 Okay, this is the Tracker and Android Country Stories session at this point where we really wanted to give everybody a chance to hear from some of the various types of implementations that are using Tracker or using Android using both. So we're very lucky to be able to have presenters from three different projects. We will hear from a project in Nigeria and then Kenya and then Ghana, but we would start first with Isaiah speaking to us about the Adolescence 360 project in Nigeria if Isaiah is on and has been given a chance to share his screen. Hi everyone, can you hear me? Yes. Thanks. Great. So I'm going straight to share my screen. Yeah. So I hope you can see my screen. Hi everyone. My name is Aizan Yamoto. I'm a DHIS2 specialist. I work for PSI, Population Services International, and today I'm going to talk about the Adolescence 360 project in Nigeria and how we deploy the DHIS2 Android at scale for client mobilization and provision of services in the public health sector. So I'll start by a brief, a very brief introduction to the A360 project, the Adolescence 360. I'll then move on to the key aspects before and during the integration of the DHIS2 apps. I'll show you our key results, and then lastly, I will close with the lessons learned. So let's get started. The Adolescence 360 project aims to raise the Arctic of modern contraceptives among young adolescent girls of age 15 to 19 years. The project implements two main health interventions. One, the Niger program, which is implemented in the southern parts of Nigeria, so the small circles in orange in the map, and Niger targets the unmarried girls with some specific forums to gain skills and knowledge about their health. The other key program is Matasa Matan Arewa, which is commonly known as the MMA. The MMA is implemented in the northern parts of Nigeria, so the small circles in the map in the northern part, so the small circles in green in the map, and MMA targets the unmarried girls and husbands through the maternal and child health program. The Adolescence 360 is active in 206 public facilities across eight states. And the project is funded by Bill and Melinda Gates Foundation and the Children Investment Fund Foundation, CIF. So to my next point, the key aspects. So before DHIS2 unencoupled apps, the client mobilization, the client and service, the client mobilization reports are being recorded on paper-based forms. Yes, which were then compiled into regional spreadsheets and then uploaded into an online shared files for easy access. So this approach presented several challenges, and despite the many attempts by the team to improve timeliness and other quality standards, the quality remained a huge challenge. The entry-60 core team wanted to streamline their data flows to improve the timeliness of reporting and also benefit from more advanced analytics and data visualization functionalities in DHIS2. So during our integration, we first did an initial assessment of the project setting. This happened in February and March, 2019. Then together with the Society for Family Health, et cetera, in Nigeria, we co-designed modules for client mobilization and service provision in DHIS2. We also trained 15 regional teams and about 600 field staff on the mobile data capture. All this happened between April and May, 2019. And then the team went on a pilot phase sometime in June through August, 2019, followed up by a scaled phase in September, all through December, 2019. One of the key results that we had through this project was streamlined data flow. So the field staff, so the Niger girls and the MMA mobilizers could then record the client mobilization and submit live reports using the DHIS2 apps. The providers also could record the client visits in paper forms with some help from the young designers based in the clinics who then verify a report using the DHIS2 under capture apps. So yeah, this is how the current data flow is. And the program assistants together with the regional managers, they also verify and validate data in DHIS2. Another key result was improved efficiency. Sometime in 2019, an average of 661 client mobilization and 8,526 service reports were completed monthly. What this means, 33 mobilization and 426 service reports were being completed on daily basis all through the DHIS2 under capture apps. Another key result was improved data quality and data list, evidenced by the timely completed and verified reports in DHIS2 and continuous program implementation and adaptation of the project. So here we've asked the DHIS2 analytics and dashboards and this is one of the outputs the program team sees on a day-to-day basis. It shows the total adopters conversion rate by state and number of clinic. In green are the conversion rates while the small circles in pink indicate the adopters, the number of adopters reported from the clinics. So green indicates a good sign which is a good performance while in pink the volume. So the bigger the size of the circle is also the bigger the volume of the adopters coming from the clinics. So I also notice the high number of adopters coming from the southwest part of Nigeria where the Niger girls program is mainly implemented. So the program team sees this and through this and other charts on the dashboards they can be able to identify the areas with most saturations and also plan for their next move. On the key results, so sorry on the lessons land we encountered some specific challenges. Number one is a issue to do with data synchronization seen in DHIS2.3 and with this we were