Living Goods’ Smart Health App

Testing the Comprehensive Family Planning Strategy in Wakiso and Mpigi. Integration of family planning services into service package of digitally supported CHWs increases uptake of services

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Contact

Allan Eyapu
Program Manager, Family Planning
Living Goods
Email

Implementation Partners

Living Goods (Lead Implementer)
Uganda and Kenya Ministries of Health (Central Coordination and Regulation)
Medic Mobile (Tech Partner/App Development and Management)

Funder

The John Templeton Foundation
Children’s Investment Fund Foundation
USAID

Implementation Dates

The strategy was piloted in May 2017 and scaled up in October 2018.

Geographic Scope

Uganda, Kenya

Target Users

Client, Health Care Provider, Data Services Provider

Enabling Environment Building Blocks

Leadership and Governance, Strategy and Investment, Infrastructure

Family Planning Program Classification

Policy and Enabling Environment

Introduction

Since 2007, Living Goods has supported community health workers (CHWs) to save and improve lives in resource-constrained communities by delivering primary health care services directly to the homes of patients. Living Goods digitally empowers thousands of government CHWs to provide accurate care and prompt follow-ups by using a smartphone app that details every patient’s contact and enables real-time performance management of health workers in outlying villages. The Smart Health app uses a basic clinical decision support system to ensure consistent and accurate diagnoses and smart workflows for pregnancy care, management of childhood diseases, nutrition, and immunization tracking.

While the total fertility rate of Uganda has declined from an average of 6.9 births per woman in 2000 to 5.4 births per woman in 2016 (UDHS, 2016), the country still has one of the world’s highest population growth rates. The burden of unintended pregnancy disproportionately falls on poor women, impacting health, economic and educational opportunities (UNFPA,2017). Unmet need for family planning (FP) in Uganda is 28 percent and only 35 percent of women use modern contraceptive methods (UDHS, 2016). This low rate of uptake presents an opportunity for digitally empowered CHWs to provide FP education and services.

The Government of Uganda (GoU) recognizes the important role community health workers play in providing health services, reporting that CHWs could prevent up to 30 percent of deaths across the country(RMNCH sharpened plan,2016). The government-run Village Health Team (VHT) program provides services at the community level through a cadre of community health workers. The VHT strategy has been established by the Ministry of Health to promote community participation and involvement in health, influence positive health behavior, promote better care-seeking practices, and strengthen timely delivery of integrated healthcare services at community and household levels.  However, village health teams are not being deployed effectively to deliver FP as only 5 percent of modern contraceptives users obtain their contraceptives from community-based channels (DHIS 2). Aware that key challenges exist that limit the potential of CHWs, Living Goods partnered with the Government of Uganda to pilot family planning service delivery using the Smart Health app in two districts to optimize impact and increase uptake.

Overview of Project/Digital Health Solution

In 2017, Living Goods and GoU piloted a comprehensive FP strategy in the Smart Health app, training and equipping government VHT cadres of CHWs to provide FP counseling; short-term methods, including DMPA-SC (Sayana Press); Emergency Contraceptive Pills; combined oral contraceptives; and the Progesterone Only Pill for breastfeeding mothers as well as referring clients in need of long-term and permanent methods to identified service delivery points. CHWs were already using the Smart Health application for maternal and child health services delivery, and Living Goods added the FP workflows to support needs of the pilot. The pilot was implemented in two districts, Wakiso and Mpigi, starting initially with 30 CHWs in each branch and rolling out to all 200 eligible CHWs. Living Goods-supported CHWs were equipped with a phone and our Smart Health app with carefully designed workflows that standardize client counselling, assessment, and administration protocols for family planning services. This enables CHWs to accurately educate clients, determine their eligibility for family planning, recommend an appropriate method and provide follow-up services.

Additionally, supervisors can see real-time performance data for every community health worker and use analytics dashboards to monitor and drive better performance—and ultimately, impact—through the app. All the data generated through these mobile health tools is shared with the government and is used to inform decisionmaking for CHW programs at every level. The program was scaled up in 2018 and more than 2,500 VHTs have been trained in 18 districts. The program is now an integral part of CHW service offerings and Living Goods is working with partners to raise funding for training and equipping all community health workers to deliver family planning services.

