Empowering Community Health Workers with Technology Solutions

Anna Frodesiak/Wikimedia Commons

Empowering Community Health Workers with Technology Solutions BRIANNA BUEHLER, RENE RUGGIERO, and KHANJAN MEHTA

Digital Object Identifier 10.1109/MTS.2013.2241831 Date of publication: 14 March 2013

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1932-4529/13/$31.00©2013IEEE

IEEE TECHNOLOGY AND SOCIETY MAGAZINE

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reat economic, social, and structural disparities exist in the world today, and these disparities have led to immense challenges for healthcare facilities around the world. The global community “lacks an equal rights-based approach in the distribution of healthcare” [1]. The burden of disease is growing disproportionately in different regions of the world, with developing countries moving toward a double burden of both chronic and infectious disease. Many countries with low economic and human resources have the highest public health burden. Of the 163 million births each year, 3–4 million babies die in their first four weeks, and 10.6 million children die before reaching the age of five. Approximately 530 000 women die in pregnancy or childbirth each year [1]. Over 17 million people will die of cardiovascular disease worldwide in 2010, with more than 60% of the global burden of coronary heart disease occurring in developing countries [2]. The number of people living with HIV/AIDS worldwide is 33.3 million, while in 2008, 1000 children became infected each day [3]. Seventy to eighty percent of the health problems are preventable, but access and utilization of the health systems remains low in some regions [4]. Poverty, both in developing and rich countries, has detrimental effects on individuals’ and populations’ health. Poverty prevents people from having access to the basic amenities needed to live healthy lifestyles, or services needed to sustain life. Evidence has shown that poor people “live shorter and sicker lives” [5]. In addition, poor people unlucky enough to become sickened by HIV/AIDS, malaria, or tuberculosis are at high risk for falling into a “medical poverty trap” [5]. Low income countries frequently experience “brain drain,” as many of their most educated healthcare professionals

Of 163 million births each year, 3–4 million babies die in their first four weeks, and 10.6 million children die before reaching the age of five. leave the country for higher salaries in developed nations. Health worker migration has contributed to the breakdown of some health systems in Sub-Saharan Africa. Overall, 36 countries in Africa did not meet the target of one doctor for every 5000 people. In 2002, the U.K. described a nursing shortage of 35 000, which was the same as the entire nursing workforce of Tanzania, Botswana, Ghana, and Malawi combined. By some estimates, Ghana lost more nurses then it trained in 1999. The absence of healthcare workers threatens the overall health services a country can provide for its people. The availability of human resources has been identified as a main determinant of health system performance. These global disparities, burgeoning and shifting burden of disease, and health worker migration have contributed to a growing primary healthcare crisis, especially in the Sub-Saharan Africa region [6]. Community Health Workers (CHW) have stepped in to meet these growing healthcare challenges. CHWs have worked to fill the gap through educating and attending to the healthcare needs of their communities. This article will provide evidence that empowering community health workers with appropriate technologies can address primary healthcare needs in developing countries. Through a comparison of case studies from various countries, a review of available resources and challenges facing CHWs, and primary data collected in Kenya, we will highlight the potential remedial impact of technology initiatives for empowering Community Health Workers.


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Community Health Workers “The only solution for public health is training of community health workers. When we talk about improvement in primary healthcare in a village, we are talking about information and changing behavior. Because community health workers are from the grassroots and they know the culture, they are able to change behavior much easier and faster.” —Harold Kodo, national KEPI education officer, Kenya [7] Community Health Workers are trained community members working in health education, prevention, and awareness in their communities. First introduced in the 1970s and 80s after the Alma Ata declaration for the initiation and provision of primary healthcare services at grass root levels, they engage in the management and treatment of illnesses [4]. The World Health Organization has set minimum guidelines for the selections of CHWs: “CHWs should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers” [8] CHWs have many responsibilities in a community. They conduct home visits, provide treatment of simple and common illnesses, and |

