Using digital technology as a platform to strengthen the continuum of care at community level for maternal, child and adolescent health in Tanzania: Introducing the Afya-Tek program

Using digital technology as a platform to strengthen the continuum of care at community level for maternal, child and adolescent health in Tanzania: Introducing the Afya-Tek program | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using digital technology as a platform to strengthen the continuum of care at community level for maternal, child and adolescent health in Tanzania: Introducing the Afya-Tek program Angel Dillip, Gloria Kahamba, Richard Sambaiga, Elizabeth Shekalaghe, and 25 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4127585/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jul, 2024 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Poor quality of care within Tanzania’s primary health system contributes to thousands of preventable maternal and child deaths, and unwanted pregnancies each year. A key contributor is lack of coordination between three primary healthcare actors: public sector Community Health Workers (CHWs) and health facilities, and private sector Accredited Drug Dispensing Outlets (ADDOs). The Afya-Tek program aims to improve the continuity of care amongst these actors in Kibaha district, through a mobile-application based digital referral system that focuses on improving maternal, child and adolescent health. The digital system called Afya-Tek was co-created with users and beneficiaries, and utilises open-source technology in-line with existing government systems. The system guides healthcare actors with individualised decision support during client visits and recommends accurate next steps (education, treatment, or referral). From July 2020 to June 2023, a total of 241,000 individuals were enrolled in the Afya-Tek program covering 7,557 pregnant women, 6,582 postpartum women, 45,900 children, and 25,700 adolescents. CHWs have conducted a total of 626,000 home visits to provide health services, including screening clients for danger signs. This has resulted in 38,100 referrals to health facilities and 24,300 linkages to ADDOs. At the ADDO level, 48,552 clients self-presented; 33% of children with pneumonia symptoms received Amoxicillin; 34% of children with diarrhoea symptoms received ORS and zinc; and 4,203 referrals were made to nearest health facilities. Adolescents preferred services at ADDOs as a result of increased perceived privacy and confidentiality. In total, 89% of all referrals were attended by health facilities. As the first digital health program in Tanzania to demonstrate the linkage among public and private sector primary healthcare actors, Afya-Tek holds promise to improve maternal, child and adolescent health as well as for scale-up and sustainability, through incorporation of other disease conditions and integration with government’s Unified Community System (UCS). Afya-Tek CHW ADDO health facility maternal health child health adolescent health digital health community primary healthcare Figures Figure 1 Figure 2 Figure 3 Figure 4 What is already known on this topic Lack of strengthened continuum of care at community level for maternal, child and adolescent in Tanzania is partly due to fragmented service provision at the primary healthcare level; lack of guidance to aid decision-making processes; and limited use of data. What this study adds: The Afya-Tek program showcases an innovative digitally enabled system which strengthens the linkages between private sector Accredited Drug Dispensing Outlets (ADDOs) and public sector community health workers and health facilities. The Afya-Tek program improves the continuum of care at community level and prompt access to care for mothers and children through digital decision support tools, patient referral and tracking. The involvement of the private sector ADDOs shows promise in improving adolescent health due to delivering private, confidential and client centred services. How this study might affect research, practice or policy: Afya-Tek’s participatory approach in co-creation of the digital system and implementation processes has been critical to ensure system usability and ownership on the ground. As the first digital health system in Tanzania to link public and private sectors, it works within a framework of Public Private Partnership and contributes to effective linkage, for a scaled-up improvement and sustainability of primary healthcare. INTRODUCTION Investing in primary health care (PHC) continues to play an important role in public health needs globally in the stride towards universal health coverage, with estimates suggesting that PHC can address 80% − 90% of a person’s health needs throughout his or her life [ 1 ]. However, the full potential of primary health systems remains to be realised in most low- and middle- income countries (LMICs) [ 2 ]. One aspect of the unrealized potential of PHC is the global challenge of fragmentation within health systems [ 5 ]. Central to these challenges is the issue of integration and coordination of care among various health system actors and programs - a goal made especially elusive in LMICs, where program funding typically comes from a variety of sources. Countries continue to face internal competition among various health services for access to finite resources, which is made even more difficult by the prevalence of siloed workforces and health programs [ 4 ]. The fallout of these systemic challenges often lies in health outcomes. The under-5 mortality rate in Tanzania is still almost double the target set out by the SDGs, currently at 47 per 1000 live births [ 15 ]. The maternal mortality rate is similarly more than 3 times higher than the SDG target value, with a maternal mortality rate of 238 [ 15 ]; adolescent fertility rate has kept on increasing and currently at 27% [ 16 ]. Estimates highlight that up to 67% of new-born deaths in sub-Saharan Africa could be prevented through a functional referral system and continuum of care, saving 700,477 lives each year [ 13 ]; while other studies showcase that further work needs to be done in Tanzania across the continuum of care for maternal, newborn and child health to improve these outcomes [ 14 ]. Tanzania, a low-income East African country, experiences similar barriers to coordination of care at the primary care level. Currently, there are inadequate linkages among the three main primary health system actors: namely, Community Health Workers (CHWs), Accredited Drug Dispensing Outlets (ADDOs), and primary health facilities (HF) [ 9 ]. While CHWs and HFs are part of Tanzania’s decentralized health system, ADDOs are privately owned community-based drug shops. ADDOs are regulated and under the mandate of the Tanzania Pharmacy Council, yet smaller than pharmacies, and are allowed to dispense over the counter medication and a limited list of prescription medicines [ 6 , 7 ]. Although there are continuous improvements in infrastructure at the PHC level, there is still limited access to HFs for many people, with large distances to HFs remaining a significant barrier to care-seeking [ 8 , 9 ]. While CHWs refer clients to HFs for certain conditions, tracking these referrals is difficult and follow-up is limited [ 9 ]. ADDOs, which are otherwise able to provide easily accessible medications for certain illnesses or family planning services right within the community, have no formal interaction with CHWs. Additionally, ADDOs have a weak link and inefficient referral system to coordinate client care with the HFs [ 9 ]. While there is an official paper-based referral system in place at the PHC level, maintaining and tracking these referrals remains a challenge; HFs are often understaffed and the health workers themselves are overburdened [ 9 – 12 ]. Thus, based on this evidence and the Tanzanian context, it is likely that more formalized linkages among CHWs, ADDOs and primary HFs in Tanzania would strengthen care coordination and increase the potential to improve maternal, new-born and child health outcomes. Given the need to optimise and improve these formalized linkages [ 9 ], one potential solution is through digital health innovation [ 17 ]. Digital technology allows for opportunities to support universal access to high quality healthcare, as well as strengthen and scale up health promotion, diagnosis, and management; though efforts need to also be made to ensure equitable impact [ 18 , 19 ]. Additionally, the specific role of country-owned stewardship of digital health and a country’s capacity to achieve this, showcases the potential of Tanzania - given its forwardness in this realm - to optimize on such digital solutions and propel its health systems into the future [ 20 – 23 ]. Thus, we present Afya-Tek : a comprehensive digitally-enabled primary health care program in Kibaha, Tanzania. The program utilizes unique (system-level) identification of patients via digital technology, as a tool to strengthen and coordinate the three main Tanzania primary health system actors: CHWs, ADDOs, and primary health facilities. The Afya-Tek program provides a unique model of service provision which links both public and private health sector actors at the PHC level, thereby highlighting a promising example of public private partnerships (PPP). This paper outlines the overall Afya-Tek program, and presents the initial program set up; the various methodologies and components of the Afya-Tek program and system design; as well as preliminary findings and analyses from various lessons learnt and challenges faced. This is then followed by a brief discussion on the program and reflections on ways forward. PROGRAM SET UP Consortium partners The Afya-Tek team is made up of a diverse consortium of partners: Apotheker Health Access Initiative , a Tanzanian organization, leads the program and is responsible for Afya-Tek implementation, sensitization and government engagement; together with D-tree International - Tanzania , which is responsible for health system strengthening, including Afya-Tek digital system design, development, capacity building, and monitoring. Simprints , a UK-based biometrics company, is responsible for contributing and maintaining the biometric fingerprint scanning technology. The Institute of Tropical Medicine (ITM) in Antwerp, Belgium, is tasked with evaluating program activities and outcomes through a Realist Evaluation in order to adapt the program to changing needs, as well as capturing transversal learnings. Another research partner is the University of Dar es Salaam , working closely with ITM to support program evaluation activities. Additionally, Inspired Ideas is a Tanzanian health-tech start-up, working on a pilot sub-project within Afya-Tek, specifically related to testing feasibility of Artificial Intelligence in select ADDOs. Finally, the program works hand in hand and collaborates with the Tanzanian Government, in particular the Ministry of Health (MoH), the President’s Office - Regional Administration and Local Government (PO-RALG), and the Pharmacy Council Tanzania. Study setting The Afya-Tek program is set in Kibaha district within the Pwani region of Tanzania. According to the latest census conducted in 2022, Kibaha district has an estimated total population of 388,727 [ 16 ]. Kibaha district is further subdivided into two councils: Kibaha Town Council (Kibaha TC) and Kibaha District Council (Kibaha DC). Each of these councils have their own local government authorities. Economic activities in Kibaha district include crop cultivation, livestock keeping, and small-scale