able to fix by an upgrade to the next release of the DHIS2 apps. Another key challenge is connectivity issues in some states which we also manage to fix by limiting access the internet access on the mobile devices. Among the enabling devices, the enabling factors were the initial assessment of the project setting as the one that we did in February. This helped us to appropriately design the tools in DHIS2. Another key enabling factors is the active involvement of the program staff from the design phase to the development and testing phases. Last but not least is the introduction of a mobile device management solution MDM which helped us to take control of other devices including managing of internet access and software updates. For more information about this project please join our discussions in the DHIS2 community of practice. You can also download a full report also available in the community of practice and in the link in this presentation and you can also contact me on the email address right there. So at this point I would like to welcome any questions from the team and also check through our page on the community of practice if there are any. Thanks. Great and so we made sure to save a couple of minutes of questions live for these country sessions so we'll try to get to a couple of them at least that have been coming through online. One of the questions was about the transmission link mapping supporting links between TEIs enrollments and events in the different programs. This was coming from Kala Hedberg. Is there anything Isaiah that you could say about the links between the TEIs enrollments and events? Yeah so I'll talk briefly about the current setup. So our current setup follows a series of single events. So we are using the single events which they don't have any electric registration so we are not implementing any tracking in the instance of the TEIs. Okay great. Marta I think you identified one about support. Yes I think it's very interesting this question is there and we have a question that says how did you address the support for mobile users as we all know the DHS to use tools like TeamViewer to go through the user issue. So remote support how did you manage for remote support? Yeah so first is that we did have a team in Nigeria who would closely help us especially during the first stage in implementing the devices. So in setting up the devices but then also we implemented the MDM devices. So this is a scale vision type of service that we are using in Nigeria. So through this platform we can be able to send any updates to the mobile devices. Yes directly so it's all about the MDM solution and then some support that also we receive from the regional teams in the field. Great and then maybe just one more and I know that there's interest in the MDM tool which was just mentioned so again in the community of practice thread perhaps asked some questions there and we can get some more details but this question was about motivation and incentives of the field staff. How do you manage and maintain the levels of motivation in the center for the data collection? So yeah this question is mainly a program question so yes but what I'm aware of is that in Nigeria there is currently an incentive mechanism through which the mobilizers are motivated so based on the number of the clients that they're able to reach and yeah and also the number of reports that they submit in DHIS too. So yeah this is more of a program aspect of the project. Yes but mainly yes there is that aspect of motivation in the field. Okay thank you Isaya. I think we can be there unless is there any other question you want to bring up now that you found interesting. No I think just please bring things over to the community of practice we'll have a lot more time there to answer questions but then otherwise I think we're ready for the next. Okay I want to address one because it's a very simple one and it's not related to the project so thank you Isaya thank you again and congratulations on the great work. This question says any update on DHIS 200 on data entry offline mode and data synchronization so that's what the data that's what the Android app does offline data entry and synchronization so just to clarify in case it was not clear and we are seeing here an example presented by Isaya so thank you Isaya I think it's time to move to the next presentation so we are going to have Beatriz Akeyo presenting us the AFIA Uzazi project which is focusing on monitoring the increase of fourth antenatal care attendants, skill birth attendants and postnatal care attendants and the project is based in Kenya so Beatriz whenever you are ready you can present and thank you Beatriz just so that you are muted I don't know if you're if you already started we can see your screen but we cannot hear you. Oh sorry I was muted. Perfect. Okay thank you very much Mata and the team so my name is Beatriz Akeyo I am data manager and information systems specialist at FHI 360 AFIA Uzazi. I'm very happy to be presenting to you today on the topic of how we are using DHIS 200 app for rapid results information gathering for monitoring to increase fourth ANC attendants skill birth attendants and PNC attendants so we are going to go through the topics of AFIA Uzazi project intro we are going to look at our implementation coverage our system architecture results and next steps so I'll give a little introduction about our project AFIA Uzazi. So AFIA Uzazi is a USID funded five-year project that runs from October 2016 to September 2021 and