The Elimination 8 Regional Surveillance Database (ERSD)

`Annie Martin May 8, 2017
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To achieve malaria elimination, an understanding of neighboring country malaria situations is critical for the prevention of introduction of parasites. Malaria parasites don’t stop at country borders, so effective elimination strategies shouldn’t either. That is why the Elimination 8 (E8), in its strategy on cross-border collaboration, identified Akros to support the development of the E8 Regional Surveillance Database System (ERSD) for the eight member states constituting the E8: Botswana, Namibia, South Africa, Swaziland, Angola, Mozambique, Zambia, and Zimbabwe. This innovative approach is a means to level the playing field and conduct malaria surveillance at a regional scale.

Figure 1. Cross-border incidence* in districts in Zambia, Mozambique, and Zimbabwe: Having access to several countries in one database allows these kinds of visualizations, which may highlight transmission patterns that occur between countries, which in turn supports decisions to invest in control methods in border areas.
*All data shown is used purely for illustrative purposes and do not reflect current or historic epidemiological status of countries. Current data can be accessed in the database itself by those granted authority.

Malaria is hardly an emerging disease, and though the interventions of preventing, treating, and monitoring malaria are somewhat standardized, each country has slight permutations of their approach to doing so. Indicators may differ slightly, investment in one prevention method versus another likely differs too, and policies surrounding implementation certainly are not identical.

Figure 2. Country malaria incidence* over time: Visualizing time trends within each country may help illuminate whether outbreaks in different countries are related. It also helps identify which countries are doing well in elimination efforts and may have lessons to share.
*All data shown is used purely for illustrative purposes and do not reflect current or historic epidemiological status of countries. Current data can be accessed in the database itself by those granted authority.

In supporting the E8 in the creation of the Elimination 8 Regional Surveillance database (ERSD), Akros leveraged its experience in developing DHIS2 databases to design a system that was specific enough to fit country needs, but also flexible enough to balance various aspects of malaria disease and response. Together, Akros and the E8 team conducted country assessments to determine current data collection and monitoring strategies and worked to harmonize these in the DHIS2 database. The ERSD now contains data from five countries, with plans to incorporate the remaining three. In addition to developing the database itself, Akros developed full training materials and system administration guides to support the longevity and expansion of the system.

The Elimination 8 secretariat and Akros have worked together, combining resident country malaria expertise and strategic technical expertise. Streamlining indicators of eight different countries into one set of indicators is complicated and creating multi-country policies surrounding the use of a shared database is complex. However, in the end the effort yields the ability to do cross-country comparisons that are critical to interpretation of disease transmission and may be catalytic in decision making surrounding strategies for disease control and elimination.

Figure 3. Zambia inpatient malaria data*: In addition to cross-country comparisons, the database also allows for comparison of indicators within countries, making it a useful tool for countries in planning resource distribution.
*All data shown is used purely for illustrative purposes and do not reflect current or historic epidemiological status of countries. Current data can be accessed in the database itself by those granted authority.


About Annie Martin

Annie Martin is a health informatics officer and Global Health Corps fellow at Akros. Her work in health spans both the private and public sector, and her interests lie in using quantitative analysis to improve health programs and make the case for better investment in health.


Mobile Platform Enables Unprecedented Sanitation Uptake in Zambia

`Andy Prinsen February 15, 2017
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CLTS has been shown to be an effective method to combat malnutrition and stunting in children under five. In this study, a mobile-to-web platform increased the uptake of CLTS even further, allowing for greater community feedback, a reduced cost per new user of sanitation, and increased data transparency.

Akros, in partnership with Zambia’s Ministry of Local Government and Housing (MLGH) and UNICEF, layered a unique mobile-to-web application over traditional CLTS delivery methods, resulting in an innovative service delivery and monitoring system dubbed “CLTS M2W.”

CLTS M2W uses mobile phones, automated data feedback loops, and engagement of traditional leaders to provide communities with the ability to clearly see their progress towards sanitation goals. CLTS M2W paved the way for unprecedented CLTS uptake in Zambia, facilitating the creation of over 1,500,000 new users of sanitation in 18 months. In short, CLTS creates the demand, and CLTS M2W creates the critical transparency necessary to drive sustained behavior change.