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offer health education including nutrition and surveillance. CHWs also support maternal and child health, are involved in family planning activities, and contribute to the treatment and care of tuberculosis, HIV/AIDS, malaria and acute respiratory disease. Trained in providing referrals, CHWs also spend time recordkeeping and collecting data on illnesses within the community. CHW programs have been developed with the goals of improving access to healthcare and decreasing morbidity and mortality rates. These

lack of healthcare professionals. The Global Health Workforce Alliance completed in-depth case studies of CHW programs around the world to evaluate the impact of CHWs on the Millennium Development goals. They reviewed the training, supervision, standards deployment, performance, and impact of CHWs in the areas of maternal and child health, HIV/AIDS, TB, mental health, and non-communicable diseases. We have discussed case studies of CHWs in Brazil, Ethiopia, Bangladesh, and Pakistan, to review best

Approximately 530 000 women die in pregnancy or childbirth each year. programs aim to lower the costs in seeking medical advice, and create self-reliance and local participation in community healthcare. Increasing access to resources and community participation in turn improves coverage and equity across the country. It has been shown that CHW programs improve health indicators, behaviors and utilization of services. Such programs also improve the cultural appropriateness of health and education campaigns. The community empowerment model of CHW programs promotes the sustainability of health interventions leading to related economic benefits. CHWs serve as a link between a community and the national health systems and provide insight into community level social and environmental determinants of health. CHWs have been recognized as an important tool in improving the health of a community [4].

practices and potential models for other CHW programs. The case studies offer a window into the reality faced by CHWs. Appropriate context-driven design of simple, low-cost technologies can empower CHWs and improve the efficiency of isolated rural healthcare centers [9]. Computer-assisted diagnostic software to process patients at rural clinics is a feasible long-term approach, particularly as smartphones become accessible, affordable and capable of supporting compute-intensive applications [10]. Understanding the CHW’s needs and context of use is an important first step towards conceptualizing and designing appropriate technology products and services or policy interventions. The functionality and reliability of the technology itself is typically not as big of a challenge as the usability, socioeconomics and incentive structures for all the stakeholders [11].

Case Studies

Brazil In 1988, the Brazilian Unified Health System was developed on the principle that health is a basic human right of all citizens. Created with the aim of reaching universal coverage of all people, it was operationalized through a focus on

For several decades, Community Health Workers have participated in primary healthcare delivery in many countries around the world. Evidence has shown that CHWs can aid in improving the health of a population, especially in areas with a 46 |

primary healthcare and the establishment of Family Health Program or Programa Saude da Familia (PSF). Through this model, a broad range of primary care services are provided by the Family Health Team composed of one family doctor, one nurse, one assistant nurse, and about six CHWs. Each Family Health Team is responsible for a specific geographic area and monitoring 3000–4500 people [4]. CHWs visit each family in their geographic area once a month, and in the case of finding someone sick, the CHW refers the patient to the nearest health facility. The CHW accompanies the patient to the health facility, maintains contact with the family, and follows up until the health issue is resolved. In this way, the CHW serves as the link between the health system and family in the community. The Family Health Team is also required to collect geographic, demographic and health information on the assigned families, and to document the services and interventions provided. Ongoing information management challenges remain at PSF and in the larger Ministry of Health, and efforts have been made to move toward software systems to monitor patient information and clinical records [4]. Brazilian CHWs are trained in building trust within their communities, through approaching issues of HIV/AIDS and family planning indirectly in the context of general health [12].The estimated yearly cost of maintaining the PSF program is equivalent to $31 to $50 per individual covered. The CHWs are considered employees of the Ministry of Health and earn the national minimum wage about $112 per month, paid by the central state funds. There are also performance based financial incentives for CHWs in some municipalities. Ethiopia The current “Health Extension Program” (HEP), started in 2004, is


