Lydia Anne

Theme: Impacts of digitization Sub theme: Strengthening of community health services What factors have led to the strengthening of community health services? How has digitization contributed to strengthening of community health services? How has strengthening of community health services impacted decision making process? Key issues from the data How the issues are described Implications for intervention, policy or programming What factors have led to the strengthening of community health services? -Training and refresher training sessions -Incorporation of service provision guidelines in one digital gadget -Availability of sufficient medicines and supplies ensures better delivery of services -Provision of stipend/compensation acts as a motivating factors in encouraging CHVs to offer better services -Digitally empowering CHVs -CHVs training sessions has led to them gaining skills and knowledge in diagnosing, identifying danger signs, prescribing medications and conducting tests leading to strengthening of community health services -Secondly, the fact that the CHVs are equipped with medicines and each and every other item that they require so as to deliver on the services they offer at the community, it goes along way -Compensation just influences the CHVs to make sure that they are reaching out to their clients. Because compensation is a motivation -the fact that the CHVs are digitally empowered, they have digital forms where they are able to attend to their clients without saying form A is done and the government hasn’t brought in the forms and all that. Since the forms are digital, they are readily available and now they can attend to each and every one of their clients. Hence improving community health services -More refresher trainings to improve CHVs skill set and knowledge -Ensure consistent flow of service provision supply and commodities -Improvement in compensation mechanisms to improve service provision How has digitization contributed to strengthening of community health services? -Digitization helps CHVs to offer better services as it guides them on how to do assessments and offer treatment - Digitization enables CHVs to provide services better as it reminds them if they forget -Digitization led to training sessions which equipped CHVs with knowledge and skills to offer services -Digitization introduced the practical side of service provision by the CHVs Digitization enables tracking of consumption of commodities informing on areas needing replenishment thus improving quality of health care -Training sessions that came as a result of digitization, has resulted into CHVs gaining skills and knowledge like conducting tests, prescribing medications, doing proper diagnosis and identifying danger signs in infants. The CHVs also now have access to essential medication which allows them to offer better services thus strengthening community health services Incorporation of service provision tools and guidelines in one gadget has eliminated the baggage of carrying heavy manual tools and made work easier for the CHVs and offers safer storage of data collected ...the phone then gives me direction on how I can help that client-if it is someone who should be tested for malaria, the phone gives me direction to test for malaria and if it a person whom I should refer, the phones then directs me also -When we went for the training, we were taught how to assess the children and the diseases that we can manage at the community level. Some of the diseases that we were told we can manage were like fever that has gone for less than seven days, diarrhea that has gone for less than seven days and cough without chest in-drawing or difficulty in breathing -Digitization has ensured timely transmission of data resulting to faster interventions on urgent cases thus better service delivery -Digitization has enabled better monitoring and following –up of MNCH clients right from the community, to facility and back -DESC has ensured health service provision for most community members, through empowered CHVs by training and equipping them with supplies which allows them to offer basic health services for those with barriers from seeking care from a health facility thus bridging the gap in the health sector - Now ECHIS is now giving this power to the county to come up with a way we can capacity-build their team from the county focal person, sub county focal person then we have the community health assistant who are now, when they are trained through the county TOT, so you realize the work will be very easy. -eCHIS has closed a lot of gaps in the health sector and improved the lives of the community members through empowering CHVs to be able to offer door to door health services to the community members -the fact that the CHVs are digitally empowered, they have digital forms where they are able to attend to their clients without saying form A is done and the government hasn’t brought in the forms and all that. Since the forms are digital, they are readily available and now they can attend to each and every one of their clients. Hence improving community health services -the fact that the CHVs are digitally empowered, they have digital forms where they are able to attend to their clients without saying form A is done and the government hasn’t brought in the forms and all that. Since the forms are digital, they are readily available and now they can attend to each and every one of their clients. Hence improving community health services - if a CHV gets into a household there are categories of questions that a CHV asked the household and I think its satisfactory even to the household member and more so to the community strengthening we feel that it’s really picking on issues that a household always encounters. -We look at even the trend consumption of commodities; it even informs the Sub-County Pharmacists and the link facilities in-charges, on the quantities of commodities that need to go to the community. How has strengthening of community health services impacted decision making process? Through timely submission of data digitally, decisions on required urgent interventions are made on time -Through digitization, real time data is available on the dashboard, allowing for timely flagging out of cases, bringing them to the attention of relevant personnel and decisions made on interventions and or action to be taken - § 2 references