CommCare in Burkina Faso: How an Existing App at Scale was Adapted for COVID-19

In this case study, we describe the implementation story of CommCare in Burkina Faso and its adaptation during the COVID-19 pandemic. At the end, there is an assessment of performance against the MAPS framework.

Introduction

More than a decade ago, Burkina Faso introduced a digital health solution to improve the health of children under five across the country. The Ministry of Health (MOH) in collaboration with the Swiss nonprofit, Terre des hommes (Tdh), implemented the Integrated e-Diagnostic Approach (IeDA), to improve protocol adherence and quality of care at the primary health care (PHC) level.

Built on Dimagi’s CommCare platform, the tablet-based app provides health workers with enhanced decision support and serves as a digital job aid for the Integrated Management of Childhood Illnesses (IMCI) strategy to reduce child mortality.^1,2,3

What started as a pilot project in one district in 2010 has since scaled up to more than 1,700 rural PHC facilities, with 6,300 health workers using the app to deliver more than 250,000 IMCI consultations per month.⁴ When the first cases of COVID-19 were reported in Burkina Faso in 2020, the CommCare app was already in the hands of health workers at 67 percent of the country’s PHC facilities.

Because the app was already in widespread use and familiar to health workers, the MOH and Tdh were able to rapidly adapt it for COVID-19. During a weekend workshop, three COVID-19 modules were designed and developed, and within three weeks the new content was deployed to health workers at PHC facilities across the country. The three modules are:

• Screening and Triage: Guides health workers through an algorithm to assess symptoms, map suspected cases, and trigger SMS alerts to health authorities for testing and follow-up.
• Counseling and Community Sensitization: Prompts health workers to share information, raise awareness, and coach caregivers on protective measures during IMCI consultations.
• E-Learning for Health Workers: Equips health workers with up-to-date information, guidance, and answers to frequently asked questions about COVID-19 in their communities.⁵

The rapid adaptation of CommCare for COVID-19 in Burkina Faso illustrates the ease with which additional content can be deployed when digital solutions are running at scale and health workers are already familiar with the tool.

Digital Solutions in Burkina Faso Before COVID-19

To reduce under-five child mortality in Burkina Faso, in 2003 the MOH introduced the IMCI strategy: a systematic approach devised by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to diagnose childhood illnesses and improve community health practices in low-resource settings.^1,3 Ten years later, however, an evaluation found that only 22 percent of nurses working at PHC facilities had been trained in IMCI and only 15 percent of children were correctly classified with the clinical protocols. The evaluation found that these low rates were due to inadequate training, a shortage of staff and supervision, low literacy, and burdensome paper-based reporting. ^6,7,8

To improve adherence to IMCI guidelines, the MOH and Tdh launched a pilot project in 2010 to digitize the cumbersome paper protocols at 39 PHC facilities in the Tougan District using a custom web-based app for laptops.⁸ The project gradually scaled up this ‘minimum viable product’ until there was evidence of improved health outcomes and quality of care. The MOH subsequently began investing in rolling out the app at across the country, and in 2014, the app was redesigned for tablets on Dimagi’s CommCare platform to achieve the anticipated scale. Dimagi was selected by Tdh because of their prior experience with implementing digital IMCI tools in Tanzania, Mozambique, Malawi, and Niger.³

Although the app’s initial users were nurses at PHC facilities, training sessions were expanded to include outreach health workers, midwives, and nurses’ assistants, who conduct consultations when nurses are unavailable.⁹

At the core of IeDA is the understanding that a digital health tool alone will not inherently improve health outcomes. IeDA therefore aims to integrate training, support, and management systems alongside the app to improve the quality of care delivered more holistically across the continuum of care. (See the four pillars of the IeDA approach below).

How Does CommCare Work?

