ACCESS Madagascar: CommCare for Health in Remote, Low-Connectivity Settings

The Accessible Continuum of Care and Essential Services Sustained (ACCESS) program is a five-year project funded by USAID, led by Management Sciences for Health (MSH) and dedicated to strengthening Madagascar’s health system. Since 2016, the program has used CommCare to adapt the Madagascar Ministry of Public Health (MOPH) paper-based forms to facilitate patient support and decision making, and to provide job aids, counseling, and disease classification tools.

The problem

The maternal mortality ratio in Madagascar is 335 per 100,000 live births, and the child mortality rate is 51 deaths among children under five per 1,000 live births. The African region carries a disproportionately high percentage of global malaria cases, and those most at risk of developing severe symptoms are infants, children under five, and pregnant women; in 2019, children under five accounted for approximately 67% of all deaths caused by malaria. It was also noted that 30% of Community Health Volunteers (CHVs) were not reaching the minimum requirements for family planning and Integrated Management of Childhood Illness (IMCI).

With a population of 28 million distributed across 22 regions and an internet penetration of 19% (as of February 2021), it was crucial to have a system that not only allows CHVs to use their application offline, but also enables CHVs with no connectivity to submit their indicators in a timely manner so that ACCESS and the MOPH have access to the data.

The solution

The application was originally built to support the continuum of care for women of reproductive age seeking family planning services, pregnant women, and children from birth to five years old. The first versions contained several modules, including maternal and child health, referrals and home visits, monthly reports, and stock management. As the program expanded, the flexibility of CommCare allowed the application to extend to content areas such as surveillance, and to respond quickly to emergency crises with the plague and COVID-19 modules. From a user point of view, the application provides job aids, reporting capabilities, and decision-making support for the different health services delivered at the community level, mainly by CHVs and supervisor nurses at the health facility (CSB, Centre de Santé de Base).

Designed for low-connectivity settings

One of the main challenges in Madagascar for a successful deployment at scale is access to the internet for users at the community level, especially in rural areas with low coverage. The current estimation is that only 35% of the 18,000 CHVs in the country have access to internet coverage. To resolve this, the application was designed for three main categories of users:

• Users with CommCare Mobile and internet access, who send data through the internet.
• Users with CommCare Mobile but without internet access, who use the application on a daily basis and submit their indicators on a monthly basis through the SMS platform.
• Users without CommCare Mobile, who submit their data using a colleague’s device.

All users have the same experience; only how they synchronize the data differs. Upstream, the data is later integrated into the MOPH DHIS2 instance for programmatic reporting, both from CommCare servers and the SMS platform built for that purpose.

“Although we still use paper registers today, the work has become lighter since using CommCare. During home visits during sensitization, I just go with my smartphone.”

Radimbiarimanana Migène, Community Health Worker, Atsinanana, Vatomandry, Ilaka Est

Module highlights

In the IMCI child-care module, the CHV can enter the different problems noted during a child consultation. When a child has a fever and coughing or difficulty breathing, the application automatically prompts the CHV to perform a Rapid Diagnostic Test (RDT) and enter the results. Based on the information collected during the consultation, job aids are displayed on screen to advise the CHV.

Medication availability and stock management is another important aspect of the program. Each medication is referenced in the application, and stock is updated accordingly when it is given to a beneficiary or received from the health center. When making an order, the application shares the Monthly Average Consumption (based on the last three months), the maximum stock, and the recommended quantity to order. A unique identifier is created for each order, which is sent by SMS to the health center, where a supervision application lets the supervisor copy the SMS into the stock form so the order is filled automatically.

Reporting to the Ministry’s DHIS2

To support users without an internet connection, ACCESS configured an on-premise SMS Gateway so that data collected by CHVs in remote areas is available for analysis by the ACCESS team and the MOPH. In the Monthly Activity Report module, multiple SMS messages are formatted and sent to the gateway, where they are deciphered and mapped to the data elements of the DHIS2 server.

Sending the monthly indicators to the Ministry of Health’s Information System Studies and Planning Department (DEPSI) DHIS2 server was a strong requirement from the MOPH for the sustainability of the application once the project ends. A total of 779 indicators are submitted to the DHIS2 server, allowing the MOPH to analyze the data collected at the local level. As of April 2022, data are aggregated and submitted for 774 locations.