Evaluation and Results Data

Results from the pilot indicated that half of the clients visited by a community health worker took up family planning. The number of women served with a family planning method per CHW per month increased from 2.4 in May 2017 to 6.7 by June 2018. Additionally, the number of women initiated on family planning per CHW equally rose from less than 0.9 per month to 1.2, and half of the women who had not used family planning before took up a method after receiving counselling from a CHW. In the same period, up to 60 percent of clients refilled their methods from a CHW during a follow-up visit. DMAP-SC was the most preferred method offered by the CHW while clients referred for long-term methods preferred implants. This demonstrated the potential of the digitally empowered CHWs to reduce unmet need for family planning and the success of this pilot gave rise to a larger scale family planning program with a goal of contributing to reduction in maternal and neonatal mortality in Uganda.

During the pilot, Living Goods also conducted a qualitative study to explore experiences and identify challenges faced by CHWs providing family planning services in Mpigi and Wakiso districts. The study uncovered the following enablers for provision of FP services at the community level: income generated by CHWs from services provided; acceptability of DMPA-SC by the community; supportive supervision; regular training and job aides, including a smart phone equipped with the Smart Health app that they received. The major challenges reported were frequently shifting peri-urban populations that impede CHWs’ ability to follow up and provide refills, clients delaying paying for services received on credit, and lack of male partner approval for use of family planning.

SmartHealth App workflow proficiency is usually a challenge for new users following initial FP training, but this is addressed through support supervision in the first three months of FP service delivery.

Lessons Learned

Introduction of family planning into the service basket led to overall improvement in CHW performance. CHWs providing a combination of family planning, immunization, and Integrated Community Case Management (ICCM) services visited 10 additional unique households and treated seven more sick children compared to when they delivered only ICCM and immunization services(Figure 1).The average number of unique households visited by CHWs when FP was introduced grew from 36 to 46 per CHW from August to November 2019. In addition, they treated 17 sick children every month as opposed to 10 sick children when implementing ICCM and immunization modules. CHWs actively providing FP services also conducted more postnatal care visits than their counterparts (Figure 2).

Adequately equipping CHWs with commodities and job aids after training shortened the learning curve. The Smart Health app generates task reminders for CHWs to follow up and advise clients who take up FP in case they experience any side effects. Reminders are also generated for clients due for refills, requiring follow-up counseling, and those referred for long-term and permanent methods. This has ensured effectiveness among CHWs delivering FP services.

Conclusion

Community health programs provide a high-impact, low-cost solution to the health systems challenges faced in low- and middle-income communities, alleviating pressure on resource-constricted health facilities, and reducing inequities in access to care. Leveraging existing digital health investments and integrating FP workflows for existing networks of CHWs increased access to FP services and help addressed major barriers to reproductive health services—including fear, social opposition, and misinformation about side effects. Such integration can also increase agency and equity, and bolster sustainable growth. Provision of digital tools, training, supervision, commodities, and compensation strengthens capacity and motivates CHWs to provide voluntary FP services. Government and partners should continue to invest in community health and supportive technology to increase coverage of FP services.

Figure 1: Household Visits

Figure 2: On-time PNC performance

References

  • Uganda Bureau of Statistics (2017). Uganda Demographic and Health Survey. Key Indicators Report, p.13 
  • United Nations Population Fund (2017). Worlds apart in Uganda: Inequalities in women’s health, education and economic empowerment, p.2
  • Uganda Bureau of Statistics (2017). Uganda Demographic and Health Survey. Key Indicators Report, p.18-20 
  • Ministry of Health Republic of Uganda (2016). Investment Case; Reproductive, Maternal, Newborn, Child and Adolescent Health Sharpened Plan for Uganda 2016/17 – 2019/20, p.16
  • Ministry of Health Republic of Uganda (2020). e-Health Management Information System, hmis.health.go.ug