Demand sensing and digital tracking for maternal child health (MCH) in Uganda: a pilot study for ‘E+TRA health’

Uganda health governance is divided into regions, districts, sub-districts, health facilities, and villages [7]. Accordingly, the health services are structured into National Referral Hospitals (NRHs) and Regional Referral Hospitals (RRHs), General Hospitals, Health Center (HC) IVs, HC IIIs, HC IIs and Village Health Teams (HC Is). At the highest level, NRHs, RRHs, and General Hospitals provide specialist clinical and comprehensive services. At the secondary district level, HC IIIs offer basic preventive, promotive and curative care. HC IIs only provide outpatient care and community outreach services. At the lowest level, Village Health Teams (VHTs)/HC Is facilitate health promotion, service delivery, and community participation [7].

Uganda’s first Health Information System (HIS) was designed in 1985 to capture and analyze data on communicable and non-communicable diseases [8, 9]. A centralized health management information system (HMIS) was introduced in 1993 that focused on morbidity and mortality reporting, collecting data from health units to the districts and national levels [10, 11]. The HMIS was completely paper-based. Monthly reports were generated from VHTs at the lowest level and submitted to HCs. HCs aggregated and submitted reports to the District Health Office (DHO). DHOs compiled reports and submitted to the Ministry of Health (MoH). This cumbersome monthly reporting process that required health workers lots of time to tally by going through logs often results in inaccurate data [18]. There are also other HIS tools, such as “mTrack”, a SMS-based HMIS tool designed to report on disease surveillance, “WinSenga”, a fetal heart rate monitor using smartphones (ibid), etc. Various HIS interventions emerged in Uganda but often ended in pilot phases due to lack of clear evaluation or limited skills, inadequate policy and low adoption by health workers [9].

Uganda’s health system recognizes the benefits of electronic medical record (EMR) systems [12‐15], mobile health [16, 17], and risk surveillance systems [18, 19]. However, limited infrastructure and resources hinder the design and implementation of these systems. In addition, current EMR systems in Uganda scarcely address the needs of MCH or primary care, mostly focusing on specifically communicable diseases such as HIV, malaria, and tuberculosis. (i.e., Uamuzi Bora Kenya [20], PIH-EMR Peru [21], HIV-EMR Haiti [22], OpenMRS Uganda [23], Lilongwe EMR Malawi [24]).

A system to capture the consumption and needs of maternal child health (MCH) commodities at each health facility is needed to guarantee high levels of service and minimize stockouts [25]. Many healthcare systems in Uganda implement standardized data registers to capture patient information and health product inventory status. However, in lower-level health facilities (e.g., Healthcare Center IV), limited computer resources prevent digitizing up-to-date recordkeeping [8]. Consequently, there is no digital data management system to capture information about product consumption and inventory. Staff at these healthcare facilities manually collect information from multiple paper-based registers. The main challenge for these paper registries is that health workers do not have consistent standards in maintaining records which makes accurate data capture impossible and hard to support real time decisions [26, 27]. At the district level, lack of patient registers, stock cards, and lab results brings barriers for stakeholders to make evidence-based commodity orders. Long resupply intervals aggravate stockout and expired medication problems [25]. Lack of coordination and human errors cause delays and waste resources, weakening responsiveness of the healthcare supply chain and putting patients at risk.

Although some EMR systems are increasingly amenable to monitor and integrate maternal and child health services in developing countries [28], few studies have addressed the application of EMR in inventory management [8, 29]. Tracking medicines, supplies and lab reagents in developing countries including Uganda is still paper-based stock books/stock cards/dispensing logs. This analog and manual tracking leads to difficulty in recording transactions in real time and requires tremendous effort and time to compile information. Duplications and errors of information make it difficult for store managers to prepare accurate consumption reports to generate right orders. Also, lack of coordination between MCH units and the main store causes difficulties in future demand/order forecasting [30, 31]. This results in stockout or overstock issues, which jeopardize the access to specific medical supplies, thus impacting survival and safety of pregnant women and their newborns. Therefore, there is a need for a digital healthcare supply management system that is tailored to meet MCH patient needs. Thus, in resource limited settings like Uganda, evidence based, coordinated, accurate stock management and quantification can prevent dangerous stockouts of health products. Also, precise ordering requires integration of quantification, EMR, dispensing and inventory control.

