,
MA-CHWs, & patients

● Data collected will support decision-making at different levels of Tanzanian MOHSW:
○ National, regional, district health offices and MA-CHW supervisors
● See suggested dashboard in IMPACT section.
The Tanzanian MOHSW
● Pharmaceutical Forecasting
● Rural Epidemiology
● Demographic and Population Data
● Rural Health System Performance
Clinic Levels
● MA-CHW Quality of Care
● MA-CHW Visit Timelines
● Clinic Level Stock Outs
● Patients with Access to Health Care
● Clinic Referrals
Introduction AFYA||CHECK IMPACT: CHWs Data Supervision Patients Costs WHY?: Global Local HIV The Time Is Now
: Decision-making support at all levels

Scale-up & sustainability of
● Increase Quality of
MA-CHW performance
and care
● Measurements:
○ # of MA-CHWs
○ % of Population
Coverage
● National eHealth
Strategy
● Limitations: Cell
Coverage and Data
Transfer availability
● Strengths: Many
mHealth programs
already implemented,
pilots provide solutions
to potential local
problems
● CHW job aids are
proven effective
● Existing CHW mHealth
pilots are effective
● Existing approval of
CHWs in communities
will bridge any cultural
diversities
Parameters Scientific BasisEnvironmental Context

IMPACT:
mHealth can
bridge delivery
gaps
1. CHWs
2. DATA
3. SUPERVISION
4. PATIENTS
5. COSTS

● Professional development
● Empowerment and Motivation
● Prioritize cases: access data
● Health system integration (26)
● Standardize care
● M&E of performance
● Transparent case mgmt
● Communication
● Feedback and reporting
● Data-driven policy & programs
● Resource allocation
● Data analysis
● Adherence to standards
● Confidentiality of information
● Lower stigma
● SMS decision-making support
● Referral systems
DATA
PATIENTS
MA-CHWs (27,36)
SUPERVISORS
can bridge service delivery gaps

CHWs: employs best practices to improve
motivation & standard of care
Low motivation of CHWs
may decrease benefits
of investments in CHW
programs (9,27).
Mobile tools help CHWs
improve quality of care,
efficiency of services,
and capacity of program
monitoring (3,27)
mHealth gives CHWs
new skills, increases
motivation, and
improves community
perceptions of CHWs
(12,27,28)

DATA: im supports data-driven policy-making,
program management, & resource allocation
“Programmatic efforts to strengthen
service delivery focus on improving
adherence to standards and
guideline. Mobile tools help CHWs
to improve the quality of care
provided, efficiency of services, and
capacity for program monitoring” (3).
CHWs use mHealth for
collecting field-based
health data, receiving
alerts, facilitating health
education sessions,
and communication (1)
Review of 25 studies
concluded: data
collection is one of
the main functions
performed by
frontline health
workers (1)

SUPERVISION: facilitates supervision and
feedback mechanisms
In Tanzania, the benefits of
mHealth will be limited
without addressing the
current “one-way upward
flow of information” (14)
A supervision process to
monitor, improve and
maintain clinical skill
performance by CHWs is
important in program
design and
implementation to obtain
health outcomes (34)
mHealth facilitates
supervision through
regular and prompt
communication across
different levels of
providers and easy
assessment of the CHW
performance through
the web-interface
dashboard (1)

PATIENTS: informs & empowers patients and
increases confidentiality
“Regular access to health
information via SMS or
mobile-based decision-
making support systems
may improve the adherence
of the FHWs to treatment
algorithms” (1).
Common barriers to care in
Tanzania: long distances to
facilities, inappropriate care,
limited decision-making
power, low financial
resources, stigma (12)
inSCALE App in
Mozambique: phone-
based job aid to help
CHWs with consultation
steps to assess,
diagnose, treat and refer
patients (25)

COSTS: = A high-impact investment
Financially sustainable mHealth programs need to transfer SMS costs to users (with lower
costs negotiated through telecom partners) (15)
Investments in CHWs (1)
1) Requirement for achieving UHC
2) Results in positive return, as high as 10:1
3) Scale up has short and long-term savings
4) Yields further societal benefits: women
empowerment, reduced patient costs,
data collection, additional service delivery
Investments in mHealth (5,6,7,10,19,21,33):
1) $100 per phone - Huawei Ascend Y 511
2) Less than $5 per month for airtime*
3) Dimagi Additional Implementation Package
Option
Growth Package - $80,000
*Cheka Bombastik Plan on Vodacom: 125 minutes, 1000 SMS, 100MB Data per month

Why should
Tanzania use
with the new
MA-CHW cadre?
1. Global context:
CHWs matter
2. Local context: current
Tanzanian mHealth
context needs better
approach
3. HIV Public health
context: MA-CHWs
transform HIV/ART care

Global context:
CHWs have great
potential with proper
support

CHWs are indispensable for the SDGs, for UHC, & for access to
care in rural areas
“Volunteer CHWs have been with us over
many decades and many programs owe
their success to these poorly trained and
equipped, least supported and unpaid
volunteer workforce. They are the unsung
heroes of our success whom we have been
taking for granted for many years” (23)
- Tanzanian Deputy Minister of Health
“Community health is foundational to
attaining many of the SDGs” (30)
115 of the 313 tasks that are essential
for HIV prevention and treatment can be
performed by CHWs (30)
In developing countries, frontline
workers represent the main way most
citizens access health services (8,35)

