Head Start
Social Challenge and Innovative Solution
Lack of access to quality primary health care, or any primary health care, is still a pressing issue in many low and middle-income countries. Preventive care measures (such as vaccines) and routine check-ups of expectant mothers need significant improvements in coverage and consistency. Improvements in coverage and equity of maternal and child health are necessary to ensure that no mother or child dies of preventable or easily curable diseases. Currently, it is estimated that around 4 million children across the globe still die of preventable or easily curable diseases.
One critical step on this journey is to ensure that patient visits and health data are recorded and followed up to close health gaps. In most LMIC countries, the Health Management Information Systems (HMIS) in use are still paper-based systems for health data collection, reporting and storage, which are needlessly time-consuming for health workers, and prone to errors in recording. Monitoring and evaluation of the correctness of this data are also resource-intensive as they need to be undertaken physically and across all health service delivery points. There are no KPIs to indicate where there may be a problem or gaps in either data collection, registry or health service delivery. In addition, despite significant global commitment, in many cases, immunisation rates of children remain below targets – in large part because the actual gaps are not closed, and children are not systemically followed up and miss out on scheduled vaccines.
To tackle these issues, Shifo Foundation began by looking into the data collection for the mother and child health component of HMIS. It developed MyChild Solution (earlier MyChild System), first as a point-of-care electronic system. Based on lessons learnt from piloting this system in low resource settings like Afghanistan and the Dokolo district in Uganda, Shifo gradually moved through iterations and pilots via the scanned “MyChild Card” to a hybrid system, known as Smart Paper Technology solutions or SPT. Currently, SPT supports maternal health, child health and supply chain.
Thanks to the Smart Paper Technology, the paper forms are scanned into a database that generates reports (per child, health centre or district) and follow-up lists for efficient mobilisation and reliable data for better decision-making across the healthcare chain.
Today, all the tally sheets and reports that had to be manually compiled by health workers are automatically generated. Along with SMS reminders sent to families, a defaulter list –indicating those families who missed their scheduled visit– ensures that children can be followed from birth to five years old and that they receive their vaccines when due. Infant Welfare Cards (called MyChild Card in the Dokolo pilot) are still issued to the caretakers and kept at home for their records and brought to each vaccination visit.
Key Social Impact Figures
The latest indicators for Uganda and The Gambia can be found on https://shifo.org
Data on Dokolo, Uganda: by September 2017
Data on Mukono and the Gambia: by September 2021
Investing for Impact
How it started
In 2014, through mutual contact, IKARE was introduced to Shifo, a non-profit foundation start-up with people who had broad experience in public health and ICT. IKARE learnt about MyChild Solution and appreciated Shifo’s approach of going to the root of the problem.
IKARE had, since 2006, been engaged in the district of Dokolo (Uganda) in the control of sleeping sickness through the Public Private Partnership Stamp Out Sleeping sickness and subsequent start-up funding of the 3 V Vets network. Therefore, the investor for impact was acutely aware of the general lack of health services infrastructure and reliable data, making early detection of epidemics, diagnosis, treatment, and follow-up very challenging.
Having seen the first fully digital version in operation in Mukono district in Uganda, IKARE thus agreed to sponsor Shifo in undertaking a six-month in-field evaluation to see if and how the digitised MyChild Solution could be adapted to work also in a low-resource setting like Dokolo. It rapidly became clear that this would not be a viable option with only one health centre out of 16 having some sort of regular access to electricity, bad ICT connectivity throughout the district, and limited computer literacy among health workers. Let alone affordability.
It was clear that the new solution, whatever its design, would not only have to show clear benefits for its users (health workers) and beneficiaries (families with children) through (1) cutting down on time spent on administrative work and (2) improving quality of data (from 20% to 99% accuracy), but also show to its future owners and operators, the Ministries of Health, and their traditional funders, that (3) the operating and maintenance cost of the new HMIS solution should ideally be equal to or even less than that of the existing system in place. Otherwise, the solution would not allow for sustainable systemic change to happen. As a first result, Shifo came up with the Smart Paper-based version of MyChild Card.
After funding the in-field study and first MyChild Card pilot, IKARE decided to also fund the first-ever district-wide implementation of MyChild Card, which Shifo undertook during July-December 2016. By January 2017, all 16 operational health centres in Dokolo had transferred to the system.
Support provided
IKARE funded the first pilot (six-month project 2015-2016) with a €52,000 grant. An additional grant of €230,000 was then agreed to implement MyChild Solution in Dokolo, including IKARE’s share of the operational and maintenance costs during the “hand-over” period to the local government.
In parallel to this implementation, the Mukono pilot continued with funding and implementation support from IKEA Foundation, Swedish Postcode Foundation and Plan International. When the Ugandan government stopped the Dokolo implementation as the Ministry of Health decided to review their HMIS strategy, which coincided with IKEA Foundation’s grant funding coming to its end, IKARE and Shifo agreed to switch the remaining Dokolo grant to Mukono.
Inspired by IKARE’s 3 V Vets exit case study and various discussions held among IKARE and Shifo during the pilot project, Shifo adapted its product and business model to better adapt to financial reality and thus be sustainable. Shifo also innovated on its scale-up strategy by working with locally-based NGOs and other partners. Where a country is unable to fund the implementation of the MyChild Solution on its own but has the funding for the operating and maintenance costs, then donors support the implementation of the system (in this case, IKARE for Dokolo) while gradually reducing their share of the operating and maintenance costs over five years, as the local government takes an increasing portion.
This ensures ownership of the solution by the Ministries of Health in the respective countries, but it also provides an exit for Shifo and catalytic donors like IKARE. The affordability coupled with rapidly recognisable benefits for users and beneficiaries provides the necessary fundamentals for systemic change. In addition, the reliability and timeliness of data provide the necessary fundamentals for enabling a move to Results-Based Funding (RBF).
