Author: Anne Fox

I-TECH and CHARESS Teams Present Lessons Learned at the Global Digital Health Forum

Casey-Iiams Hauser, Senior Informatics Implementation Specialist, presents on laboratory information systems at the Global Digital Health Forum in Washington, D.C.

The Fifth Annual Global Digital Health Forum was held from 10-11 December in Washington, D.C., attracting more than 300 participants to the FHI 360 Conference Center. At the forum, representatives from the new Digital Initiatives Group at I-TECH (DIGI) and its partner in Haiti, CHARESS, shared knowledge and lessons learned from 15 years of experience implementing digital health solutions worldwide.

The theme for this year’s forum was “A Shared Language for Digital Health,” and built on a foundation of the World Health Organization’s Classification of Digital Health Interventions.

“I welcome the messages from donors funding digital health work that they are shepherding a new era through the Digital Investment Principles,” said Joanna Diallo, DIGI Managing Director. “The conference provided DIGI an opportunity to present our contributions to global goods like OpenELIS, OpenMRS, and OpenHIE.”

Diallo moderated a panel titled “Different Labs Need Different Systems: An Exploration of Open Source Laboratory Information Systems Use in Global Health and the Community of Practice that Brings Them Together.” Jan Flowers, DIGI Faculty Co-Lead and Director of Global Health Informatics at the University of Washington Clinical Informatics Research Group, and Casey Iiams-Hauser, Senior Informatics Implementation Specialist with DIGI, were panelists, along with Steven Wanyee of IntelliSOFT, a former member of the I-TECH Kenya team.

The panel highlighted LIS as a critical component of national health information systems (HIS) architecture, exploring a complementary suite of open source LIS that are implemented across low- and middle-income countries, describing the laboratories and use cases each serves.

“The forum is a fantastic opportunity to meet with funders, on-the-ground implementers and technologists to discuss our work and learn about new initiatives and technologies,” said Iiams-Hauser. “We can leverage this knowledge for success both in our existing health information projects and in future partnerships.”

CHARESS HIS Lead Nathaelf Hyppolite participated in a session highlighting the development, implementation, and transition of EMR in developing countries, drawing on I-TECH and CHARESS’s work in Haiti. Participants heard about the benefits of an interoperable EMR: a unified data format, the ability to back up data, and that same data can be used to generate reports via DHIS2 from both the cloud servers and hardware EMR system. Hyppolite also shared the advantages and limitations of transitioning to an OpenMRS and OpenHIE platform, which bring experts together to share knowledge, standards, and best practices, as well as collaborate on technologies.

This focus on community and communication was noted by Diallo and the other participants. “DIGI really appreciated the opportunity to learn more about new standards and technologies, how to best approach digital health governance work, and how a shared language will help us collaborate and work together to ultimately improve health outcomes,” said Diallo.

Renewed Awards Totaling $24 Million Help Usher Zimbabwe Toward HIV Epidemic Control

Dr. Batsi Makunike (L), I-TECH ZImbabwe Country Director, presents Dr. Ann Downer, I-TECH Executive Director and former PI of the Zimbabwe Care and Treatment project, with a farewell gift. The batik was made by using sadza porridge to apply the dye to the fabric.

Last Saturday, 1 December 2018, marked the 30th World AIDS Day, with a focus on urging all people to know their HIV status, as well as on ensuring access to prevention, care, and treatment services for those affected by the disease. Two programs at the International Training and Education Center for Health (I-TECH) are working in concert with local partners to help make those goals a reality in Zimbabwe.

A center in the University of Washington (UW) Department of Global Health, I-TECH has worked in Zimbabwe since 2003, starting with a $150,000 grant for an assessment of the need for HIV training in the country. Since then, work in the country has expanded to two awards totaling more than $24 million for the current year—one of which focuses on HIV testing, care, and treatment and the other on voluntary medical male circumcision (VMMC) for HIV prevention.  Both projects are funded by the U.S. Centers for Disease Control and Prevention, through the President’s Emergency Plan for AIDS Relief (PEPFAR), and operate through consortia comprising I-TECH and local partners.

The consortium for the VMMC award, ZAZIC, will continue to be led by Dr. Scott Barnhart, Professor in the UW Department of Global Health and School of Medicine. However, the consortium for the care and treatment award, the Zimbabwe Partnership to Accelerate AIDS Control (ZimPAAC), has undergone a change in leadership: its new Principal Investigator (PI) is Dr. Stefan Wiktor, Professor in the UW Department of Global Health. Dr. Wiktor was handed the baton by the project’s previous Principal Investigator, Dr. Ann Downer, I-TECH Executive Director and also a Professor in the department, during a ceremony in Harare in October 2018.

