Operationalizing spatial intelligence means saving lives

Operationalizing spatial intelligence means saving lives

By Anna Winters on March 21, 2019 in Health Data Systems, Malaria, News

As a spatial epidemiology PhD student, I was drawn to questions about how the environment relates to and facilitates vector-borne disease (diseases that are spread by vectors like mosquitos). These questions and interests tend to lead spatial epidemiology graduate school students (like I was) straight into the land of building spatial models. We effectively try to understand how measures like wetness, greenness, and elevation may combine mathematically to tell us where high numbers of mosquitoes live. If those mosquitoes live near human hosts, or even animals, there may be greater risk of vector-borne diseases.

So, I too built a lot of maps and models during graduate school. I mapped the risk of West Nile virus (WNV) in Colorado, USA. At the time, WNV had, somewhat shockingly, erupted in that region of the US. I also modeled human plague in Uganda—effectively developing maps to precisely depict areas at high and low risk of plague transmission. “Target interventions where it’s red” was the more-or-less summary, where red equaled high-risk areas. Point made. Thesis closed. Safe on the shelf.

But here I sit on the other end of the world, far away from hallowed academic halls that are often lined with dead dissertations and theses like mine. Here in southern Africa, disease transmission is much more tangible. Before, I read about death rates due to malaria and HIV from my school in Colorado, US. Here, I witness the impact of those death rates every day when I drop my kids off at school—new graves being dug closer and closer to the road. I am involved with a local school that is inundated with orphans and vulnerable children—even from one of the more affluent regions of Zambia. In this environment, high morbidity and mortality rates are incessant. Help is highly dependent on securing increasingly limited resources. Navigating the challenging logistics of getting those resources to the right people at the right time and in the right place are often broken. However, despite the acute need to target limited resources, mapping approaches like the one I developed in school are rarely seen nor used to inform interventions.

It is time for the public health community—both globally and locally—to do business differently. It’s time to more appropriately lean on the idea of spatial intelligence through epidemiological and map-based approaches to inform the practice of intervention planning and delivery. Academic, math-based modeling can lend a good understanding of where and how we should focus our limited resources to save the most lives. “Why aren’t these approaches being actively used?” you might ask. Part of the challenge is a lack of tools and finite planning approaches to translate maps and models into operational, boots on the ground, public health programming decisions. Questions like, “Where are all the houses located?,” “Which houses exactly should receive the intervention based upon the model output?,” and “Has the intervention effectively reached everywhere it was targeted?” are challenging to assess, particularly in regions like here in southern Africa, where so many areas consist of rural villages with no addresses.

Spatial approaches, when used correctly and operationalized simply and efficiently, can maximize the effectiveness of an intervention. By changing strategy and implementing smartly, we can turn those dusty maps and models into actionable, impactful strategies. Akros has worked hard to make smart, yet simple, mapping approaches useful for in-field operations. With our partner, Ona, we have designed and developed Reveal (and its predecessor, mSpray) to effectively support field staff to plan and guide interventions by applying spatial intelligence.  This includes determining where people live, where the risk of disease transmission is highest, and then prioritizing what villages and households must receive interventions to ensure that no one is missed.

After several years of refining this approach, we are now seeing the tangible results that we, intrinsically, knew would follow. Interventions are more effective. Because of the Reveal approach, fewer people are contracting malaria. And the approach is widely relevant to multiple other diseases as well. I am motivated to move the needle much faster, though. I refuse to complacently watch those grave sites move closer and closer to the road while millions of dollars are spent on public health, and so many of the right disease cures are already in hand. So here at Akros, we remain standing at the juncture between academic theory, innovation, and in-field application, continuing to push for new and better solutions to marry these ideas and save lives. These solutions may not be the shiniest tools that dazzle audiences at conferences, but they have been tried, tested, and developed right next to where the most severe health crises exist… and they are working.

About Anna Winters

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

The Inside of Context is King

The Inside of Context is King

By Anna Winters on January 31, 2019 in Capacity Building, Health Data Systems, News

Akros is a bit different than most development NGOs. Instead of a large corporate office in a distant setting, Akros bases its team in Southern Africa. If we are solving problems in rural developing contexts, shouldn’t we be near enough to the challenges so we understand them? We have chosen to be close to the beneficiaries of our work to receive feedback, learn from what works and what doesn’t, and provide simple yet innovative solutions to the everyday problems that are faced. Since our goal is to provide support to communities and their governments and to transition lessons learned into sustainable programs, shouldn’t we work very closely with our government partners both in the office and in the rural communities we serve?

We think yes. And that’s driven our design.

At Akros, we bring innovative ideas for gathering and using data to solve development challenges through a “boots on the ground” approach. We’ve built our organizational culture and nuanced approach to implementation by being where our work is: in Southern Africa. Akros has been supporting government and partner counterparts from our headquarters in Lusaka, Zambia for over ten years. This close partnership has helped to contextualize our work and to ensure that we are only scaling ideas and approaches that are proven to make impact and be sustained in under-resourced settings.

Being close to the challenges has meant the solutions that we’ve fostered gain ownership by community leaders. This type of accountability has created a huge impact. In Zambia, a chief’s wishes and commands hold a lot of weight. Getting these leaders data about their community, talking to them about health standards, and teaching them about health promotion and awareness can mean significant positive change for rural areas. For example, in some rural communities, open defecation was quite common. Our people went into communities, brought data and statistical evidence to the chiefs in formats they appreciated, and succeeded to get these community leaders on board with several water and sanitation interventions. Chiefs encouraged their communities to build latrines and use them. And then, the people did! The problem and effects of open defecation were therefore greatly reduced. The result was that some of the first open defecation free districts in all of Africa were named within Zambia.

If we had been based far from the situation, we may have missed the nuances of the problem by being outside of its context. We may have designed solutions that were too tech heavy for the environment. We may have created a “mobile tool” but not helped build an enabling environment for its success. We may not have understood how chiefdoms work and just gone into the situation blindly, wasting time and resources. We may have done “business as usual” and missed our mark. In short, we may have not made the impact on health that we strive to make.

There’s a joke in here somewhere about inside jobs. But for now, we’ll just say that at Akros, context is king.

About Anna Winters

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

It’s all about the maps

It’s all about the maps

By Anna Winters on January 15, 2019 in Health Data Systems, News

The Sustainable Development Goals (SDGs) set out big goals and targets—and countries are making real progress in some cases. Under five mortality has reduced by 58% in under 20 years. New drugs and vaccines are continuously coming to market. Some diseases, like polio and guinea worm, are nearing elimination.

Even still, large gaps remain. Every day, 3,000 children die from malaria. About 100,000 children die from HIV-related causes each year. These are diseases that are entirely preventable and treatable. Malaria is controlled with mosquito bed nets, antimalarial treatment courses, and insecticides. Antiretroviral treatments are making it possible for people living with HIV to live a long, healthy life.

If solutions exist, then why do we continue to see such levels of morbidity and mortality in the developing world? Too often it comes down to a lack of the right tools in the right place and at the right time. In seventeen malaria endemic countries in Africa, for example, indoor residual spraying (IRS) is used at a cost of hundreds of millions of dollars per year to kill mosquito vectors of malaria. In many cases, this tool is not achieving its full potential of reducing malaria, in part because it is not distributed to obtain a high enough true coverage. The World Health Organization tells us that IRS must be applied to at least 85% of a community in order to reach “true” coverage. Given the costs and the lack of enough resources to go around, the impact of this intervention sways further away from optimally saving lives from malaria.

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.

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.