Health Delivery Systems

eHealth Africa supports data collection on the prevalence of Hepatitis B in three districts in Sierra Leone

eHealth Africa (eHA) is supporting data collection on the prevalence of Hepatitis B in the Bo and Bombali districts, and Western Urban area in Sierra Leone, through its Hepatitis B Sero Survey project. U.S. Centers for Disease Control and Prevention (CDC) is funding this project.

A Sero Survey is a test of blood serum from a group of individuals to determine seroprevalence.

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The African Regional Committee of the World Health Organization in 2014, endorsed a resolution to reduce chronic Hepatitis B virus (HBV) infection prevalence to <2% in children less than 5 years of age in all member states by 2020. In Sierra Leone, there is no accurate data on Hepatitis B Virus (HBV) infection among children and women of childbearing age. Hence the need for a survey to determine the prevalence of HBV infection among infants, children and women of childbearing age in order to inform the HBV vaccination policy of Sierra Leone.

In 2007, the country introduced the Hepatitis B vaccine as a component of the pentavalent vaccine provided at 6, 10 and 14 weeks of age. However, a birth dose of Hepatitis B vaccine recommended by WHO to prevent mother - to - child HBV transmission is not yet included in the routine immunization schedule.

The Hepatitis B community serosurvey conducted in the 3 districts, targeted some 2,544 infants aged 4- 24 months and their biological mothers to evaluate the risk of mother to child transmission and subsequent need for a Hepatitis B vaccine birth dose;

and also 2,332 children aged 5- 9 years to assess the impact of childhood pentavalent vaccine on the prevalence of Hepatitis B virus infection among children.

Prior to collecting data, a five- day classroom and practical field training was conducted to:

  • build the knowledge of the surveyors

  • identify households

  • counsel families ahead of the survey

  • conduct a rapid diagnostic test on Hepatitis B and  the processing and tracking of venous blood specimen

As part of the training, a practical field exercise was also conducted to pretest participants’ knowledge on the classroom training.

eHA is a technology-driven organization. In a drive to discourage potential errors via paper-based methods and to present an automated approach to health data collection, eHA also trained supervisors and phlebotomists on the use of the Open Data Kit (ODK) tool. eHA provided the phones and data for the survey and installed the ODK  app (which is used for data collection in the field), the age= app for age calculation, and the  ODK dashboard. With ODK, data collection is done easily, and survey activities monitored in near real time.

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A total of 3,934 forms were submitted via the ODK tool of which 3,158 (80%) of households visited were willing to participate in the survey. Out of the 2,232 households selected for children aged 2 months - 24 months, 1,704 children were enrolled which is 76% and 1,604 biological mothers of these children were also enrolled.

For the 5-9 year-olds, out of the 2,250 households selected, 80% participated with 1,811 enrolled. For children with vaccination cards, 1,186 were enrolled and 401 for the 5- 9 year- olds. A total of 551 serum samples were collected during the 6-week community serosurvey.  

eHA continues to work with the CDC and other partners with a view to increasing the early detection and reporting of government-identified priority diseases, especially when very little is known about HBV prevalence in Sierra Leone.

Benefits of a Direct Delivery Model

By Adamu Lawan and Emerald Awa- Agwu

eHealth Africa's third- party logistics service, VDD ensures that vaccines are delivered to last mile health facilities in a timely manner

eHealth Africa's third- party logistics service, VDD ensures that vaccines are delivered to last mile health facilities in a timely manner

Vaccination is one of public health’s most cost-effective interventions. According to the World Health Organization1, it prevents between 2 million to 3 million deaths every year. Even though there has been great progress towards achieving universal coverage, there are still 20 million unvaccinated and under-vaccinated children worldwide. To reach these children and to meet global disease elimination targets, all countries must provide an uninterrupted supply of potent vaccines to the most hard-to-reach and conflict-affected areas.

Nigeria has experienced challenges in maintaining functional vaccine cold chains and supply chains, leading to low vaccination coverage rates. Nigeria’s cold chain system consists of five levels: a national cold store which stores all vaccines in the country and supplies six zonal cold stores located in each of Nigeria’s six geopolitical zones. The zonal stores supply vaccines to the state cold stores, which in turn supply the LGA cold stores. The primary health care facilities staff have to visit the LGA cold stores to collect their vaccines on a weekly or daily basis depending on the status of their cold chain equipment.

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This system was inefficient and time- consuming because health workers from over 9,000 health facilities in Nigeria often had to leave work to collect vaccines when they could be treating patients instead. In addition, the system was fraught with high operational costs and poor vaccine stock visibility, especially in transit.

To alleviate this problem, the Nigerian government adopted a direct delivery model called Push Plus in 2013, to transform its supply chain at the state level. A direct delivery model is one which delivers vaccines and dry goods directly from the state cold store to the last mile health facilities according to customized schedules, bypassing the LGA warehouses completely and preventing stock-outs.

The benefits of this model have been enormous. The direct delivery model has freed up an additional 1- 6 hours each week for health workers to attend to patients—time previously spent by health workers in transit to obtain vaccines. In addition, vaccine availability at the last mile health facilities has improved. By increasing the number of health facilities that have functional cold chain equipment, health posts and smaller health facilities can receive vaccines from closer health facilities instead of going to the LGA cold store every day. This has led to a massive drop in the stock-out rate. In Kano state, vaccine stock-out rates dropped from 93% to 3% and in Lagos State, from 43% to none. Not surprisingly, the immunization coverage of Lagos State increased from 57% to 88%. WHO2 lists vaccine shortages and stock-outs as a major cause of missed opportunities to vaccinate.