“We are all so grateful to Dr. Downer for the past five years; for gently, but firmly leading us through the transition from a training and mentoring grant to a high-impact service delivery grant in five provinces,” said Dr. Batsi Makunike, I-TECH Zimbabwe Country Director. “Looking ahead, we welcome Dr. Wiktor to our team and the opportunity to tap into the wealth of experience that he brings as our new PI.”

Dr. Wiktor expressed hope that, through the continued hard work of the Zimbabwe consortium, the country will achieve its national and global targets. “Zimbabwe is one of the countries in Africa closest to reaching the UNAIDS 95-95-95 targets, and ZimPAAC is a critical partner to the Ministry of Health in that effort,” said Dr. Wiktor. “I am delighted to be working with such an outstanding team of public health professionals.”

Through ZimPAAC, I-TECH provides direct service delivery and site support for care and treatment at 372 public sector health facilities to strengthen health systems and improve the quality of care and treatment services and increase enrollment, initiation and adherence.

The VMMC project has already performed 313,267 VMMCs, as of October 2018, surpassing PEPFAR targets. The new award aims to circumcise 500,000 men over five years, resulting in the prevention of approximately 100,000 new cases of HIV.

“It has been such a privilege to work in Zimbabwe, a country that has a real chance to control the AIDS epidemic—both because of generous funding from PEPFAR and, more importantly, because of the caliber of the Zimbabwean people who live and work here,” said Dr. Downer at the handover ceremony.

“Our Zimbabwe team, consisting of both Harare- and Seattle-based members, is one of the finest I’ve ever worked with,” she continued. “Dr. Wiktor inherits a highly productive consortium that is partnering with ZAZIC and the Ministry of Health to propel Zimbabwe toward a healthier future and an AIDS-free generation.”

I-TECH’s Samantha Dolan Wins Gates Foundation Grand Challenges Explorations Award

Samantha Dolan, a Monitoring and Evaluation Advisor with the Kenya team at the International Training and Education Center for Health (I-TECH), has received the Bill & Melinda Gates Foundation Grand Challenges Explorations award. Along with I-TECH Kenya’s Ian Njeru and I-TECH PI Peter Rabinowitz, professor in the Department of Global Health, Dolan has been awarded $100,000 to conduct a project over the next 18 months to improve digital data collection and monitoring of childhood immunizations at Kenyan health facilities.

Read more about Dolan and her project on the UW Department of Global Health website–and congratulations from the I-TECH family!

Formulating Guidelines and Operating Procedures

I-TECH India PL is part of various national ART and testing guideline groups of NACO in India, including Journey of ART Programme in India; HTS Guidelines; ART Guidelines for HIV-Infected Adults and Adolescents, May 2013; National Guidelines on Second-line and Alternative First-line ART For Adults and Adolescents, May 2013; Operational Guidelines for ART Centers, July 2012; HIV/TB Guidelines, 2015; and National ART Technical Guidelines, October 2018 (http://www.naco.gov.in/care-support-treatment).

The team also assisted NACO in designing standard operating procedures for implementing newer program initiatives such as Treat All, Pre-ART mop-up, co-located ART and OST (Oral Substitution Therapy) Centres, ART through targeted intervention programs, and multi-month dispensation of ART.

Enhancement of Health Information Systems and Data Quality in India

I-TECH India PL has provided national, state, and facility level technical assistance for improving quality, analysis and presentation of ART program data; developed innovative tools for tracking program progress based on data analysis of selected indicators over a period of time and submitted for national scale-up; and provided technical mentoring to improve quality of data collection and reporting by the ART Centers at 48 sites of India in the last three years.

Building the Capacity of the Health Workforce in India

I-TECH India PL has worked with stakeholders to develop national training curricula for health care staff on delivering HIV care and treatment services. In addition, it has:

  • Planned and implemented training programs for various cadres of clinical and program staff;
  • Participated in medical officer training programs at the national level;
  • Designed and conducted five regional continuing medical education (CME) courses in North, South, West and Northeastern regions on “Invigorating HIV Care” for ART center medical officers;
  • Designed and conducted four workshops in two weeks reaching 164 ART counselors for improving care support and treatment services provided to key population clients accessing ART centre services in Maharashtra;
  • Conducted National Distance Learning Seminars (webinars)—an average of 25 sessions per year on clinical- and program-related topics for the past five years reaching over 50% of ART Centers in India, with average participation of 1000 per session. These sessions are recorded and are available on YouTube channel “I-TECH India.”
  • Conducted Regional Distance Learning Seminars (webinars)—an average of 60 sessions per year through 15 HIV/AIDS Centres of Excellence in more than six languages during the last five years reaching over 50 % of ART Centers in India, with average participation of 50 per session; and
  • Coordinated certificate courses from UW on Leadership and Management in Health, Principles of STD (Sexually Transmitted Diseases) and HIV Research, Introduction to Epidemiology for Global Health, Clinical Management of HIV, and Fundamentals of Implementation Science for over 500 individuals during the past five years.