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implemented by “Health Extension Workers” (HEW), who are selected by their communities and provided one year of training. The requirements for the selection process for a HEW state that the person must be female, at least 18 years old, have completed grade 10, and be a wellrespected member of the community. The criteria are relaxed in rural and pastoralist areas where educational requirements may not be met by women in particular. The training is well structured with clear curriculum training materials, and is available at all the technical training facilities around the country. In contrast to the CHW program in Brazil, the HEWs in Ethiopia are entitled to upgrade their education to a level of registered nurses through a distance learning program and hands-on training [13]. The HEWs are responsible for a population of 5000 people, and are supported by a group of Volunteer Community Health Workers (VCHW); one VCHW for every 250 people. The HEWs spend about 25% of their time on administrative duties at the health post and 75% of their time in the field. Part of their field work includes training “model families” in waste management, separating human and animal quarters, family planning, malaria monitoring, mosquito breeding sites, information on common health problems, and general support and encouragement [4]. The HEWs have also been tasked with HIV/AIDS education, psychological support, prevention of mother to child HIV transmission, and home care visits [13]. Bangladesh The Bangladesh Rural Advancement Committee (BRAC) is the largest national non-governmental organization with semi-voluntary CHWs. BRAC began in 1972 and provides basic and curative healthcare through ShasthoSebikas (SS), the local name for CHWs. The SS are women between 25 and 45 years of age, with a few years

The community empowerment model of CHW programs promotes the sustainability of health interventions leading to related economic benefits. of schooling, and a willingness to provide volunteer services in their community. The SS work 2 hours a day, 6 days a week for 15 days a month. Their roles include health education in five essential components: water and sanitation, health and nutrition, family planning, basic curative services and immunization. They sell medicine, contraceptives, sanitary latrines, vegetable seeds, and tube-wells. SS have a strong focus on pregnant women by encouraging them to utilize services in government facilities, visit women at 42 days of delivery, and give special care to low birth weight babies. They also connect with the community by using interactive communication through folk music and theater. There are currently about 78 000 SS and each SS is responsible for 150-200 households [4]. Once chosen, SSs are trained in fundamental and essential curative health for 4 weeks, spending about four days per week at the regional office. They are trained specifically in the following common illnesses: ringworm, scabies, worm infestation, common cold and cough, diarrhea, anemia, gastric and peptic ulcers, angular stomatitis, and dysentery. SSs must continue monthly refresher programs for the next two years. These meetings discuss problems SSs have encountered in the past month and disseminate new health and nutrition knowledge [4]. SS workers are volunteers and do not receive a salary. They make an income from the sales of drugs and health commodities (contraceptives pills and condoms). Motivational factors are enforced, such as social prestige and fame that comes with


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being an SS and the enthusiasm to work for the betterment of one’s community. Certain paid incentives have been given for specific tasks that involve pregnancy and health of newborns. CHWs have been found to be more cost-effective than government services for the implementation of the DOTS campaign against tuberculosis in resource-poor settings [14]. Pakistan In 1994, the federal Lady Health Workers Program was developed to provide services for family planning and primary healthcare. With about 90 000 trained Lady Health Workers (LHW), the program was designed to address the high maternal mortality ratio of 320 deaths per 100 000 live births. The LHW, responsible for about 1000 individuals, provides primary health services and organizes women groups and health committees in her area. She is expected to visit 5–7 households each day and re-visit them every 2 months. LHWs promote family planning and encourage mothers to seek pre- and post-natal care, among other primary health services [4]. The LHWs attend 15 months of training consisting of two parts, three months of integrated classroom training and 12 months of task-based training. After training, the LHWs report to the training site once a month for refresher training and supplies, to ask questions and turn in reports. LHWs are paid during training followed by a salary of Pakistani Rs. 3090 (~USD 35) every month. They supplement their income by selling contraceptives to their clients. Lady Health Supervisors are trained for a one-year |

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Several technology interventions are being designed, tested, and utilized to supplement the hard work of healthcare professionals. period and provide daily support to 25 LHWs [4]. In a research study investigating the LHW perceptions of their own effectiveness, they found that “nazr (evil eye), garam & thanda (hot & cold) food, male child preference, fear of stigma in TB and other diseases, and fatalism” were common barriers to their work. This study also found that media campaigns enhanced the credibility of the LHWs work in their communities [15]. The LHW face challenging terrain that makes it difficult to reach all clients in a timely fashion, and malfunctioning equipment such as weighing scales. The program is currently trying to construct an effective information system, “to respond to the information needs of various decision making levels of the health system” [15].

