Five steps to wrap technology and optimize impact: community malaria surveillance for elimination in Zambia

Five steps to wrap technology and optimize impact: community malaria surveillance for elimination in Zambia

By Anna Winters on December 5, 2018 in Malaria, News

Image caption: Community health workers (CHWs) provide malaria testing and treatment; line-lists in paper registers and aggregated by “data” CHWs and submitted to the DHIS2. Malaria data are mapped to both CHW posts and health facilities.

Akros supports countries and their partners to design, test, and deploy interventions to scale for impact. Often this involves supporting governments to transition from paper-based to digital data collection and reporting. Below is a case study which outlines our approach of applying simple technology that is wrapped in the necessary processes, protocols, and trainings to deliver quality data and build intervention impact that scales.

Component D was initially implemented in districts of Southern, Central, and Western Province, Zambia. Now multiple partners are supporting the rapid scale up of Component D across Zambia, improving malaria surveillance data, while also expanding access to care across the country. Thanks to PATH-MACEPA for this map.

The Government of Zambia (GRZ) has an ambitious goal of malaria elimination by 2021. One approach to achieve this goal is to improve malaria surveillance at the community level. Akros worked alongside the National Malaria Elimination Program and PATH-MACEPA to develop a community-based malaria surveillance system called “Component D.” The goal of Component D is to build community structures that will increase access to malaria testing and treating, identify and eliminate parasite reservoirs, and understand where (within health facility catchments) malaria transmission is happening. Effectively: to better understand and respond to the “needle in the haystack” which malaria can often be.

To assist the GRZ, Akros applied its five-part approach of “wrapping” technology with the processes, protocols, and training that ensure the technology contributes to impact and is able to scale:

  1. Discover and assess—we explored the systems that were already in place in Zambia, evaluated the data needs, and identified the change agents that needed to understand and action information.
  2. Build a “prototype design”—we leveraged simple technology (java feature phones and open data kit software) and documented and developed the processes, protocols, training materials, and supervision needed to support that technology and make it sustainable. We built feedback loops to assist programs to respond to those data.
  3. Work with country governments and partners to test the design through small-scale implementation—we implemented Component D in Southern, Central, and Lusaka Province, Zambia.
  4. Wrap that implementation with research to understand cost efficiency and disease impact—we learned that Component D was one of the primary drivers expanding access to care and treating reservoirs of parasite infection.
  5. Work with our host governments and partners to iterate and smartly scale—from its initial small-scale implementation, Component D has become country policy. Since then, numerous partners and GRZ have now expanded to 36 districts in Zambia.

Did the country switch over to the new system en masse or was there a pilot area / time period? How was this decided? Discovery and assessment processes began in 2009, leading to implementation throughout several districts in Southern, Central, and Lusaka Province over a period of three years. These districts were determined based upon their malaria burden and their existing leadership being open to leveraging community health worker (CHW) activity to better understand the malaria burden at local levels. Component D has now become the GRZ policy for malaria surveillance in malaria elimination districts. Isdell Flowers, PATH-MACEPA, the Global Fund, USAID PMI, and others are leveraging their resources to assist GRZ to continue to expand and improve Component D.

Was there duplicative reporting on the legacy system during the transition period? Component D brought more rigorous “structure” to existing CHW registers, but still relied on the familiarity of these registers while also introducing simple aggregation processes for digital reporting of data.

What measures did you use (or are you using) to validate that data in the new system is adequately high quality in order to build confidence in the new system’s data and switch off the legacy system? Data validation includes periodic record reviews validating CHW registers with aggregated figures, locations and stock use, and in-built validations within the DHIS2.

What resources (e.g., licensing costs, technical support, new printed training materials) were required in order to make the transition? Resources required to transition toward digital data have been the greatest up front, including technical support to prototype and implement, cascade training costs, and initial “supervision visits” to support system continuity and health. As the system has become embedded in the GRZ, external supervision visits have reduced, while internal GRZ supervision has increased.

What have been some of the impacts of this system?

  • The proportion of children with fever to malaria testing increased from only 9% prior to CHW scale-up to 81% by 2017.
  • Parasite prevalence fell from the normal range of ~30% down to 4% by 2016 and remained stable.
  • Access to care doubled.
  • Community malaria data became available at central and district levels, which was not previously available. These data guide health facility stocking and intervention prioritization and planning.
  • Sub-health facility malaria data now available and mapped within DHIS2.
Component D utilizes a reactive case detection approach to follow-up with malaria cases (index cases) identified at clinics or community health worker posts by testing and treating neighbors of that index case. Figure from: https://www.ncbi.nlm.nih.gov/pubmed/26586264.