it is a consortium of two two organizations that is FHI 360 and Gold Star Kenya and it aims to increase family planning reproductive maternal newborn child and adolescent health impact increasing access to and demand for these health care services in the project coverage areas. So the project coverage areas consist of two counties in Kenya that is Nakuru County and Baringo County and in Nakuru County we operate in two sub counties that is Kuresoi North and Kuresoi South sub counties and that is where we started to implement the DHIS 200 data capture in Baringo County we operate in four sub counties that is Baringo Central, Baringo North, Marigata and Mogotio. So within the implementation coverage I'll start by giving a little background on the reasons why we implemented the Android data capture app to collect data. So through the implementation of our project what we noted in our implementation coverage areas is that most of the pregnant women are attending first ANC visits but are still finding it a challenge to complete four ANC visits as recommended by WHO to deliver to a health facility and also to access PNC health care services within three days of delivery. So we can see that in 2018 only 49% of the pregnant women completed four ANC visits, 65% deliver data hospital and only 21% access PNC services within three days after delivery. So in Kuresoi South we had only 22% of the pregnant women completing four ANC only 41% deliver data health facility and only 43% access PNC services within three days after delivery. So that prompted us to partner up with the Department of Health for Nakuru County to implement a rapid result initiative. We called this rapid result initiative surge and we started by implementing in 29 health facilities in Kuresoi North and Kuresoi South sub counties. So in this implementation we adopted the use of DHIs to data capture app so that you can be provided with timely data to generate reports that would then be used for collaborative implementation progress reviews and decision making. So this is how the system architecture looks like. So we provided healthcare workers with mobile phones. These are Android based mobile phones and we installed DHIs to data capture app within the mobile phones so that the healthcare workers can use it to submit data to us. So the kind of data that we were collecting, let me just go back to the first screen. So we were collecting, okay it's not showing all of them, but for each and every facility they were submitting to us the number of pregnant women who are coming for first ANC visits, the number who are completing four ANC visits and the number of pregnant women delivering at their facilities and the number of mothers who are accessing PNC services within three days after delivery. This data was transmitted over the Internet to a centralized server also hosting DHIs to system. So the data we managed to collect with this system, we used it to generate Excel based reports that we then transmitted, disseminated through WhatsApp groups that we created for each sub-counting and also they were used by technical teams during project technical review meetings and we also used it during quarterly advisory meetings with the regional teams. So there were sub-groups involved the health management teams at the county and sub-county levels and also the project technical teams and the healthcare workers. So the results we have received is we've managed to have timely data for decision making. This process has also helped us to identify service delivery and uptake challenges in a timely manner and provide resolutions. We've also been able to design interventions towards service uptake and also the interventions that we were already implementing, we were able to note implementation gaps and it helps us to increase the impact of our implementation. So because we were able to do these three things, we noted an increase in maternal and newborn health service uptake. If we compare the period when we didn't implement this system and the period when we implemented this system, we noted a significant increase in the number of maternal and newborn health services uptake. So we are comparing the period October 2018, January 2019 and October 2019 January 2020. So between that period, the number of pregnant women completing four NCVs increased from 1,440 to 1,998. The numbers delivering at health facilities increased from 2,399 to 2,815. And the number of infants receiving postpartum care within three days after delivery increased from 2,314 to 2,817. So because of the results, the successful results we achieved, we scaled up the system to an additional 45 surge health facilities across Baringo County in the sub counties where we are implementing. So these are the lessons that we were able to, that we noted. These are the lessons. So we were able to shorten data submission period because of the direct submission by health care workers. So there was no third party involved. We were receiving data directly from the health care workers. And then we were able to eliminate printing of paper-based forms. We initially started by using paper-based forms and then we moved to the system. So through this process, we were able to eliminate that. And then we also realized efficient report generation through centralized data repository. That made it easy for us to automate some reports. So we also experienced some challenges during the process of implementation. So one of the biggest challenges was staff turnover. This led to frequent trainings