Read the full study in PLoS Neglected Tropical Diseases.

Read this and more CLTS-related news on the CLTS Knowledge Hub.

Gavi Pacesetter organizations

`Andy Prinsen February 8, 2017
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GAVI is an international organization – a global Vaccine Alliance – bringing together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest countries. It is backed in part by the Bill and Melinda Gates Foundation.

GAVI held its first INFUSE workshop (Innovation for Uptake, Scale and Equity in immunization) in Geneva. Around 60 organizations and companies applied to the program, and 18 of these projects were selected for a final round of vetting in front of a panel with representatives from the organizations and companies like the World Health Organization (WHO) and UNICEF. At the end of the workshop, the panel selected seven “pacesetter” organizations who will work with GAVI to scale up their ideas and projects and bring them to new countries.

We are excited to announce that Akros has been selected as one of these seven pacesetter organizations for a concept that follows in-line with our approach of gathering village level information to inform decision making. The approach takes existing monitoring tools in the country, like stock monitoring and commodities tracking, and merges them into a single vaccine-tracking database using a platform called DHIS2. In the database, Rural Health Clinics (RHCs) log immunizations delivered using simple feature phones. Parents of children due for their next immunization receive SMS appointment reminders along with a list of clinics that have the vaccine in stock. The RHC also receives a list of patients in the area who are due for follow-up vaccination appointments.

“Vaccine coverage has made big leaps, but until we reach the last mile of care, we won’t see disease elimination,” said Akros Portfolio Lead, Laurie Markle. “We are excited what this partnership could mean for reaching the ‘fifth child,’ not just in Zambia but around the globe.”

Akros shares its designation as a 2016 Gavi Pacesetter with six other organizations: Shifo, IRD, KhushiBaby, Energize the Chain, Broadreach, and Nexleaf Analytics.

As part of the partnership, Akros and GAVI will work closely over the coming year to identify resources and partnerships that will enable both implementation of the program and maximum impact.

Chipo’s Story

`Andy Prinsen February 3, 2017
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Akros is proud to be working with Sightsavers, an organization working in more than 30 countries to eliminate avoidable blindness and support people with visual impairments to live independently. Recently, we spent a day with Chipo, a young girl living in rural Zambia. Both Chipo’s great grandmother and great-great-grandmother are blind as the result of an infection called trachoma. Their disability would make life more difficult anywhere in the world, but especially so in the setting where their family lives. Chipo must work extra hard every day to care for her elders, often times at the expense of her studies.

Sightsavers has featured Chipo’s story, created in partnership with Akros, at their Exposure site. Click here to read the story, and stay a while to browse the other powerful pieces demonstrating the difference that can be made for those with blindness – and in the prevention of blindness – around the world.

For a longer version of Chipo’s story, click below to download the PDF.

Download Chipo’s story in PDF format

Piloting Zambia’s first mobile-to-web education monitoring system

`Laurie Markle October 18, 2016
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About two years ago, Zambia’s Ministry of General Education (MoGE) approached us with an idea: let’s build a more routine, faster method for capturing key school indicators. At that point, the Ministry was collecting a 27-page annual census and using the data to make nearly every key decision like procurement of school supplies, investments in infrastructure, and distribution of teachers. The data was outdated by the time it was received and the Ministry needed a method of responding to student needs more than once per year. Shortages in teachers, textbooks and toilets require a more timely response than an annual survey allows.

And so began the work of setting up Zambia’s first mobile-to-web Education Management Information System (EMIS). Though education was a new sector for Akros, we knew what it takes to build out a national system and began applying those principles:

(1) Keep your eyes on sustainability

I remember walking out of our initial stakeholder meetings with a list of over 40 data elements in hand. We knew this was too many. Sending data, though inexpensive, adds up when you grow to scale and sending too much data creates reporter fatigue. It took us a few months of asking key questions, like “when are you making decisions?” and “What do you need to know in order to make them?” to get the list of data elements down to 11. With only 11 questions, we’re monitoring student and teacher attendance, school-feeding program activity, grant distributions, access to sanitation and menstrual hygiene management, and test scores in literacy and numeracy.

