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Using Digital Health to Support Community Health Worker Programs

An 18-month follow-up on Living Goods’ Maturity Model and Toolkit, a practical ‘how-to’ guide on implementing a digitally-equipped CHW program.

Technology has created an unprecedented opportunity to support community health. Globally, the number of cellphone users has crossed the 5 billion mark. We can harness mobile technology to connect community health workers (CHWs) to their clients, peers, and supervisors, to new data and information, and to health systems. Connected health systems are more efficient, more responsive, and more patient-centered.

Digitally-supported CHW programs have been demonstrating increased CHW performance across a range of geographies and contexts. For example, escalating mobile-based reminders of overdue visits resulted in an 86% reduction in the average number of days a CHW’s visits were late (9.7 to 1.4 days). When a personalized mobile-based performance dashboard was added to the routine supervision package of a CHW program in Mali, it increased the mean number of CHW home visits by almost 40 per month. In India, community health workers called ASHAs (Accredited Social Health Activists) who received tech-supported performance feedback increased their annual monthly visits by 21.5%.

Recognizing this potential, the Johnson & Johnson Center for Health Worker Innovation is working with partners to accelerate the adoption of digital technologies to strengthen community health and the ability of distributed CHW teams to deliver life-saving care.

One such example is Living Goods. By equipping CHWs with mobile technology, Living Goods has facilitated the reduction of reporting times from 4-6 weeks to near real-time, and ensured more accurate tracking of patient data over time, helping to improve consistency and quality of diagnoses and treatments. This includes better coordination of care, more follow-up on referrals, and reminders for treatment adherence. Mobile technology has also improved the quality of supportive supervision by tailoring support to individual CHW performance and needs.

The Center for Health Worker Innovation collaborated with Living Goods in East Africa to distill their lessons implementing a digitally-equipped CHW program into a practical ‘how-to’ guide to support others wishing to embark upon this same journey. Now, 18 months later, we reflect on the impetus for this work and what it has achieved.

Developing the Living Goods Maturity Model and Toolkit

Government-run community health systems often struggle with poor quality data from their CHW programs, as well as ensuring the accountability of field-based staff and managing the quality of care that is being delivered at the last mile.

At Living Goods, we are hoping to build on the successes of our community health model and drive sustainable impact beyond our current areas of direct operations. We are committed to delivering technical assistance to national governments and other implementers, drawing upon our own years of implementation experience, particularly in the field of digital health.

The Using Digital Health to Support Community Health Worker Programs Maturity Model and Toolkit was launched in December 2019 with support from the Johnson & Johnson Foundation. It is an assessment tool to help governments and other interested implementers gauge their readiness to digitize their community health systems. This assessment then guides the design of a targeted package of technical assistance. Working with HealthEnabled, we conducted a series of stakeholder interviews and workshops to inform the assessment tool and to test it with potential users.

Putting the Maturity Model and Toolkit Into Use

A year and a half since its launch, we’re pleased to say that the Maturity Model and Toolkit has been used in a range of contexts, including Kenya, Uganda, and Burkina Faso, demonstrating its adaptability.

Presenting the tool at the Institutionalizing Community Health Conference, Carolyn Kamasaka, Digital Health Specialist at the Uganda Ministry of Health’s (MoH) Division of Health Information Management, highlighted its value when implementing community-level digital technologies: “The maturity model has been an eye-opener in pointing out areas to focus on as we implement digital tools in the communities. We have been able to understand that technology is a means to an end, not the end itself. There are other areas that should receive the main focus before we bring in technology.”

For example, she noted several areas of government activity that could be supported by the tool, including development of case management data flows to support quality of care, user-centered design and testing with CHWs, capacity building on both hardware and software, planning for sustainability, and change management.

Additionally, the following examples from Uganda illustrate how the tool has guided specific decision-making:

1. Conducting a Bottleneck Analysis for Intelligent Community Health Systems

The Local Council chairman of Kasese district in Uganda is giving closing remarks at the end of a 2-day workshop where the Living Goods Maturity Model and Toolkit was used to assess digital maturity of Kasese district during the iCoHS bottleneck analysis activity on March 16, 2021.

UNICEF, in partnership with the Rockefeller Foundation and working through Living Goods and its partners BRAC, Medic, and DataKind to support the Ugandan MoH to achieve Objective 3 of the Intelligent Community Health Systems (iCoHS) project, which refers to the “use of digital health technologies to sustainably address bottlenecks in the delivery of integrated services at the community level, including visualization and use of community level data.”

To further this objective, the consortium assessed bottlenecks encountered in the delivery of services, and gaps in data generation and use, to identify opportunities that are amenable to digital health solutions. The Maturity Model and Toolkit was one of the tools used in five districts of Uganda to assess digital maturity and preparedness to inform planning for effective implementation of the digital solution that will be designed.

2. Partnering with the Uganda MoH to improve malaria case management

In March 2021, the Ugandan MoH and the National Malaria Control Division (NMCD) held a workshop with various stakeholders during which the Maturity Model and Toolkit was used to assess Uganda’s readiness to implement community-level digital tools as part of U.S. President’s Malaria Initiative (PMI). This project, in collaboration with MoH, NMCD, and Digital Square at PATH, aims to improve malaria case management at the community level by strengthening the use of digital tools.

Community Health in the Digital Age

Digitally-enabled CHW teams have been a lifeline during COVID-19. They have demonstrated their ability to maintain essential services even in the face of major health system disruptions. At a time when facilities were closed, strained, or feared by the public, CHWs were more motivated than ever to deliver essential health services so that vulnerable children and women did not fall through the cracks. The 11,130 CHWs supported by Living Goods across Kenya and Uganda delivered an unprecedented level of performance in 2020, saving an estimated 17,000-19,000 lives—double that of 2019—at a time when facility-based care plummeted.

It is no longer a matter of whether it makes good sense to digitize community health worker programs, but only of when and how. We encourage organizations to make use of the Maturity Model and Toolkit when planning their own digital transformations. Let’s work together to ensure that CHW teams around the globe are supported with technology to increase their productivity and performance and realize their life-saving potential.