HealthConnect in South Africa: A Chatbot Tool for Pandemic Response

In this case study, we describe the implementation story of the HealthConnect and related suite of tools (including COVIDAlert, HealthCheck, and HealthWorkerAlert) in South Africa in the context of COVID-19. At end, there is an assessment of performance against the MAPS framework.

Introduction

During one of the most severe COVID-19 outbreaks on the African continent in the spring of 2020, with the help of the Praekelt Foundation, South African health officials acted quickly to develop a suite of tools for COVID-19 communication and risk passports.

These tools are known collectively as HealthConnect. They were inspired by a program that was already in widespread use in South Africa: MomConnect, a communications platform that connects mothers to health services. Like MomConnect, HealthConnect uses WhatsApp’s business API and a chatbot platform to communicate instantly with users’ smartphones. HealthConnect’s three related systems¹ — COVIDAlert, HealthCheck, and HealthWorkerAlert — streamline the contact tracing process; provide on-demand information on vaccines, cases, testing, and travel; facilitate the school-reopening process by providing screening passports; and visualize the data they collect and send it to relevant government agencies.

• COVIDAlert provides on-demand information on COVID-19 case numbers and best practices for the general public.
• HealthCheck enables users to check their symptoms, assess their own COVID-19 risk, and get COVID-19 screening clearance, while collecting information for the public health system on the location of potential cases.
• HealthWorkerAlert provides up-to-date guidance and other information to frontline health workers and links them to specialists and other resources.

Since the spring of 2020, tens of millions of people in South Africa have used HealthConnect, and its tools have collected even more data points for health officials. The HealthCheck tool was implemented by the nonprofit Higher Health and has reached nearly two-thirds of college and university students and staff in South Africa and processed over 10 million screenings, for an estimated savings of more than US$20 million.

What Is South Africa’s Enabling Environment?

• Population: Nearly 59 million
• Strict regulatory environment: South Africa’s health system is highly regulated. Several privacy regulations related to tracking people’s data and movement are in place, given the country’s history with respect to civil rights and inequities. The government began allowing telehealth services during the COVID-19 pandemic only out of necessity.
• Previous push toward digital health and national standards: The South African government is already familiar with the use of digital tools in specific contexts, such as MomConnect, and has defined standards for data use.
• Decentralized health system: Many decisions are made and implemented at the provincial or district levels, which results in multiple data systems that are not fully interconnected. One strength, however, is the notifiable diseases system used for surveillance. In the first six months of the pandemic, provinces took different approaches to key response elements including testing and surveillance.
• Most adults own smartphones, although data availability and connectivity can be limited in more rural areas. The country has high inequality and unemployment rates, so smartphone ownership is estimated to vary widely by urban and rural divides and income levels.²

Existing Health Communication Apps Before COVID-19

In 2014, as a part of a national push to develop a comprehensive digital health program, the South African National Department of Health (NDOH) and the Praekelt Foundation developed MomConnect, a communication system that connects mothers to health information and services. Initially, the MomConnect program used SMS technology and integrated registration and usage data into the DHIS2 system. The program scaled up quickly and soon evolved to include a chatbot, a help desk, and a way to provide feedback on services in health care facilities. The success of the initial MomConnect program in South Africa led to its implementation in other countries including Uganda and Nigeria.

The development team at Praekelt ultimately determined that the SMS model for MomConnect was unsustainable because it required significant support from Praekelt and the customized platforms were not easily replicated and therefore quickly became outdated. The programs were also expensive to operate. Combined, these challenges and limitations led the development team to shift from SMS to a customized WhatsApp platform in 2017, which the Praekelt team then developed further to create a replicable tool (which would later be used for COVID-19). These changes resulted in a lower-cost, improved version of MomConnect with more features.

Adapting to a New Challenge

In the spring of 2020, using a mix of funding from the Global Fund, Bill & Melinda Gates Foundation, and telecommunications companies, South African health officials worked with Praekelt to develop COVIDAlert, a new COVID-19-specific communications platform for the general public. The tool launched in March 2020 and enabled the public to receive information through text messages or their WhatsApp account. Users could access information on many COVID-19 topics, such as the latest case counts, current social distancing restrictions, and tips on how to stay well and prevent spread. From the start, the COVIDAlert tool was available in several of South Africa’s 11 official languages.

