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 email@example.com
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.
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.
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:
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.
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.
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.
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.
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.
Malaria kills a staggering number of people every year — nearly half a million. That number is unacceptable given malaria is both preventable and treatable and somewhat surprising given donors and governments spend hundreds of millions of dollars each year attempting to control malaria.
So why is that number still so high? Well, first of all, malaria is primarily in countries with largely rural and hard to reach populations. Getting to those populations is logistically complicated and costly. Secondly, the mosquitos that transmit malaria quickly adapt to resist insecticides and to evade interventions. Thirdly, the scale of the problem is massive. While there are half a million deaths and over 200 million cases annually, the population at risk is even larger – half of the global population. Half of seven billion people are at risk for malaria.
With this context, hundreds of millions of dollars in control efforts begins to sound like a drop in the bucket. In order to make the most of the resources at hand, we must maximize the impact of each dollar spent. For example, interventions like indoor residual spraying (IRS) – where spray operators move household to household spraying the walls of homes with insecticide in order to kill the malaria transmitting mosquitoes – are very effective at killing mosquitoes and reducing malaria. However, IRS is expensive. We need to ensure we are distributing IRS resources in the most strategic and likely most impactful way.
In 2017, Akros worked with the Zambia National Malaria Elimination Centre (NMEC), the Africa Indoor Residual Spray (AIRS) Project implemented by Abt Associates, and the U.S. President’s Malaria Initiative (PMI) to conduct a comparison control trial of IRS prioritization strategies. The question was simple: If we do not have enough resources to spray every house, where should we spray to see the greatest decreases in malaria incidence? Should we spray one condensed geographic area? Should we spray the areas near the health centers with the highest burden of malaria? Or, should we spray the areas predicted to have the most mosquitoes? Each of these questions defined an arm of the study; one arm targeted IRS by concentrating it in one geographic area, one arm targeted IRS by prioritizing its delivery by health facility-measured malaria burden, and one arm targeted IRS by prioritizing its delivery by predicted mosquito density due to ecological factors. The NMEC implemented each arm in two districts of Eastern Province during the 2017 IRS operations.
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 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 project will focus on supporting national malaria control programs in USAID-supported Malaria Endemic countries including 25 in Africa and three in Asia. The interventions aim to improve quality of and access to malaria case management and malaria in pregnancy interventions. They will also improve quality of and access to other malaria drug-based approaches and provide support to pilot/scale-up newer malaria drug-based approaches. Global technical leadership, support for operational research, and advances in program learning are priorities as well. In addition to the core team, private sector partner Akros and University of Oslo and Medicines for Malaria Venture will support.
Akros will lean into its experience working with national ministries by leading efforts on strengthening capacity building of Ministries of Health (MoHs) for HMIS and executing a central strategic plan around data use within the MoHs and communities.
Globally, the world has made remarkable progress in controlling malaria; halving the burden of disease between 2000 and 2015, but progress is stalling. The WHO’s most recent World Malaria Report highlights the current state of case management of children under five years and delivery of intermittent presumptive treatment for pregnant women as major concerns.
The President’s Malaria Initiative, led by USAID and implemented with the U.S. Centers for Disease Control and Prevention, is the U.S. Government’s primary vehicle for assisting malaria affected countries to scale up proven malaria control and elimination interventions.
The PMI Strategy for 2015-2020 accounts for much progress over the past decade and offers a strategy for new and emerging challenges. Malaria prevention and control remains a major U.S. foreign assistance objective and PMI’s strategy fully aligns with the U.S. Government’s vision of ending preventable child and maternal deaths and protecting communities from infectious diseases. By working with PMI-supported countries and partners, the U.S. Government aims to further reduce malaria deaths and substantially decrease malaria morbidity, towards the long-term goal of elimination.
This new contract comes as PSI launches its new global strategy for consumer-powered healthcare. APMSD will innovate ways to bring healthcare closer to the consumer in developing countries. PSI is proud to be associated with USAID and its partners to achieve this goal.
How can the same sort of systems we use to collect and organize health data from rural areas be used to collect and organize land use? Why is land use important for development? Check out this recent article from “The Best of Africa” blog to learn some of those answers and more!
If you missed the webinar we did with the Nonprofit Organizations Knowledge Initiative, take a look at the full recording below. Akros team members Dr. Robert Ntalo, Rabson Zimba, and Bethany Joy Larkin share some of the things Akros learned while implementing CLTS across Zambia. The title of the webinar is “Data Empowers Decisions – How Traditional Zambian Leaders are Making Decisions using DHIS2 Mobile Platforms.”
On November 16, current and former Akros GHC fellows shared their experiences and fielded questions from hopeful GHC candidates. Each year, GHC a diverse group of young leaders with a vested interest in health equity joins GHC to complete a 13-month fellowship with partner organizations in five countries: Malawi, Rwanda, Uganda, Zambia, and the U.S.
Below is a full recording of the webinar in case you missed it!