Zanzibar's National Digital Health System THE JAMII NI AFYA COMMUNITY HEALTH PROGRAM

The story: after a close call, a reason for hope

When Mashaka Peter met Sabrina Ally Mohammed in their rural village in Zanzibar, Sabrina was pregnant with her fourth child. Her prior three children had been born at home, without a skilled birth attendant. Mashaka was a community health worker with D-tree’s digital community health program—a job that would prove to save Sabrina’s life. During regular visits with Sabrina throughout her pregnancy, Mashaka used the D-tree’s mobile app as a guide to screen Sabrina for danger signs that could point to health risks. The app also helped the pair to develop a birth plan; it provided education and counseling; and it prompted Mashaka to engage Sabrina’s husband in the process, a culturally vital aspect.

On one such visit, Mashaka noted Sabrina’s swollen feet. Entering this observation in the app, Mashaka saw a warning message appear: “swollen feet” was flagged as a danger sign. The app identified that Sabrina may have had hypertension and was at increased risk for complications during pregnancy and delivery. It prompted an immediate referral to a health facility, where Sabrina then received professional care while continuing to interact with Mashaka through additional counseling on healthy nutrition and preparing for delivery.

If left untreated, Sabrina’s condition could have been fatal; but, thanks to her interactions with Mashaka through the digital community health program, Sabrina delivered in a hospital with skilled care for the first time in her life. When she returned home, she held her healthy baby boy—along with his official birth certificate, a first in her family.

The background: Safer Deliveries

To understand the current community health program, we need to start at the beginning. The story of Mashaka and Sabrina was made possible by D-tree’s digital community health program at the time, “Safer Deliveries.” Started nearly a decade ago, the Safer Deliveries program helped the Government of Zanzibar re-imagine healthcare delivery by developing digital tools to support community health workers (CHWs) like Mashaka and their supervisors to address complex but very real barriers that stood between pregnant women like Sabrina and skilled deliveries at health facilities—barriers such as lack of transportation, insufficient financial preparations, and difficulties in obtaining customary permissions from male partners.

Even in its infancy, the Safer Deliveries program demonstrated the potential of digital technology to radically transform the quality of a health system, producing powerful outcomes from 2015-2019.

The innovation: scale-up & sustainability

In 2018, the Revolutionary Government of Zanzibar decided to formally adopt and expand the digital community health program that was formerly Safer Deliveries. The new program, called Jamii ni Afya (“Communities are Health”), consolidates all previously siloed community health interventions under one unified system and cadre of health workers. The Zanzibar Ministry of Health launched the nationwide effort in February 2020 as part of its revised National Community Health Strategy (2020-2025).

What sets Jamii ni Afya apart?

  • From the outset, stakeholders (including beneficiaries, CHWs, and various technical and managerial government staff) have been actively involved in designing and developing program structure, content, and digital tools as part of Jamii ni Afya’s Human-Centered Design approach.
  • Jamii ni Afya will bring quality health services to every household in Zanzibar in all 11 districts. That’s 1.6 million people who will have access to efficient, high-quality care.
  • Supported services extend beyond antenatal care and include long-term care for everyone in the household, maternal and newborn health services, and essential child services such as nutrition, immunizations, WASH (Water, Sanitation, and Hygiene) and early childhood development, while making space for additional functionalities in the future as other priorities emerge.
  • Jamii ni Afya is fully integrated into the health system structure, meaning that it supports not only CHWs, but also their health facility-based supervisors and the district- and national-level managers.

App demo

See how Sharifa, a Community Health Volunteer with Jamii ni Afya, navigates through the app and provides essential health services to her community.

The lessons learned: going beyond the app

In many ways, the evolution story of this national program in Zanzibar follows the same trajectory as the field of digital health over the past decade. Since we began this program, D-tree has internalized three key lessons that we feel are instructive both for this program as well as the for the broader field of digital health as it continues to mature.

LESSON 1: Build to improve

In close collaboration with Ministry of Health stakeholders, CHWs, beneficiaries and development partners, we have used human-centered design to build a digital backbone for the community health system in Zanzibar to simultaneously improve the quality, efficiency, and accountability of the health services at all levels.