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Building one of the world’s largest data surveillance platforms

`Alexis Barnes September 19, 2016
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Chief Singani of Zambia’s southern province displays the tablet that he uses to check up on his chiefdom’s sanitation progress.

Leveraging a massive network of community volunteers, Akros works with the Zambian government and UNICEF to manage one of the world’s largest data surveillance platforms. The platform, designed and scaled for monitoring sanitation uptake in rural villages, relies on a network of over 3,600 community champions (CCs), environmental health technicians (EHTs), and other government representatives at the district level to report on sanitation uptake from ~ 21,000 villages across Zambia using mobile devices. The sanitation platform, which includes information on community and school led total sanitation and facial and environmental cleanliness for trachoma elimination is the largest surveillance platform in Zambia. However, Akros also supports similar community data collection systems in Zambia for malaria, education and land tenure. The systems, although different in content, all funnel data up from the community level into national level DHIS2 databases using similar technology. Many of the community volunteers use their mobile phone to collect data for more than one of the systems, reporting on multiple issues simultaneously such as latrine standards and mosquito net usage in their communities.

How does this work?

Across all sectors, it begins with a feature phone, a simple Nokia model mobile device. In their respective sectors, volunteers visit the households in their specific catchment area and survey specific indicators such as hand washing stations, proper number of mosquito nets per household member and latrine covers. They then input this information into the mobile phone DHIS2 platform for that month. With consistent data input, the software then allows anyone with a username, password and Internet access the ability to see up-to-date data on malaria, sanitation and trachoma statistics for different districts and provinces in Zambia. In community-led total sanitation (CLTS) alone, more than 1,300 village-level Community Champions (CCs) provide monthly reports to DHIS2 from over 13,500 villages.

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Akros-led consortium to develop Elimination 8 regional malaria database

`Andy Prinsen August 19, 2016
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We are excited to announce that an Akros-led consortium has been selected to develop a regional malaria surveillance platform for a coordinated, eight-country effort to achieve the historic goal of eliminating malaria in eight southern African countries. The Southern African Malaria Elimination 8 (E8) is a partnership between Botswana, Namibia, South Africa, Swaziland, Angola, Mozambique, Zambia, and Zimbabwe. The first four of these countries (frontline countries) have an elimination goal of 2020, and the later four (second line countries) hold a goal of elimination by 2030. Consortium members working with Akros include HISP-SA and Compre Health.

E8 countries reported a tremendous reduction of malaria cases of more than 50% since 2004. However, the closer we get to elimination, the better surveillance we must have. Malaria does not respect borders, meaning the four eliminating countries cannot eliminate as long as high transmission remains within the region, and human migratory patterns facilitate parasite movement from more highly endemic countries. Therefore, new regional strategies are needed to support the surveillance and control efforts by the second line countries in order to reduce the reservoir of malaria parasites which have a potential for cross border spread of infections that could re-establish infection in the frontline four countries. As frontline countries progress towards malaria elimination, second-line countries are intensifying their malaria control efforts in order to achieve pre-elimination status.

The knowledge of malaria trends between countries will be one of the main factors influencing the success of malaria elimination. To facilitate the ease of information sharing, the E8 working with the consortium have developed a regional database, which will sit within the District Health Information System (DHIS 2), a system already familiar to many of the 8 countries. The regional database will not be a parallel system — no new malaria data elements or indicators will be collected. Rather several malaria data indicators already captured in countries will be shared amongst countries via the regional database. This is in-line with E8 country-level commitments to malaria data sharing in efforts to eliminate the disease. The more data we have consistently and accurately, the better we can plan and target relevant interventions that will drive the malaria burden in southern Africa down to zero.