and mentorships because what we realized was that staff whom we had trained on the system were transferred to other health facilities that didn't have the system and other staff were brought into our health facilities where we were supporting the system. So we had to train them so that they can continue with submission. We also noted poor network coverage in some of our implementation areas. So that made it some health care workers had to move around the facility to find areas where there was a stronger network or even move to other locations so that they could be able to submit data. So we also had cases of phone loss and malfunctioning and where we were not able to replace the phones or repair the phones. Then we had disruption of data submission and for some facilities that meant reverting back to the paper based system. So thank you very much. I'll leave it there and see if there are any questions. Thank you very much. Back to you, Marta. Thank you, Beatriz. That was a great presentation and very interesting project. We do have one question. I'm going to read it for you. It says, what do the health care workers think of the system and if they can use it for other things apart from capturing data? I guess they mean maybe the device. That's what the question is. Okay. Thank you very much. So yeah, the health care workers really were really receptive to the system and because it reduced the amount of work because initially they had to use the paper based forms and now when they are using the Android phones, they were really happy to have reduced kind of effort in data submission and also yes, they are using the phones for other activities like for us, we are really trying to increase uptake of maternal and newborn health services. So you find that sometimes they use the phones to also do things like calling the pregnant mothers who are defaulting for anti-natal care services and also in Kenya we are running health insurance for the mothers and they are using the phones to also enroll the mothers into the health insurance schemes that has been rolled out in the country. So yes, they are finding more uses for the phone and because of that, it is also motivating them to use the phone more. Okay. Thank you. We are almost out of time, but there is one last question for Beatriz. Which is about managing data confidentiality using WhatsApp. So I don't know if you were actually sending patient data over WhatsApp, but that's the question. And I think that would be the last one. Okay. So we were not sending patient data over WhatsApp. Over WhatsApp we were just sending aggregated data because the data that is submitted to us by the healthcare workers is P1D aggregated data. So when we send through the WhatsApp, we are just sending simple Excel-based tables that are showing how many, like for example, how many in C1 plans they have seen at the health facility, their targets and also the percentage that they have achieved so that they can be able to see how far they are in terms of achieving their target. So we were not sending any patient-level data. Okay. Thank you, Beatriz. We don't have more time for questions. So I'm going to please ask all of you answering, asking questions that we got some in the now very last minute to please post them in the community. We can answer those generic and I think Beatriz you can also go there and answer the ones related to your project. So I'm going to pass it over to Mike to introduce us our next presenter. Thank you very much for the presentation and congratulations again on the great project and implementation. Thank you. Thank you very much, Matta and everyone. Great. Then our last country story for this session is coming from Ghana, from the Ghana Health Services. We have a very large tracker implementation running there. The Ghana Health Services has been responsible for. Kwame who works within the PPME unit there is going to share his screen with us and talk through some of the lessons they've learned over this last year. Kwame, are you able to share your screen? Meanwhile, we can thank you for the flexibility on presenting while you are traveling as we can see. Yes, we know it was the Health Services activity this afternoon and work to do, but I appreciate you sharing your time with us. Hello, Kwame. Hello. Yes. Okay. So, okay, great. Hello. Good afternoon, everyone. Well, it's afternoon in Ghana. So I would say good afternoon. Well, my name is Kwame with the Ghana Health Services and I'm just going to walk you quickly through some of the use cases we have in Ghana for tracker. So this is just a background. Ghana has since 2011 used DHIS as a national data repository. So we use DHIS for all our biggest reporting across all facilities in Ghana. And that has actually motivated us to now move into client-based data capture in our facilities. Due to the scale, we are currently concentrating on specific programs and interventions. And then as we move on, we shall scale up to other areas. So basically, this is just to highlight the areas we have rolled out a tracker for. So we have the safe motherhood, which looks at antenatal care delivery post-natal care. So we track mothers right from antenatal care through to delivery through post-natal care. We pick these children and then also track them from zero to 59 months through the immunization schedule as well as growth promotion. And then we are currently also tracking all our HIV clients as well as TB clients. We also have a very simple clinical tool, which is still developed with a tracker