The e-diagnostic app for IeDA was originally designed as a digital IMCI job aid for health workers at the PHC level.² The mobile system is built off Dimagi’s CommCare platform and includes a tablet-based app and web dashboards for different user types. Health workers are prompted to fill in the information requested before receiving an automated diagnosis (which they use to make their own diagnosis) and guidance for proper treatment.² The app is designed to be user-friendly—it guides health workers through decisions step-by-step, ensuring they follow the proper IMCI protocols to complete their consultations.¹⁰ Instructional videos, audio files, and limited text fields enables easy use by all health workers, regardless of digital literacy, and e-learning modules help to refresh knowledge and provide continuous training for health workers who use the app every day.¹¹

The app generates value for users at every level of the health system:

• PHC level —Health workers can access patient registries and the full medical history of the patient, which was previously impossible with the paper-based system. They can also view reports and assess their own performance relative to their peers.
• District level—District health management teams can visualize the data collected during consultations on dashboards for monitoring and disease surveillance. CommCare also generates timestamps on app usage, enabling district staff to see the date, time, and speed of data entry for health workers, which facilitates performance coaching, targeted supervision, and tailored trainings to address real needs.
• National level—CommCare integrates directly with the government’s national health information system (Entrepôt National des Données Sanitaires, or ENDOS, built on DHIS2), creating an automatic end-to-end data pipeline from data collection and aggregation to national-level monitoring and reporting on key indicators.^2,3

Since 2018, the MOH and Tdh have worked with the Cloudera Foundation and the University of Geneva to integrate artificial intelligence features and machine learning to make data processing more efficient, improve anthropometric measurements, provide health workers with real-time recommendations based on their performance history, and generate smart dashboards and predictive models for epidemiological surveillance.¹²

Adapting to a New Challenge

While IeDA originally focused on improving adherence to IMCI protocols, the long-term vision was to expand in scope to improve quality of care at the PHC level. Since 2018, new modules have been integrated for maternal care, nutrition, malaria, tuberculosis, stock management, family planning, epidemiological surveillance, and other emerging health priorities. Because the CommCare platform was widely familiar to health workers and the app was easily adaptable, Burkina Faso was able to use it to respond rapidly to the COVID-19 health emergency. Three months after the first cases of COVID-19 were reported in Burkina Faso, technicians from the government’s Directorate for Health Information Systems (with technical support from Tdh) developed three COVID-19 modules on the CommCare platform:

• The screening and triage module (Corona Triage) enables the identification of suspected cases by guiding health workers through a WHO-based algorithm to assess symptoms when patients arrive at the PHC facility. Suspected cases trigger an SMS message to district health management teams for testing and follow-up in line with the national COVID-19 case management protocols.
• Two other modules were developed in parallel: one module focuses on counseling to help health workers raise awareness of preventive measures among patients and caregivers and the other module provides health workers with up-to-date information and guidance on COVID-19.¹³

At the end of May 2020, the three COVID-19 modules were deployed to approximately 1,200 PHC facilities in 37 districts. District health management teams, nurses, and their assistants were trained on the new content during regular quality improvement sessions. Supervisory visits were then conducted to ensure effective use and address any difficulties observed. Because the COVID-19 modules were integrated into the existing app, health workers already had the necessary equipment and knowledge to begin using it with limited training. With funding from the Bill & Melinda Gates Foundation, additional tablets were purchased for larger PHC facilities so that COVID-19 triage efforts would not jeopardize use of the tool for regular IMCI consultations.

The Path to Sustainability and Scale

Since the initial pilot in 2010, IeDA has been co-developed with the government of Burkina Faso. Early on, key people within the MOH believed in the transformative potential of digital health for PHC, and they played a pivotal role in the design, influencing decision makers, and drumming up demand. A chief medical officer involved with the first pilot in Tougan District later transitioned to the central level of the MOH and continues to be an important advisor and ambassador for scaling up IeDA.

The app has been fully integrated into Burkina Faso’s health infrastructure and is considered a national priority within the country’s digital health strategy. It transmits data for key indicators automatically to the government’s health information system (DHIS2) for national-level monitoring. Since 2018, Tdh and the MOH have worked on a road map to officially transfer ownership of the app to the Burkina Faso government. This transfer entered its final phase in April 2021 and is scheduled for completion in June 2021—with funding from the German Corporation for International Cooperation (Deutsche Gesellschaft für Internationale Zusammenarbeit or GIZ) and the Global Fund to Fight AIDS, Tuberculosis and Malaria—which reinforces the Ministry of Health’s commitment to the management and use of data from this project.

The sustained success of IeDA can be attributed to strong partnerships between the government and Tdh and many other organizations, such as Dimagi, which have assisted with operations, research, and funding for the project. Tdh has cultivated trust and a strong working relationship with the government over the past 35 years, which has enabled both vertical and horizontal growth in recent years.