coded [2.05% Coverage] Reference 1 - 1.33% Coverage R: I think the advantage to this phone; it has really helped us because earlier on we used to go the community and we’re not issued the medicine. Secondly, they also never trained us on how to test a child. As soon as they brought about the phones with the various apps, I can say it has really expanded our knowledge because now I know how to test a child, I even teach them such things. I also know the amount of medication to give depending on how old they are. If they have pneumonia or fast breathing, I know I have to give them amoxylin of this amount. Earlier on we didn’t have any idea about all this. We would just go to the communities to collect data. If we noticed any sick children, we had to report it in our feedback. The only thing that that we had to our rescue back then was the referral. Right now I can consult with a mother and child, I know how to diagnose odema, kwashiorkor, fast breathing. It really has helped us a lot... Reference 2 - 0.71% Coverage R: All I can say is that these phones can now allow us to visit more households because now we only carry a small purse to carry the phone which has all the tools. Aside from the phone, maybe other things like medications are what we bring along. Back then even the rain was a threat because with those books, once you’re caught in a storm the books come into contact with rainwater and all the work goes to nothing. Now with the phones, we’re not even worried about rainfall. It makes everything so easy. - § 8 references coded [4.32% Coverage] Reference 1 - 0.56% Coverage R6:I can say that this phone helps me, when I am doing home visit I can find that there is a sick person in that household...now we are talking about everyone; so I can find someone who is sick. So when someone tells what their problem, the phone then gives me direction on how I can help that client-if it is someone who should be tested for malaria, the phone gives me direction to test for malaria and if it a person whom I should refer, the phones then directs me also Reference 2 - 0.59% Coverage R8:Just to add something, if I have gone to the field and gets into the households and then find maybe an adult is sick, if I have medicines that I should be giving to him or her...I was taught how to administer the medicine and maybe I have forgotten, maybe I am dealing with an older person of maybe twelve years and above, how many tablets should I administer to that person? The phone will direct you on the age of that person and the dosage to give to that person. So the phone also helps us with that Reference 3 - 0.27% Coverage R2:These phones help us with issues of Family Planning. A person can give birth and they should be able to space their children. So we each them...the phones has those information so you teach them how to space giving birth Reference 4 - 1.10% Coverage R1:In addition, when you do the follow ups, you go back to the household and request for the book that she went with to the hospital and look at it, after that...maybe there is medication that she has been given and you know sometimes the doctor gives you medicine and explained how to take them but sometimes because of the way you were feeling, you didn’t understand how the doctor explained the prescription to you. So you can ask the client, did the doctor explain to you how to take the medication that he gave you? Sometimes they can say yes, then you ask them to explain to you what the doctor told them, sometimes she might be confused while explaining it, so you will give her the right direction Or sometimes they come to the hospital but there was no medication, so she will tell you I went to the hospital but there was no medication, so you will tell her, mama look for money and go and get such and such medicine and take Reference 5 - 0.27% Coverage R5:When I get into a household and I find that there is a sick child there, I will then take my RDT and test that child. If the test comes out positive if I have the medicine I give them but if I don’t have then I refer that child Reference 6 - 0.85% Coverage R2:First of all when you want to test a patient, you put on gloves, you then place everything you need to test the patient on the table, you then start the clock, and then you test the patient with the time already running. So after you have pricked the finger, the first blood that comes out you wipe it off, and then you test the second blood that comes out-just one drop. You will see the blood moving and then you will also be checking the clock. We were taught that if it indicates one line then the test is negative and if indicates two lines then the test is positive. So the clock will tell you how long the test has taken to give our results. So when you are done, you remove the gloves and place them in the dustbin Reference 7 - 0.42% Coverage R4:When we went for the training, we were taught how to assess the children and the diseases that we can manage at the community level. Some of the diseases that we were told we can manage were like fever that has gone for less than seven days, diarrhea that has gone for less than seven days and cough without chest in-drawing or difficulty in breathing Reference 8 - 0.26% Coverage R1:In the past we had a lot of theory work but right now we do even practical, like testing for malaria is very practical that you have to do and see that it is successful, that's where I have gotten a lot of assistance - § 3 references coded [4.62% Coverage] Reference 1 - 1.13% Coverage R:Yeah, I think it will improve digitization. When we normally get the timely feedback, you know, we need to transmit the data. The data has to reach its destination on time. If the data delays, we are not able to get back the feedback to the community. And once, there are some cases that need urgent interventions. So, if we don’t act appropriate or promptly, we might delay the service delivery. Reference 2 - 1.71% Coverage R:Yeah, it has really increased the uptake of maternal child health because, when I started saying that when the CHVs actually do the early identification of pregnancy, they have to submit that data so that we can monitor the progress of this client who was referred. Did that client reach the health facility and if she totally reached, what were the services that were rendered to her? Yes, and did the CHV actually left what we call the referral form