Adoption and Scale-up of an mHealth Initiative to enhance Early Infant

Diagnosis (EID) of HIV in Zambia Presentation by:

Kaluba K. Mataka

mHealth Project Manager,

Zambia Center for Applied Health Research and Development (ZCAHRD)

December 10-11, 2014

Background • The Human Immunodeficiency Virus (HIV) prevalence in

Zambia estimated at 14.3%

• 21% of HIV infections result from Mother-to-child

transmission (MTCT)

• Antiretroviral (ART) therapies are used to prevent MTCT

• However, EID is critical to support early initiation of ART

in infants when prevention of MTCT fails

• Dried blood spot (DBS) samples from infants are sent to a small number of regional

laboratories to be tested for HIV with polymerase chain reaction (PCR)

• Timely sample transportation and result delivery constitute a big challenges to

developing an effective EID service in low resource settings

Background (2)

• The Zambia Ministry of Health (MOH) and partners introduced Programme Mwana,

an SMS-based text messaging system to send HIV infant test results directly from the 3

national testing laboratories to the distant health facility of origin within minutes instead

of days

• Prior Turnaround Time

(TAT) from sample

collection to result delivery

in 10 pilot sites was 66 days

ref - Early Infant Diagnosis: System Summary (2008) – MoH & Clinton H/A Initiative

• In 2008 CHAI, ZCAHRD and UNICEF began exploring measures to

reduce lengthy HIV testing turnaround times:

Meetings with MOH and identification of groups/persons at the

ministry to spearhead this process

Identify stakeholders in EID and implementers with expertise

• CHAI (Clinton Health Access Initiative)

• ZPCT II (Zambia Prevention Care and Treatment Partnership)

• ZCAHRD (Zambia Center for Applied Health Research and Development)

• UNICEF (United Nations Children’s fund)

• MOH (Zambia Ministry of Health)

Site and Facility selection for pilot phase based on partners

identified

Partners Identification

Partners: Aligned Interest

MOH

• Focus on EID program • Central control and support for mHealth intervention • Local ownership and direction

CHAI

• Conducted EID study in 2008

• Proposed usage of SMS printers

ZCAHRD

•PMTCT capacity for quick on-site implementation

•Ability to conduct research and evaluations

UNICEF

• RapidSMS experience + technical capacity

• Funding

Locations of Pilot Sites Luapula Province: • 11 Sites • Across 3 Districts • Implementer: UNICEF

Southern Province: • 10 sites • Across 2 Districts • Implementer: ZCAHRD

Central Province: • 3 Site • Across 3 Districts • Implementer: CHAI & ZPCTII

Copperbelt Province: • 3 Sites • Across 2 Districts • Implementer: CHAI & ZPCT II

Northern Province: • 2 Sites • Across 1 District • Implementer: CHAI & ZPCT II

North-Western Province: • 2 Sites • Across 2 Districts • Implementer: CHAI & ZPCT II

Programme Mwana • Built on RapidSMS©, an open source framework

• System is free of charge to the end users and is available across the two

major networks in the country

• Programme Mwana main features:

Results 160

• Designed for Health workers

• Delivers infant HIV lab results to Facilities via SMS

• Tracks samples through logistics system

RemindMi

• Designed for Community health workers

• Patient follow up • Patient tracing • Birth registration

Web Management Tool

• Manages Program • Monitors compliance • Full program statistics,

reports, charts, alerts, message boards

• National, provincial, district and partner level

From Pilot to scale MOH approved Pilot Proposal

Onsite system development supported by UNICEF

Launch of the Pilot phase (8

Months)

Publication of pilot

evaluation (WHO bul.)