businesses. Kibaha inhabitants include mixed ethnic groups and cultural diversities with Zaramo, Kwere, Mang’ati and Masai representing the majority. The two councils showcase the typical rural-urban disparity, in terms of access to and the utilization of health-care services [24, 25, that can be found across Tanzania]. Being part of the Pwani region, Kibaha district residents represent strong coastal traditions that may favour early pregnancies [ 26 , 27 ]. Target populations The target population of the Afya-Tek program includes the Afya-Tek digital system users and community beneficiaries. The users are CHWs, ADDO dispensers, and health facility workers (HFW). All eligible CHWs, ADDOs, and HFs within the two Kibaha councils were equipped with a smartphone, programmed with user-customized versions of the Afya-Tek system app. Beneficiary groups included all households within the catchment areas of both councils, with particular focus on: antenatal and postnatal women; children under age 5; and adolescents ages 11–19. Additionally, other key actors included: Village/Ward government leaders, Council/Regional Health Management Team (C/RHMT) members, as well as ADDO owners. AFYA-TEK PROGRAM AND AFYA-TEK SYSTEM DESIGN Afya-Tek is a program and a digital system. The Afya-Tek program (see Fig. 1) coordinates care by linking together the three main actors of the Tanzanian primary health system, i.e. health service providers: namely CHWs, ADDOs, and HFs - through a digital referral system. Additionally, Afya-Tek registers community members, screens them for health danger signs, and facilitates digital referrals (issuing, following up, and closing) across health workers. This is achieved by equipping the three health worker groups with user-customized digital smartphone applications, tailored to the needs and responsibilities at each point of care. The applications are available in both Kiswahili and English languages. Finally, as part of its ongoing research and learning from the program, there is a specific focus on generating lessons and traversal learning using Realist methodologies. Figure 1: A visual illustration of the Afya-Tek system and its varying program components 1 Participatory Approaches to design 1.1 Human-Centred Design A primary facet in the conception and ongoing implementation of the Afya-Tek program was the use of a human-centred design approach. This is an approach that includes active participation of stakeholders (i.e., users of the solution and those affected by the solution) throughout program activities so that the solution fits the needs and preferences of stakeholders and is more likely to be adopted and sustained. Several steps were taken to ensure that the digital system is, and continues to be, closely aligned to local needs and resources, while simultaneously bringing together a wide array of local, national, and international experts. To that end, the Afya-Tek digital system was co-created and co-produced using community participatory approaches with all relevant stakeholders, such as the local communities, health systems actors, app-developers, researchers, and program implementers. Human-centred-design activities continued throughout the course of program activities so that the community’s and other relevant stakeholder needs were reflected as the program evolved. This helped to ensure that the digital system was created and adjusted to specifically meet the needs of those who would be using the technology, as well as be coordinated with the needs of the Tanzanian health system at large. 1.2 Initial literature search and formative research In July 2019, a thorough desk review of Tanzanian national health and technical documents was conducted. This review gave the Afya-Tek team valuable insights related to the current Tanzanian digital health strategy [ 21 – 23 , 28 ]. Combined with an in-depth exploration through the existing national initiatives and guidelines at the time [ 7 , 29 , 30 ], it allowed us to understand current best practices for CHWs, ADDOs, and HFs. The desk review was part of a large-scale formative research across Kibaha TC and DC [ 26 ]. The purpose of this investigation was to develop an in-depth situational and contextual analysis, which explored existing barriers and facilitators to the continuum of care in the primary healthcare system. This included exploring current health seeking behaviours and practices of community members, as well as the motivations and challenges faced by the health service providers. More details on this study can be found in Haroun et al’s publication [ 26 ]. The findings from these investigations informed the system design and allowed the Afya-Tek team to begin designing the Afya-Tek digital system as per the needs identified from the research. 1.3 Government engagement Government engagement has been key in program creation and implementation. The Afya-Tek team has been working closely with the MoH, PO-RALG (including district and village governments), and the Pharmacy Council. Each entity is highly influential and relevant to the Afya-Tek program in providing guidance and direction on how the program fits into Tanzania’s strategic plans. These included following all relevant guidelines and policies, as well as building the Afya-Tek system within Open Smart Register Platform (OpenSRP). This engagement and meeting this latter requirement were deemed crucial for Afya-Tek’s vision for program scale-up and sustainability within Tanzania. 2 Digital System Development The Afya-Tek team began developing the digital system in November 2019 by following an agile development process, in which a set of functionalities were iteratively developed in three-week “sprints” or “cycles” of development. After each sprint, the Afya-Tek team tested the applications internally across 275 test cases to ensure that each new set of functionalities were working properly. Testing feedback was then triaged and worked back into development during the following sprint. Once a “minimum viable product” (in which all essential functionalities were set up, but with the intention of further development) had been developed, user acceptance testing was conducted with users. All user feedback was then taken into consideration during subsequent development cycles. 3 The developed Afya-Tek digital system The Afya-Tek digital system consists of the CHW, ADDO and Health Facility OpenSRP applications or apps. The development of each app is described below. 3.1 Afya-Tek CHW app The mobile app developed for CHWs allows each CHW to register and manage all clients within the CHW’s village. At least one CHW has been assigned to each village/ mtaa within the Kibaha district by the local government authority, and each CHW is responsible for registering all households and individuals within the catchment area. Once clients are registered in the Afya-Tek system, CHWs conduct home visits according to specific visit schedules in order to screen the client for danger signs, counsel the client or caretaker on age-appropriate health education and prevention topics. The whole screening process is guided by the CHW app. If the screening process uncovers a danger sign, the CHW is prompted by the app to either link clients to an ADDO, or refer the client to a health facility, depending on the severity of the issue. The Afya-Tek app also alerts CHWs of any follow-up visits that are due after referral completion. After the client completes the referral at the HF, the CHW is prompted by the system to then conduct a final follow-up visit to ensure the client received sufficient care and treatment. The digital tool for CHWs was developed in accordance with all Tanzanian MoH guidelines [ 29 , 30 ] for community care. These guidelines specify home visit schedules for new-borns, children under 5, and pregnant and postpartum women; symptoms to screen for during home visits; and which of these symptoms warrant a referral to the health facility. Figure 2: Demonstration of the CHW app within the Afya-Tek system 3.2 Afya-Tek ADDO app The mobile app developed for ADDOs allows each ADDO to identify, screen, and treat each client that comes into the ADDO shop. After a thorough screening using the app, the ADDO dispenser can indicate back into the app what medications, if any, have been dispensed to the client. If the screening identifies any danger signs, the system prompts the dispenser to refer the client immediately to a health facility. The digital tool for ADDOs was developed in accordance with all Pharmacy Council, Tanzania Medicines and Medical Devices ADDO lists of medicines, and MoH guidelines for ADDO services [ 7 , 29 ]. These guidelines specify symptoms to screen for during client visits and which of these symptoms warrant a referral to the health facility. Figure 3: Demonstration of the ADDO app within the Afya-Tek system 3.3 Afya-Tek health facility app The mobile app developed for HFs, gives health facility staff visibility of the Afya-Tek system’s referral information, including client symptoms, origin of the referral (whether from a CHW or ADDO), and time of the referral. Once a referred client (from a CHW or ADDO) reaches the health facility and checks in with a HFW, the HFW can confirm attendance via the Afya-Tek health facility app, and the status of that client’s referral on the CHW app changes to “Received”. The CHW then knows that the client has completed the referral and is ready for a follow-up visit. In this way, Afya-Tek’s digitized process of referral allows for a complete circuit of referral and follow-up of clients, from home to facility and back to home. Figure 4: Demonstration of the HF app within the Afya-Tek system 3.4 App integration and coordinated care provision Each of the three Afya-Tek health service provider apps is integrated with the others in order to strengthen the continuum of care at the primary level, reduce redundancy in assessments, and facilitate longitudinal tracking of client health (see Table 1). CHWs can link clients to ADDOs or refer to HFs; ADDOs can refer clients to HFs; and all clients completing referrals at HFs receive follow-up care from CHWs. In this way, the Afya-Tek system closes referral loops that are otherwise difficult to track and help provide sufficient support for clients. Table 1: The created applications and their functionalities per user group 3.5 App coordination and biometrics Coordination of care across CHWs, ADDOs, and HFs is enabled by the “Afya-Tek ID” that is assigned to each client at registration. This unique identification number is used at each point of care to call up the client’s profile as he or she is identified. The client profile can be edited by CHWs, while the referral status can be updated at each point of care, meaning that health data captured by each service provider can be used to build a consistent, longitudinal client profile. App coordination, longitudinal care and referral completion was originally supported by the biometric identification component of the Afya-Tek system. Biometric capture was done at the point of client registration by the CHWs, and at each future point of entry (whether at home with a CHW, at a drug shop with an ADDO dispenser, or at the health facility) clients were identified by thumb and forefinger scans. This was matched with the corresponding registered Afya-Tek ID and the matching client’s profile, and up-to-date referral information was retrieved and presented on the service provider’s app. However, this component was later removed as part of Afya-Tek’s iterative, responsive and adaptive system design. 