Strengthening Health Service Delivery in India

  • I-TECH India PL has successfully designed and implemented four differentiated ART service delivery models, including models for key population clients, in collaboration with other stakeholders in states of Maharashtra, Nagaland, Manipur and Mizoram to develop a proof of concept for the national level scale up;
  • Improved delivery of health services through onsite technical mentoring and supervison of health care staff in 9% of the ART centers of the country in the last three years;
  • Technically assisted successful implementation of newer initiatives such as treatment of TB through the ART centers, the “Treat All” initiative, and routine viral load monitoring at 48 ART centers; and
  • Conducted/participated in health service delivery assessments of facilities such as the national HIV/AIDS Centers of Excellence, ART Centers, Link ART Centers, and other care and support centers for the NACO.

I-TECH India and Haiti Offices Transition to Local Organizations

I-TECH India will continue to support a complete array of educational services and technical assistance to 17 Centers of Excellence in India.

In spring 2018, the International Training and Education Center for Health (I-TECH) made University of Washington (UW) history when two of its country offices transitioned into independent organizations. I-TECH’s office in India is now the independently run I-TECH India, and its former office in Haiti now operates as CHARESS (Centre Haïtien pour le Renforcement du Système de Santé). Both organizations are sub-contractors on current I-TECH awards.

“With the India and Haiti I-TECH office transition to a local identity, we are applying what we already know about transition to creating new relationships with these independent entities,” says Dr. Ann Downer, I-TECH Executive Director and Professor in the UW Department of Global Health. “To help ensure long-term sustainability, we are working together on business plans and mapping out strategic priorities and mutual interests. This transition has intensified our partnership rather than creating distance.”

A roadmap for the university

I-TECH has worked closely with UW Global Operations Support over the past decade to inform the internal procedures and structures necessary for international office registrations. According to Doug Divine, Director of UW Global Operations Support, this work has promoted operational effectiveness by enabling a safe, compliant, and legal environment for conducting international work.

“I-TECH has been our key partner in the justification and implementation of these registrations, establishing 11 of the 15 entities registered abroad,” says Divine. “It has been so rewarding to have partnered with I-TECH on such an innovative administrative approach. Seeing these registrations become fully functioning independent entities not only fulfills a key mission of I-TECH to help establish sustained capacity where it is needed most, but also reflects the commitment of the UW community toward international engagement.

I-TECH’s close work with Global Operations Support has also prepared I-TECH India and CHARESS for success, helping to create the administrative and policy structures necessary for them to more easily fledge.

New opportunities

The team at CHARESS will continue to oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.

The transition of the India and Haiti offices marks new territory in I-TECH’s move toward country ownership, allowing in-country teams to simplify administration and explore funding opportunities that weren’t available to them as UW entities.

The I-TECH India team looks forward to these new opportunities. “This really opens doors to new things,” says Dr. Anwar Parvez Sayed, Clinical Programs Director for I-TECH India. “We were previously looked at as a foreign entity, and we can now apply for local grants.”

I-TECH India has provided technical assistance to 10 Indian Centers of Excellence (CoE) on HIV/AIDS since 2003. In the years ahead, it will continue to support a complete array of educational services and technical assistance to the CoE network in India, plus an additional seven pediatric sites, called pCoE.

“We will now be complying with local Indian regulations, which simplifies things,” says Madhuri Mukherjee, Country Representative of I-TECH India. “Though we no longer have the layer of Washington State and federal compliance, we will remain closely aligned with I-TECH’s and UW’s missions. It’s beneficial from both sides to maintain a close relationship.”

In fact, I-TECH India and CHARESS will each have a memorandum of understanding (MOU) with I-TECH/University of Washington. Each MOU will underscore the organization’s shared history with I-TECH and outline elements of an ongoing commitment — including being preferred partners on new funding opportunities.

In Haiti, CHARESS will continue to maintain, train, and deploy health information systems (HIS) such as iSantéPlus and the Système d’Echange d’Information de Santé d’Haïti (SEDISH), a national health information exchange. It will also ensure that the national sites for both receive on-site and remote technical assistance. In addition, the team will oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.

