Designing for Scale

Case Study: Designing a mHealth system for the community health supply chain in Malawi

Malawi Context

• Community Health Workers (called HSAs) in Malawi live and work in hard to reach areas (>8km from health center)

• HSAs are one of the lowest paid cadre in Malawi Civil Service • Supervised under the District Health Management Team • Previously HSAs did not manage products, only focused on prevention activities

• Recently HSAs have been trained to treat common diseases such as malaria, pneumonia and diarrhea to children under 5 years and provide family planning to women.

• HSAs can now manage up to 17 products that they store in a drug box in their home.

• HSAs collect medicines from the closest health center (>8km).

Problem Statement

Key Quantitative Baseline Assessment Data 2010 • 27% of HSAs who manage health products had four CCM tracer

drugs* in stock on day of visit • 43% HSAs submitting reports that contain logistics data to HC • 14% of HCs reported passing HSA information to higher levels

*cotrimoxazole, artemether lumefantrine 1x6 and 2x6, ORS

• Poor availability of medicines • Irrational drug management process • Lack of visibility of HSA logistics data due to low

reporting rates and poor movement of data • Lack of coordination in drug management at all

levels • Weak linkages between community and health

facilities • HSAs would travel long distances to collect

products only to find there were no products

Solution

• 94% of the HSAs surveyed had basic GSM mobile phones

• 80% of HSAs and health facility (HF) staff had continuous network coverage at their place of work

• all districts surveyed had computers and access to the internet

Mobile based system to manage reporting

and resupply process

Ecosystem • Different MOH departments involved:

Pharmaceuticals Department and Child Health Unit

• Different implementing partners support different districts

• Project only had resources for piloting in 6 districts and did not have the resources to take the system to scale

• Multiple partners piloting different mHealth solutions for supporting service delivery at community level, no common vision

• Infrastructure and capacity for data hosting, software development and maintenance is low in MOH and in Malawi

• Supply chain information systems was only automated above district, but not networked, relies on data being transferred by flash drives

Designing for Scale

• Design for scale from the start, and assess and mitigate dependencies that might limit ability to scale.

• Employ a “systems” approach to design, considering implications of design beyond an immediate project.

• Be replicable and customizable in other countries and contexts.

• Demonstrate impact before scaling a solution.

• Analyze all technology choices through the lens of national and regional scale.

• Factor in partnerships from the beginning and start early negotiations.

Group Discussion

What considerations would you make when designing the system and the pilot to ensure it can be taken to scale?

1. Technology and Infrastructure

2. Institutional Stakeholders (policy makers and implementing partners) and System Users

3. Data Use, System Monitoring and Evidence Generation

Overview cStock is a RapidSMS, open-source, web-accessible logistics management information system for community-level health

products in Malawi.

• Uses basic GSM phones already owned by HSAs to report data via SMS on a toll free phone line

• HSAs in Malawi only manage up to 17 products but generally manage about 7 or 8, so SMS reporting for all products in one message was feasible and not too burdensome

• Data is cloud hosted • inexpensive, secure, reliable and easy to

manage option for a small scale system like cStock in a country like Malawi

• did not require recruiting/training IT support staff and procuring/maintaining a server

District, Zonal and Central staff

access HSA logistics data via

dashboard

Health Facility supplies the HSA based on SMS

message

HSA sends SMS with SOH each

month

The database calculates – Months of Stock and resupply

quantities, reporting rates, number and duration of stock outs, displays on dashboard

Data and Product Flow

Reports & Dashboard

A web-accessible dashboard with simple, easy-to-use

reports, shows stock levels, reporting rates, and alerts for central and district level

managers

S s

In addition to cStock, SC4CCM introduced District Product Availability Teams (DPATs) that use cStock data to monitor and improve supply chain performance

Connecting to the Health System

DPATs have proven to be an important complement to cStock. DPATs “demand” updated data that cStock “supplies,”: motivating HSAs to continue reporting.

Operationalizing MOH ownership of the system • Formation of a taskforce (MOH chair) with all stakeholders dedicated to

institutionalization of cStock and DPATs • Formation of national team of implementing staff to monitor implementation,

monitor the dashboard and provide follow up support to users • Finding champions in MOH by having central level advocates and trainers in

every districts • Capacity building of MOH to provide management and leadership, currently have

a secondee in MOH • Development of comprehensive, five year transition plan with cost estimates for

resource mobilization, in the short term, and eventual transition to MOH budget

Scale Up And Institutionalization Partnering to Scale builds broader ownership and capacity that lasts after project ends • As of last week all 29 districts (3059 HSAs) have been trained with funding from

WHO, Save the Children, UN Foundation, USAID and SC4CCM

Designing cStock for Scale

• Kept the design simple and suitable for the context • Used GSM for data transmission so HSAs could use their

personal phones

• Collects minimal data so as not to overburden

• Appropriate for the skill level of the HSA

• Revisited some of design early in the pilot when users had experience to draw from • user centered approach to build local ownership

• Used cloud hosting as it was cheap, reliable and easy to manage • capacity for data hosting was low and as cStock only requires a

small data hosting space was not worth investing at this stage

Designing cStock for Scale

• Engaged partners and MOH from the outset

• continued to provide updates and data throughout pilot and encouraged partnering for scale up to broaden ownership

• Created a open source system that can be interoperable with other systems

• have supported partners to integrate cStock into their newer mHealth systems for HSAs

• Combined the mHealth solution with interventions that take a systems approach which ensured the data was valuable and used to improve the system

• Developed a transition plan well before the end of the project and help set the ground work for sustainability

ore information on cStock visit: //sc4ccm.jsi.com/cstock/