for very small facilities where the attendance is not so high. And then also we have a strategy known as CHIPS, which we use to manage our clients in communities, more like a community-level facilities, which help us to expand our reach and provide health services to our clients at a community level. So we use the tracker to track the implementation process. Now for us, there are some broad areas, which we think any country or organization who is interested in deploying the tracker should look at. And the first area is the design and the configuration. So we are posting security. Now we have real-time versus secondary data entry. You realize that it should have been appropriate if all facilities or all users could enter data real-time. But due to a lot of challenges, internet connectivity, sometimes challenges with the devices and all that, you have to really evaluate how you can marry the two real-time versus secondary. Some facilities can do real-time, others cannot, so they might have to do secondary data entry. And then also the scale. You need to start small and then scale it up gradually because you don't have to create a situation where people become demotivated because the tracker has been rolled out in a large scale and it's not really meeting the expectations of users. So you need to be a bit strategic in there. And then you need to have a very solid team to support the rollout of the tracker. And then also you should look at the Android versus the web. So depending on the environment. So both Clayton and I had a good chat on Friday where we talked about some of the things also. So we have a sign like a few issues now to Paolo. But I think also like one thing we learned today is like we need filtering by name for the UN schema. I think just so we can make the new UI work, right? I mean the basic filtering for views for instance would be nice to take it. So maybe you can create a ticket there, Luis, for at least have the same functionality that we have for pipelines for views so we can get the new UI working at least. Even if it's an intermediate step, I think that would be nice. I have updated JIRA. So if you look in JIRA and just filter by Assignee, you will also see that. Well, okay. So let me quickly move to some of the challenges we encountered. So we realized that limited coordination and analysis of data cross-programs was a challenge. So what this means typically is that you have programs who have common data needs. But because there is no coordination, you realize that you will be capturing the same set of data on the same individuals for multiple programs. And when that happens, it becomes a bit problematic. And then also lack of standard naming conventions. So each program comes with its own naming convention. So sometimes even though you have the same set of data, you have multiple naming conventions for these data elements and it becomes again very difficult to get the users to appreciate what is sadly you need them to capture. Now, legacy configurations and excessive data quality. In Ghana, for instance, specifically with HIV, we had a legacy system which was being used and we had to decommission and migrate onto the DHIS2 tracker. But then in migration, we realized that the legacy system was capturing so much data which was not really needed for the current program. So we had to do a lot of cleanup and then we adopted only what was very key. Now device procurement and management. I'm sure there is going to be a common problem. Most of them is difficult to get governments to support procurement of devices, especially in such an extensive scale. So it is also another challenge. Internet connectivity and then running different versions of DHIS for different implementation. So yes, we might have a version, a specific version for HIV, another version for maternal and child health, and then another version for other use cases. So sometimes managing all these different versions at the same time by the same team becomes a bit of a problem. And then having a dedicated team for training and support for various implementations. So that is also key. You need to have a defined team whose task it is to, whose task it will be to just maintain and respond to issues as and when they arise from end users. Because prompt response of course will also go a long way to help in the success of the implementation. And then there is this very important challenge, unique identification. Ghana, fortunately for us, the government is currently rolling out an extensive national identification program. So we are hoping that once that is completed, we can adopt the unique identification for our clients. But currently we are trying to manage the situation. We are using some improvised ways to uniquely identify our clients. It comes with its own challenges though. Now what are successes? We have successfully been able to roll out the maternal and child health tracker in five out of 16 regions. And we are doing that progressively because we did not have enough resources to procure tablets and then do extensive training across the country. So as and when we get funding and devices, we target regions who are ready and then we deploy. Then we have also successfully rolled out the ART tracker in all ART sites across the country. We have done same for the TB tracker for all TB building districts. And then currently we have been also able to generate all summary reports and key indicators for all the interventions. And then service providers are able to easily schedule appointments