Technologies to Aid CHWs CHW programs have been developed in many countries with the most successful programs targeting the needs of specific populations. Certain factors form the building blocks of successful CHW programs. First, community participation is essential to securing participants and involving them in all aspects of the program. Second, it is necessary to have adequate and reliable resources, such as governmental and political support to ensure crucial involvement with the other health sector activities. Third, because of organizational and geographical limitations, sustained and attentive management plays a critical role in keeping the program alive. Village health committees (VHCs) are often established to take charge of selecting CHW candidates. Fourth, CHW training programs should ideally be located 48 |

close to the working context of the trainee and continuing/refresher training should be emphasized to reinforce training and learning of new skills. Fifth, an incentive package should be arranged, including financial incentives, such as a salary, and non-financial incentives, like uniforms and medicine [8]. Many challenges exist for those trying to achieve these five elements of a successful CHW program. Issues include constrained resources and institutional environments, problems of sustaining a volunteer workforce due to lack of resources for incentive packages, logistics and supply chain obscurities, training and supervision needs, and multisectoral support. However, these challenges also present opportunities for creating value through technology-based solutions. Table I outlines the supplies provided to CHWs by their central governments to aid their work in the community. The tools vary widely from country to country, with some countries providing more medicines and others providing basic medical equipment. The supplies also highlight the various responsibilities of CHWs, from flip charts and flyers for educational outreach, to condoms for family planning, and chloroquine for treating common illnesses. Some of the stipulations, like “bicycle, canoe or ship” for CHWs in Brazil and various vaccines in Haiti, raise questions about their feasibility, practicality, and sustainability. Technology can empower community health workers and enhance their effectiveness in addressing primary healthcare needs, help synergize with the healthcare system, and amplify their impact. In the case

of Brazil, the family health team is responsible for collecting demographic data on patients and communities as well as documenting their efforts and interventions. The Ministry of Health has made efforts to digitize data systems and continues to struggle with the task. In the case of Ethiopia, the HEWs spend 75% of their time in the field providing basic health services to the community [4]. Tools to improve data collection, management, and organization would greatly enhance the community level work of CHWs. Access to portable basic medical equipment and cell phone technologies could significantly advance the CHWs ability to accurately assess a patient’s symptoms and correctly communicate those symptoms to a doctor. Affordable cell phone-based technologies can address major gaps in knowledge and promote information sharing among healthcare workers at the community and district levels. Several technology interventions are being designed, tested, and utilized to supplement the hard work of healthcare professionals. For example, the Kenyan Ministry of Public Health and Sanitation’s Division of Immunization has initiated a new system that uses cell phone technology to track vaccine stocks at various district stores. The system, known as Healthtrack, enables users to manage and automatically update vaccine stock information through their cell phones. Employees can also communicate to each other by sending text messages and reports through the system [16]. In another example, the Ministry of Health of Zanzibar in Tanzania has initiated an intervention termed “Wired Mothers.” Wired mothers are pregnant women with cell phones who receive regular SMS text messages reminding them of appointments and allowing them to call health providers for advice on acute or non-acute problems [17]. The government of Brazil partnered with Nokia in 2008, to launch Mobisus, a cellphone-based


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Table I Equipment and Supplies Provided to Community Health Workers in Various Countries Brazil

Ethiopia

Pakistan

Bangladesh

A distinctive dress and ID badge Clipboard A format of Basic Care Information System Bicycle, canoe or ship, if the CHW needs to reach remote places Scale for weighing children at home Chronometer to verify respiratory rate Thermometer Tape measure Educational material

Adult and baby weighing scales ANC kit Blood pressure apparatus Fetoscope, Refrigerator Vaccine carriers (ice bags) Ice box, Stethoscope Thermometer, Spatula Torch light Syringes and needles Gloves, gauze, alcohol Iodine, GV Disinfectants cord tie Condoms Essential medicines RDT for Malaria

Cotton wool Sticking plaster Pencil, torch with two cells Thermometer, Scissors, LHW kit bags (containing weighing scale) Salter Scale with trouser Condoms, Oral contraceptive pills Simple medicines, Oral rehydration solution, Cotton Bandages Benzyl Benzoate lotion, Eye Ointment Antiseptic lotion

