Running CHT implementations

There are various ways of running Community Health Toolkit implementations. It is important to understand the different models for integrating CHT tools into a community health program as discussed below.

Accompaniment approach

In this approach, Medic accompanies partners; including ministries of health, through their digital journey that may include designing, building, deploying and supporting CHT based tools for their unique health system needs.

Community led implementations

Community led implementations emphasize on the importance of collaboration, local ownership and sustainability. This is a self-led model where a community identifies a digital health problem and solves it using CHT tools. The CHT also has a community of practice that is made up of a network of local and regional technical organizations that have been onboarded on CHT and are able to provide design, development, deployment and support services for implementing partners - including ministries of health. This network also contributes their learnings to the community through documentation, reference applications, CHT forum and CHT core improvements.

Research initiatives, innovations and studies

Through human centered design, research institutions and academia design, test, refine and deploy open source digital health innovations which are based on the CHT or other mature open source technologies. These innovations ultimately contribute knowledge through publications. These implementations incubate and test concepts or interventions before large scale implementation. They run for a limited time and often have pre-determined objectives.

Considerations for digital health implementations

To run a successful digital health implementation, the following considerations are made:

• Scope. Clear definition of the challenge, duration of implementation, implementation deliverables, and the change expected as a result of implementation.
• Technical requirements. Infrastructure (servers - physical/ cloud) and hardware (devices such as smartphones/tablets, laptops/computers) requirements.
• Context. General understanding of the geography (country/region) in the following domains; legal and policy landscape, infrastructure penetration e.g. mobile and electricity connectivity, community health setup and maturity e.g cadres of community health workers, coverage and functionality.
• Human resource requirements. Skills to build, implement and sustain the implementation.

CHT Lifecycle

CHT implementations follow a process from beginning to end in order to deliver a complete functional digital health solution. This process is referred to as the CHT Lifecycle. Although the process may differ from implementation to implementation, the process below is what has been used for most deployed implementations. It is an agile and iterative process that involves feedback collection and improvement.

• Initiation - at this stage, the project scope, goal and use cases are defined.
• Planning - includes coming up with detailed workplans, schedules, budget estimation, baseline data collection, user estimation and resource planning.
• Design - a design activity is conducted to gather user insights and requirements that will inform the design of the workflows in the CHT.
• Building - refers to the app development process where workflows are configured, tested and improved.
• Hosting - includes different hosting options, data migration, configuration and optimization of CHT applications in various environments.
• Implementation - refers to the process of training end users and them using the CHT application to support the delivery of health care services. It includes training plan development, logistics planning, expenditure estimation and tracking, tech support training and application installation.
• Support - this is the support provided to end users to address any technical issues and ensure the usability of the tools.
• Evaluation - includes budget tracking, discussions on scaling, report writing and user feedback activities to help improve user experience and impact before the next development cycle begins.

Implementation personas

Various people interact with CHT implementations at various stages. The list below may not be exhaustive but highlights bare minimum requirements for a successful implementation. In some cases, personas may have overlapping roles.

• Project managers - They may also be referred to as program heads or program leads. They are involved in planning, coordinating and overseeing digital health projects. Although they oversee the entire implementation, they interact with the CHT implementation more closely during the implementation and evaluation stages.
• Designers - They include service designers, user experience/user interface designers, product designers, graphic designers among others. Designers interact with CHT implementations during the design phase. They carry out field immersion visits to gather technical requirements from the prospective end users, program leads at MoH, policy makers among others. The technical requirements gathered inform the final application. Product and UI/UX designers are involved in the design and evaluation phases to explore opportunities for improvement and user experience optimization.
• Developers - they include app developers, core developers and software developers who are involved in the building stage. App developers build custom applications based on the CHT core. These apps are composed of application and contact forms, application settings among other configurations. Core developers contribute to the CHT Core framework that powers the mobile apps.
• System administrators - they include database administrators, security engineers, site reliability engineers, devOps engineers and network managers. They are responsible for configuration of computers, servers, databases, pipelines and infrastructure of CHT applications, monitoring health status of the infrastructure and application such as performance, server resources utilization, and uptime. They interact with CHT implementations at the planning, hosting and support stages.
• Technical support team - they include information communication and technology (ICT) officers and monitoring & evaluation officers. ICT officers are responsible for mobile device testing, application installation and technical assistance for issues experienced by end users post deployment. Monitoring & Evaluation officers are responsible for monitoring project indicators performance, impact evaluation, data analysis and reporting. They interact with CHT implementations at the design and support stages.
• Researchers - they include Data Scientists, UX researchers and research scientists. They integrate research aspects such as implementation research into the project cycle to test hypothesis. They are involved through out the project cycle.

In case an implementing partner does not have the expertise listed above, the CHT has a robust network of technical partners who have built CHT applications and have a deep understanding of how CHT implementations work.

Running successful community health implementations

Digital health implementations do no exist in silos. To be successful, there are other critical enablers to be aware of and champion for;

Community health workers

Community health workers deliver essential health services to the last mile to improve health outcomes. Community health workers require good working conditions and the right tools to perform their responsibilities. To enable this, the items listed below are important. You can learn more on the eight proCHW best practices.

• Skilled. Continuous training for skill growth
• Supervised. Supportive supervision for optimal performance management
• Salaried. Compensation for economic growth and sustainability
• Supplied. Equipping with required supplies and kits

Technical performance optimization

For CHT implementations to be successful and sustainable, the following requirements are integral.

• Privacy and protection of user and client data
• Routine monitoring and evaluation to identify and resolve issues on time
• Data backups
• Redundancy
• Regular CHT upgrades to benefit from new features and performance improvements
• Device maintenance
• Regular Android app and security updates
• Alternative power sources e.g solar chargers or powerbanks
• Phone covers and screen protectors
• Device replacements (losses, end of life) and repairs (broken screen, faulty chargers etc)
• Design
  • Designing with the user (Human-centered design)
  • Consistent user feedback to inform improvements
  • Consistency with material design guidelines for intuitive use.