with the client and did the client actually accompany herself with that referral form to the health facility. So, there is that kind of coordination. Reference 3 - 1.78% Coverage R:Yes, yes. Actually, it really improves that because as I said earlier, when a CHV comes a case in the community that needs referral, the CHV actually cannot wait. What they normally do is they just make a prompt referral to the health facility and then they document using the MOH100. Yeah, so there is that linkage. Then at the end of the month when we are also doing our review, we go to track referral forms and see how many people were referred and how many people reached the facility? Maybe if there is somebody who has not gone to the facility, we can find out from them as to why they didn’t reach the health facility. - § 1 reference coded [1.50% Coverage] Reference 1 - 1.50% Coverage So they are able to generate household profiles; health profiles of these individuals which are then summarized; and at a dashboard level, we have several filters where we can filter up to a specific community unit. And on a weekly basis when we pick our primary health care team to look at this dashboard, we are able to see for instance the number of diarrheal cases reported in this community unit, compare it to the last week and if there is an increase, we contact the health promotion officer. We link them, we direct them “Look here there is this community health unit, we have had an increase say of 10 or 15cases; go look at maybe hand washing.” - § 1 reference coded [2.86% Coverage] Reference 1 - 2.86% Coverage R:Another issue is on non-communicable diseases which may not focus in our smart health [Inaudible10:34] but it is something that will come up with eCHIS and also CBDS, community health disease surveillance. So those are the things that we have come up with in ECHIS. Another approach that ECHIS has brought in is that element of capacity building. Yeah the county team, so that there is ownership of the program, which will, like initially we used to use our trainers who could [Inaudible 11:10] then the CHV we used to have our supervisors who were [Inaudible 11:14] they could carry out this work. Now ECHIS is now giving this power to the county to come up with a way we can capacity-build their team from the county focal person, sub county focal person then we have the community health assistant who are now, when they are trained through the county TOT, so you realize the work will be very easy. Instead of targeting like training over 3000 for example in Homa Bay, we can capacity-build a team of 20 or 40 county ToTs who will now castigate progressively at a very low cost. - § 1 reference coded [1.46% Coverage] Reference 1 - 1.46% Coverage M:So, generally what is your perception about the national ECHIS policy? R:Okay, the national Electronic Community Health information Systems, I think ECHIS is a powerful tool because it is like you have many systems under one roof. So, I can say that my perception of ECHIS, it has actually closed a lot of gaps in the health sector and it has also improved the digital health strategies and actually improving the lives of the community because you see, before, we had challenges yes, there were challenges whereby the households that the CHVs visit before, they never actually had the opportunity to go to the maybe health facilities and with the CHVs in place and also implementing using the ECHIS tool now we are able to bring door to door health service closer to the community and to the houses that they visit. So, all in all, ECHIS is a very powerful tool - § 1 reference coded [2.54% Coverage] Reference 1 - 2.54% Coverage M:The community data, the community health data that we get from the community via the CHVs, how is this data being used to improve the maternal, newborn and child health services that the community seeks? R:I’ll give an example, like yesterday we have this Doctor << >>, the guy you are seeing, he made a call to a certain focal sub-county person. The issue was around maternal health. I think it was a maternal death? The data had captured, a number of CHVs had captured it was either rightly or wrongly but it I tend to think it was wrongly. It had captured some pregnant mother had died. So, because him, dr. _ being a responsible guy on top made a call, he made a real-time call to the focal person and the focal person summoned the CHEWs and the CHEWs actually summoned the CHVs and they gave out the number and the focal person again called the CHVs to come to her office and explain because this is a very serious situation. I don’t know if I have tried to… M:Yes. R:So, I believe they came out with a very good decision, either it was a user problem or it was a situation that was really on the ground. I can’t say coz I was not in their meeting. - § 2 references coded [2.02% Coverage] Reference 1 - 1.40% Coverage R: So DESC is supporting health service delivery by one: the fact that the CHVs are digitally empowered, they have digital forms where they are able to attend to their clients without saying form A is done and the government hasn’t brought in the forms and all that. Since the forms are digital, they are readily available and now they can attend to each and every one of their clients. Hence improving community health services Secondly, the fact that the CHVs are equipped with medicines and each and every other item that they require so as to deliver on the services they offer at the community, it goes along way Reference 2 - 0.62% Coverage R: Compensation just influences the CHVs to make sure that they are reaching out to their clients. Because compensation is a motivation, so once the CHVs are motivated, they will be able to get out, go and see their clients and deliver services that are required of them - § 5 references coded [12.07% Coverage] Reference 1 - 2.20% Coverage M: What are some of the strengths that you have encountered while enrolling this digitization process? Reference 2 - 1.85% Coverage M: Great, 2019… so what are some of the opportunities that are there to improve the roll out so far? (Turning paper pages) R: Yes we have the opportunities to improve the roll out, looking at the work flow, since it was presented or looking at the work flow that we are using, we have seen that the work flow is really capturing a lot of things, a lot of metrics, a lot of KPIs which I think the CHVs feels