Oral contraceptive pills Delivery kit Sanitary napkins Soaps and iodized salt Paracetamol Vitamins Antihistamines Oral rehydration solutions Antacids Anti-helminthics

Haiti

Mozambique

Thailand

Kenya

Dressing kit Flip chart, Educational flyers Syringes Weigh scales, centimeters Thermometers Boots, rain coats Road to health charts Data collection forms Monthly/daily report forms Referral forms Phone cards, pens Clean gloves, scalpels Cotton, gauzes, condoms, Vaccines (Polio, DTP, TT, BCG) SROs, iron, folate, vitamin A

Cotton wool Sticking plaster Pencil, torch with two cells, Thermometer Scissors CHW kit bag (weighing scale) Salter scale with trouser Oral rehydration solution, Simple medicines Cotton bandages Benzyl Benzoate Lotion Antiseptic lotion

Simple non-prescription medicines (effective in treating common illnesses) Herbal medications

Weighing scale Few drugs Some have blood glucose machine One temporary UNFPA project in Kenya provides: Training, Delivery kits, Manual Vacuum aspiration kits, Cell phones

program to help Brazilian health workers effectively collect health data including immunizations, oral health, nutrition, and maternal and child health [17]. CHWs and Technology: Perspective from Kenya In May and June of 2010, our team of researchers from the Humanitarian Engineering and Social Entrepreneurship (HESE) Program at the Pennsylvania State University traveled to Kenya to engage with local partners to evaluate the appropriateness of a telemedicine system in the Kenyan context and explore other potential entry points for similar health innovations. We conducted a series of seven focus groups, varying in size from seven people to a maximum of 25, with about 75 people engaged in the focus groups. Four of the focus groups were held

in parallel to health clinics at the Children and Youth Empowerment Center (CYEC) in Nyeri, Kenya. The aim of these clinics was to provide basic health services to the community while evaluating the effectiveness and consistency of our telemedicine system. The focus group questions were developed with the assistance and insight of a Kenyan nurse, and approved by Penn State’s Institutional Review Board (IRB). The focus groups participants included CHWs, doctors, nurses, community members, and local university students. During these conversations, Community Health Workers were repeatedly mentioned as having a need for technology, as well as the “respect required to utilize medical equipment” to benefit the community. Our focus group participants also enlightened us to some specific


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challenges facing the introduction of technologies to the work of CHWs, highlighting the importance of partnering with local communities to gain insight, ideas, and endorsements. We have narrated some of the perspectives shared by participants in the focus group discussions in this section. Overall our research group received positive feedback concerning the potential for telemedicine technologies to alleviate the healthcare burden. “I think it would best work for people in the community to use it (telemedicine) door to door. This way they can take permissions and then get the data easily. A community nurse or doctor can then use this and be trusted by the community to get information.” |

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(Medical professional participant, Mweiga Hospital Focus Group, 2010) “We can reach more people through this telemedicine technology. Doctors would participate because they want to reach the people in the community but (presently) they cannot.” (Medical professional participant, Outspan Hospital Focus Group, 2010) “I think they (doctors) make these kinds of decisions (remote triage) already, it would organize data faster and move it at a cheaper cost. I think it is a good idea. I think it would help someone far away to make a decision or if I have a question about a patient. Let’s assume she has traveled, maybe consultants can see graphs and data for themselves to assist in making a decision.” (Medical professional participant, PGH Hospital Focus Group, 2010) Participants repeatedly stressed the need for qualified, trained medical personnel to operate and use a telemedicine system. Throughout these conversations, we learned the diverse perceptions of the role of CHWs working in communities. Participants in the focus groups described the CHWs as: “Twenty Community Health Worker volunteers are responsible for 5000 patients - they are responsible for those households- if a patient has been coughing and has not gone to the hospital, the CHW would go to that house and assess and then refer them to the hospital. A skin rash- they might send that patient to the hospital, but if it is something 50 |

like malaria they can recognize, then they might diagnose and treat it in the village.” (Medical professional participant, PGH Hospital Focus Group, Kenya 2010)

that we cannot handle, then we refer them, but if we find something that is in our care, then we do it.” (Community Health Worker, PGH Hospital Focus Group, 2010)

