Could this app transform delivery of last-mile health services?

A lot has changed in the six years since Lilian Anyanga began working as a community health worker in Kenya. She and her peers used to do their work manually, carrying notebooks and heavy bags filled with paper records. Today, Anyanga uses a mobile app that prompts her with questions to ask her patients, along with step-by-step guidance and reminders for follow-up visits. It also provides the organization she works for, the Lwala Community Alliance, with data on patients’ health outcomes. Anyanga is one of 120,000 people worldwide using CommCare, the most widely deployed and adopted digital platform for frontline workers in low- and middle-income countries. Some 80% of those users work in the health sector. It is the flagship product of Dimagi, a technology company that builds data collection and service delivery software for frontline workers. Dimagi wants to go even further. Working with partners such as Lwala Community Alliance, it’s now testing a new product called CommCare Connect that allows workers to opt in — and get paid for — additional work. For example, a health worker like Anyanga could add screenings for services such as mental health or early childhood development onto her existing visits with patients — and donors could fund such interventions by individual workers. The technology’s appeal to donors and frontline workers alike is that it allows workers to be compensated for a fraction of their time. “If you had 15 minutes of time to get a worker to do anything for a household, what would you have her do?” asked Dimagi’s co-founder and CEO Jonathan Jackson. “Nobody bothers pondering that question right now, because you can’t buy 15 minutes of time.” Last year, the Steele Foundation for Hope provided Dimagi, a for-profit social enterprise, with $25 million to build the technology. The idea, experts say, has the potential to revolutionize last-mile service delivery by bundling services together, decreasing their costs, and allowing services to be expanded and rolled out more rapidly. In addition to health, CommCare Connect could apply to frontline workers in education and agriculture. It can also help donors, NGOs, and governments leverage existing investments in the community health workforce to deliver interventions that are highly effective but expensive to implement on a large scale. Improving jobs and outcomes Jackson and his colleagues believe that technology can improve the jobs of frontline workers — and therefore the outcomes of their work. For example, multiple studies have shown that CommCare helps community health workers do their jobs more effectively, leading to outcomes such as fewer errors in cardiovascular health screenings in South Africa, improved child nutrition in India, and more in-facility births in Tanzania. To date, the mobile phone app and web interface have been used by 1 million frontline workers across 130 countries, largely in the public health sector. Since its founding 20 years ago, Dimagi has evolved away from project-based funding, which supported custom-coded projects and software, toward open-source technology that allows paying clients to customize mobile, web, and SMS applications such as CommCare built for offline data collection. Dimagi has benefited from growing donor support for digital tools to support national-scale frontline health workers. These programs are hard to run, due in large part to challenges related to training frontline workers, monitoring their work, and paying for their services, Jackson said. But CommCare addresses these problems, with software that helps frontline workers learn new skills, deliver services, verify that the work was completed, and get paid. An ‘aha’ moment The COVID-19 pandemic was a turning point for Dimagi. For one thing, it built a system to help frontline workers in the United States with COVID-19 patient screening and contact tracing. This “supercharged” the company’s business, according to Jackson, bringing in revenue that allowed the team to make improvements to CommCare globally. At the same time, countries around the world relied on community health workers in their COVID-19 response. Some governments, including several states in India, provided them with extra pay in order to deliver services ranging from testing to contact tracing. But most countries lacked the technology to support frontline workers with all they were already being asked to do, let alone support them in developing new skills overnight, Jackson said. This led to a sort of “aha moment,” Jackson said, as Dimagi considered how frontline workers might fill those gaps going forward. “We had the ability to reflect, after two years of kind of sprinting with our hair on fire doing COVID[-19] response, what is really going to potentially change the game?” Jackson said. That led to the concept of CommCare Connect. ‘Bold but humble’ Community health workers are “trusted messengers” in their communities, said Rebecca Weintraub, founding faculty director of the Global Health Delivery Project at Harvard University and senior advisor at the Steele Foundation for Hope. They have unique insights into the people they serve. For example, they understand the gap that often exists between “intention versus practice.” That understanding is critical for work on a wide range of issues, from contraception to water and sanitation, to depression, she said. If community health workers could take on more tasks to serve their communities, and get paid to do so, the global health community could expand its focus from disease-specific interventions to the more comprehensive “health and well-being” of the people they serve, Weintraub said. But the global rollout of Dimagi’s technology has not come without challenges. For example, starting in 2014, Dimagi collaborated with the Bill & Melinda Gates Foundation and the Indian government to build an app to support frontline workers to address child malnutrition. But after the company handed over the system in 2020, the government replaced it with a new app that workers say is too costly to operate and riddled with errors. And in general, health workers often question new technologies because they have seen so many digital health interventions come and go, and they often say that funding should go directly to health interventions. CommCare Connect may also face resistance. Many frontline workers report they feel like they are doing the work of several people, and most of them aren’t getting paid for it. In fact, 86% of community health workers in Africa are not salaried, with the majority receiving little or no compensation for their work. The app might benefit them by allowing donors to pay for individual interventions in communities where frontline workers are already operating and want to earn more income, Jackson says. CommCare Connect could bring both the benefits and risks of the gig economy. It provides income for on-demand work offering more flexibility and income, but critics say it could also turn workers’ jobs into tasks without job security. Jackson acknowledges that technology will always have positive and negative impacts on jobs, and said Dimagi is focused on trying to make sure the positives outweigh the negatives. “We’re trying to be bold but humble about these ideas,” he said. Testing the technology Dimagi is working with organizations including Lwala Community Alliance to confirm that frontline workers do want to earn more money for more work, while also getting their feedback and making adjustments to the technology. “The challenge in the community health workspace is that it’s really hard to determine the right service package: How much is enough?” said Ash Rogers, co-CEO of Lwala Community Alliance. With CommCare Connect, community health workers can demonstrate the type and amount of work that is best for them, by choosing whether or not they opt in to additional tasks. Dimagi has collaborated with experts in early childhood development to develop training materials that at least 100 frontline workers across 3 countries will use to learn new skills, perform screenings, and get paid via the app. Lwala Community Alliance is finding that community health workers are up for taking on some added tasks, such as checking whether children have birth certificates, or doing nutrition screenings. But not all of these optional add-ons have worked as seamlessly. For example, reporting on parenting, from counting toys and books to observing how parents and children interact, can put too much of a burden on these community healthcare workers, getting in the way of the other work they do with communities. “I see CommCare Connect as an opportunity to make those additions to the service package available, but not overwhelm our really important workforce,” Rogers said.