4 Sensitization, Recruitment, and Training In February 2020, the Afya-Tek team led sensitization meeting sessions in the two Kibaha councils to inform stakeholders about the project, update them on its status, and seek their participation and collaboration. Sensitisation targeted community leaders, ADDO owners, C/RHMT members, and Council heads of various departments. After sensitization, user training was done in two cohorts. Cohort I training (July 2020) involved only CHWs, who were trained exclusively on general phone usage, program objectives, consent protocols, biometric capture, and client registration. Cohort II training (October 2020) began once nearly 60% of the population of Kibaha had been registered by CHWs into the Afya-Tek system, and involved all users. Users were trained on home visits, referrals, follow-ups, medication dispensing, and referral closures, according to which component of the health system they represented and were required to use. The apps were released prior to user training in a staggered format in both July 2020 and September 2020. CHWs received a performance-based monthly stipend (in line with government recommendations), mobile data and airtime bundles, along with all other health worker user groups, to facilitate reliable data syncing and communication. 5 Monitoring and Evaluation The Afya-Tek program focused on a continuous and participatory approach to monitoring and evaluation (M&E) of the program. Multiple strands of work (outlined below) allowed for an iterative approach that has led to the development of a digital system that is more aligned with user and community needs. A key learning and outcome of this agile and continuous M&E occurred in the fall of 2021, a year after implementation began, when it was acknowledged that the biometric component of unique identification was a recurrent barrier to implementation within this context. As such, the system was re-adapted without biometric identification processes to ensure smoother utilisation and more user- and client-friendly uptake of the Afya-Tek system. 5.1 Continuous Improvement and Refinement of the System The Afya-Tek team continued with OpenSRP system development to continuously and iteratively improve the system based on both internal testing and feedback from users. The Afya-Tek team’s strong testing and development processes, along with the follow-up activities outlined below, encouraged regular feedback gathering, prioritization, and incorporation. By having open communication around the feedback, the Afya-Tek program was adaptable to the changes and information coming from users and remained flexible in planning the way forward for each iteration of the digital system. 5.2 Continuous Supervision and Monitoring Performance monitoring is an ongoing activity performed by the Afya-Tek team, CHW supervisors and CHMT. The team monitors the performance of the end users and provides on-site support (technical or advisory), guidance and instruction with respect to the Afya-Tek system competencies, and supportive supervision by documenting challenges found on the field and identifying areas for improvement. Various monitoring platforms utilised by the program include a) remote support through dashboard monitoring, communication via WhatsApp groups, and by conducting follow up calls to users, and b) physical monitoring through supervision visits where the Afya-Tek team and CHMTs observe user interaction with clients and provide on-site support where needed. (More information can be found in Appendix 1) 5.3 Dashboards, data sharing and communication across stakeholders A key component of the M&E process was to create supervisory dashboards at the council levels to evaluate system activity and track key indicators that could assess program progress and/or user performance. All dashboards were customized based on the user (supervisors, CHMTs, and Afya-Tek program teams) and on the user device type (e.g., the supervisor dashboard was configured to be viewed on a phone, whereas the CHMT dashboard was configured for desktop view). The dashboards have been critical for program M&E in order to increase data transparency and accessibility across partners and serve as a platform to conduct M&E analyses with large datasets. Being actively part of this M&E process has been instrumental in particular for consortium partners and for CHMTs in decision-making and resource planning. Any feedback or recommendations based on discussions have been continually used to strengthen dashboards and program activities. 5.4 Realist monitoring and evaluation The Afya-Tek program has at its core a major learning objective: To generate transversal learnings, that are based on context-specific understandings of how digital innovation within the continuum of care at primary care level can lead to responsive, people-centred healthcare which improves the maternal, child and adolescent health outcomes in coastal Tanzania. Realist Evaluation (RE) is a structured, yet flexible, research approach that combines quantitative and qualitative research methodologies to monitor, intervene, and evaluate a program's impact [ 32 ]. The basic premise under which it operates is the observation, analysis, and explanation of how, why, for whom, and under what circumstances an intervention does or does not succeed [ 33 ]. Realist evaluation is particularly useful for evaluating new initiatives as it allows one to fully understand and delineate their complexities and see how best to adapt the intervention within new contexts, thereby informing potential program scale up. As such, multiple strands of mixed-methods research were conducted throughout the program implementation, with ongoing programmatic interventions and outcomes iteratively informing each strand of research. The key RE study components within Afya-Tek are highlighted in Box 1. (See Appendix 2 for more information) Box 1: Key RE study components within Afya-Tek PRELIMINARY FINDINGS & ANALYSIS The Afya-Tek full system deployment began in November 2020. With 2.5 years of implementation thus far, preliminary findings of the program highlight that current service provision through the app is coordinated across approximately 400 health providers (240 CHWs, 110 ADDOs, and 53 HFs) within Kibaha. Table 2 provides initial data and key achievements of the Afya-Tek program since its deployment into Kibaha district (July 2020 - June 2023). Table 2: Initial data and key achievements of the Afya-Tek program since its deployment into Kibaha district (July 2020 - June 2023) Key highlights from this data include: CHWs being instrumental in counselling clients during household visits regarding malaria prevention, family planning and nutrition; the contribution of the ADDO as a private health sector actor within the continuum of care is quite evident with adolescents; while the high linkage and referral completion rate at both ADDOs and HFs, respectively, is a positive indicator of a stronger coordination system. Additionally, the Afya-Tek systems provides an easy-to-use supervisory mechanism for the CHW supervisors to easily monitor performance of the CHWs, as well as for the CHMTs to digitally monitor and follow progress within their councils, which has subsequently aided them in resource management and planning. Further details of Afya-Tek’s results and outcomes will be shared in upcoming publications. In the course of implementing the Afya-Tek program, several lessons learnt were documented, see Table 3 for key lessons learnt. Table 3: Key lessons learnt through the Afya-Tek program A multi-user program such as Afya-Tek is complex, and requires significant efforts and time, as well as regular monitoring and problem-solving to overcome challenges. Being a complex program bringing together public and private health sector actors, Afya-Tek naturally experienced various implementation challenges. As ongoing challenges were encountered, due the responsive and agile nature of the program, Afya-Tek ensured prompt mitigation and problem solving. These challenges can be categorised as either being contextual or technical challenges. As challenges differed based on location and target-population, the solutions thus needed to be context- and actor-specific. As with all in-field challenges, solutions were continuously generated and rolled-out in an iterative design. Table 4 highlights some of the challenges faced by the program and identified solutions thus far. Table 4: Specific challenges and associated solutions as encountered in the Afya-Tek program DISCUSSION & CONCLUSION The Afya-Tek program is the first digital health system in Tanzania to demonstrate the link among CHWs, private sector ADDOs, and HFs for a strengthened continuum of care. It purports to create and effectively implement an innovative digital health intervention that ensures the provision of smooth, coordinated care among primary healthcare system actors for communities in the Pwani region of Tanzania. Afya-Tek thus demonstrates a proof-of-concept model that addresses the problem of coordination of care. As an illustration of the PPP model in Tanzania, ADDOs are proving to be an important entity for capturing clients with illnesses at the community level, managing them and providing referrals to HFs. Strengthening the use of these private sector platforms also offers unique opportunities for reaching adolescents and providing them with person-centred and confidential services with easier access to contraceptives and condoms. Going forward, the program intends to strengthen the adolescent health component by incorporating adolescent youth clubs to ensure greater engagement of the youth. Afya-Tek also provides a potential platform to test and incorporate other disease conditions. For instance, this can include exploring the addition of other national high priority health areas, such as NCDs (e.g., diabetes, hypertension) and nutrition, and other infectious diseases like tuberculosis and HIV. The platform can be used to ensure appropriate management of these conditions and access to services and medications across the continuum of care. With the Afya-Tek system being built on the OpenSRP platform, it has a broad endorsement from the Government of Tanzania. This allows for interoperability and integration within national digital health systems such as the Unified Community System (UCS), Government of Tanzania-Hospital Management Information System (GoT-HoMIS), and District Health Information System 2 (DHIS2). The potential for continued data-use from the Afya-Tek system is high, and thus next steps include continuing on-going collaboration and engagement with health and ICT technical teams at various levels of Government (MOH, PO-RALG, Pharmacy Council, R/CHMT) for eventual integration and adaptation into the National digital community system. By and large, the findings reflected in this article are consistent with ongoing discussions in the digital health literature, both nationally and within sub-Saharan Africa [ 36 , 37 ]. Despite the growth of digital technology in recent years, Tanzania, like other LMICs, still faces a problem of the digital divide. In general, while urban settings by and large have access to the benefits of emerging digital technologies, the majority of rural areas still experience low access [ 38 ]. In regards to scaling up and sustainability in the LMICs, there is a consensus that the success of digital health intervention and subsequent scaling up of the same require several interrelated pillars [ 39 ]. These include, but are not limited to, the intrinsic features of the programme; stakeholder engagement; simplicity, interoperability