“As CHARESS, we look forward to continuing the programming that we have been so proud of,” remarks Dr. Jean-Guy Honoré, CHARESS Executive Director. “Our HIS work, in particular, has had a real impact in Haiti, and our new local status will allow CHARESS to pursue even more opportunities to become a global leader.”

An updated vision of sustainability

In its 16 years of operation, I-TECH’s ultimate goal has always been to strengthen local capacity and to help build sustainable health systems. To that end, I-TECH’s direct service and technical assistance programs are tailored from the initial planning stage to produce projects that can be successfully absorbed into national systems. Its main partner in this endeavor is always the local Ministry of Health.

At the International AIDS Society conference this year in Amsterdam, Dr. Downer presented recently completed research on six transitioned I-TECH programs (of more than 350 that have transitioned), exploring the degree to which investments had been sustained by local partners, as well as identifying the key elements of successful transition.

I-TECH’s experience with transition to local ownership and long-term sustainability of interventions aligns with those presented by Vogus and Graff (PEPFAR Transitions to Country Ownership, June 2015), including the need to plan for:

  • Communication of transition strategies through high level diplomacy;
  • Stakeholder participation in transition planning;
  • Government support of the plan, including alignment with local government policies, practices, and salaries;
  • Use of planning tools (i.e., a roadmap); and
  • Adapting approaches to the local context during transition.

“In addition to the known characteristics of successful transition of projects to local ownership, I-TECH has found that we also need to identify a champion within local government to advocate long-term for the adopted interventions,” says Dr. Downer. “We also need to plan intentionally for how much and what type of technical assistance or short-term funding will be needed in order to ensure sustainability.”

Doug Divine sees massive benefits at each stage of I-TECH’s country office relationships, from registration to independence. “Without I-TECH and the projects it has spearheaded, I’m not sure UW would have made the advancements it has made on the international front,” he says. “I-TECH had the vision, the infrastructure need, and the boots on the ground — which gave us impetus to set up structures for the rest of the university. Other departments can now leverage those resources, and now the spin-off offices fulfill our commitment to allow these structures to grow in their own context.”

Namibian Primary School Receives Platinum Certificate for VMMC Saturation

Facing Ashitenga Primary School students at the VMMC certificate ceremony are, from left to right: Levi Vries, Education Inspector for Oluno Circuit; Lusia Ndemuweda, I-TECH Demand Creation Coordination Nurse; Ashitenga Principal Edward Asser; Frieda Mupetami, a representative of Okatyali Constituency office; and Life Skills teacher Teopolina Mupetami (in red).

In Namibia, the prevalence of HIV infection among adults aged 15 to 49 is nearly 14%.[1] A key component of national efforts to prevent the spread of HIV is voluntary medical male circumcision, or VMMC, which has proved to reduce the rate of male-to-female transmission by upwards of 60%.

Since 2010, the International Training and Education Center for Health (I-TECH) has supported the VMMC efforts of the Namibian Ministry of Health and Social Services (MOHSS) in the Oshana and Zambezi regions. I-TECH not only supports health care worker training in the provision of VMMC, it is also engaged in critical efforts to create demand for the procedure.

A key element of these efforts is the recognition of schools and school leadership who are supportive of VMMCs. In February, Ashitenga Primary School in Oshana Region was awarded a platinum certificate by I-TECH Namibia for achieving 96% saturation of boys receiving a VMMC. Platinum is the highest honor, with bronze signifying 55-69% saturation, silver awarded for 70-79% saturation, and gold given for 80-89% saturation.

Present at the event was the Oluno Circuit Education Inspector Levi Vries. In his remarks, Mr. Vries encouraged other schools to emulate Ashitenga’s good example. He emphasized the importance of student health to attaining educational goals and urged students to spread the VMMC message to others in their families, villages, and neighborhoods.

As part of the Life Skills curriculum, older boys are instructed on HIV prevention, while the younger boys are taught personal hygiene – messages that are reinforced by I-TECH community mobilizers. Teopolina Mupetami, the Life Skills teacher at Ashitenga, encouraged Life Skills teachers at other schools in the area to support the VMMC program. Ashitenga principal Edward Asser echoed the importance of the school’s recognition; he promised to display the certificate proudly in his office.

Three of the circumcised students were interviewed by the Ministry of Information Communication and Technology, which is charged with spreading the message about “the smart cut” in the government media. The boys responded that “they feel clean and protected from sexual related disease,” said Helena Ferdinand, I-TECH community mobilizer. The students prompted boys at other schools to enroll in the VMMC program and expressed their satisfaction with the service.