“There is one person (CHW) per every 20 households. The community worker is in charge of the education of health for these homes.” (Medical professional participant, Outspan Hospital Focus Group, Kenya 2010)

The focus group participants quickly grasped the concept and practicalities of telemedicine and provided valuable feedback on the challenges and opportunities for such a system in their community:

During discussions with medical professionals as well as community members, Community Health Workers were frequently referenced as perfect candidates to use telemedicine systems and other technologies: “When a patient has been assigned a CHW they might become attached to those people. They have a bit of knowledge on health but they know the health of every person in the communitywe need to follow up in the community.” (Medical professional participant, PGH Hospital Focus Group, Kenya 2010) “The CHWs have a weighing scale and a few drugs. Some have blood glucose machines.” (Medical professional participant, PGH Hospital Focus Group, Kenya, 2010) “Yes it is difficult (to refer a patient) when we don’t know the fever and BP, we are not medics. Sometimes we cannot refer because we don’t know exactly what the problem is- sometimes on the follow-up we can have a better idea. If we find a case

“We have seen in the past that digital blood pressure cuffs break before nondigital cuffs, because of this we are concerned about the reliability of the technology. Also, power sources in rural and community settings could be a challenge.” (Medical professional participant, PGH Hospital Focus Group, 2010) “When a Community Health Worker is in the community, he has few resources to refer the people to, he can send them to the dispensary for medicine, but this (telemedicine) will help connect the CHW to a doctor…it could best be used in places without hospital where transportation is a big problem.” (Medical professional participant, Outspan Hospital Focus Group, Kenya, 2010) Focus groups held with Kenyan University students from Kimathi University and Kenyan Methodist University proved especially enlightening, as the students offered some of their own solutions to the constraints discussed in relation to a telemedicine system. The students suggested: “If we have diseases that have similar symptoms like malaria and typhoid, why


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don’t we have a database-like setup where certain symptoms or vitals values will indicate that a certain disease is occurring…. so certain symptoms or vital values are programmed in, such that the information doesn’t actually get sent to the doctor but the programmed server will alert for certain symptoms immediately.” (Kimathi University Student, Focus Group, Kenya, 2010) “The telemedicine system and service should be paired with a pharmacy, then the medical consult could be free and the charges transferred to another sector like the pharmacy. If you charge and don’t give drugs, then people will not come.” (Kimathi University Student, Focus Group, Kenya, 2010) “Telemedicine systems should also be connected to existing networks, when used in the community; they should be connected to transportation if needed. Also, it should be connected with larger brands, like Nairobi Hospital, so people will recognize the service and trust it.” (Kimathi University Student, Focus Group, Kenya, 2010) “More rural places don’t have electricity needed to support the technology, is there a way to use solar power to power the system?” (Kimathi University Student, Focus Group, Kenya, 2010) “Male and female health workers should be partnered together, to show respect to patients, and give them the option of choosing who will treat them.” (Kimathi University Student, Focus Group, Kenya, 2010)

“If Community Health Workers use a technology system, it would have to be portable. Can you make the system small? Reduce the size so they can travel easily with the system.” (Kenyan Methodist University Student, Focus Group, Kenya, 2010) These responses highlight and elucidate the breadth of the enlightening conversations with local participants. These conversations were made possible only through the relationships HESE has built with local institutions such as Children and Youth Empowerment Center (CYEC). Through engaging the community, university students, and medical professionals, our researchers gained valuable feedback about the challenges and potential of the telemedicine system. These conversations sparked new research initiatives like delving deeper into the actual mechanics of how Community Health Workers function in rural Kenya and the challenges they face. This small piece of ethnographic research, run in parallel to the testing of our telemedicine system, was invaluable to development of a long-term implementation strategy. We acknowledge that the opinions of local people, the future customers and users of the system, will determine the success of any intervention. Combining this local knowledge and the insight gained by our students visiting Kenya and seeing first-hand the context of the healthcare system, will improve this project and inspire the students to engage in other technology-based social innovations. The positive feedback and guidance received from these partnerships has confirmed that entry points exist for technological innovation in rural health. We encourage all social entrepreneurs to engage local counterparts, develop partnerships, and experience how these relationships enrich research and innovation.