and adaptability; alignment with policy environments; and adaptable extrinsic ecosystems. Additionally, it remains crucial to understand the role of artificial intelligence decision support tools, as our consortium partner Inspired Ideas has been exploring [ 40 ]. Thus, there is much scope and potential for a program like Afya-Tek’s, which bridges this digital divide, to have a significant impact on health outcomes in the long run. Through such a digitally coordinated system, the Tanzanian PHC system would be able to digitally create efficiency and communication in referral systems across public and private primary healthcare providers. Discussions on long-term sustainability allow for possibilities to scale across other settings within Tanzania, alongside generating transversal learnings to utilize in other LMICs contexts. If continuity of care and follow-up could be made efficient by digital innovations such as the Afya-Tek system, the quality and coordination of primary care would be improved especially in resource constrained settings; thereby allowing focus back to ensuring equitable, quality, person-centred care for all. Declarations Ethical Approval The Afya-Tek program received ethical approval from the Tanzanian National Institute for Medical Research (NIMR) (NIMR/HQR.8a/Vol.IX/308), the Tanzania Commission for Science and Technology (COSTECH) (2019-454-NA-2018-246), and National Health Research Ethics Committee (NatHREC) which provided approval for the study. It also received ethical approval from the Institute of Tropical Medicine’s (ITM) Institutional Review Board (1315/19). Consent to Participate Consent was sought from household heads and members for participation in the Afya-Tek program. Prior to that, household members were provided with an information sheet to read and understand their roles and rights, plus confidentiality of information collected. Household members were also informed that participation in the program was voluntary and that they were free to withdraw from the program anytime they wish. While those above eighteen (18) years of age were consented themselves, for adolescents who were below eighteen, parental consents were sought. All methods were performed in accordance with the relevant guidelines and regulations and the National Health Research Ethics Committee (NatHREC) approved it. Consent for Publication Informed consent was obtained from all participants for publication. Legal guardians were consulted for the participants below the age of 18 years. Funding The study was funded by Botnar Foundation, Switzerland. Acknowledgements The authors wish to thank the Kibaha community, PORALG, Pharmacy Council and MoH for their participation in the program, and Foundation Botnar for funding the Afya-Tek program. References World Health Organization, Declaration of Astana: Global Conference on Primary Health Care: Astana, Kazakhstan, 25 and 26 October 2018 . 2019, World Health Organization. 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Regulations & Guidelines . 2023; Available from: https://www.pc.go.tz/regulation_guidelines/. Nyamtema, A.S., et al., Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model. PLOS ONE, 2016. 11 (3): p. e0151419. Dillip, A., et al., Can formalizing links among community health workers, accredited drug dispensing outlet dispensers, and health facility staff increase their collaboration to improve prompt access to maternal and child care? A qualitative study in Tanzania. BMC Health Services Research, 2017. 17 (1): p. 416. Kassile, T., et al., Determinants of delay in care seeking among children under five with fever in Dodoma region, central Tanzania: a cross-sectional study. Malaria Journal, 2014. 13 (1): p. 348. Harahap, N.C., P.W. Handayani, and A.N. Hidayanto, Barriers and technologies of maternal and neonatal referral system in developing countries: A narrative review. Informatics in Medicine Unlocked, 2019. 15 : p. 100184. 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Administrative Units Population Distribution Report . December 2022; Available from: https://www.nbs.go.tz/nbs/takwimu/Census2022/Administrative_units_Population_Distribution_Report_Tanzania_Mainland_volume1b.pdf. World Health Organization, Global strategy on digital health 2020-2025 . 2021: Geneva. Azzopardi-Muscat, N. and K. Sørensen, Towards an equitable digital public health era: promoting equity through a health literacy perspective. European Journal of Public Health, 2019. 29 (Supplement_3): p. 13-17. Onodera, R., S. Sengoku, and K. Miyazaki. Exploring the potential of Mobile Health for product and process innovation . in 2016 Portland International Conference on Management of Engineering and Technology (PICMET) . 2016. Frost, M.J., et al., What Does It Take to Be an Effective National Steward of Digital Health Integration for Health Systems Strengthening in Low- and Middle-Income Countries? Global Health: Science and Practice, 2018. 6 (Supplement 1): p. S18-S28. Tanzania, U.R.o., Tanzania Digital Health Investment Road Map (2017-2023) . 2017. United Republic of Tanzania, M.o.H., Community Development, Gender, Elderly and Children, Digital Health Strategy (July 2019 - June 2024) . 2019. Watts, G., The Tanzanian digital health agenda. The Lancet Digital Health, 2020. 2 (2): p. e62-e63. Ntegwa, M., E. Mcharo, and J. Mlay, What explains the rural and Urban inequalities in maternal health services utilization in tanzania? A fairlie decomposition analysis. Asian Journal of Social Health and Behavior, 2023. 6 (2): p. 47-55. Iyer, H.S., et al., Evaluating urban–rural access to pathology and laboratory medicine services in Tanzania. Health Policy and Planning, 2021. 36 (7): p. 1116-1128. Haroun, Y., et al., A human centred approach to digital technologies in health care delivery among mothers, children and adolescents. BMC Health Services Research, 2022. 22 (1): p. 1-15. Zeelen, J., et al., The Burden of Educational Exclusion: Understanding and Challenging Early School Leaving in Africa . The Influence of Initiation Culture on Early School Leaving Amongst Girls: Experiences from the Coastal Regions of Tanzania. 2010: Brill. 115-125. Tanzania. Wizara ya Afya, M.y.J., Jinsia, Wazee na Watoto, et al., Tanzania Digital Health Investment Road Map 2017-2023: The Journey to Better Data for Better Health in Tanzania . 2017: Ministry of Health, Community Development, Gender, Elderly and Children. United Republic of Tanzania. Ministry of Health, C.D., Gender, Elderly and Children, The National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child & Adolescent Health in Tanzania (2016 - 2020) ONE PLAN II . 2016. United Republic of Tanzania, M.o.H.a.S.W., Women and Children First - Countdown to ending preventable maternal, newborn and child deaths in Tanzania . 2015. Digital Development Principles Working Group. Principles for Digital Development . Available from: https://digitalprinciples.org/. Jagosh, J., Realist Synthesis for Public Health: Building an Ontologically Deep Understanding of How Programs Work, For Whom, and In Which Contexts. Annual Review of Public Health, 2019. 40 (1): p. 361-372. Pawson, R., The science of evaluation: a realist manifesto . 2013: sage. Ajzen, I., The theory of planned behaviour: Reactions and reflections. Psychology & Health, 2011. 26 (9): p. 1113-1127. Rogers, E.M., Diffusion of innovations . 2010: Simon and Schuster. Swartz, A., et al., Multiple pathways to scaling up and sustainability: an exploration of digital health solutions in South Africa. Globalization and Health, 2021. 17 (1): p. 77. Schuetze, L., et al., Factors Affecting the Successful Implementation of a Digital Intervention for Health Financing in a Low-Resource Setting at Scale: Semistructured Interview Study With Health Care Workers and Management Staff. J Med Internet Res, 2023. 25 : p. e38818. Latio, R.G.W., Social and cultural issues: The impact of digital divide on development and how satellite addresses this problem. Online Journal of Space Communication, 2021. 2 (5): p. 11. Labrique, A.B., et al., Best practices in scaling digital health in low and middle income countries. Globalization and Health, 2018. 14 (1): p. 103. Salim Ally, Allen Megan, Mariki Kelvin, Masoy Kevin, Liana, Jafary. Understanding how the use of AI decision support tools affect critical thinking and over-reliance on technology by drug dispensers in Tanzania . ArXiv-CS-Human-Computer Interaction, 2023 Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.pdf Table2.pdf Table3.pdf Table4.pdf Box1.pdf Box 1: Key RE study components within Afya-Tek Cite Share Download PDF Status: Published Journal Publication published 30 Jul, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 25 Mar, 2024 Submission checks completed at journal 23 Mar, 2024 Editor assigned by journal 23 Mar, 2024 First submitted to journal 19 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4127585","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":283442267,"identity":"045d08fc-32b9-486c-9c55-2cc4237095ed","order_by":0,"name":"Angel 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16:01:34","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":130300,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4127585/v1/bcc725d37960c48b5e82536d.pdf"},{"id":53659112,"identity":"b3e5e91b-807b-470e-b985-db96d859b49d","added_by":"auto","created_at":"2024-03-28 16:01:35","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":27344,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBox 1: Key RE study components within Afya-Tek\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Box1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4127585/v1/cd3341b83ba2d2afbe263be7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using digital technology as a platform to strengthen the continuum of care at community level for maternal, child and adolescent health in Tanzania: Introducing the Afya-Tek program","fulltext":[{"header":"What is already known on this topic","content":"\u003cp\u003eLack of strengthened continuum of care at community level for maternal, child and adolescent in Tanzania is partly due to fragmented service provision at the primary healthcare level; lack of guidance to aid decision-making processes; and limited use of data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds:\u0026nbsp;\u003c/strong\u003eThe Afya-Tek program showcases an innovative digitally enabled system which\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003estrengthens the linkages between private sector Accredited Drug Dispensing Outlets (ADDOs) and public sector community health workers and health facilities. The Afya-Tek program improves the continuum of care at community level and prompt access to care for mothers and children through digital decision support tools, patient referral and tracking. The involvement of the private sector ADDOs shows promise in improving adolescent health due to delivering private, confidential and client centred services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice or policy:\u0026nbsp;\u003c/strong\u003eAfya-Tek\u0026rsquo;s participatory approach in co-creation of the digital system and implementation processes has been critical to ensure system usability and ownership on the ground. As the first digital health system in Tanzania to link public and private sectors, it works within a framework of Public Private Partnership and contributes to effective linkage, for a scaled-up improvement and sustainability of primary healthcare.