In a new learning paper published today, Malaria Consortium reviews the effectiveness of upSCALE, a community digital health platform implemented in Mozambique. Over a four-year period, upSCALE proved to be a supportive, agile platform able to respond to changing contexts and the needs of communities by providing high-quality, actionable data for improved quality and coverage of health services at the community level.
In Mozambique, scattered health facilities and an inadequate number of health professionals have resulted in insufficient access to health services, which stood at 68 percent in 2018. To address this gap, government-trained community health workers – known as agentes polivalentes elementares (APEs) – provide community-based care to remote communities as part of the government’s Community Health Workers’ Programme.
To assist APEs in their performance, and to improve their motivation and retention, Mozambique’s Ministry of Health (MoH) in collaboration with Malaria Consortium and partner Dimagi, developed an open-source mobile phone app as part of the Innovations at Scale for Community Access and Lasting Effects (inSCALE) project (2010–2016). Recognising the potential of inSCALE to be tailored and adapted for wider health systems strengthening, the MoH and Malaria Consortium transformed upSCALE into a comprehensive digital health platform, complete with modules from the expanded APE national curriculum as well as a complementary APE supervisor application to monitor performance.
“Digital tools better enable stronger enumeration, planning and monitoring of hard-to-reach populations, thus programmes such as upSCALE can support the attainment of achieving universal health coverage” commented Poppy Farrow, Malaria Consortium’s Senior Digital Strategy Specialist.
Data quality and use for better decision-making
upSCALE was originally created to support the government’s Community Health Workers’ Programme and strengthen APE supervision – the data generated were used to tailor supervision efforts to APEs requiring additional monitoring. By 2019, the platform use-case had evolved to integrate a decision-support tool to all APEs, primarily for integrated community case management (iCCM) service delivery protocols. The Power BI dynamic dashboards of the upSCALE platform provide data visualisations for actionable data, allowing supervisors, subnational and national-level stakeholders to identify programmatic inconsistencies, stock-outs and reporting issues that can be identified at the village level, facilitating improvements in data quality over time. APEs and decision-makers reported that access to rich data, as captured by upSCALE, increased confidence when making healthcare decisions.
As a result of the extensiveness and richness of the upSCALE data collected, by the end of 2021, Malaria Consortium secured funds to support the integration of upSCALE data into the national health management information system (HMIS), known as SISMA in Mozambique for improved central-level decision-making. Integration within the local HMIS will improve multi-sectoral decision-making by other divisions such as the National Malaria Control Program (NMCP), and the Nutrition and Child health departments, who will be better able to visualise data collected on the platform. The unique contribution of individual-level community data is also helping to address knowledge gaps that persist in malaria research, such as characterisation of severe malaria at the community level, factors influencing co-morbidities, and spatio-temporal trends of disease at a very granular level.
Agility and responsiveness
In the context of COVID-19, utilising the digital platform upSCALE enabled additional challenges posed by the pandemic to be overcome thanks to the ability to rapidly adapt the platform in response to the country context. Misinformation arising from a lack of accurate and up-to-date evidence on the virus and confusion over diagnoses – due to similarities of some COVID-19 symptoms to those of malaria and pneumonia – has made it more difficult for APEs to do their job effectively and support the COVID-19 response. New COVID-19 modules were developed for these health workers to cover awareness, education, disease surveillance and stock control. Changes in government advice and new symptoms as they were identified were communicated to APEs via the app – including SMS, audio and video messages.
Knowledge and awareness mapping surveys were also added, in addition to a stock-management system to track levels of equipment – such as PPE – provided by Mozambique’s MoH. A COVID-19 dashboard to report on geospatial outbreaks and key outcomes relating to the disease at the community level was also integrated. These agile additions demonstrated that the platform can rapidly respond and adapt to new demands and provide intelligence required to inform decisions in a timely way. The rapid modification of the platform is valuable to the MoH, whose continued ownership and leadership of upSCALE will optimise government capacity to respond to the changing needs of the country and its population.
An upSCALE user, interviewed as part of Malaria Consortium’s insight gathering for the learning paper, added: “Another success is the COVID work. We were dynamic and at the forefront, quite pioneering…how to educate APEs and the community on COVID prevention. We were quick to develop seven COVID modules and uploaded those on the platform, we modified content to meet that need.”
Training selected community members (APEs) in the skills required to diagnose, treat and, in serious cases, refer young children suffering from common childhood diseases such as malaria, pneumonia and diarrhoea brings essential healthcare for the most vulnerable to their doorstep, in addition to bringing skills to the community, reducing the burden on overstretched health facilities and saving lives by saving time. Integrated community case management (iCCM) – the approach used to diagnose and treat diarrhoea, pneumonia and malaria in children under five at the community level – can only be effective as part of a wider health systems strengthening approach if APEs, are well-trained and equipped, supported by the formal health system and motivated in order to provide high quality care.
UpSCALE provides APEs with the data, supervision and commodities needed to effectively provide health services to the communities in which they work. Consisting of a smartphone app, upSCALE guides APEs through patient registration, assists with diagnosis and advises on treatment and referrals. A tablet-based app also allows supervisors to monitor APEs performance and stock levels. Each APE receives a full week of initial training on how to use the platform. Ongoing APE supervision via the app means that performance issues are easily identified and swiftly addressed, ensuring that a high quality of care is provided to communities.
UpSCALE was designed to address the key programme challenges for APEs in rural areas: poor adherence to clinical guidelines; insufficient supply of commodities; and lack of access to community health information. An upSCALE interviewee commented: “We refined the training model approach, with a strong cascade for APEs, which saved a lot of money, and was a successful training model.”
Recommendations for digital health strategies
Malaria Consortium believes investment in digitising primary- and secondary-level health workers to improve the digital connectivity between health systems and data flow should be prioritised. Better adoption and integration of community-level data into the provincial level and national level information systems, as well as improved district-level ownership of digital platforms will strengthen access to data and promote its use for decision making. Supporting technical capacity development of digital skills and knowledge sharing within all levels of the MoH is also key to facilitate the embedding of technical knowledge and skills at all levels.
While digital strategies have the potential to strengthen health systems, these need to complement and enhance existing service delivery models and strengthen people-centred care. More data around the effectiveness of digital health strategies is required, something Malaria Consortium is working to address through its ongoing research.