Nigeria is projected to spend about US$ 450 million by 2020 on vaccines, By increasing vaccine accountability and visibility, the direct delivery model has also reduced the amount of money that could be lost due to wastage and pilfering of vaccines.

eHealth Africa implemented Vaccine Direct Delivery, a third-party logistics service based on the direct delivery model in Kano State from 2014 to 2016 and currently implements it in Bauchi and Sokoto states. We work with the state primary healthcare development agencies to ensure that vaccines and dry goods are delivered safely and in a timely manner to health facilities. Using our LoMIS Deliver solution, eHA plans, schedules, and routes deliveries to enable health delivery officers choose the correct quantity of vaccines and dry goods from the state cold stores and deliver them to health facilities equipped with cold chain equipment. The process of determining what quantities to deliver at the health facility is fully automated to avoid manual errors. The project also incorporates reverse logistics—returning balance stock or waste, if any to the state cold store. VDD provides governments and other stakeholders with accurate, near real-time data for decision making and forecasting.

Through VDD, over 28 million doses of vaccines have been delivered to health facilities in Kano, Bauchi and Sokoto State from 2014 to date, reaching over 13 million children under the age of one. eHealth Africa continues to support governments across Africa with system-level approaches to transforming health service delivery.

Partnering to Address Sickle Cell Disease in Northern Nigeria

By Muhammed Hassan

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According to the U.S. Centers for Disease Control and Prevention (CDC), Nigeria alone accounts for more than 100,000 new sickle cell births every year1. Statistics from African region of the World Health Organization (WHO) puts the prevalence of the Sickle cell trait in Nigeria at 20% to 30%2. In sub-Saharan Africa, very few control programs exist and those that do exist, lack national coverage or the facilities to manage patients. Proactive, routine screening for sickle cell disease is not common practice so diagnosis is usually made when a severe complication occurs.

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At eHealth Africa, we aim to improve the quality and availability of healthcare for underserved populations and to increase access to timely and quality diagnostic services. We partnered with Sickle Cell Well Africa Foundation (SCWAF), Pro-Health International and the Presidential Committee on the North- East Initiative (PCNI) to hold a two-week outreach in Bajoga LGA, Gombe state, and Toro LGA in Bauchi State from the 2nd-16th December 2018.

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The team hosted community and school outreaches in both LGAs. Beneficiaries of the outreaches in both LGAs were educated about Sickle Cell Disease (SCD), inheritance, signs and symptoms, and the importance of genotype testing for SCD and prevention. Free genotype tests were conducted using the Sickle Scan Rapid Test Kit.

Patients who tested positive for SCD and those who presented with severe complications were given routine medication, advised on first-level crisis management and referred to tertiary hospitals. eHealth Africa captured, stored and analyzed the results of the tests. The analyses provided insight into the geographic distribution of patient and the average age distribution of patients who tested positive for SCD and the categories of complications presented at the outreach.

eHealth Africa, Pro-Health and SCWAF presented these results at stakeholder meetings in both states and provided evidence-based recommendations to enable the states to tackle Sickle Cell Disease. Going forward, eHA intends to work with Pro-Health to develop a comprehensive data collection tool which will support tracking and follow up of SCD patients in Prohealth Sickle Cell Clinics.

The Impact:

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Practical Solutions to Challenges in Reporting: LoMIS Stock and eIDSR

By Abdullahi Halilu Katuka and Emerald Awa- Agwu

LoMIS Stock is an electronic stock management tool, developed by eHealth Africa as a part of a suite of mobile and web applications that address supply chain and logistics challenges in health systems, especially in Northern Nigeria. LoMIS Stock helps health workers report and keep track of vaccine stock usage and availability at the health facility level. Using these reports, their supervisors can prevent stock-outs at their health facilities by ensuring that vaccines and other commodities are always available. The information from LoMIS Stock also gives governments the real-time data that is needed to plan programs and interventions and to resolve issues.

The LoMIS Stock solution was introduced to Kano State in 2014 and is currently the official logistics management tool for Kano State Primary Health Care Management Board (KSPHCMB). Currently, the State cold store, all 44 Local Government cold stores, and 484 apex health facilities in Kano send weekly reports using the LoMIS Stock application.

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Although health facilities reporting times have dropped by over 50% and reporting rates have tripled since the introduction of LoMIS Stock, certain facilities in hard to reach areas were consistently unable to send reports due to mobile data network challenges. Gleaning from lessons learned from a similar challenge encountered with our electronic Integrated Disease Surveillance and Response System (eIDSR) solution in Sierra Leone, eHealth Africa added an SMS compression feature to the LoMIS Stock application.

In Sierra Leone, we have recorded a significant improvement in the number of facilities that send timely reports using the eIDSR application. Health facility workers in Sierra Leone use eIDSR to collect data offline on epidemiologically important diseases and send surveillance reports. Initially, in areas with poor connectivity, the application would store the reports and submit automatically as soon as an internet or mobile connection became available. However, this meant that such facilities didn’t always meet the targets for timely reporting.

Introducing the SMS compression feature enabled health workers in the defaulting facilities to send their weekly reports using a USSD short code if an internet connection or mobile data was unavailable. Thanks to this feature,  all the districts in Sierra Leone consistently exceed the World Health Organization (WHO) African region and national report completeness and timeliness targets.

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The USSD feature for LoMIS Stock has been piloted with the pharmaceutical department of KSPHCMB to monitor incoming and outgoing stocks and the results have promising. In the first month, the stock count report at the pilot health facilities shows 100% stock sufficiency reporting and 0% wastage. After the pilot period, the feature will be rolled out to all departments of KSPHCMB to allow better reporting and increased efficiency across health facilities in Kano state.

Innovative problem solving is one of our values at eHealth Africa and this is an example of how eHA develops context-specific solutions to problems in healthcare delivery.

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