\u0026nbsp;\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eInvesting in primary health care (PHC) continues to play an important role in public health needs globally in the stride towards universal health coverage, with estimates suggesting that PHC can address 80% \u0026minus;\u0026thinsp;90% of a person\u0026rsquo;s health needs throughout his or her life [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the full potential of primary health systems remains to be realised in most low- and middle- income countries (LMICs) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne aspect of the unrealized potential of PHC is the global challenge of fragmentation within health systems [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Central to these challenges is the issue of integration and coordination of care among various health system actors and programs - a goal made especially elusive in LMICs, where program funding typically comes from a variety of sources. Countries continue to face internal competition among various health services for access to finite resources, which is made even more difficult by the prevalence of siloed workforces and health programs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe fallout of these systemic challenges often lies in health outcomes. The under-5 mortality rate in Tanzania is still almost double the target set out by the SDGs, currently at 47 per 1000 live births [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The maternal mortality rate is similarly more than 3 times higher than the SDG target value, with a maternal mortality rate of 238 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]; adolescent fertility rate has kept on increasing and currently at 27% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Estimates highlight that up to 67% of new-born deaths in sub-Saharan Africa could be prevented through a functional referral system and continuum of care, saving 700,477 lives each year [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]; while other studies showcase that further work needs to be done in Tanzania across the continuum of care for maternal, newborn and child health to improve these outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTanzania, a low-income East African country, experiences similar barriers to coordination of care at the primary care level. Currently, there are inadequate linkages among the three main primary health system actors: namely, Community Health Workers (CHWs), Accredited Drug Dispensing Outlets (ADDOs), and primary health facilities (HF) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While CHWs and HFs are part of Tanzania\u0026rsquo;s decentralized health system, ADDOs are privately owned community-based drug shops. ADDOs are regulated and under the mandate of the Tanzania Pharmacy Council, yet smaller than pharmacies, and are allowed to dispense over the counter medication and a limited list of prescription medicines [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough there are continuous improvements in infrastructure at the PHC level, there is still limited access to HFs for many people, with large distances to HFs remaining a significant barrier to care-seeking [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While CHWs refer clients to HFs for certain conditions, tracking these referrals is difficult and follow-up is limited [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. ADDOs, which are otherwise able to provide easily accessible medications for certain illnesses or family planning services right within the community, have no formal interaction with CHWs. Additionally, ADDOs have a weak link and inefficient referral system to coordinate client care with the HFs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While there is an official paper-based referral system in place at the PHC level, maintaining and tracking these referrals remains a challenge; HFs are often understaffed and the health workers themselves are overburdened [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, based on this evidence and the Tanzanian context, it is likely that more formalized linkages among CHWs, ADDOs and primary HFs in Tanzania would strengthen care coordination and increase the potential to improve maternal, new-born and child health outcomes. Given the need to optimise and improve these formalized linkages [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], one potential solution is through digital health innovation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Digital technology allows for opportunities to support universal access to high quality healthcare, as well as strengthen and scale up health promotion, diagnosis, and management; though efforts need to also be made to ensure equitable impact [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, the specific role of country-owned stewardship of digital health and a country\u0026rsquo;s capacity to achieve this, showcases the potential of Tanzania - given its forwardness in this realm - to optimize on such digital solutions and propel its health systems into the future [\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, we present \u003cem\u003eAfya-Tek\u003c/em\u003e: a comprehensive digitally-enabled primary health care program in Kibaha, Tanzania. The program utilizes unique (system-level) identification of patients via digital technology, as a tool to strengthen and coordinate the three main Tanzania primary health system actors: CHWs, ADDOs, and primary health facilities. The Afya-Tek program provides a unique model of service provision which links both public and private health sector actors at the PHC level, thereby highlighting a promising example of public private partnerships (PPP).\u003c/p\u003e \u003cp\u003eThis paper outlines the overall Afya-Tek program, and presents the initial program set up; the various methodologies and components of the Afya-Tek program and system design; as well as preliminary findings and analyses from various lessons learnt and challenges faced. This is then followed by a brief discussion on the program and reflections on ways forward.\u003c/p\u003e"},{"header":"PROGRAM SET UP","content":"\u003cp\u003eConsortium partners\u003c/p\u003e \u003cp\u003eThe Afya-Tek team is made up of a diverse consortium of partners: \u003cem\u003eApotheker Health Access Initiative\u003c/em\u003e, a Tanzanian organization, leads the program and is responsible for Afya-Tek implementation, sensitization and government engagement; together with \u003cem\u003eD-tree International - Tanzania\u003c/em\u003e, which is responsible for health system strengthening, including Afya-Tek digital system design, development, capacity building, and monitoring. \u003cem\u003eSimprints\u003c/em\u003e, a UK-based biometrics company, is responsible for contributing and maintaining the biometric fingerprint scanning technology. The \u003cem\u003eInstitute of Tropical Medicine (ITM)\u003c/em\u003e in Antwerp, Belgium, is tasked with evaluating program activities and outcomes through a Realist Evaluation in order to adapt the program to changing needs, as well as capturing transversal learnings. Another research partner is the \u003cem\u003eUniversity of Dar es Salaam\u003c/em\u003e, working closely with ITM to support program evaluation activities. Additionally, \u003cem\u003eInspired Ideas\u003c/em\u003e is a Tanzanian health-tech start-up, working on a pilot sub-project within Afya-Tek, specifically related to testing feasibility of Artificial Intelligence in select ADDOs. Finally, the program works hand in hand and collaborates with the Tanzanian Government, in particular the Ministry of Health (MoH), the President\u0026rsquo;s Office - Regional Administration and Local Government (PO-RALG), and the Pharmacy Council Tanzania.\u003c/p\u003e \u003cp\u003eStudy setting\u003c/p\u003e \u003cp\u003eThe Afya-Tek program is set in Kibaha district within the Pwani region of Tanzania. According to the latest census conducted in 2022, Kibaha district has an estimated total population of 388,727 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Kibaha district is further subdivided into two councils: Kibaha Town Council (Kibaha TC) and Kibaha District Council (Kibaha DC). Each of these councils have their own local government authorities. Economic activities in Kibaha district include crop cultivation, livestock keeping, and small-scale businesses. Kibaha inhabitants include mixed ethnic groups and cultural diversities with Zaramo, Kwere, Mang\u0026rsquo;ati and Masai representing the majority. The two councils showcase the typical rural-urban disparity, in terms of access to and the utilization of health-care services [24, 25, that can be found across Tanzania]. Being part of the Pwani region, Kibaha district residents represent strong coastal traditions that may favour early pregnancies [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTarget populations\u003c/p\u003e \u003cp\u003eThe target population of the Afya-Tek program includes the Afya-Tek digital system users and community beneficiaries. The users are CHWs, ADDO dispensers, and health facility workers (HFW). All eligible CHWs, ADDOs, and HFs within the two Kibaha councils were equipped with a smartphone, programmed with user-customized versions of the Afya-Tek system app. Beneficiary groups included all households within the catchment areas of both councils, with particular focus on: antenatal and postnatal women; children under age 5; and adolescents ages 11\u0026ndash;19. Additionally, other key actors included: Village/Ward government leaders, Council/Regional Health Management Team (C/RHMT) members, as well as ADDO owners.\u003c/p\u003e"},{"header":"AFYA-TEK PROGRAM AND AFYA-TEK SYSTEM DESIGN","content":"\u003cp\u003eAfya-Tek is a program and a digital system. The Afya-Tek program (see Fig.\u0026nbsp;1) coordinates care by linking together the three main actors of the Tanzanian primary health system, i.e. health service providers: namely CHWs, ADDOs, and HFs - through a digital referral system. Additionally, Afya-Tek registers community members, screens them for health danger signs, and facilitates digital referrals (issuing, following up, and closing) across health workers. This is achieved by equipping the three health worker groups with user-customized digital smartphone applications, tailored to the needs and responsibilities at each point of care. The applications are available in both Kiswahili and English languages. Finally, as part of its ongoing research and learning from the program, there is a specific focus on generating lessons and traversal learning using Realist methodologies.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFigure 1: A visual illustration of the Afya-Tek system and its varying program components\u003c/em\u003e \u003c/p\u003e \u003cp\u003e1 Participatory Approaches to design\u003c/p\u003e \u003cp\u003e1.1 Human-Centred Design\u003c/p\u003e \u003cp\u003eA primary facet in the conception and ongoing implementation of the Afya-Tek program was the use of a human-centred design approach. This is an approach that includes active participation of stakeholders (i.e., users of the solution and those affected by the solution) throughout program activities so that the solution fits the needs and preferences of stakeholders and is more likely to be adopted and sustained. Several steps were taken to ensure that the digital system is, and continues to be, closely aligned to local needs and resources, while simultaneously bringing together a wide array of local, national, and international experts. To that end, the Afya-Tek digital system was co-created and co-produced using community participatory approaches with all relevant stakeholders, such as the local communities, health systems actors, app-developers, researchers, and program implementers. Human-centred-design activities continued throughout the course of program activities so that the community’s and other relevant stakeholder needs were reflected as the program evolved. This helped to ensure that the digital system was created and adjusted to specifically meet the needs of those who would be using the technology, as well as be coordinated with the needs of the Tanzanian health system at large.