good about, if a CHV gets into a household there are categories of questions that a CHV asked the household and I think its satisfactory even to the household member and more so to the community strengthening we feel that it’s really picking on issues that a household always encounters. Yeah Reference 3 - 2.97% Coverage M: Okay, so are decisions made at the KHIS level or there is a higher level that the decisions are made? R: Okay so we have something called data reviews, so when we hold this data reviews each and every month, after looking at the data, there are a lot of ideas that come, that idea is transmitted to the county, so when we do our data reviews it happens within us at the sub county then the sub county picks it. So when we talk about it the sub county picks it to the county then the county to the national. So I think the decision making starts within the sub county going forward so we only get a feedback of whatever happened like for example we talked about having water treatments, maybe we have a lot of diarrhea, we talk about having water treatment so we discuss it we get away forward they decide they will provide water treatment elements so you will find that even before it reaches the nationals something has been done with the county, sub county so there are some decisions that are made immediately then there are some decisions that needs time and the discussion at a higher level for it to be implemented. Reference 4 - 2.97% Coverage M: Alright, so the same data collected here at the community level how is it used at the district level? (Cock crowing) R: So the district level now is the sub county or the county I mean! (All speaking at the same time) R: Sub County. M: Sub County. Reference 5 - 2.07% Coverage M: We are aware that DESC is a platform with different components right! We have the digital tool, we have the enablement, the equipment whereby we are talking about the commodities and all that, we have the supervision part of it then the compensation part of it, so the current digital platform how is it going to impact the whole package, the implementation of the whole package. R: Okay it is going to improve the community health system because a CHV who is a digitally empowered is able to go to that household and find out if they are okay. So let’s say one CHV goes to one household all CHVs go to all those households, it’s a healthy community that we are going to have right! So the digital part of it or the best part of it really boosts the community health strengthening. - § 7 references coded [4.05% Coverage] Reference 1 - 0.64% Coverage R:So motivation towards the development of policy for digitization...I think looking at the health strategy, in community health strategy we have the different elements that needs to be done and it is out of number four or five, there is an element to it that speaks to having a digitized system as a way of strengthening the community health system. So I think in that light, this is what gave birth to the strategy that was-the national digitization strategy... Reference 2 - 0.28% Coverage Looking at the community health system, we are able to collect that data using the application and this may also be deployed to ensure that community health data collection and reporting is strengthened. Reference 3 - 0.77% Coverage R:...who are accountable because they know that there is that visibility. Another thing I just wanted to add was the quality of the service delivered, at least people will standardize because the platform has a standardized messaging, so whether you are a CHV who went up to class eight level or form four level, there is no that struggle that to have to remember things because within the work flow you have standardized messages that we have and just remind the CHVs what to do. So that also improves the quality of health care given at the household level Reference 4 - 0.60% Coverage R:No it is not the furthest because the algorithm is the same, if you get it at the Sub-County, it still relates when it gets to the top. So I would give an example of just the ending month-August; before the month ended I was being pressurized to give back end data so that we can see which particular CHVs reported maternal deaths, and this was an ask by the CEC Health Kisumu. So like in my Sub-County we had five maternal deaths Reference 5 - 0.73% Coverage So during our data review we talk about these indicators, we see out [?], we flag areas that need interventions and it informs even the activities of the preceding month. So like now we are in September, before the 12th we need to have reviewed August data. During the review is when it will inform the health coordinators what we are going to do. So we realize there are a lot of diarrheal cases in a region and we need a dialogue day and action days that is what we do. So it helps us in planning interventions and areas to focus on Reference 6 - 0.70% Coverage Same to the facility-at the facility level we also...during data reviews we have the in-charges. We look at even the trend consumption of commodities; it even informs the Sub-County Pharmacists and the link facilities in-charges, on the quantities of commodities that need to go to the community. It informs them on how many women were referred, how many reached the facilities and where did we lose. If we say like ten women were referred and the link facility only got three women, where did the seven go? Reference 7 - 0.32% Coverage So I would say that we consume that data a lot...not as much as we would want to because again it is huge; it is a lot of data, but I’d attest that it is contributing to strengthening of service delivery even at the health facilities. - § 1 reference coded [1.07% Coverage] Reference 1 - 1.07% Coverage or universal health coverage you find that maybe everybody is not able to access the health facility but now because the CHV has been equipped with the knowledge, has equipped the CHVs with the tools that the CHVs require to help them do diagnosis at community level, the CHV has been equipped with the medicine they are able like to treat the mild cases like for example mild cases of malaria at community level…at house hold level so you find that they are able to ensure that those who are coming far from the hospital that require transport for them to go to the hospital are already being sorted with the CHV at the comfort of their house.