LESSON 2: Build to leverage

In supporting a culture of using data for decision-making, we have found that less is more. In order maximize the impact of data collection, dashboard content is designed to be specific, relevant, actionable, reliable, and accessible in real-time for the people who need it most.

  • Supervisors and CHWs have at their hands a wealth of data about the health services provided, trends in behaviors, gaps and needs, and feedback from communities;
  • District Health Management Teams use this data to answer questions and inform routine performance reviews and supervision plans; and
  • National managers monitor CHW workload, trends in service delivery, and health behaviors and outcomes.

District- and national-level managers are able to review the dashboard, document areas of greatest interest or concern, then relate the concern to government policies and National Community Health Strategy priorities. This builds the government’s capacity not only to monitor and supervise CHW activity, but also to analyze the data and inform decision-making. Such decision-making could (i) improve community health service delivery, and, ultimately, health outcomes at the community level, as well as (ii) adjust activities at other levels of the health system. For example, if immunization coverage is low, the government might implement facility-level interventions to improve this coverage.

“Our health facility supervisor is able to see what we do in the community. The app automatically updates our information, and the supervisor usually calls and asks if she doesn’t see our work. This arrangement has helped me cross-check my data sync and performance.”

-Community Health Worker

With the collection of millions of data points every month and availability of secondary data such as geospatial data and trends in cell phone usage, there is also a tremendous opportunity to leverage big data to target and optimize health service delivery, further personalizing care and prioritizing those most in need.

With funding from the Government of Belgium (Enabel), D-tree is working to integrate predictive analytics into the Zanzibar national community health system. We have taken bold steps in developing modeling systems for predicting the drivers for perinatal mortality and are continuing to refine these techniques. We see an exciting and enormous potential to (i) couple the application data with other data sources in order to identify high-risk clients and tailor care pathways, and (ii) to optimize health workers time and the services they provide.

LESSON 3: Build to last

Over the years, countless studies have pointed to the considerable disconnect in the progression from digital system development, to government adoption, to acceptance and sustainability. At D-tree, we understand that involving the government from the outset of the design phase and building capacity for them to lead is a key factor in bridging these divides; and that designing sustainable digital systems means gradually setting the stage for ownership. This often results in a longer timeline than originally envisioned, but leads to increased ownership and long-term impact.

In Zanzibar, the Ministry of Health and district Council Health Management Teams have been critical to program planning, strategy, implementation, and continued monitoring and management. By engaging in co-creation and co-implementation of Jamii ni Afya, the government is gaining firsthand experience in managing the program, taking the lead in scaling the program, and embraces its ownership as part of the government health system.

The vision: 2020 and beyond

Frameworks such as the Digital Investment Principles and WHO Guidelines for Digital Health have created a roadmap for how to develop government-led, integrated digital health systems. However, the fragmentation in many countries from legacy systems and uncoordinated efforts, as well as limited government experience have yielded very few examples of these systems working in practice.

In Zanzibar, we offer a unique example of strong and coordinated government leadership, a unified digital community health system, and a strong foundation of trust and collaboration upon which to advance the vision of a fully integrated digital primary healthcare system. We are proud of our deep partnership with the Zanzibar government on Jamii ni Afya and grateful to our donors for helping position this program for success.

The Zanzibar Ministry of Health’s long-term vision for this digitally enabled health system is one in which everyone, no matter who they are, has access to high quality health services when and where they need them.

As we look to future directions for this program, we see tremendous potential, not only for the people of Zanzibar, but also for the broader field of digital health. Many other low- and middle-income countries are also committed to integrating digital community health programs into their health systems at national scale, but outside of Zanzibar, no other country has successfully realized this vision. While we recognize that there is no one-size fits-all digital solution for all countries, the approach we are taking in Zanzibar of focusing on co-creation, co-implementation, and capacity building has the potential to be leveraged in other settings and inform other countries to join the Government of Zanzibar in achieving nationwide coverage of a unified digital community health program.

Photography by Mark Leong/World Health Organization and Kevin Ferguson.

Created By
D-tree International