\u003c/p\u003e \u003cp\u003e1.2 Initial literature search and formative research\u003c/p\u003e \u003cp\u003eIn July 2019, a thorough desk review of Tanzanian national health and technical documents was conducted. This review gave the Afya-Tek team valuable insights related to the current Tanzanian digital health strategy [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Combined with an in-depth exploration through the existing national initiatives and guidelines at the time [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], it allowed us to understand current best practices for CHWs, ADDOs, and HFs.\u003c/p\u003e \u003cp\u003eThe desk review was part of a large-scale formative research across Kibaha TC and DC [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The purpose of this investigation was to develop an in-depth situational and contextual analysis, which explored existing barriers and facilitators to the continuum of care in the primary healthcare system. This included exploring current health seeking behaviours and practices of community members, as well as the motivations and challenges faced by the health service providers. More details on this study can be found in Haroun et al’s publication [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings from these investigations informed the system design and allowed the Afya-Tek team to begin designing the Afya-Tek digital system as per the needs identified from the research.\u003c/p\u003e \u003cp\u003e1.3 Government engagement\u003c/p\u003e \u003cp\u003eGovernment engagement has been key in program creation and implementation. The Afya-Tek team has been working closely with the MoH, PO-RALG (including district and village governments), and the Pharmacy Council. Each entity is highly influential and relevant to the Afya-Tek program in providing guidance and direction on how the program fits into Tanzania’s strategic plans. These included following all relevant guidelines and policies, as well as building the Afya-Tek system within Open Smart Register Platform (OpenSRP). This engagement and meeting this latter requirement were deemed crucial for Afya-Tek’s vision for program scale-up and sustainability within Tanzania.\u003c/p\u003e \u003cp\u003e2 Digital System Development\u003c/p\u003e \u003cp\u003eThe Afya-Tek team began developing the digital system in November 2019 by following an agile development process, in which a set of functionalities were iteratively developed in three-week “sprints” or “cycles” of development. After each sprint, the Afya-Tek team tested the applications internally across 275 test cases to ensure that each new set of functionalities were working properly. Testing feedback was then triaged and worked back into development during the following sprint.\u003c/p\u003e \u003cp\u003eOnce a “minimum viable product” (in which all essential functionalities were set up, but with the intention of further development) had been developed, user acceptance testing was conducted with users. All user feedback was then taken into consideration during subsequent development cycles.\u003c/p\u003e \u003cp\u003e3 The developed Afya-Tek digital system\u003c/p\u003e \u003cp\u003eThe Afya-Tek digital system consists of the CHW, ADDO and Health Facility OpenSRP applications or apps. The development of each app is described below.\u003c/p\u003e \u003cp\u003e3.1 Afya-Tek CHW app\u003c/p\u003e \u003cp\u003eThe mobile app developed for CHWs allows each CHW to register and manage all clients within the CHW’s village. At least one CHW has been assigned to each village/\u003cem\u003emtaa\u003c/em\u003e within the Kibaha district by the local government authority, and each CHW is responsible for registering all households and individuals within the catchment area.\u003c/p\u003e \u003cp\u003eOnce clients are registered in the Afya-Tek system, CHWs conduct home visits according to specific visit schedules in order to screen the client for danger signs, counsel the client or caretaker on age-appropriate health education and prevention topics. The whole screening process is guided by the CHW app.\u003c/p\u003e \u003cp\u003eIf the screening process uncovers a danger sign, the CHW is prompted by the app to either link clients to an ADDO, or refer the client to a health facility, depending on the severity of the issue. The Afya-Tek app also alerts CHWs of any follow-up visits that are due after referral completion. After the client completes the referral at the HF, the CHW is prompted by the system to then conduct a final follow-up visit to ensure the client received sufficient care and treatment.\u003c/p\u003e \u003cp\u003eThe digital tool for CHWs was developed in accordance with all Tanzanian MoH guidelines [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] for community care. These guidelines specify home visit schedules for new-borns, children under 5, and pregnant and postpartum women; symptoms to screen for during home visits; and which of these symptoms warrant a referral to the health facility.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFigure 2: Demonstration of the CHW app within the Afya-Tek system\u003c/em\u003e \u003c/p\u003e \u003cp\u003e3.2 Afya-Tek ADDO app\u003c/p\u003e \u003cp\u003eThe mobile app developed for ADDOs allows each ADDO to identify, screen, and treat each client that comes into the ADDO shop. After a thorough screening using the app, the ADDO dispenser can indicate back into the app what medications, if any, have been dispensed to the client. If the screening identifies any danger signs, the system prompts the dispenser to refer the client immediately to a health facility.\u003c/p\u003e \u003cp\u003eThe digital tool for ADDOs was developed in accordance with all Pharmacy Council, Tanzania Medicines and Medical Devices ADDO lists of medicines, and MoH guidelines for ADDO services [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These guidelines specify symptoms to screen for during client visits and which of these symptoms warrant a referral to the health facility.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFigure 3: Demonstration of the ADDO app within the Afya-Tek system\u003c/em\u003e \u003c/p\u003e \u003cp\u003e3.3 Afya-Tek health facility app\u003c/p\u003e \u003cp\u003eThe mobile app developed for HFs, gives health facility staff visibility of the Afya-Tek system’s referral information, including client symptoms, origin of the referral (whether from a CHW or ADDO), and time of the referral. Once a referred client (from a CHW or ADDO) reaches the health facility and checks in with a HFW, the HFW can confirm attendance via the Afya-Tek health facility app, and the status of that client’s referral on the CHW app changes to “Received”. The CHW then knows that the client has completed the referral and is ready for a follow-up visit. In this way, Afya-Tek’s digitized process of referral allows for a complete circuit of referral and follow-up of clients, from home to facility and back to home.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFigure 4: Demonstration of the HF app within the Afya-Tek system\u003c/em\u003e \u003c/p\u003e \u003cp\u003e3.4 App integration and coordinated care provision\u003c/p\u003e \u003cp\u003eEach of the three Afya-Tek health service provider apps is integrated with the others in order to strengthen the continuum of care at the primary level, reduce redundancy in assessments, and facilitate longitudinal tracking of client health (see Table\u0026nbsp;1). CHWs can link clients to ADDOs or refer to HFs; ADDOs can refer clients to HFs; and all clients completing referrals at HFs receive follow-up care from CHWs. In this way, the Afya-Tek system closes referral loops that are otherwise difficult to track and help provide sufficient support for clients.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTable\u0026nbsp;1: The created applications and their functionalities per user group\u003c/em\u003e \u003c/p\u003e \u003cp\u003e3.5 App coordination and biometrics\u003c/p\u003e \u003cp\u003eCoordination of care across CHWs, ADDOs, and HFs is enabled by the “Afya-Tek ID” that is assigned to each client at registration. This unique identification number is used at each point of care to call up the client’s profile as he or she is identified. The client profile can be edited by CHWs, while the referral status can be updated at each point of care, meaning that health data captured by each service provider can be used to build a consistent, longitudinal client profile.\u003c/p\u003e \u003cp\u003eApp coordination, longitudinal care and referral completion was originally supported by the biometric identification component of the Afya-Tek system. Biometric capture was done at the point of client registration by the CHWs, and at each future point of entry (whether at home with a CHW, at a drug shop with an ADDO dispenser, or at the health facility) clients were identified by thumb and forefinger scans. This was matched with the corresponding registered Afya-Tek ID and the matching client’s profile, and up-to-date referral information was retrieved and presented on the service provider’s app. However, this component was later removed as part of Afya-Tek’s iterative, responsive and adaptive system design.\u003c/p\u003e \u003cp\u003e4 Sensitization, Recruitment, and Training\u003c/p\u003e \u003cp\u003eIn February 2020, the Afya-Tek team led sensitization meeting sessions in the two Kibaha councils to inform stakeholders about the project, update them on its status, and seek their participation and collaboration. Sensitisation targeted community leaders, ADDO owners, C/RHMT members, and Council heads of various departments.\u003c/p\u003e \u003cp\u003eAfter sensitization, user training was done in two cohorts. Cohort I training (July 2020) involved only CHWs, who were trained exclusively on general phone usage, program objectives, consent protocols, biometric capture, and client registration. Cohort II training (October 2020) began once nearly 60% of the population of Kibaha had been registered by CHWs into the Afya-Tek system, and involved all users. Users were trained on home visits, referrals, follow-ups, medication dispensing, and referral closures, according to which component of the health system they represented and were required to use. The apps were released prior to user training in a staggered format in both July 2020 and September 2020.\u003c/p\u003e \u003cp\u003eCHWs received a performance-based monthly stipend (in line with government recommendations), mobile data and airtime bundles, along with all other health worker user groups, to facilitate reliable data syncing and communication.\u003c/p\u003e \u003cp\u003e5 Monitoring and Evaluation\u003c/p\u003e \u003cp\u003eThe Afya-Tek program focused on a continuous and participatory approach to monitoring and evaluation (M\u0026amp;E) of the program. Multiple strands of work (outlined below) allowed for an iterative approach that has led to the development of a digital system that is more aligned with user and community needs.