In addition to expanding its scope to include modules for COVID-19 and other health priorities, IeDA coverage has continued to grow throughout the pandemic. By June 30, 2021, it is expected to cover 84 percent of PHC facilities (1,755) across 54 districts. Tdh has also begun to implement IeDA in Mali and Niger, with plans of scaling across West Africa in the coming years.

Capacity-building has played an important role in sustaining the IeDA approach. Between 2014 and 2019, Dimagi worked closely with Tdh and the MOH to transfer app-building knowledge on the CommCare platform to ensure they could independently manage, maintain, and modify the app. In addition, e-learning modules and regular coaching visits have helped sustain use of the app in the context of high health worker turnover. A robust troubleshooting hierarchy and technical support system to address bugs and broken equipment have been key to its sustained success.¹⁰ Above all, sustained use of the app links back to its original function as a job aid. Most health workers use the app because it makes their daily tasks easier. All of these components laid the foundation for the rapid deployment of COVID-19 modules.

Impact and Results

Because the burden of COVID-19 in Burkina Faso has remained relatively low, the ability to evaluate the impact of this app in the context of COVID-19 has been limited. However, previous evaluations of IeDA have demonstrated proof of improved health outcomes and quality of care.

Evidence from independent evaluations performed by the London School of Hygiene and Tropical Medicine indicated that in PHC facilities covered by IeDA, 97 percent of consultations for children under five were conducted with the digital tool, leading to a 50 percent improvement in adherence to the IMCI protocol. ^3,18 An economic impact study projected that yearly savings from IeDA were between US$830,000 and US$1.7 million as a result of reduced training times for health workers and reduced paper consumption at PHC facilities.^19,4

The evaluations also found that IeDA increased health worker satisfaction and generated indirect benefits for the community. Because Tdh provided PHC facilities with solar kits to ensure a steady supply of energy for the tablet, a qualitative study found that communities appreciated the supply of electricity at PHC facilities, especially at night.¹⁰

Beyond the app itself, coaching and supervision are core pillars in the IeDA approach. By the end of 2017, the MOH and Tdh had trained 88 percent of the country’s nurses on the app with quality improvement sessions held two to four times per year. Coaching visits were conducted every month during the first year of implementation and every three months thereafter. An evaluation found that 90 percent of supervision was conducted as planned every month. ^20,10

While health workers agreed that the addition of COVID-19 triage module has been a valuable initiative and that the e-learning and counseling modules have equipped them with information to answer pressing questions, no formal impact evaluation of the COVID-19 modules has been conducted to date. This is, in part, because the project is not among the top priorities for the authorities leading the response and the direct burden of COVID-19 in Burkina Faso has remained relatively low (166 deaths recorded as of May 26, 2021).¹⁴ In the context of asymptomatic transmission, the impact of the symptom triage tool is inherently limited, in addition to the fact that overall transmission has been concentrated in urban areas, whereas IeDA operates primarily in rural areas.

The ability to rapidly visualize and monitor data collected through IMCI consultations has also uncovered interesting trends related to the disruption of services and indirect health effects caused by COVID-19 and the lockdowns in Burkina Faso. With access to data from more than 10 million IMCI consultations since 2014, decision makers can compare data with previous years to better understand changes in health-seeking behaviors and service delivery during the pandemic.⁴

What Were the Key Drivers of Scale?

The MOH and Tdh, with support from a wide range of partners, recently expanded IeDA’s scope to include workflows for maternal care, nutrition, malaria, tuberculosis, stock management, family planning, COVID-19, and more. This expansion was made possible by leveraging the existing IeDA infrastructure and CommCare’s modular platform allows for the rapid addition of new content. The following key drivers of scale were instrumental to the success of the app:

• Operations – Existing scale and familiarity with CommCare: COVID-19 modules for triage, counseling, and e-learning were rapidly designed, developed, and deployed to 6,300 health workers across Burkina Faso in a matter of weeks. Rather than building and scaling a new solution from scratch, COVID-19 content was promptly integrated into the existing CommCare app and remotely deployed to health workers at PHC facilities that already had the equipment and knowledge to begin using the app with limited training. A robust troubleshooting hierarchy and technical support system to address bugs and broken equipment have been key to its sustained success.
• Partnerships – Key champions and sustained collaborations: Since the initial pilot in 2010, IeDA was co-created with the MOH. The intention to scale nationally was established after evidence of impact, and the system was built with this objective in mind. Key champions within the MOH in addition to strong partnerships between the government, Tdh, Dimagi, and other organizations have contributed to the success of IeDA. The COVID-19 modules were initiated by the government’s Directorate for Health Information Systems with technical support from Tdh.
• Technology and architecture – Designing for the end user: From day one, IeDA was built to provide technology support, with equitable and comprehensive coverage of all communities including hard-to-reach areas. Initial architecture, participatory user design, and pilot rollouts were all undertaken across a wide range of regions and communities. The design of the app's offline functionality was instrumental to enabling use of the tool in all districts, including those with poor connectivity. Building the solution from the ground up, rather than the top down, ensured that critical bottlenecks in more challenging contexts could be addressed with in-depth solutions before scaling up.
• Monitoring and evaluation – Evidence of impact across the health system to drive scale: The large amount of data generated by IeDA (from over 10 million consultations since 2014) has provided health officials at the district and national levels with access to near real-time information for decision making. Customizable and predictive dashboards have facilitated monitoring, surveillance, and statistical analyses, as well as performance coaching and targeted supervision for health workers at the PHC level.
• Groundwork – Leveraging an existing digital platform: By choosing an established global good with a proven capacity for scale, the MOH and Tdh have been able to focus on the scope and content for the app rather than the platform itself. ^2,15 Furthermore, the platform was already compliant with individual health data collection and storage regulations (such as the Health Insurance Portability and Accountability Act and the General Data Protection Regulation). After initial knowledge transfer and capacity-building sessions from Dimagi, CommCare’s modular “no code” platform has enabled the MOH and Tdh to independently maintain and modify the scope of the app to address emerging health priorities.

What Implementation and Scaling Challenges Remain?

Despite achieving significant scale, enduring challenges remain for the implementation of IeDA and the continued expansion of the CommCare app. Some can be addressed with technology, while others cannot.

• Financial Health – Reliant on donor funding: The MOH and Tdh have leveraged a range of partnerships and funders to support IeDA, but it is ultimately reliant on donor funding. Despite the substantial projected savings in recurring costs, the initial investment required to scale up this technology is also substantial. From 2014 to 2017, IeDA’s overall expenditure was about US$4.8 million, and IeDA has since received more than US$14 million in funding from donors including the Bill & Melinda Gates Foundation, Global Fund, UNICEF, Novartis, UNITAID, and Cloudera.¹⁰ It is likely that IeDA will continue to rely on donor funding even after the full transition to the MOH is complete.
• Operations – High health worker turnover: IeDA has been implemented in rural communities where health worker staff turnover is high. One report found that every 12 months, about 40 percent of nurses and midwives move to a different facility, causing challenges at PHC facilities where health workers were asked to use the app without having received the training.¹⁰ The integration of e-learning modules and demonstrative videos have partially addressed this challenge, and studies have found that the majority of users perceive the app as an educational tool for continuous knowledge development.^15,9 Additionally, as the scale of the tool continues and it is used more widely, new health workers are more likely to have had previous exposure to the app.
• Groundwork – Connectivity challenges persist: While the CommCare app can be used offline, submitting reports and sharing data requires connectivity. A 2021 evaluation by the Economist Intelligence Unit placed Burkina Faso in 117th place out of the 120 countries reviewed for network coverage (minimum 3G).²¹ Although access to the internet in Burkina Faso has improved in recent years, the connection in many parts of the country remains limited and the majority of users have complained about the slow speed of tablets where this is the case.

Conclusion

Even before the COVID-19 pandemic, CommCare was a rare example of a digital health tool with widespread use across sub-Saharan Africa. Burkina Faso’s decade-long experience with one of the largest digital health projects in sub-Saharan Africa demonstrates that a rapid response to an emerging health crisis is possible when a strong digital infrastructure exists.

Moreover, the implementation of IeDA for child health—and an expanding list of other health areas, including malaria, nutrition, maternal health, tuberculosis and pneumonia—offers important lessons on how to scale up and sustain digital health interventions for a variety of use cases in low- and middle-income countries.²