Several computerized systems need to be combined for a healthcare supply chain system EMR systems record patient history, medicine regimens and dosages. Dispensing systems record health products dispensed (i.e., mSupply, iDart, RxSolution, ADT). Inventory control systems track individual supplies by names, batch numbers, stock quantities and expiration dates (i.e., SIGMED, ORION, mSupply, HIV-EMR Pharmacy system, Navision, Syspro, ePICs). Quantification systems assist in calculating budget requirements and order quantities (i.e., FoCaMed, Quantimed, RxSolution, PIH-EMR, MSF ARV Drug Order Tool). However, EMR, Inventory control, and Dispensing systems manage patient data, inventory data and dispensing data separately. Moreover, all these tools have been mainly applied at the national and/or regional/state levels, not at the clinical level. Therefore, there is no all-in-one solution that has the capability to integrate all demand and supply data together to suggest a procurement plan at the clinical level.

Despite substantial needs, very few software applications are available in resource scarce environments. Current limitations include: (1) none of the existing systems combine the EMR, inventory control, dispensing and quantification systems. (2) Not all datasets are considered when preparing order quantities, which diminishes accuracy of order data due to the lack of data accessibility. (3) Most application designs are complex and geared toward national warehouses or retail pharmacies. (4) Most systems are proprietary, making customization and technical support difficult and costly. (5) Systems are designed under the assumption that high-bandwidth internet networks are available. (6) Supplies for test and laboratory regiments for preventive/diagnostic care are often not linked to the patient demands.

The focus of this study is to analyze information flow and design a health information technology solution to address gaps in the last mile supply chain associated with MCH in the Ugandan health system.

Key features of E+TRA Health system are listed in the Table 2 to fulfil the system requirements listed in Table 1.

The district medical store receives health products (medicines, supplies and laboratory reagents) every 2 months from National Medical Store (NMS) according to a predefined schedule for the six cycles of the year and stores them temporarily, for few days until they are distributed to health facilities in with 3 ~ 4 days after receipt. The products delivered to the district medical store are already earmarked to each of the health facilities. A private contractor, called 3-ways, picks the products from the district medical store and delivers them to each of the health facilities in the district. At the facility, the storekeepers/managers receive the products and accompanying documents (delivery notes and invoices). The physical type, count, expiry dates and other physical features are checked against the delivery notes and invoice. If there is any discrepancy, discrepancy form is filled out and signed by all the parties concerned. The delivery of the products happens in the presence of a representative from council and health unit management committee. In general, products are short delivered compared to cyclic orders both in type and quantity. In 2018, more than 80% of Health Centers (HCs) and hospitals were stocked out of one or more health commodities. [41].

We observed multiple issues in the overall process:

Securing early buy-in from MOH is very important. The Ministry has a number of bureaucratic channels and levels through which the necessary buy-in can be obtained. The earliest level for buy-in is at the ‘user’ department or unit who are the potential users of the innovation. Typically, a department to which the proposed innovation speaks. The department assigns a focal person who should understand how the innovation works. This focal point is supposed to handhold the innovation team to navigate the next level of buy-in. This involves a series of pitches to the Ministry's Technical Working Groups (TWGs).

While MOH has been championing for a migration from paper-based system to electronic system, there is still a long way to go. The Ministry has a number of e-health systems that have been piloted, and some scaled. However, there is still a large reliance on paper-based systems to collect and report routine data including HMIS data.

The health workers at both Kojja and Mukono where the innovation was piloted exhibited large interests and enthusiasm. The use of portable tablets was new to them. The health workers had been accustomed to collecting routine data using paper-based HMIS forms.

Incentives in the form of allowances to the health workers and volunteer research assistants were key for data collection to proceed. Health workers continue to operate with paper-based forms as required by the MoH, so the allowances are necessary for them to take on this additional task.

E+TRA Health is designed for intermittent internet connectivity. For daily operation, it operates without the internet. When online, the system provides additional features such as backups, system updates, and remote diagnosis/troubleshooting. As infrastructure improves and internet connectivity becomes more accessible and reliable, E+TRA Health can provide real-time monitoring and visibility of inventory levels, improving coordination and strategic planning among facilities locally, regionally and nationally.

We faced challenges of setting up intranet networks within both facilities. The units where services are delivered, MCH, laboratory, main store and dispensary, are not in close proximity, spreading over multiple isolated buildings that are located apart. Setting up an effective intranet was a challenge right from the start of the pilot with limited local supplies, technical support and capacities.

In addition, power was unreliable at both Kojja and Mukono, frequently suffering from outages. During the time of our pilot, there was a power line replacement that took about 3 months. Unscheduled two-to-four-hour power outage each day during our pilot imposed further challenge in wi-fi coverage. For future design, backup battery for all IT equipment/devices, especially intranet wi-fi related devices, will be important to include. In addition, adequate budget and understanding local capacities for installing and sustaining/maintaining IT system and internet/intranet network are also critical to consider for making long-term systemic change.