As part of a broad agenda of building inclusive digital economies, UNCDF has partnered with BRAC Uganda and Medic to engender sustainable digital health approaches to enhance the impact of the existing Ministry of Health community health structures towards achieving universal health coverage. Due to the significant shortage of trained health workers in Uganda, community health workers, notably Village Health Teams (VHTs), have become the cornerstone of Uganda’s primary health system. Working primarily in a voluntary capacity, VHTs are community members who receive basic health care training to provide home visits and health management services. They are a critical link between the formal health sector and their communities. Our partners BRAC Uganda and Medic are piloting the use of a Community Health Information System popularly known as the VHT App to facilitate VHTs in their routine essential care, education, data collection and reporting.

Why digital?
The Community Health Information System aims to introduce a sustainable digital solution that will enhance efficiency in service delivery and reporting by the VHTs through digitizing the already existing paper reporting systems. Consequently, the tool is envisaged to improve service quality, productivity, motivation, and the performance of the community health workers. The tool is based on the Health Management Information Systems (HMIS) form. HMIS is an integrated reporting system used to collect relevant and functional information on a routine basis to monitor the Health Sector Strategic Plan indicators.

The overall learning theory to this intervention is the accompaniment approach that involves working closely with all stakeholders to create buy-in of the districts and their health systems so that they can own the initiative and sustain the developments in a way that keeps everyone accountable to the community’s vision for health and well-being. The partners work with districts to design, implement, embed, and scale the digital health tool in the district and national health system, focusing on government leadership, adoption, and ownership. Previous experience by Medic using a Community Health Toolkit (CHT) in community health care provision for over five years has taught us that digital health significantly enhances the quality of care provided by community health workers.

Leveraging this experience, the partners conducted a needs assessment, system design and prototyping, training of trainers and end-users, and user feedback sessions to augment the effectiveness of the tool. Implementation of health programmes is prioritized based on resources available and the opportunities to demonstrate quick implementation successes to mobilize more resources and secure both grassroots and political support. The solution is being implemented in the districts of Koboko, Maracha, Lira and Nebbi, where BRAC Uganda is implementing related projects to leverage prior resources and existing engagements and lessons learned for evidence-based planning.

What Challenges will the VHT App Solve?
The prevailing paper-based reporting system is costly and leads to inaccurate and untimely reporting and cumbersome data validation. The VHT App is expected to reduce the costs related to paper-based reporting and inaccuracies and promote efficiency through timely reporting and easy data validation.

Besides monitoring and support supervision being a very hectic process in the national health system, a study conducted at the inception of the project to understand the reporting challenges found that while the districts report that VHTs are being supervised by the in-charges of health centres, health inspectors, assistants, and educators, these workers were found to lack transport to monitor and supervise VHT activities regularly. As a result, most of the support supervision conducted is not informed by the timely availability of data. This reduces the effectiveness of the support supervision.

Districts lack evidence of monitoring, supervision, and coordination of the VHT programme. Consolidating paper-based reports is also difficult, and the reporting rate into the community module for District Health Information Software (DHIS2) and the national health information system is therefore low. Without DHIS2 reporting, it is difficult to make evidence-based decisions on quality improvement, coverage of health services, equity, and ultimately difficult to influence policy and national planning for communities.

There are also inconsistencies and inaccuracies in the diagnosis of Integrated Community Case Management diseases due to lack of a tool to guide Community Health Workers (CHWs) on the chronology of questions that they should ask a client to arrive at an accurate diagnosis. As such, the vast cohort of CHWs depend on their memory to ask relevant questions to arrive at a diagnosis. The digital solution will provide a chronological approach for CHWs to arrive at a diagnosis in line with government guidelines.

The future for adopting a digital tool for community health is in progress; the need for remote work presses and faster information from the community is apparent as the very future of seeing another day depends on being able to work from home. If these volunteers are to stay relevant in the fight against diseases in the community, they need to adapt to digitalization, and a community health information system offers such an opportunity. Be it decision flow processes or the reminders for referrals or the emergency tasks, it creates for the health worker the ability to suggest an emergency dosage to treat an onset of pneumonia to a child under five years or detect a high-risk pregnancy by a simple and esy to understand diagnosis.

Adopting the VHT App for the Public Sector
Just like any other innovation, adopting the digital tool is not a straightforward process. To begin with, there are disparities in the technical capacity for digital health at the community level. There is still weak human resource capacity in skills and numbers. There is a low literacy rate among VHTs, and this calls for the use of colours, numbers, and pictures to help them identify conditions in the tool. Translating the tool may not be a solution since most cannot read and write in the local language. Grasping the tool, therefore, requires additional training and support supervision.

Some of the VHTs are also advanced in age and have eyesight challenges. Yet, the districts prefer them since the younger ones are more susceptible to attrition as they are considered more mobile and possess more risk to the mobile phones that will be provided to them to access the tool, especially in border districts where monitoring and follow-up are complex.

Secondly, even when we deploy the digital system, the community health workers still face the challenges of a non-functional emergency response system, inadequate inputs (kits) such as thermometers, weighing scales, etc., for them to observe the recommended standards of care and quality of service. The result is that they cannot do their job correctly even in the tool, for example, if a temperature reading is required and they have no thermometer. Failure to meet the expectations of the communities destroys the image of the VHTs and undermines their credibility.

There is a lack of sustainable ways for motivating the VHTs. To identify approaches for VHT motivation, monetary and non-monetary forms of motivation are present. Monetary motivation is primarily provided by health care implementing partners, mostly non-governmental organizations. The VHT engagement in the districts is tailored mainly to the specific programme interests of these partners. Development partners have made significant contributions to the overall implementation of the VHT programme through financial, technical, and logistical support. However, there is an inequitable distribution of partners among and within districts and as a result, VHTs efforts are concentrated more on these programmes than Government programmes.
There is a need for collaboration of the different partners working in the same space for efficiency and alignment with the Ministry of Health objectives. We are looking into integrating the solution with the District Health Information Software as the systems are interoperable and have also established working relationships with the Division for Health Information & National IT Authority to host and manage the digital system in-country. The MoH is working towards a shared vision for interoperability with the national eHealth system.

There is also growing consensus that the implementing partners need to have a strong local footprint and understanding of the local culture to promote efficiency in service delivery and swift adoption and buy-in of the communities where they work. This is critical for the sustainability of the solution to be achieved.

The district health teams are rightly concerned about sustainability and adoption of the digital solution. One district biostatistician asked “We have had one for every year and we work so hard at it but what happens to adoption, have you done enough?”

Sustainable solutions for the future
Sustainability is at the core of the community health information system. It harnesses the community level experience of the partners to enhance the existing working tools of a community worker. The partners are looking into opportunities with the flexibility that comes with dealing with a fragile, not straightforward system to provide the least expensive solution to the districts by funding most of the core product development. As a result, the partners do not charge any per community health worker or per-user license fees, making scale achievable at a very low cost. This approach and pricing are envisioned to increase replication, reuse of the tools, scale without pricing constraints, and long-term ownership and adoption of the core software components by partners.

As observed during the recent long-awaited deployment activity, the VHTs are enthusiastic and excited to have a handset. The district teams are optimistic about the solution with promises to ease reporting with the endless possibilities the application offers in collecting real-time community data, real-time reporting, faster follow-ups, at-a-glance reporting of performance using dashboards and mitigating all the issues that come with paper reporting.
We shall share more on this journey as we go.