Shortly after the launch of COVIDAlert, with technical support from Wits Reproductive Health and HIV Institute and financial support from the Bill & Melinda Gates Foundation,³ Praekelt added a new tool to the HealthConnect interface. HealthCheck is a self-assessment tool that gathers demographic information such as a user’s age and location, screens for symptoms and exposure, and provides suggested actions (e.g., isolate, get tested, receive care) based on risk information entered by users. Free texting access to the tool was negotiated with four cell phone service providers in the country, and the public was advised to use the tool weekly.⁴ The data collected was sent to the NDOH and National Institute for Communicable Diseases databases to trace contacts and map infections. The NDOH set up prompts to remind citizens to check their status in the event of an exposure.⁴

The South African government initially tried to augment its contact tracing capacity by using cell towers to help identify user locations, but this process was unreliable and raised confidentiality concerns. To simplify the contact tracing process for users and tracers, the government adapted HealthConnect and another WhatsApp-based tool. HealthConnect was used to monitor contacts for symptoms and the other tool was used to communicate with positive cases. The tools are connected through a complex framework that links data between the tools and laboratory information systems. The contact tracing system was developed and implemented quickly—after a six-week trial, the system rolled out nationally by the end of April 2020.

HealthConnect is not a full digital contact tracing system, which would require automatic detection of contacts, as has been seen in numerous countries. Instead, it supplements the manual process by using text messages to limit the number of phone calls needed to reach positive cases and their contacts.

The Path to Scale and Sustainability

By the end of 2020, HealthConnect had reached at least 8 million users in South Africa — 25 percent of adults. Health officials also worked to gain traction with the public through radio and TV interviews — for example, both the minister of the NDOH and the president conducted interviews promoting the use of HealthConnect. However, by early 2021, active users had fallen to about 10 percent of the adult population. Factors limiting the tool’s reach included public distrust for the government and the limited proportion of the population with mobile data, as well as incomplete or incorrect contact information collected by testing laboratories that prevented outreach to users.

After learning about the upcoming HealthCheck feature, Higher Health began working in March 2020 to develop a unique version to be used as a “passport” on university and vocational school campuses. This became the most consistently used tool within the HealthConnect suite of tools.

In the early days of the COVID-19 pandemic, Higher Health was navigating how to continue education while under South Africa’s strict lockdown and the uncertainty of how long the lockdown would last. Learning during lockdown was difficult because many students had limited access to devices and the internet, and the reality was that the over 1 million students taking vocational, hands-on courses would not be able to replicate their educational experience online. The notion of screening everyone in person also faced challenges because it would be expensive to staff and potentially create more exposure to COVID-19 while people queued at screening stations. Yet the longer the students remained off campus, the greater the projected economic fallout.

The Higher Health team soon learned of the HealthCheck feature, then under development with Praekelt and the NDOH. However, Higher Health needed more functionality beyond general screening — it needed a certified passport tied to a specific individual, at a specific time, for a specific location. As a result, Higher Health worked separately with Praekelt to develop its own version of HealthCheck, initially supported by funding from the Bill & Melinda Gates Foundation. By late April 2020, the tool was ready to be deployed and was accessible via text message, WhatsApp, and online.

Higher Health launched an aggressive outreach campaign to garner support and uptake of the HealthCheck passport app. There was a formal launch by the Department of Higher Education and Training in June 2020, and Higher Health made agreements with faculty and staff leaders across campuses. HealthCheck was also clearly defined as just one part of the solution to minimize COVID-19 cases on campuses and was situated within a comprehensive set of protocols and resources for campuses.

The team also prioritized student outreach, which was critical because students were the largest group of users. Higher Health launched a multimodal campaign to increase familiarity and awareness of the tool. In addition to meetings with student leaders, SMS and media campaigns via Facebook, WhatsApp, and on-campus radio stations reached over 1 million students.

Another contributing factor to the success of the HealthCheck passport app is its ease of use. The tool starts with a simple screening questionnaire via WhatsApp or SMS, to be filled out before someone wishes to go on campus. Based on their responses to the screening questions (e.g., surrounding recent symptoms or COVID-19 exposure), students and staff are designated as low, moderate, or high risk. Low-risk people receive a “green receipt” as their passport, which is good for 24 hours and gives them access to campus (after they pass a temperature check), whereas moderate- and high-risk people are barred from entry.