Scaling-up in other countries
While the district implementations had been successful, SPT solutions’ full potential could really only be assessed if scaled nationwide. IKARE, together with Swedish Postcode Lottery and af Jochnick Foundation, provided the private sector funds, which Gavi then matched to form the consortium funding the first-ever country-wide implementation of the system in The Gambia. IKARE’s contribution was of €150,000 grant.
While The Gambia became the fourth country where Shifo operated it was the first where an SPT solution was scaled at the national level. The roll-out in the Gambia was completed by the end of 2020 when the SPT solution for data collection fully replaced the existing HMIS for child health and immunisation services in The Gambia.
To replace the health management information system that has been in place for over 50 years, a considerable amount of work had to be done by Shifo to first demonstrate to all the necessary stakeholders all of the benefits of the Smart Paper Technology. External evaluators were also brought on board. However, following the success of the Gambian scaling process, Shifo applied the same strategy in Kenya, Uganda, Afghanistan and Zambia, aiming to implement the Smart Paper Technology at the national level with the financial support of these countries’ traditional health funders, but always starting with a pilot to make the necessary country specific adjustments. IKARE is funding also the Zambian pilot which is expected to be launched in 2022.
Fundraising
Fundraising
Management team and CEO support
Management team and CEO support
Business planning
Business planning
Marketing
Marketing
Impact Measurement
September 2021, in Mukono District, Uganda:
| Outcome | Indicator | Baseline | Result |
| Improved vaccination | # of children fully immunised (BCG to MR1) | Unknown | 21,790 |
| Improved reporting system | # of children registered | Unknown | 100,053 |
| No of children receiving SMS reminders | # follow-up reminders sent | 0 | 51,575 |
| Reduced data gaps | # availability of digitised patient-level data and other daily transactions | No or limited data availability on patient level |
Data visibility on: 1. Individual child’s, girl’s and mother’s vaccination coverage and other preventive services. 2. Timeliness of receiving vaccines, Vitamin A and Deworming. 3. Daily medicine stock availability. 4. Daily wastage rates for vaccines and other supplies. 5. Data and medical errors made by health workers. |
| Reducing time spent on administration and reporting | # time spent on data-related administrative tasks by health workers |
Data-related admin tasks for: 1. Newborns/first visit – 05:30 minutes 2. Follow-up vaccinations – 02:36 minutes 3. Admin tasks after sessions and at the end of the month – 11:13:00 hours |
Data-related admin tasks for: 1. Newborns/first visit – 02:28 minutes – 49% reduction 2. Follow-up vaccinations – 24 seconds – 84,6% reduction 3. Admin tasks after sessions and at the end of the month – 00.25.40 hours – 96% reduction |
September 2021, in The Gambia:
| Outcome | Indicator | Baseline | Result |
| Improved vaccination | # of children fully immunised (BCG to MR1) | Unknown | 102,321 |
| Improved reporting system | # of children registered | Unknown | 309,333 |
| Children receiving SMS reminders | # of children to whom follow-up reminders were sent | 0 | 192,624 |
| Reduced data gaps | # availability of digitised patient-level data and other daily transactions from health centres | No or limited data availability on patient level |
Data visibility on: 1. Individual child’s, girl’s and mother’s vaccination coverage and other preventive services. 2. Timeliness of receiving vaccines, Vitamin A and Deworming. 3. Daily medicine stock availability. 4. Daily wastage rates for vaccines and other supplies. 5. Data and medical errors made by health workers. |
| Reducing time spent on administration and reporting | # time spent on data-related administrative tasks by health workers |
Data-related admin tasks for: 1. Newborns/first visit – 04:10 minutes 2. Follow-up vaccinations – 01:24 minutes 3. Admin tasks after sessions and at the end of the month – 2:21:52 hours |
Data-related admin tasks for: 1. Newborns/first visit – 02:29 minutes – 40% reduction 2. Follow-up vaccinations – 33 seconds – 61% reduction 3. Admin tasks after sessions and at the end of the month – 00.09.31 hours – 93% reduction |
- Full list of indicators
What they think
What's Next?
Both Shifo and IKARE have learned how to refine the model and its cross-country replication, leverage the data generated, and collaborate with other partners. They are now better able to demonstrate how Smart Paper Technology works and improves follow-up and the closing of gaps within each country’s primary health care delivery system.
Shifo is continuously working on scaling up the implementation of SPT Solutions to other countries struggling with the same issues. To do so rapidly, while keeping their focus on product innovation and adaption, Shifo works with NGOs (e.g. ActionAid, Plan International, Swedish Committee for Afghanistan, etc.) that have a long-standing local presence and are trusted by the government and local health authorities, and builds their capacity on MyChild and RMNCA Solutions, work processes and systemic changes.
By working with all these partners, Shifo has managed to spread knowledge about the benefits of SPT worldwide and have it implemented in many countries simultaneously. Currently, Shifo is operating in eight countries in Africa, Asia and Latin America.
It is also important to note that the Smart Paper Technology version of e.g. MyChild Solution can easily be upgraded to the fully electronic version without losing any data. Therefore, whenever technology and enabling ICT and electricity infrastructure catches up in low resource areas, and as people become more computer literate, the upgrade can easily be done as everything is already prepared.
Over time, Shifo can see similar process improvements and systems expanded to other health service points beyond maternal and child health. Shifo is currently collaborating with the Global Fund to work out such an expansion, which has started with a pilot project in Haiti for tracking vaccines, drugs and other supplies. This would lead to much improved logistics management as well as more reliable data on health, which could, in turn, inform governments on appropriate measures to take in the continued closing of gaps in their health services delivery and in achieving their SDG targets.