\u003c/p\u003e \u003cp\u003eA key learning and outcome of this agile and continuous M\u0026amp;E occurred in the fall of 2021, a year after implementation began, when it was acknowledged that the biometric component of unique identification was a recurrent barrier to implementation within this context. As such, the system was re-adapted without biometric identification processes to ensure smoother utilisation and more user- and client-friendly uptake of the Afya-Tek system.\u003c/p\u003e \u003cp\u003e5.1 Continuous Improvement and Refinement of the System\u003c/p\u003e \u003cp\u003eThe Afya-Tek team continued with OpenSRP system development to continuously and iteratively improve the system based on both internal testing and feedback from users. The Afya-Tek team’s strong testing and development processes, along with the follow-up activities outlined below, encouraged regular feedback gathering, prioritization, and incorporation. By having open communication around the feedback, the Afya-Tek program was adaptable to the changes and information coming from users and remained flexible in planning the way forward for each iteration of the digital system.\u003c/p\u003e \u003cp\u003e5.2 Continuous Supervision and Monitoring\u003c/p\u003e \u003cp\u003ePerformance monitoring is an ongoing activity performed by the Afya-Tek team, CHW supervisors and CHMT. The team monitors the performance of the end users and provides on-site support (technical or advisory), guidance and instruction with respect to the Afya-Tek system competencies, and supportive supervision by documenting challenges found on the field and identifying areas for improvement.\u003c/p\u003e \u003cp\u003eVarious monitoring platforms utilised by the program include a) remote support through dashboard monitoring, communication via WhatsApp groups, and by conducting follow up calls to users, and b) physical monitoring through supervision visits where the Afya-Tek team and CHMTs observe user interaction with clients and provide on-site support where needed. (More information can be found in Appendix 1)\u003c/p\u003e \u003cp\u003e5.3 Dashboards, data sharing and communication across stakeholders\u003c/p\u003e \u003cp\u003eA key component of the M\u0026amp;E process was to create supervisory dashboards at the council levels to evaluate system activity and track key indicators that could assess program progress and/or user performance. All dashboards were customized based on the user (supervisors, CHMTs, and Afya-Tek program teams) and on the user device type (e.g., the supervisor dashboard was configured to be viewed on a phone, whereas the CHMT dashboard was configured for desktop view).\u003c/p\u003e \u003cp\u003eThe dashboards have been critical for program M\u0026amp;E in order to increase data transparency and accessibility across partners and serve as a platform to conduct M\u0026amp;E analyses with large datasets. Being actively part of this M\u0026amp;E process has been instrumental in particular for consortium partners and for CHMTs in decision-making and resource planning. Any feedback or recommendations based on discussions have been continually used to strengthen dashboards and program activities.\u003c/p\u003e \u003cp\u003e5.4 Realist monitoring and evaluation\u003c/p\u003e \u003cp\u003e The Afya-Tek program has at its core a major learning objective: To generate transversal learnings, that are based on context-specific understandings of how digital innovation within the continuum of care at primary care level can lead to responsive, people-centred healthcare which improves the maternal, child and adolescent health outcomes in coastal Tanzania.\u003c/p\u003e \u003cp\u003eRealist Evaluation (RE) is a structured, yet flexible, research approach that combines quantitative and qualitative research methodologies to monitor, intervene, and evaluate a program's impact [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The basic premise under which it operates is the observation, analysis, and explanation of how, \u003cem\u003ewhy, for whom, and under what circumstances\u003c/em\u003e an intervention does or does not succeed [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRealist evaluation is particularly useful for evaluating new initiatives as it allows one to fully understand and delineate their complexities and see how best to adapt the intervention within new contexts, thereby informing potential program scale up. As such, multiple strands of mixed-methods research were conducted throughout the program implementation, with ongoing programmatic interventions and outcomes iteratively informing each strand of research. The key RE study components within Afya-Tek are highlighted in Box 1. (See Appendix 2 for more information)\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eBox 1: Key RE study components within Afya-Tek\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"PRELIMINARY FINDINGS \u0026 ANALYSIS","content":"\u003cp\u003eThe Afya-Tek full system deployment began in November 2020. With 2.5 years of implementation thus far, preliminary findings of the program highlight that current service provision through the app is coordinated across approximately 400 health providers (240 CHWs, 110 ADDOs, and 53 HFs) within Kibaha. Table\u0026nbsp;2 provides initial data and key achievements of the Afya-Tek program since its deployment into Kibaha district (July 2020 - June 2023).\u003c/p\u003e\u003cp\u003e \u003cem\u003eTable\u0026nbsp;2: Initial data and key achievements of the Afya-Tek program since its deployment into Kibaha district (July 2020 - June 2023)\u003c/em\u003e \u003c/p\u003e\u003cp\u003eKey highlights from this data include: CHWs being instrumental in counselling clients during household visits regarding malaria prevention, family planning and nutrition; the contribution of the ADDO as a private health sector actor within the continuum of care is quite evident with adolescents; while the high linkage and referral completion rate at both ADDOs and HFs, respectively, is a positive indicator of a stronger coordination system.\u003c/p\u003e\u003cp\u003eAdditionally, the Afya-Tek systems provides an easy-to-use supervisory mechanism for the CHW supervisors to easily monitor performance of the CHWs, as well as for the CHMTs to digitally monitor and follow progress within their councils, which has subsequently aided them in resource management and planning. Further details of Afya-Tek’s results and outcomes will be shared in upcoming publications.\u003c/p\u003e\u003cp\u003eIn the course of implementing the Afya-Tek program, several lessons learnt were documented, see Table\u0026nbsp;3 for key lessons learnt.\u003c/p\u003e\u003cp\u003e \u003cem\u003eTable\u0026nbsp;3: Key lessons learnt through the Afya-Tek program\u003c/em\u003e \u003c/p\u003e\u003cp\u003eA multi-user program such as Afya-Tek is complex, and requires significant efforts and time, as well as regular monitoring and problem-solving to overcome challenges. Being a complex program bringing together public and private health sector actors, Afya-Tek naturally experienced various implementation challenges. As ongoing challenges were encountered, due the responsive and agile nature of the program, Afya-Tek ensured prompt mitigation and problem solving. These challenges can be categorised as either being contextual or technical challenges. As challenges differed based on location and target-population, the solutions thus needed to be context- and actor-specific. As with all in-field challenges, solutions were continuously generated and rolled-out in an iterative design. Table\u0026nbsp;4 highlights some of the challenges faced by the program and identified solutions thus far.\u003c/p\u003e\u003cp\u003e \u003cem\u003eTable\u0026nbsp;4: Specific challenges and associated solutions as encountered in the Afya-Tek program\u003c/em\u003e \u003c/p\u003e"},{"header":"DISCUSSION \u0026 CONCLUSION","content":"\u003cp\u003eThe Afya-Tek program is the first digital health system in Tanzania to demonstrate the link among CHWs, private sector ADDOs, and HFs for a strengthened continuum of care. It purports to create and effectively implement an innovative digital health intervention that ensures the provision of smooth, coordinated care among primary healthcare system actors for communities in the Pwani region of Tanzania. Afya-Tek thus demonstrates a proof-of-concept model that addresses the problem of coordination of care.\u003c/p\u003e \u003cp\u003eAs an illustration of the PPP model in Tanzania, ADDOs are proving to be an important entity for capturing clients with illnesses at the community level, managing them and providing referrals to HFs. Strengthening the use of these private sector platforms also offers unique opportunities for reaching adolescents and providing them with person-centred and confidential services with easier access to contraceptives and condoms. Going forward, the program intends to strengthen the adolescent health component by incorporating adolescent youth clubs to ensure greater engagement of the youth.\u003c/p\u003e \u003cp\u003eAfya-Tek also provides a potential platform to test and incorporate other disease conditions. For instance, this can include exploring the addition of other national high priority health areas, such as NCDs (e.g., diabetes, hypertension) and nutrition, and other infectious diseases like tuberculosis and HIV. The platform can be used to ensure appropriate management of these conditions and access to services and medications across the continuum of care.\u003c/p\u003e \u003cp\u003eWith the Afya-Tek system being built on the OpenSRP platform, it has a broad endorsement from the Government of Tanzania. This allows for interoperability and integration within national digital health systems such as the Unified Community System (UCS), Government of Tanzania-Hospital Management Information System (GoT-HoMIS), and District Health Information System 2 (DHIS2). The potential for continued data-use from the Afya-Tek system is high, and thus next steps include continuing on-going collaboration and engagement with health and ICT technical teams at various levels of Government (MOH, PO-RALG, Pharmacy Council, R/CHMT) for eventual integration and adaptation into the National digital community system.\u003c/p\u003e \u003cp\u003eBy and large, the findings reflected in this article are consistent with ongoing discussions in the digital health literature, both nationally and within sub-Saharan Africa [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Despite the growth of digital technology in recent years, Tanzania, like other LMICs, still faces a problem of the digital divide. In general, while urban settings by and large have access to the benefits of emerging digital technologies, the majority of rural areas still experience low access [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In regards to scaling up and sustainability in the LMICs, there is a consensus that the success of digital health intervention and subsequent scaling up of the same require several interrelated pillars [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. These include, but are not limited to, the intrinsic features of the programme; stakeholder engagement; simplicity, interoperability and adaptability; alignment with policy environments; and adaptable extrinsic ecosystems. Additionally, it remains crucial to understand the role of artificial intelligence decision support tools, as our consortium partner Inspired Ideas has been exploring [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, there is much scope and potential for a program like Afya-Tek\u0026rsquo;s, which bridges this digital divide, to have a significant impact on health outcomes in the long run. Through such a digitally coordinated system, the Tanzanian PHC system would be able to digitally create efficiency and communication in referral systems across public and private primary healthcare providers. Discussions on long-term sustainability allow for possibilities to scale across other settings within Tanzania, alongside generating transversal learnings to utilize in other LMICs contexts. If continuity of care and follow-up could be made efficient by digital innovations such as the Afya-Tek system, the quality and coordination of primary care would be improved especially in resource constrained settings; thereby allowing focus back to ensuring equitable, quality, person-centred care for all.