The app sends data to NICD and NDOH to be aggregated with the broader HealthConnect data for tracking, tracing, and case mapping. By making data-sharing more efficient, especially compared with a paper-based system, the app saves time for students and on-campus staff.⁶ By early 2021, more than 11 million screenings had been performed using the HealthCheck passport app and nearly 200,000 passports were issued per day. Of the first approximately 10 million screenings, 9.4 million were identified as low-risk cases, 0.4 million as moderate risk, and just over 50,000 as high risk.⁵ The app has helped limit the number of moderate- to high-risk people who arrive on campus.

Impact

Thus far, the impact of HealthConnect has been tracked primarily via engagement metrics. By mid-June 2020, the HealthCheck app had been completed over 1 million times, and the simpler helpline that launched in March 2020 had been used over 7 million times.⁷ Meanwhile, as of early 2021, the Higher Health HealthCheck passport app has been used over 10.5 million times by 1.6 million unique users. Without the app, Higher Health estimated that 30,000 to 50,000 additional in-person screenings per day would have been required at a cost of over US$20 million dollars.

What Were the Key Drivers of Scale?

• Partnerships – Sustainable partnerships between government and partners: Connections between Praekelt, the NDOH, and major funders have been in place since 2014. This means they were primed to step in for the earliest messaging needs, and when different agencies faced challenges, they were referred to the Praekelt team for a potential solution.
• Technology & Architecture – Adaptability and speed to develop and implement: The time from decision to implementation was short (less than two months for the contract-tracing functionality and the HealthCheck passport app). The Praekelt team has worked with the government to provide updates and customizations quickly to ensure the latest guidance is in place within COVIDAlert and to tailor the tools to specific needs, adapting to the government’s active management approach to the platform.
• Operations – Outreach to community members:The Higher Health implementation of the HealthCheck passport app focused efforts on reaching campus leadership (e.g., deans, chancellors) and students. For the general public, there were heavy recruitment efforts accomplished through news media, push messages from telecom providers, and even publishing the helpline number on food packaging. Initial efforts to embed the tool into the community is critical for success—once a tool reaches a certain widespread level of use, it can achieve natural growth. Because millions of women had already used MomConnect’s WhatsApp messaging for health, and because South Africa spent a significant amount of time on community outreach, initial uptake of HealthConnect, especially COVIDAlert, was high.

What Implementation and Scaling Challenges Remain?

• Monitoring & Evaluation – Lack of impact assessments: Neither Praekelt nor the South African government has assessed the impact of the tools. Higher Health is considering conducting a study, but no specific plans are currently in place.
• Groundwork – Path to scale beyond COVID-19: Within South Africa, the HealthConnect apps developed were customized for COVID-19 and therefore could not be used to address other health outcomes. However, the MomConnect platform is still in widespread use in South Africa. In addition, the NDOH, Higher Health, and other agencies are exploring ways to build on the platform for other health outcomes such as tuberculosis screening and vaccine passports to access campuses.
• Financial Health – Working on sustainable funding: The programs are designed to be sustainable when used at scale, so once they reach a critical mass of users, costs come down to US$1 to $2 per user. However, the programs can be expensive: the HealthCheck passport app initially cost about US$10 million per month (covering 2.5 million students) after the free service from telecom providers ran out. When initial emergency funding as part of the COVID-19 response expired in June 2020, Higher Health assembled a donor consortium, including the private sector, to sustain funding for three years. The work of transitioning to longer-term funding still needs to be done. Before the COVID-19 pandemic, Praekelt experimented with different revenue models including ads and collecting survey data, but these have not yet proven to be successful.

Conclusion

The technology platform for HealthConnect can handle millions of regular users without issue, making its potential unlimited. After the success of the HealthCheck passport app in higher education, the South African government began to roll out HealthCheck for teachers and parents of younger students. This version of HealthCheck functions the same way as the passport app by helping students conduct their own symptom check and issuing clearance based on risk level, but it is connected through the newer TeacherConnect platform that launched in September 2020.⁸ In addition, driven by the high prevalence of tuberculosis in South Africa, COVIDConnect began integrating tuberculosis screening in February 2021.⁹ Higher Health is also exploring how to implement HealthCheck for vaccine passports and other health outcomes such as HIV and gender-based violence, which are currently reliant on paper forms.