 

Links to more information:

https://www.nmec.org.zm/enhanced-surveillance

https://www.ncbi.nlm.nih.gov/pubmed/26586264

https://akros.com/malaria-prevention/community-surveillance/

About Anna Winters, PhD

Anna Winters founded and serves as the CEO of Akros. Winters holds a PhD and MS in epidemiology coupled with extensive field experience leading the development and implementation of community-wide surveillance systems in sub-saharan Africa aimed at targeting health interventions to maximize impact. Through Akros and previously with the Centers for Disease Control and Prevention, Dr. Winters works directly with host country governments to ensure viability and integration of health innovations. Contact her at awinters@akros.com

Finding a village never before visited by IRS

Finding a village never before visited by IRS

By Ernest Mulenga on March 8, 2018 in Malaria, News

Background

The mSpray tool is more than just a mobile data collection tool that improves data quality and timeliness. The mSpray tool provides spray teams with maps to navigate to areas that might otherwise be difficult to find. These maps are highly accurate and complete, made through our satellite enumeration process. The district mop-up teams are especially reliant on these maps. Mop-up teams, are teams designated by the district with the specific task of revisiting areas that were not sprayed well during an initial visit or areas that were missed completely.

Unsurprisingly, mop-up teams help more areas reach the coverage goal of 90% sprayed and these teams visit some of the most remote villages, some of which have never been visited before. Ernest Mulenga, an Akros Surveillance Officer, documents the Chadiza’s mop-up team visit to a village; because the the team relies heavily on maps to navigate, they adopt vernacular of mapping and navigation, referring to the villages by the codes assigned to the “polygon” shapes appearing on the maps.

The search for polygon 01-455

It was the 9th of November 2017 when the mop-up team left Chadiza IRS base in search of Polygon 01-455 under Mtaya catchment area, which is located to eastern side of Chadiza district about 45 km from the district main post office.

Passing through Ngala area under Miti catchment, the team made a first stop at polygon 01-457 around 11:00 before proceeding to 01-455. The team used the GPS locator on the mSpray application, to navigate to a road that would lead to the village. Discovering the road to be impassable due to flooding from the heavy rain the team was re-directed by locals to a path that went through the mountain, and was said to be passable with a vehicle.

The Mtaya catchment area. The spray team was progressing through this area when they found polygon 01-455, which had never before been visited by a spray team.

The journey through the mountain started off well. After climbing some distance, however, the path became too filled with potholes for the Land Cruiser to continue. The team was left with no choice but to complete the journey on foot. At this point the team felt that they had covered a considerable distance with the Cruiser and that the polygon must not be far off. Thus, the team began to move with the aid of a GPS on the tablet. Once the direction of walking was set, the tablet was switched off for fear of using too much battery power.

“The Professor” Charles Mwiinga on life as a teacher, farmer, and Community Champion

“The Professor” Charles Mwiinga on life as a teacher, farmer, and Community Champion

By Andy Prinsen on November 19, 2017 in News, Water and Sanitation Health

I’ve realized that, in Zambia, almost everything is done in groups. I’ve arrived at a village called Ngandu Jakalasi expecting a short sit-down interview with a certain Mr. Mwiinga, but am instead greeted by every adult in the village, beginning to spread out on blankets and on logs. “Yes, everything in groups,” laughs my companion, Akros Surveillance Officer Anne Mutunda. “It’s the way we do transparency!” she muses, though I think she’s actually quite serious.

When my subject arrives I am at first a bit confused because my preparation notes say the man is 70. Instead the man I meet is spry-looking, wearing a trim gray goatee, a mischievous grin and a red bucket hat. After we exchange greetings and have a seat on opposing logs, ingeniously supported about a foot and a half above the ground by separate, y-shaped logs, I ask him about this apparent age discrepancy. “I am 70!” he tells me, “though I feel younger than that. Look, I can even run!” he says as he springs back up from his log and gives a demonstrative lap around the collected audience who clap and laugh in approval.

Elijah Charles Mwiinga, 70, sits with his neighbors to discuss bringing the message of CLTS to his community.

