Guideline Adherence in Slums Project - Template-based documentation and decision support for primary healthcare clinics in the private sector

Lead Research Organisation: Strathmore University
Department Name: Institute of Healthcare Management, SBS

Abstract

With large numbers of people in slums seeking care through the private sector, it is important to develop tools to help providers in these clinics improve the quality of their services. For example, documenting the need for an antibiotic helps reduce the number of cases of unnecessary antibiotic prescriptions.

Clinical practice guidelines (CPGs) are tools developed to help doctors and nurses give evidence-based care. These are however not easy to use in a patient-facing scenario (e.g. a doctor looking through a manual when the patient is seated in front of him/her). They also need to be tweaked to be relevant to the local context (e.g. is the first line drug available or affordable?). For CPGs to be relevant in low-resource settings it is important to address multiple, if not all, barriers to using guidelines, but in a manner that does not strain limited resources.

Our intervention involves working with clinical care providers and developing templates (think checklist) that can be used while they are seeing the patient. The templates take the form of rubber stamps that can be printed into the paper case sheet (e.g. if a woman presents with increased frequency of urination, the clinician stamps the Urinary Tract Infection template into her case sheet). This template is both a guide to what questions to ask the patient and how to manage UTIs. Other illnesses get other templates, but a set of 6-8 templates covers the majority of patients walking into primary care clinics.

Importantly these templates are easy to digitise and analyse. They are in the form of a multiple choice exam paper where bubbles need to be shaded. A cell phone image of a filled-in template can quickly give us data on how the case was managed without revealing patient identity. Being rubber stamps we avoid the need to keep track of multiple printed sheets of paper. We also avoid wastage when guidelines change because changing the rubber engraving on the stamp is simple and cheap.

We now have a tool to easily monitor the clinician's work, check for quality, and work with them if there are reasons to deviate from the guidelines by during regular feedback sessions. The intervention is being used in two slum clinics in Nairobi with great initial responses.

We now want to study this intervention in a set of 10 different private sector clinics in Nairobi's slums. We would like to test if this intervention is:
a) Usable - different clinics have different priorities and attitudes and we need to be sure that the intervention poses no big challenges
b) Effective - does the intervention actually improve clinical practice (e.g. by reducing unnecessary antibiotic prescription)?
c) Sustainable - how much does it cost for us to support these clinics with tools and feedback? Can the clinics afford to pay us for this service?
d) Scalable - is there a realistic chance for us to roll this intervention out at national (or even provincial) level?

If successful the intervention has the potential to change how healthcare is delivered in low-resource settings. More and more people are seeking care in the private sector, but very few regulations, services and tools exist to ensure that care in the private sector is of high quality. We hope to make a significant impact in the quality of care that is delivered to the poor.

Technical Summary

This study employs an exploratory sequential mixed methods research design with phased, concurrent data collection. The challenges of providing quality healthcare are highly complex especially in LMICs that face multiple health system shortcomings.

Phase 1 (Exploration): Understanding the challenges in implementing currently prescribed national (or international/WHO) guidelines in low-resource urban settings. This aspect will be addressed by a set of in-depth interviews (IDIs) with the following set of stakeholders involved in the implementation of guideline recommendations:

Phase 2 (Implementation): This phase includes two intervention elements:
a) Developing CPG-based templates (in rubber stamp format) for a set of commonly encountered conditions in adults.
b) A clinical audit and feedback system to review and aid providers in their adherence to CPGs (and templates).

Phase 3 (Paths to scale): This phase will explore scaling of the intervention using IDIs with clinic managers, managers of social enterprise clinic chains and FBOs, health managers of county governments, healthcare financiers, funders and policy makers.

This research approach explores both, the technical aspects of quality improvement interventions and also issues that affect the adoption of such interventions. Understanding the context in which the research is being conducted (eg. clinic financing, provider incentives, etc.), and also the paths to scale (and impact) is a central to our proposal and aims to maximise the chances of success of any larger research and/or implementation project in the future.

Planned Impact

Who will benefit from this research?

In the short term:
1. Clinical care providers and managers of clinics in resource-constrained settings in LMICs. Most clinics in low-resource settings in Kenya are staffed by nurses and clinical officers who appreciate support in guiding their practice. Our initial efforts in Access Afya clinics have been highly rewarding with clinicians embracing principles of evidence-based practice. The templates are very useful tools for clinical practice that other clinics can benefit from.