Fighting trachoma in Zambia

`Alexis Barnes August 12, 2016
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There isn’t much to the town of Namwala itself – an assortment of mobile phone “talk time” sellers and wholesale farmer feed stores. But it’s 20 minutes outside of town before you arrive at Kalundu Primary School, which hosted the first facial cleanliness for trachoma elimination pilot in southern province. Students donned heart and star-shaped molds of glycerin soap hanging from strings for one month to reinforce hand washing and facial cleanliness.

“The first day it was hard to teach!” said grade one teacher, Mukena Fortress. “They were so excited to use the soap necklaces that they kept wanting to go use the latrine.”

Fortress demonstrated how to use the necklace, bringing a bucket into her 47 student-filled classroom to teach proper hand washing.

Seven-year-old Misika likes the shape of the soap.

“Our soap is like a heart,” she said. I like always having it to wash.”

Kalundu Primary School is located in Namwala district in southern province, a region in Zambia where trachoma prevalence reaches 37%. Trachoma, an eye infection caused by the Chlamydia trachomatis bacterium, is a major cause of blindness especially in areas with limited access to water and sanitation. Repeated infections lead to scarring of eye tissue. When this scarring happens, the eyelid eventually turns in on itself and eyelashes continuously scratch at the cornea, which may eventually lead to blindness. The infection can be spread by bacteria on hands and the legs of flies, and the common sharing of cloths to wipe the face, especially of children. It is responsible for three percent of global blindness.

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Akros partners with College of William and Mary’s AidData, selected as one of DREAMS Challenge winners

`Andy Prinsen August 5, 2016
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On July 18, the U.S. President’s Emergency Plan For Aids Relief (PEPFAR), announced the provisional winners of its $85 million DREAMS innovation challenge to reduce HIV/AIDS rates among adolescent girls and women in sub-Saharan African countries.

Akros is excited to announce that we will be working with the College of William and Mary’s AidData research lab to help policymakers in Zambia make healthcare decisions based on the best available data.
The DREAMS challenge points out that, despite considerable progress in the global response to the epidemic, AIDS is the leading cause of death for adolescents in sub-Saharan Africa. Girls and young women account for 75 percent of all new HIV infections among adolescents in the region, and more than 7,000 new infections a week globally.

DREAMS is an ambitious public-private program whose partners include, in addition to PEPFAR, the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences, and Viiv Healthcare. PEPFAR is administered by the U.S. Department of State, and implemented by a number of U.S. government agencies, including DoS and USAID. By improving targeting and resource coordination, PEPFAR programs, particularly those focused on women, girls, orphans and vulnerable children (OVC) can reach more beneficiaries more efficiently and effectively.

Akros and AidData are excited to utilize our combined years of experience to develop solutions in the fight against HIV/AIDS here in Zambia. Learn more about the DREAMS Innovation Challenge at www.dreamschallenge.org.

Tracking the construction of latrines

`Andy Prinsen and Alexis Barnes June 7, 2016
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Story originally published on the CLTS Knowledge Hub.

Monitoring is always an important part of the development process, especially in CLTS. What are the factors and milestones we discuss when it comes to improving Water, Sanitation and Hygiene? We discuss Open Defecation Free status (ODF). We discuss uptake of handwashing with soap. We also discuss the construction of latrines. All of these factors can be indicators that will point to improved sanitation standards and the potential reduction of diarrheal disease. But how can we monitor and evaluate these indicators in a regular, timely, and accurate way?

Recently, the Government of Zambia and its partners implemented a system to track one of these factors – the construction of latrines – at a local, granular level, meaning the collected data can be sub-divided with information about each latrine, helping policy-makers know what type of improvements to implement in each area. Using the District Health Information System (DHIS 2), the same system the country uses to track things like malaria indicators and community-level trachoma prevention, everyone using the system can now see where latrines have been built and where they are lacking.

“DHIS2 is one of the few systems that enables simple feature phones to report directly into a central database that enables users to build custom dashboards from all levels, live feedback mechanisms, and custom reports,” said Scott Russpatrick, Informatics Manager at Akros [www.akros.com]. “It’s also free and open source to use, which is essential for ministries to sustain the system beyond the lifetime of donor projects.”

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