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Guidelines for Innovators While technology solutions hold great potential for addressing the needs of developing communities, new and advanced devices are at high risk of becoming scrap metal and closet clutter in developing community hospitals. The World Health Organization (WHO) estimates that international donors or foreign governments fund nearly 80% of healthcare equipment in some developing countries [18].The vast majority of the biomedical equipment is designed and manufactured in western countries by engineers not familiar with the physical, socio-cultural and economic environment in developing countries. In sub-Saharan Africa, almost 70% of donated medical equipment is not in use because of lack of maintenance or spare parts, or because local personnel do not know how to use it [19]. About 95% of the instruments that are usable fail within five years since they are all imported, extremely expensive, not ruggedized, and not repairable when they fail [20]. A disconnect between the functionality of medical devices and the context of developing countries arises because of the divergent infrastructures, social and behavioral norms, and larger eco-systems among western and developing countries. There is an emerging trend to design devices specifically for use in developing communities such that they are inexpensive, rugged, robust, and culturally appropriate. Biomedical engineers and socially conscious designers need to be familiarized with the unique challenges of designing devices for CHWs working in resource-constrained environments. A systematic approach that takes into consideration pertinent anthropometric, contextual, social, and economic considerations in the design of appropriate technologies is essential. As described in the case studies, there is often a significant disconnect between governmental policies related to CHWs and how the |

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system actually works. Our research team discovered that within the country of Kenya itself, there is a significant variation in the CHWs’ roles, responsibilities, and resources from region to region. Ethnographic studies of the CHWs that capture their resources, needs, constraints, communication mechanisms, and operating models can help identify contextual constraints and keep the technologies user-centered. Such studies can themselves be facilitated by cellphones and other technologies. CHWs do not always have access to the equipment and supplies stipulated by the government. Studying what tools CHWs have access to and how they are actually being used can help uncover opportunities for innovation. CHWs travel long distances by foot, bicycle, and public transportation. Lightweight, portable, and multi-functional designs would be well received by the CHWs. Electric power is hard to access and expensive, making electronic gadgetry less attractive. Affordable computing technologies and the growing popularity of cellphones, an extremely multi-functional device in developing countries, presents many opportunities for real-time coordination and data sharing. The CHWs’ toolkit does not include simple tools that would help connect CHWs to each other, share medical information with doctors, or maintain digital records, transmit information, or provide basic triaging services. These technologies are crucial to addressing the logistical challenges posed by resource-constrained environments. While the CHW programs have been successful, several inefficiencies need to be addressed to ensure that the CHWs are working in tandem with the larger healthcare system. Sustainable business models and incentive structures are crucial to empowering CHWs in the longer term. The power of trust and social capital in developing communities must be harnessed to ensure that the CHWs are able to work harmoniously in their communities. 52 |

Conclusion Community healthcare workers play a critical role, and have great potential for increased involvement in addressing the health inequities and the evolving global healthcare crisis in developing countries. The operating model and responsibilities of CHWs are well-defined in some countries, and yet to be understood in others. CHWs have access to some basic equipment and supplies such as educational materials and simple medicines, but lack communication and data collection systems that would greatly enhance their work. There is a huge need for technology and policy interventions to enhance CHWs’ efficiency and effectiveness in order to amplify their impact. Our team, with students from medicine, engineering, and business is now applying ethnographic methodologies to understand the operating model, challenges, and resources for CHWs in central Kenya. This article is meant to be a call to action, to challenge engineers and designers to further investigate the needs of CHWs in specific contexts, partner with this population, and conceptualize appropriate technology solutions. The goal is user-centered devices that are designed for the context, which can be seamlessly integrated into the country’s healthcare system and function in a sustainable manner.

Author Information The authors are with the Humanitarian Engineering and Social Entrepreneurship (HESE) Program, The Pennsylvania State University, University Park, PA.

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spring 2013