In the medium term:
1. Researchers of healthcare quality, healthcare financing and health policy.
2. Health policy makers
3. Health researchers in Kenya
4. Innovators in healthcare
5. Individuals and communities in low-resources settings like slums

How will they benefit from this research?

1. Clinical care providers and managers of clinics can benefit from an approach to improve clinical care quality that is potentially highly effective, easily implemented and cheap.

2. Researchers in healthcare quality, financing and policy can benefit from the results of the study. Healthcare quality is closely related to financing and health policy makers can benefit from efforts to improve quality at low cost.

3. The project proposed here is a good example of implementation research. This is an important area of research in a country like Kenya which is a test bed for numerous interventions. There is very little learning from the numerous interventions that are undertaken. More implementation research is needed in Kenya to ensure that lessons are learned and mistakes are not repeated.

4. The intervention itself has implications on multiple fields including healthcare innovation in resource-constrained settings. The intervention has been designed with a number of constraints in mind, and incorporates learnings from health systems, human behaviour, health economics and technology. The research will benefit the field of frugal innovation by documenting successful principles.

5. The ultimate beneficiaries of the research are individuals and communities in low-resource settings in countries like Kenya. Healthcare for the poor is currently highly inaccessible in many dimensions. The are huge gaps in their abilities to perceive their healthcare needs, seek appropriate care, reach healthcare, pay for care or engage the providers. If healthcare in LMICs is to become more patient-centred, as in developed countries, it is important to support primary care providers and improve the care they deliver.
 
Description Participant in Kenya's e-Health Policy and Strategy formulation
Geographic Reach National 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
Impact I have been playing a major role in the development of Kenya's e-Health Policy, e-Health Strategy, Health Sector Enterprise Architecture & m-Health Standards and Guidelines with the aim to standardize development and implementation of e-Health in the country.
 
Description Global Challenges Research Fund Networking Grant Scheme
Amount £25,000 (GBP)
Funding ID GCRFNG\100306 
Organisation Academy of Medical Sciences (AMS) 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2018 
End 02/2019
 
Description Healthymagination Mother & Child Alumni Technical Assistance Grant
Amount $30,000 (USD)
Organisation General Electric 
Sector Private
Country United States
Start 01/2018 
End 12/2018
 
Description Healthymagination Mother & Child Alumni Technical Assistance Grant
Amount $30,000 (USD)
Organisation General Electric 
Sector Private
Country United States
Start 01/2018 
End 12/2018
 
Description LifeNet International 
Organisation LifeNet International
PI Contribution Collaboration to adapt and implement GASP tools in primary healthcare facilities in Uganda. The partnership is funded through a grant from GE.
Collaborator Contribution LifeNet International will implement tools and approaches designed under GASP at their facilities with support from Dr. Pratap Kumar.
Impact It is a multidisciplinary collaboration with LifeNet building their expertise in quality improvement in primary healthcare clinics with support from the tools to document healthcare delivery. Outputs include funding from GE, and co-development of documentation templates for delivery and post-natal care.
Start Year 2017
 
Description Partnership to explore a unified framework for QI in public and private sector primary healthcare 
Organisation LVCT Health
Country Kenya 
Sector Charity/Non Profit 
PI Contribution I am the PI of a research proposal that brings together Strathmore University, LSTM and LVCT. The proposal aims to use the clinical documentation approach pioneered in GASP in both private sector primary healthcare facilities (where GASP is already working) and community health workers in the public sector.
Collaborator Contribution LSTM, specifically Dr. Miriam Taegtmeyer and the REACHOUT team, provide tools and experience in embedding QI into community health worker programs. LVCT, under the SQALE project, is working with CHW programs in eight counties in Kenya.
Impact The main output has been a proposal to Round 4 of the Health Systems Research Initiative. The collaboration is multi-disciplinary, involving community health work, mobile health technology, and human resources for health.
Start Year 2017
 