Evaluation & Dissemination meeting with

MoH and Partners

Recommendation to scale and

National Launch

2009 – 10 Jul ‘10 – Feb ‘11

May‘11 Nov ‘11 Mar ‘12

* National Scale-up activities for Programme Mwana commenced in 2012 beginning with 200 sites

Govt. Ownership

• mHealth platform • Identification of key staff • Scale-up in non-partner

supported sites

Partnership • Implementation in

partner’s supported sites • Coordination of efforts

Govt. Leadership

• Aligning mHealth as a strategic priority

• Inclusion in ICT policies

• Inclusion in 2015 activities (budget)

• Involved in entire system process

Enabling environment

• Feedback and reporting • Inclusion in PMTCT,

Pediatric/HIV TWGs; provincial, partner and district Data review meetings

• Creation of mHealth TWGs

Critical success factors

Coordination • Provided through leadership of MOH & UNICEF

• Use of both international and local software developers Collaboration of

development teams

• Provision of system on two major networks Collaboration with mobile

service providers

• To coordinate and oversee all mHealth activities Creation of the mHealth

TWG

• Based on lessons learnt from pilot and scale-up phases Refinement of system

• Creation of national training materials based on lessons learnt

Standardization of training materials

• At partner and provincial level Training of national

master trainers

• Creation of national scale-up through mHealth TWG Coordination of scale-up

process

System Integration • System fit into already existing PMTCT and EID programs • Translated into the 7 major languages • Standardization of registers used • Inclusion of mHealth in National eHealth strategy

Adaptability

• Reports generated by system included in national review meetings • Users receive monthly aggregated reports • Use of data to inform the management and direction of the program

System data

• Use of local developers • Access databases located in DNA PCR testing labs • System server based at MOH • Ease and duration of trainings

System

• No cost to end users • Simplicity of messages • Use of personal phones

Usability

• MOH endorsed national scale up to all PMTCT/EID sites in the country

o Partners involved in the scale-up strategy development and

adoption

• MOH established the national mHealth TWG chaired by the ministry to

oversee, manage and report back on the scale up process

• Master trainers formed at provincial and district levels to cascade localized

training and support

• Scale up activities commenced in 2012 with 200 facilities targeted

o Currently operating in > 730 facilities (52% coverage) across 10 provinces

Sustainability

System Impact

Scale-up activities conducted in

facilities with and without mobile network access

Availability of program data for implementers via

the Mwana web tool at National, provincial,

district and partner level

Increase in DBS testing numbers

from 4829 samples in 2010

to 11076 in 2012*

Effective usage of the blast

messaging feature for other health related issues

(+7790 messages sent out)

Transparency of data: https://mwana.moh.gov.zm

Challenges “mHealth is by no means a panacea that will solve all of the challenges we face in the Health sector”

Pilot Phase Scale-up Phase

Difficulties in establishing leadership and ownership esp. at provincial and district levels due to small number of sites running the system (limited system impact)

New structural reorganizations within the MOH leaving the mHealth TWG with no clear leadership

Initial lack of confidence in the results sent via SMS especially with Clinical officers

Partner commitment: different partners entails different scale-up approaches based on sites supported and funding

Difficult collaboration with mobile phone providers

Despite system being free to end users, contracts with mobile providers need to be serviced and sustained

Limited number of staff at facility were trained and procured facility phones posed a challenge esp. phone charging and phone repairs

challenges being experienced in sample courier processes, availability of DBS kits and Lab reagents as success of system dependent on these factors as well

Dependence of mobile network availability and seamless internet service

Next steps with mHealth in Zambia

• MCDMCH (Ministry of Community Development Mother and Child Health) is scaling up Option B+ in Zambia and this offers up new creative and innovative way to use Mwana: o Adherence

o Mentorship

o Community

o Patient follow up

• Other possible system modules for inclusion o Disease Surveillance module

o Stock module to address issues related to stock management

• Working closely with the ministries to further enhance partnerships with the mobile providers o Bring on board 3rd mobile provider

Thank You Contributors: Judith Nguimfack, Corrie Haley, Jill Berkowitz, Kebby Musokotwane & Donald Thea

Funders: CDC, Bill & Melinda Gates Foundation, Johnson & Johnson, USAID, Global Fund

Government through: MOH & MCDMCH

Partners: UNICEF, CHAI, CHAZ, CIDRZ, ZCAHRD & ZPCTII