“The atmosphere at the handover was joyful and a lot of excitement,” said Ms. Ferdinand. “The principal indicated that they will continue to work hard to get a second platinum certificate.”

[1] UNAIDS; http://www.unaids.org/en/regionscountries/countries/namibia

Case Study of iSanté proposes sustainability as key success factor for health information systems in LMIC

I-TECH Haiti’s Dr. Marinho Elisma works with clinician Belhamie Ketleen on the iSanté electronic medical record system.

To mark the 10th year of the iSanté electronic medical record (EMR) system, the International Training and Education for Health (I-TECH) team in Haiti embarked on an analysis of the EMR’s implementation, the results of which were published as a case study last month in Health Policy and Planning.

The study focuses on factors of success, contributing to the industry’s understanding of what it takes to sustain and transition an EMR system in a low- and middle-income country (LMIC) like Haiti. The team found that while functionality and technical factors continue to be relevant as EMR implementations mature, other factors also become significant over time, including governance and leadership, ongoing user capacity, data quality, integration within a larger eHealth framework and financing.

The team assessed factors for success in eight categories: functionality, technical, organizational, training, political, ethical, financial, and sustainability. Seven of these were determined by the work of Fritz et al. in a review of factors contributing to EMR system success in low-resource settings.[1] However, one of the main findings was the eighth category the Haiti team added to the list of factors: sustainability.

Why sustainability is critical

When a system like iSanté is implemented at scale for so many years, the definition of success shifts from design, planning, and rollout to financing, governance, maintenance, and long-term ownership of the system by Haitian stakeholders. Transition planning, including long-term financial sustainability of the system, needs to begin at the start of any implementation.

“iSanté is a part of the legacy of the HIV information system, a model that will be used from generation to generation especially in terms of sustainable HIV/AIDS interventions,” said Nirva Duval, M&E Lead at the National AIDS Control Programme of the Ministry of Public Health and Population (MSPP) in Haiti, a case study author who has been involved in the iSanté implementation since its beginning in 2005. She went on to add, “Use of iSanté data is a major asset and an opportunity to better understand issues and contribute to decision-making at all levels.”

Ultimately, the goal is for iSanté to be fully owned, managed, and maintained in Haiti and wholly integrate into clinical practice. In 2016, I-TECH, the U.S. Centers for Disease Control and Prevention (CDC), and the MSPP undertook an overhaul of iSanté, including moving all servers and the majority of software development to Haiti.

Lessons learned pave the way for integration

The rebuild, known as iSantéPlus, uses an OpenMRS platform, which is supported by a growing global community. The phased national rollout of iSantéPlus is under way and will continue during 2018. I-TECH is also supporting the creation of a new national health information exchange known as “SEDISH” (Système d’Echange d’Information de Santé d’Haïti in French).

SEDISH will ensure a seamless flow of data between the community level to sites to the national level and back, improve clinicians’ ability to see patient history from other sites, and maintain a continuity of care document for patients who move between care sites. SEDISH uses international data standards and a Master Person Index to facilitate harmonization and information sharing between the EMR and other health data systems like lab and supply chain systems, transitioning the Haiti HIS landscape from multiple disparate systems to an interconnected network. Both iSantéPlus and SEDISH will promote collaboration between MSPP and CDC- and USAID-funded partners to improve how health care providers serve individual patients and populations across these systems.

Many of the lessons learned during the implementation of iSanté were applied in the design and execution of iSantéPlus and SEDISH. “iSanté has kept Haiti on the leading edge of HIS implementation in resource-constrained countries,” said Dr. Scott Barnhart, Principal Investigator and Professor in the University of Washington’s Departments  of  Medicine and Global Health. “The changes under way will have broad global applicability — integrating across direct patient care, lab, pharmacy, as well as supply chain. We have an exciting opportunity to come together and build on our success to respond to the challenges of local ownership, financing, cost-effectiveness, and governance so that these important tools are sustainable.”

Once the team completes and assesses the results of the iSantéPlus and SEDISH pilot, the new systems will be deployed throughout Haiti. It will be critical that the MSPP, CDC, and I-TECH’s partners in Haiti come together to assess the sustainability of iSantéPlus and SEDISH and their impact on the HIS landscape in Haiti.

[1] Fritz F, Tilahun B, Dugas M. 2015. Success criteria for electronic medical record implementations in low-resource settings: a systematic review. Journal of the American Medical Informatics Association 22: 479–88.