Description Partnership to explore a unified framework for QI in public and private sector primary healthcare 
Organisation Liverpool School of Tropical Medicine
Country United Kingdom 
Sector Academic/University 
PI Contribution I am the PI of a research proposal that brings together Strathmore University, LSTM and LVCT. The proposal aims to use the clinical documentation approach pioneered in GASP in both private sector primary healthcare facilities (where GASP is already working) and community health workers in the public sector.
Collaborator Contribution LSTM, specifically Dr. Miriam Taegtmeyer and the REACHOUT team, provide tools and experience in embedding QI into community health worker programs. LVCT, under the SQALE project, is working with CHW programs in eight counties in Kenya.
Impact The main output has been a proposal to Round 4 of the Health Systems Research Initiative. The collaboration is multi-disciplinary, involving community health work, mobile health technology, and human resources for health.
Start Year 2017
 
Description Partnership to use GASP tools to improve efficiency of private health insurance 
Organisation Britam Holdings Limited
Country Kenya 
Sector Private 
PI Contribution I am the PI in a grant application to Grand Challenges Africa. I will lead the extension of the tools and methods used in GASP for use in claims management for private health insurance programs.
Collaborator Contribution Britam General Insurance Company is one of the leading private health insurance providers in East Africa. They will provide access to their partner healthcare facilities processing health insurance claims.
Impact We have submitted a grant proposal to Grand Challenges Africa. The partnership is between a University and a private health insurance company.
Start Year 2017
 
Description Partnership to use GASP tools to improve maternal and newborn health in Turkana County 
Organisation Aga Khan University
Country Pakistan 
Sector Academic/University 
PI Contribution I am the PI in a proposal to the County Innovation Challenge Fund. The tools developed in GASP will be extended to capture maternal and newborn care delivered in public sector healthcare facilities in Turkana County, a remote region in northwestern Kenya.
Collaborator Contribution KWTRP are providing expertise in monitoring and evaluation. The Aga Khan University is providing expertise in quality improvement for maternal and newborn health
Impact This is a multidisciplinary collaboration that combines clinical expertise in maternal and newborn health, statistical expertise in evaluating documentation of healthcare, and innovative mobile health tools for capturing data at low cost. The output is a grant application to DFID's County Innovation Challenge Fund. The proposal has been shortlisted for the award.
Start Year 2016
 
Description Partnership to use GASP tools to improve maternal and newborn health in Turkana County 
Organisation Wellcome Trust
Department KEMRI-Wellcome Trust Research Programme
Country Kenya 
Sector Multiple 
PI Contribution I am the PI in a proposal to the County Innovation Challenge Fund. The tools developed in GASP will be extended to capture maternal and newborn care delivered in public sector healthcare facilities in Turkana County, a remote region in northwestern Kenya.
Collaborator Contribution KWTRP are providing expertise in monitoring and evaluation. The Aga Khan University is providing expertise in quality improvement for maternal and newborn health
Impact This is a multidisciplinary collaboration that combines clinical expertise in maternal and newborn health, statistical expertise in evaluating documentation of healthcare, and innovative mobile health tools for capturing data at low cost. The output is a grant application to DFID's County Innovation Challenge Fund. The proposal has been shortlisted for the award.
Start Year 2016
 
Description RTI International 
Organisation RTI International
Country United States 
Sector Charity/Non Profit 
PI Contribution Leading the technology development for digitising information in paper-based templates.
Collaborator Contribution RTI will provide technical assistance in developing a mobile tool for digitising information in paper-based templates
Impact Technology development is ongoing.
Start Year 2017
 
Description University of Warwick 
Organisation University of Warwick
Department Warwick Medical School
Country United Kingdom 
Sector Academic/University 
PI Contribution Learnings from the design and implementation of the GASP tools
Collaborator Contribution Expertise in health economics and evaluation of complex health interventions
Impact The grant provides the opportunity for multi-disciplinary collaboration between the Universities of Warwick (UK), Strathmore (Kenya) and Sergipe (Brazil) to develop a clinical trial of the GASP tools in multiple LMIC countries.
Start Year 2017
 
Title METHOD AND DEVICE FOR PRODUCING AN ELECTRONIC HEALTH RECORD FROM PAPER 
Description Although mobile technology has great potential for assisting a variety of activities in low-resource settings, there have been few successes at scale. Herein is provided an innovation that improves access and quality while considering the costs of healthcare. The innovation efficiently extracts digital information from paper-based records using low-cost and locally produced rubber stamps to improve adherence to clinical practice guidelines. By bringing down the costs of clinical audit, this innovation offers the potential for clinics in resource-limited settings to deliver high-quality care. 
IP Reference  
Protection Patent application published
Year Protection Granted 2017
Licensed Yes
Impact The approach is being used by Health-E-Net Limited, a social enterprise, to develop a paper-based electronic medical record system.
 