“There are countless benefits to using CommCare, but what stood out to me the most was that it makes it easier for CHW to complete their activities and speeds up reporting data and improves completeness, promptness as well as accuracy.”

Anicet Lemarazafy, Software Engineer, IT System Department, Ministry of Health

Implementation and scale

The CommCare application has scaled up since it was initially launched in 2016. It began with fewer than 400 users and 300 indicators integrated into DHIS2, amounting to 16,000 forms submitted monthly. During the second phase of the project, which started in 2018, the application integrated the new Monthly Activity Report introduced by the MOPH in 2019, resulting in 779 indicators. Over the past three years, the application has been launched to more than 3,500 users and more than 700 locations. Each year, it is updated with feedback from CHVs or to integrate new workflows shared by ACCESS and the MOPH, and CommCare now sends reminders so that CHVs receive alerts to complete routine visits and follow-up.

The CommCare application is already used as the staple application by two other partners: Pivot and ONN PARN. Pivot collaborated with Dimagi in 2020 to adapt the ACCESS application by adding malnutrition, community-based tuberculosis care, and more detailed IMCI modules and workflows. ONN PARN aims to harmonize with the ACCESS application to increase the use of an evidence-based package of nutrition interventions and improve key behaviors known to reduce stunting in targeted regions of Madagascar.

“CommCare platform for CHWs and Supervisors is a first in our Region. Indeed, it will improve our performance in community health in terms of quality of service offered by CHWs and reporting timeliness and completeness.”

Dr. Rakotoarivony Falihery, Head of Medical and Health Service, SAVA Region

Impact

One of the application’s modules supports community surveillance, making it possible to track and report on 16 disease-related symptoms and 3 animal-health-related suspicious events that carry particular health risks and have epidemic potential. Alerts are sent to higher levels of the health system via the internet or SMS, helping to quickly detect and report suspicious cases and preventing localized cases from turning into a national epidemic. Through the data shared by CHVs using the application, the MOPH was able to detect suspicious cases of Rift Valley Fever (RVF) in the Atsimo Andrefana region in March 2021.

“CommCare assists the Ministry in the early detection and monitoring of outbreaks at the community level. Reports of cases of disease and epidemics at the community level reach us quickly.”

Voahangimalala Hanitra, Ministry of Health

From October 2020 to September 2021, ACCESS conducted a study to check the performance of CHVs using CommCare in the treatment of uncomplicated malaria in children under five, tracking two indicators: the percentage of children under five with fever who were tested for malaria, and the percentage of children under five with malaria who received treatment. CHVs using CommCare tested 96% of children under five with malaria, compared with 78% for CHVs not using it. For treatment, 85% of children under five with malaria received it from CHVs using CommCare, compared with 79% for the rest. The CHVs using CommCare showed better adherence to the protocol, and both indicators have been constantly improving.

“CommCare! Grassroots community saves lives through high tech!”

Dr. Serge Raharison, Chief of Party, USAID ACCESS Program

Governance and sustainability

A key activity identified at the program’s inception was the transition of the digital solution to the MOPH. To allow a smooth transfer of the system at the end of the five-year project (August 2023), ACCESS has built a strong team with the MOPH through capacity-building sessions running since 2021, on topics ranging from application building to migrating CommCare to the local server. In 2018, collaboration with the MOPH helped secure funding from the World Bank to finance the system during the period between the two USAID programs. The objective is a unified system in which a core application is shared by ACCESS, Pivot, and ONN, with changes and maintenance centralized at the MOPH level to lay the foundation for consolidated DHIS2 reporting across partners.

One anecdote captures why sustaining this work matters. During the nine-month hiatus between the end of the Mikolo program (ACCESS’s predecessor) and the beginning of ACCESS, one CHV whose phone had stopped working, and who could not get support from the MOPH, bought a new phone with her own means and traveled to the capital, Antananarivo, to get CommCare reinstalled. Asked why she spent her time, resources, and energy to do it, she answered that on top of how useful the application was, it gave her credibility in her community and the ability to support more people.