He attributes much of this energy to his having been a teacher for 20 years, first in Zambia’s Western Province and then in its Southern Province. When Mr. Mwiinga was a boy, his uncle was a teacher, and he envied the man, who he saw as getting to spend enjoyable days with the children of his class, having fun while passing down knowledge. So go into teaching he did, and successfully, rising through the ranks of teacher and head teacher and, eventually, school principal. He says his job was difficult at first – the schools at times had no materials. As the years went on, the job got easier as he knew more of what to expect.

In 1990 he retired from teaching and decided to return home. He had grown up in the village and he wanted to return. “I was brought up as the son of a farmer so I decided to come back and farm,” he said. “We depend on the farms. We grow what we eat.” He now grows cabbage, tomatoes, onions, rape, and sometimes carrots. Though he had begun his new “retired” life as a farmer, Charles was still a connector of people – he maintained his teacher’s proclivity for explaining things in ways people could understand. (He has been given the nickname “The Professor” in his community as a result.) It was likely for this reason that the Environmental Health Technician (EHT) for his community chose him to attend a workshop in Mazabuka when the first training for Community Champions began. “I didn’t know exactly what it was but I went,” he said.

Akros in India: Perspectives on ICT4D

Akros in India: Perspectives on ICT4D

By Brian O'Donnell on June 20, 2017 in Health Data Systems, News

What do you feel when the Star Wars end credits roll? If you’re like me, it’s an abrupt mental shift from awestruck fantasy back to real life, a reminder the movie only got made when thousands of real people collaborated towards a singular vision. If you’re nerdy enough to dive into “behind the scenes” extras, all the grunt work needed to make a blockbuster franchise looks… well… less exciting. Of course, once you discover how a film was made, you begin to appreciate its artistry on a whole other level.

I had the same feeling as I absorbed two weeks of conferencing in India with digital development and global health practitioners from around the world on behalf of Akros. At the Information and Communication Technology for Development (ICT4D) conference in Hyderabad, we joined global experts to share our practical experiences in applying new technologies across a wide spectrum of development and humanitarian programs. Akros also participated in the Health Data Collaborative’s community health experts’ consultation in Goa, The workshop convened academics, government officials, and implementers from eight countries to craft technical guidelines on digitizing mobile health data from community health workers, the volunteers who deliver critical services in the most remote regions of Africa and Asia.

From theorizing on the broad meaning of the “Data Revolution” down to nitty-gritty tech requirements of community information systems, the overarching theme of both events was mainstreaming technology into day-to-day operations of development programs. That means moving past the futuristic “gee wiz” stage of exploring what’s possible with ICT4D, towards setting practical expectations and realistic national strategies. This is very familiar territory for us at Akros, where we have a developed for applying practical informatics systems for a variety of complex development challenges, ranging from malaria prevention to education management.

Some of the tips shared at the ICT4D Conference might seem obvious in theory, but can be surprisingly rare in practice, especially in public health. For example, before you start an new system to collect community level health data, you ought to know what kind of data already exist, and ask real people how these data are used. This tactic was exemplified by Cooper/Smith, which presented a robust landscape analysis of HIV data in Malawi under the Kuunika – Data for Action! project. Their focus groups with stakeholders found over 3,527 unique data elements across five systems, informing 335 unique decisions. Detailed assessments like these will not only increase the use of routine health data for decision-making, but might catalyze new innovations to send data where its most needed. Ona presented on the tablet-based mSpray tool, deployed by Akros in Zambia, which gives managers of Indoor Residual Spray teams the localized geographic information they need to manage local spray operations. Mangologic and e-Registries also presented on two adaptive tools for health professionals to bridge individual-level patient records with population-level health management systems— two solutions which only arose from assessing what tools already exist, and finding their design inappropriate for the complex user needs.

The Elimination 8 Regional Surveillance Database (ERSD)

The Elimination 8 Regional Surveillance Database (ERSD)

By Annie Martin on May 8, 2017 in Capacity Building, Health Data Systems, Malaria, News

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.

Chipo’s Story

Chipo’s Story

By Andy Prinsen on February 3, 2017 in News, Trachoma Prevention

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.

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

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

By Laurie Markle on October 18, 2016 in Capacity Building, News

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.

Building one of the world’s largest data surveillance platforms

Building one of the world’s largest data surveillance platforms

By Alexis Barnes on September 19, 2016 in Health Data Systems, News

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.

Fighting trachoma in Zambia

Fighting trachoma in Zambia

By Alexis Barnes on August 12, 2016 in News, Trachoma Prevention

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.