Gaps in CHW training = Gaps in service
How mHealth can bridge gaps & improve quality of care
Dynamic, easily customizable platforms
Standardized quality of service delivery +
M&E tools
Portable devices: job aids for in-service
practice
Mobile platforms for communication &
coordination
Mobile toolkit for improved quality of service
Lack of adaptation of training to support local
languages (23)
Inconsistent delivery methods and M&E practices
(11)
Failure to train where CHWs practice (23)
Lack of coordination with other health providers (25)
Gap in curricula: lack of emphasis on
communication skills (23)

Incorporating interactive
methods
Repetitive interventions
Case-based training
Blended training (integrating
technology)
Emphasizing communication
skills
Improve M&E through
incorporating consistent CHW
feedback and transparent
evaluation
Digital health can improve MA-CHWs in-practice training (2)

Lessons from CHW apps: Feedback is crucial
CommCare Escalating Reminders: SMS reminders and supervisor feedback to CHW to
reduce overdue days of patient visits. Improved the timeliness of CHW-patient visits by 86%
reduction in number of days an appointment was overdue, decreased from 9.7 days late to
1.4 days. When there was no feedback to the supervisor, CHW performance decreased
significantly. (34)
Monitoring of performance and feedback are key in application development

Local context:
mHealth in Tanzania
should be collaborative
CHWs are “unsung heroes of
our success whom we have
been taking for granted for
many years”
Tanzanian Deputy MoH

Four large MNOs, but
systems are marginal
and operate below
capacity(24)
Mobile Access
64% people have
access to a cell phone
31.9 million mobile
users(4)
Policy
National eHealth
Strategy for 2012-2018
prioritizes professional
development for health
care workers through
mHealth(17)
mHealth
Lack of collaboration &
cohesion
mHealth projects in
Tanzania are often
pilots
Setting the scene: Mobile Access, mHealth, policy

Current mHealth projects in Tanzania are diverse & disjointed,
not collaborative or comprehensive.
Examples:
● Mobile for Reproductive Health (m4RH): a national text-message (SMS) based health
communication service in Tanzania and Kenya that provides “simple, accurate and
globally relevant information on reproductive health”. Award winning, deployed + created
by FHI 360 (15).
● Management Information System (MIS) for control of Neglected Tropical Diseases (NTD):
was and mHealth system piloted where village health workers were given mobile phones
with web-based software to capture health data (14).
● D-Tree Safer Deliveries in Zanzibar: A collaboration between D-Tree, Tanzania Ministry of
Health, JHPIEGO, and Gates Foundation to equip traditional birth attendants and MA-
CHWs to register and screen pregnant/postpartum women and newborns (31)

HIV Public health
context: MA-CHWs
transform HIV/ART care

CHWs play a critical role in community care of PLHIV
The biggest obstacle to scaling up ART care in Sub-Saharan Africa is the lack of qualified
human resources for health (10)
MA-CHWs can help fix this problem through task-shifting to community-level care
● CHWs in Zambia are shown to provide adherence counseling of equal quality to clinic
counselors, with significantly less loss to follow up rates (29)
● After CHWs in Haiti were trained on HIV care, households in the intervention area
increased uptake of ART and attendance at primary health care (18)

MA-CHWs can alleviate HIV Burden in Tanzania
HIV prevalence among adults in Tanzania in 2014 was 5.34% which is estimated at
1,499,400 people living with HIV/AIDS (4).
140,000 of PLHIV are children
There are only 0.03 physicians per 1,000 population (4).
Literacy:
70.6 percent of total population (75.9% M, 65.4% female) over the age of 15 can read
and write Swahili, English, or Arabic (4).

MA-CHWs improve ART adherence in Tanzania
● Having low perceived quality of patient-provider interaction and missing a clinic
appointment was associated with poor adherence (32).
● A study of HIV+ mothers found their motivation to take ART decreased after birth and
having prevented MTCT (21).
● Among children, poor adherence was predicted by living with a non-parent caretaker
(22).
● Improving adherence counseling in clinic settings may effectively improve adherence to
ART (16).
● Mobile phone text message reminders are recommended to improve ART adherence
(13).

The time to lead is now
The opportunity is NOW

The time to lead is NOW
Step up as a regional leader
in mHealth standards, regulation, and systems integration
➔ Quality of close-to-community care over quantity of mHealth
projects
➔ Improve the country’s community health information databases.
➔ Take ownership over the nationwide mHealth program

The opportunity is NOW
A well-developed, comprehensive smart mHealth project will have significant impact on MA-
CHW performance in Tanzania and on health issues like ART adherence and ensure
evidence-based, sustainable, data driven programs that empower local communities and
make use of the best technology and innovation models.

Contact Information
Boston University School of Public Health
Caitlin Gillespie MPH May ‘16 cgillesp@bu.edu
Lauren Hodsdon MPH May ‘16 lhodsdon@bu.edu
Sarah Jacobson, MSW MPH May ‘16 sajacobs@bu.edu
Paola Peynetti V. MPH Jan ‘17 ppeynett@bu.edu
Natalie Sanfratello MPH May ‘16 nsanfrat@bu.edu
James Wolff (Faculty) MD, MPH jwolff@bu.edu
Initiatives Inc
Rebecca Furth Ph.D. rfurth@initiativesinc.com

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Annex II - Dimagi Costing Tool
Dimagi Costing Tool
If link is inactive, can be found at: https://confluence.dimagi.
com/download/attachments/14549044/Dimagi%20-%20CommCare%20-%20TCO_v5-cp.xlsx?
version=1&modificationDate=1370536055234&api=v2

Tanzania's New MA-CHWs: A Mobile Health App for Quality Care

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