and also track missed appointments using the tracker. Now these are some of the lessons linked. We believe that you have to critically evaluate what level of health service you can use the tracker system because it is very, very important. For us, our evaluation helped us really to identify where exactly the tracker could work. So we targeted the programs, we targeted the smaller facilities where you don't have a lot of procedures. I mean in a very small facility, the clients comes, it is only one person who serves as the records officer, as the clinician and as every so everything happens around one person. So it is very, very easy to drop just two tablets to help you know capture clients either in real time or even on secondary basis. And then also you need to build trust in the tracker to avoid nervousness of data ownership and privacy. Once you move into the domain of individual data, clients based data, the issues of privacy comes up and ownership of the information comes up. So you need to also have a very good strategy to win the trust of the service providers and even to some extent the clients so that they can be comfortable with whatever you are going, you are doing with them. Now create standard operating procedures to ensure appropriate access to data system. So for us what we did was that for each implementation, we had a standard operating system which clearly spells out the meaning, the definitions, the rationale of everything we are capturing and even how to go about it and even the period at which that data needs to be collected. So all those things were spent out clearly. So it gave us the opportunity to have a very common language across all facilities. So they all comply and work with the same set of rules. Now adopt secondary data entry instead of real time at the early stages of implementation to avoid data loss. Now here we are looking at a situation where you set up your tracker after the training, you just add the facilities to do away with all paper based systems. We strongly think that if you pick such an approach, you are likely to have problems because even after training, it takes time for the end users to get their hands wrapped around the system. So it is always good to run the two systems, the paper based system first as a primary and then the tracker as a secondary for a while until such a time where the users are very comfortable, then you can take a decision on whether to switch entirely to real time. Now we also believe that you start small and build capacity over time. You configure all required aggregated reports to prevent counter-collation and also to serve as motivation to service providers. Well, because you will be running the paper based and electronic system concurrently at the initial stages. We strongly advise that as much as possible you try to generate all their or automate the generation of all the service reports to make it easier for them. Else they will have to collect reports manually whilst they still do the double entries into the manual system and then the electronic system. And we think that is also a big motivation for the end users. And then finally, you need to understand from the very beginning that it is not cheap to run the paper based on your data, you can run it on a large scale, just as we are attempting to do in Ghana because it involves a lot of heavy procurement. You need to procure so many gadgets. You need to have extensive training across the country. All these things have come with very huge costs. So I will end here. Thank you very much. If there are any questions I will be glad to take them. Thank you. That was great. It is a wealth of experience from Ghana that has been scaling up over the last couple of years to get to this point. We unfortunately don't have a lot of time left for questions, but maybe I can ask one that came up in the previous presentation as well, which was how Ghana is managing what your final point there about data bundles, covering the cost of devices, replacing devices. If you could just say a word about the cost of those devices. Okay. So what we currently doing is this. With the procurement of the devices, we formally support from partners to procure the devices. We've had global fund supporters with devices. We've had other partners, UNICEF other partners provide supporters with devices. Now with the issue of bundle, what we have done is this. We realized that it would be very difficult to get support from partners to provide bundle for the facility. So we've made it a policy that the facilities will use their internally generated funds to support the procurement of bundle for the system. Now where there are smaller communities, smaller facilities, we have bigger facilities coming to support them with some funding to be able to procure the bundles. So currently that is the strategy we have adopted. Great. Thank you. I think we unfortunately don't have more time. We need to give time for the next session. Just to say a number of the questions that were posted have been moved over to the community of practice. So I think we can continue the conversation over there. We aren't closing those threads at the end of the session. They'll continue throughout the week and even longer if needed. The only other thing I would mention before turning it over to Max is that there are the expert lounge sessions. There's one starting just now that is looking at indicators. There are a couple of more around tracker and Android in the next few days. Please take a look at your schedules.