Title Rubber stamp CPG templates 
Description The project aims to increase provider adherence to clinical practice guidelines (CPG). Rubber stamp CPG templates (RST) are designed to place selected important elements of a CPG into the paper-based case sheet. RSTs are also designed to improve paper-based clinical documentation and rapid digitisation using a cellphone camera. RSTs represent a first step towards the development of a set of paper-based interfaces to electronic medical records. The project is raising revenues through quality improvement initiatives and we are actively involved in raising funding for continued development of the intervention. 
Type Management of Diseases and Conditions
Current Stage Of Development Early clinical assessment
Year Development Stage Completed 2016
Development Status Actively seeking support
Impact The main impact from the development of the product is in improving quality of clinical care as measured by adherence to clinical practice guidelines. It also represents a 'platform technology' that improves use of paper at the point-of-service, providing an alternative to expensive data collection activities using multiple tablet computers or smart phones. 
 
Title PaperEMR - a paper-based electronic medical record 
Description The webapp is able to extract optical marks entered into rubber stamp templates. We are currently developing a mobile app which will form the core of PaperEMR 
Type Of Technology Webtool/Application 
Year Produced 2018 
Impact The biggest impact of the technology will be to make digital health data available from primary healthcare clinics with no electricity or reliable internet. 
 
Description Developing a Research Agenda in Global Healthcare Management, Innovation & Entrepreneurship 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Professional development workshop (PDW) at the 2018 Academy of Management (AOM) meeting in Chicago, IL. Dr. Pratap Kumar was an invited panel speaker at the session.
Year(s) Of Engagement Activity 2018
 
Description Expert roundtable workshop: The Role of Technology in Primary Healthcare 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Invited participant in an expert roundtable workshop on "The Role of Technology in Primary Healthcare" organised by the Pathways for Prosperity Commission. The input from the roundtable will be presented in a report by the commission on the role of digital technologies in health and education.
Year(s) Of Engagement Activity 2019
URL https://pathwayscommission.bsg.ox.ac.uk/
 
Description Host of the Kenya Health Informatics Association meeting on big data analytics 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The first Kenya Health Informatics Association (KeHIA) meeting was hosted by the Institute of Healthcare Management at Strathmore Business School, Nairobi. The meeting included academics, NGOs and members of the healthcare industry and was an opportunity for sharing ongoing efforts in collecting, curating and analysing 'big data' in healthcare.
Year(s) Of Engagement Activity 2016
 
Description I've got 99 problems but a phone ain't one: Lessons from design, gaming, agriculture and education for using mHealth to create inclusive health systems 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Dr. Pratap Kumar organised a panel presentation at the 5th Health Systems Research conference in Liverpool, UK
Year(s) Of Engagement Activity 2018
URL http://healthsystemsresearch.org/hsr2018/program/
 
Description Keynote speaker at 'Startup Safaris' 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The keynote address delivered by me highlighted innovative approaches to overcoming healthcare challenges in developing countries. The audience members included entrepreneurs, IT developers, members of the healthcare and technology industry and investors in Kenya and Canada.
Year(s) Of Engagement Activity 2016
 
Description Long oral presentation at the 12th World Congress of the International Health Economics Association 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
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Description NNAK conference presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
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Year(s) Of Engagement Activity 2017
 
Description Poster presentation at PMAC 2017 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Poster presented at the Prince Mahidol Awards Conference, 2017, a global health systems research symposium. The theme of this year's conference was "Addressing the Health of Vulnerable Populations for an Inclusive Society." Our poster was titled "Quality improvement at the frontier of healthcare delivery through participatory tool development, novel documentation and provider feedback - Experiences of the Guidelines Adherence in Slums Project"
Year(s) Of Engagement Activity 2017
 
Description Poster presented at HSR2016 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Poster presented at a global symposium on health systems research in Vancouver, Canada.
Year(s) Of Engagement Activity 2016
URL http://epostersonline.com/gshr2016/node/2359
 
Description Presentation at ECTMIH 2017 in Antwerp 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
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Year(s) Of Engagement Activity 2017
 
Description Social impact pitch at Global Health & Innovation Conference 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
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Year(s) Of Engagement Activity 2018
URL https://www.uniteforsight.org/conference/speakers-2018
 
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Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
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