Marc Mitchell, M.D., S.MHarvard School of Public Health and

D-tree International

Providing Decision Support to Health Workers

“[There is] an estimated shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide. The shortage is most severe in the poorest countries, especially in sub-Saharan Africa, where health workers are most needed. “

The Problem

BUT

less basic education

less training

limited supervision

monitoring difficult

Using less trained health workers to provide health care in clinics and the community.

Task Shifting

The Solution

What is Needed

End to End solution

1. task identification

2. skills taught

3. reinforce knowledge

4. monitor performance

Task Identification: assessing child with cough

Task Identification: treating child with cough

1. How to measure respiratory rate

2. How to detect indrawing, stridor

3. How to classify

4. How to treat; what dose?

Teaching Specific Skills

Reinforcement: at point of care

How sick?

very □mild □well □

Emergency?unconscious □

bleeding □seizure □

other □next

fever □

cough □diarrhea □

abd. pain □rash □

Symptoms

next

Bringing evidence-based medicine to frontline health workers worldwide

next

ampicillin 500 mg +

paracetemol 1 tab

Treat Pneumonia

next

getting sicker □Respir.Rate >40 □

indrawing □stridor □

wheezing □no source found □

Symptoms

next

REFERURGENTLY

Reinforcement: at point of care

patientdatabase

Performance ReportLocal Care yields better outcomesOutcomes of patients in Eastern Cape, SA

who completed 12 months of ARVs

78 %90 %VL undetectable

75 %87 %CD4 > 200

83 (19 %)13 (2 %)Lost to follow-up

58 (13 %)99 (17 %)Deaths

289 (68 %)483 (81 %)Still on ARVs

430595Patients

HOSPITALCLINICS

78 %90 %VL undetectable

75 %87 %CD4 > 200

83 (19 %)13 (2 %)Lost to follow-up

58 (13 %)99 (17 %)Deaths

289 (68 %)483 (81 %)Still on ARVs

430595Patients

HOSPITALCLINICS

source: Hermann Reuter, MBChB, Doctors Without Borders

patients lost to f/u1. ali samuel2. ben hasan3. etc.

growth monitoringimmunizationslab testspregnancy registrationreferral tracking

Enable continuum of careClinical Protocol

Monitor performance in real time

SMS alerts for missed clients

Monitor performance in real time

eIMCI

Nutrition

Link CHW and clinic HW

Support to CHW

Support to clinic staff

providing a continuum of care

across space and time

Antenatal care newborn care

Link CHW and clinic HW

Can we reduce the 3 delays of Home Births through:

1.phone based protocols2.mPesa to pay transportation and fees3.cell numbers of vehicles for hire in emergency4.recorded permissions for emergency transfer5.SMS or phone call to receiving hospital

Obstetric Plan B

Support community midwives

Grand Challenges

1. Develop or adapt clinical protocols that enable task shifting

2. Validate protocol effectiveness to ensure quality of care

3. Design open-source software to support scale up and correct use of protocols

4. Improve decision making by making data available at and across points of care

What we do

End to End solution to support HW throughout the system

client(basic phone)informationalertsreminders

CHW(java phone)pt. registrationpt. recordprotocolsschedulingtrainingalertsremindersmsg to clinic

supervisor(phone or netbook)messagingexception rules for supervisionsurveillancelearningnotificationsalerts

clinic(smart phone)pt. registrationpt recordprotocolsschedulingtrainingalertsreminderstelemedicine

manager(laptop)exception rules for supervisionsurveillancelearningdata queries

Marc Mitchell, M.D., S.MHarvard School of Public Health and

D-tree International

Providing Decision Support to Health Workers