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Afya-Tek program received ethical approval from the Tanzanian National Institute for Medical Research (NIMR) (NIMR/HQR.8a/Vol.IX/308), the Tanzania Commission for Science and Technology (COSTECH) (2019-454-NA-2018-246), and National Health Research Ethics Committee (NatHREC) which provided approval for the study. It also received ethical approval from the Institute of Tropical Medicine\u0026rsquo;s (ITM) Institutional Review Board (1315/19).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent was sought from household heads and members for participation in the Afya-Tek program. Prior to that, household members were provided with an information sheet to read and understand their roles and rights, plus confidentiality of information collected. Household members were also informed that participation in the program was voluntary and that they were free to withdraw from the program anytime they wish.\u0026nbsp;While those above eighteen (18) years of age were consented themselves, for adolescents who were below eighteen, parental consents were sought. All methods were performed in accordance with the relevant guidelines and regulations and the National Health Research Ethics Committee (NatHREC) approved it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants for publication. Legal guardians were consulted for the participants below the age of 18 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Botnar Foundation, Switzerland.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the Kibaha community, PORALG, Pharmacy Council and MoH for their participation in the program, and Foundation Botnar for funding the Afya-Tek program.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization, \u003cem\u003eDeclaration of Astana: Global Conference on Primary Health Care: Astana, Kazakhstan, 25 and 26 October 2018\u003c/em\u003e. 2019, World Health Organization.\u003c/li\u003e\n\u003cli\u003eBitton, A., et al., \u003cem\u003ePrimary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries.\u003c/em\u003e Journal of General Internal Medicine, 2017. \u003cstrong\u003e32\u003c/strong\u003e(5): p. 566-571.\u003c/li\u003e\n\u003cli\u003eKruk, M.E., et al., \u003cem\u003eHigh-quality health systems in the Sustainable Development Goals era: time for a revolution.\u003c/em\u003e The Lancet Global Health, 2018. \u003cstrong\u003e6\u003c/strong\u003e(11): p. e1196-e1252.\u003c/li\u003e\n\u003cli\u003eMounier-Jack, S., S.H. 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Available from: https://data.unicef.org/country/tza/.\u003c/li\u003e\n\u003cli\u003eThe United Republic of Tanzania (URT), M.o.F.a.P., Tanzania and O.o.t.C.G.S. National Bureau of Statistics and President\u0026rsquo;s Office - Finance and Planning, Zanzibar. The 2022 Population and Housing Census: Administrative Units Population Distribution Report; Tanzania Mainland. \u003cem\u003eAdministrative Units Population Distribution Report\u003c/em\u003e. December 2022; Available from: https://www.nbs.go.tz/nbs/takwimu/Census2022/Administrative_units_Population_Distribution_Report_Tanzania_Mainland_volume1b.pdf.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, \u003cem\u003eGlobal strategy on digital health 2020-2025\u003c/em\u003e. 2021: Geneva.\u003c/li\u003e\n\u003cli\u003eAzzopardi-Muscat, N. and K. 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S18-S28.\u003c/li\u003e\n\u003cli\u003eTanzania, U.R.o., \u003cem\u003eTanzania Digital Health Investment Road Map (2017-2023)\u003c/em\u003e. 2017.\u003c/li\u003e\n\u003cli\u003eUnited Republic of Tanzania, M.o.H., Community Development, Gender, Elderly and Children, \u003cem\u003eDigital Health Strategy (July 2019 - June 2024)\u003c/em\u003e. 2019.\u003c/li\u003e\n\u003cli\u003eWatts, G., \u003cem\u003eThe Tanzanian digital health agenda.\u003c/em\u003e The Lancet Digital Health, 2020. \u003cstrong\u003e2\u003c/strong\u003e(2): p. e62-e63.\u003c/li\u003e\n\u003cli\u003eNtegwa, M., E. Mcharo, and J. Mlay, \u003cem\u003eWhat explains the rural and Urban inequalities in maternal health services utilization in tanzania? A fairlie decomposition analysis.\u003c/em\u003e Asian Journal of Social Health and Behavior, 2023. \u003cstrong\u003e6\u003c/strong\u003e(2): p. 47-55.\u003c/li\u003e\n\u003cli\u003eIyer, H.S., et al., \u003cem\u003eEvaluating urban\u0026ndash;rural access to pathology and laboratory medicine services in Tanzania.\u003c/em\u003e Health Policy and Planning, 2021. \u003cstrong\u003e36\u003c/strong\u003e(7): p. 1116-1128.\u003c/li\u003e\n\u003cli\u003eHaroun, Y., et al., \u003cem\u003eA human centred approach to digital technologies in health care delivery among mothers, children and adolescents.\u003c/em\u003e BMC Health Services Research, 2022. \u003cstrong\u003e22\u003c/strong\u003e(1): p. 1-15.\u003c/li\u003e\n\u003cli\u003eZeelen, J., et al., \u003cem\u003eThe Burden of Educational Exclusion: Understanding and Challenging Early School Leaving in Africa\u003c/em\u003e. The Influence of Initiation Culture on Early School Leaving Amongst Girls: Experiences from the Coastal Regions of Tanzania. 2010: Brill. 115-125.\u003c/li\u003e\n\u003cli\u003eTanzania. Wizara ya Afya, M.y.J., Jinsia, Wazee na Watoto, et al., \u003cem\u003eTanzania Digital Health Investment Road Map 2017-2023: The Journey to Better Data for Better Health in Tanzania\u003c/em\u003e. 2017: Ministry of Health, Community Development, Gender, Elderly and Children.\u003c/li\u003e\n\u003cli\u003eUnited Republic of Tanzania. Ministry of Health, C.D., Gender, Elderly and Children, \u003cem\u003eThe National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child \u0026amp; Adolescent Health in Tanzania (2016 - 2020) ONE PLAN II\u003c/em\u003e. 2016.\u003c/li\u003e\n\u003cli\u003eUnited Republic of Tanzania, M.o.H.a.S.W., \u003cem\u003eWomen and Children First - Countdown to ending preventable maternal, newborn and child deaths in Tanzania\u003c/em\u003e. 2015.\u003c/li\u003e\n\u003cli\u003eDigital Development Principles Working Group. \u003cem\u003ePrinciples for Digital Development\u003c/em\u003e. Available from: https://digitalprinciples.org/.\u003c/li\u003e\n\u003cli\u003eJagosh, J., \u003cem\u003eRealist Synthesis for Public Health: Building an Ontologically Deep Understanding of How Programs Work, For Whom, and In Which Contexts.\u003c/em\u003e Annual Review of Public Health, 2019. \u003cstrong\u003e40\u003c/strong\u003e(1): p. 361-372.\u003c/li\u003e\n\u003cli\u003ePawson, R., \u003cem\u003eThe science of evaluation: a realist manifesto\u003c/em\u003e. 2013: sage.\u003c/li\u003e\n\u003cli\u003eAjzen, I., \u003cem\u003eThe theory of planned behaviour: Reactions and reflections.\u003c/em\u003e Psychology \u0026amp; Health, 2011. \u003cstrong\u003e26\u003c/strong\u003e(9): p. 1113-1127.\u003c/li\u003e\n\u003cli\u003eRogers, E.M., \u003cem\u003eDiffusion of innovations\u003c/em\u003e. 2010: Simon and Schuster.\u003c/li\u003e\n\u003cli\u003eSwartz, A., et al., \u003cem\u003eMultiple pathways to scaling up and sustainability: an exploration of digital health solutions in South Africa.\u003c/em\u003e Globalization and Health, 2021. \u003cstrong\u003e17\u003c/strong\u003e(1): p. 77.\u003c/li\u003e\n\u003cli\u003eSchuetze, L., et al., \u003cem\u003eFactors Affecting the Successful Implementation of a Digital Intervention for Health Financing in a Low-Resource Setting at Scale: Semistructured Interview Study With Health Care Workers and Management Staff.\u003c/em\u003e J Med Internet Res, 2023. \u003cstrong\u003e25\u003c/strong\u003e: p. e38818.\u003c/li\u003e\n\u003cli\u003eLatio, R.G.W., \u003cem\u003eSocial and cultural issues: The impact of digital divide on development and how satellite addresses this problem.\u003c/em\u003e Online Journal of Space Communication, 2021. \u003cstrong\u003e2\u003c/strong\u003e(5): p. 11.\u003c/li\u003e\n\u003cli\u003eLabrique, A.B., et al., \u003cem\u003eBest practices in scaling digital health in low and middle income countries.\u003c/em\u003e Globalization and Health, 2018. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 103.\u003c/li\u003e\n\u003cli\u003eSalim Ally, Allen Megan, Mariki Kelvin, Masoy Kevin, Liana, Jafary. \u003cem\u003eUnderstanding how the use of AI decision support tools affect critical thinking and over-reliance on technology by drug dispensers in Tanzania\u003c/em\u003e. ArXiv-CS-Human-Computer Interaction, 2023\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Afya-Tek, CHW, ADDO, health facility, maternal health, child health, adolescent health, digital health, community, primary healthcare","lastPublishedDoi":"10.21203/rs.3.rs-4127585/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4127585/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePoor quality of care within Tanzania\u0026rsquo;s primary health system contributes to thousands of preventable maternal and child deaths, and unwanted pregnancies each year. A key contributor is lack of coordination between three primary healthcare actors: public sector Community Health Workers (CHWs) and health facilities, and private sector Accredited Drug Dispensing Outlets (ADDOs). The Afya-Tek program aims to improve the continuity of care amongst these actors in Kibaha district, through a mobile-application based digital referral system that focuses on improving maternal, child and adolescent health. The digital system called Afya-Tek was co-created with users and beneficiaries, and utilises open-source technology in-line with existing government systems. The system guides healthcare actors with individualised decision support during client visits and recommends accurate next steps (education, treatment, or referral). From July 2020 to June 2023, a total of 241,000 individuals were enrolled in the Afya-Tek program covering 7,557 pregnant women, 6,582 postpartum women, 45,900 children, and 25,700 adolescents. CHWs have conducted a total of 626,000 home visits to provide health services, including screening clients for danger signs. This has resulted in 38,100 referrals to health facilities and 24,300 linkages to ADDOs. At the ADDO level, 48,552 clients self-presented; 33% of children with pneumonia symptoms received Amoxicillin; 34% of children with diarrhoea symptoms received ORS and zinc; and 4,203 referrals were made to nearest health facilities. Adolescents preferred services at ADDOs as a result of increased perceived privacy and confidentiality. In total, 89% of all referrals were attended by health facilities. As the first digital health program in Tanzania to demonstrate the linkage among public and private sector primary healthcare actors, Afya-Tek holds promise to improve maternal, child and adolescent health as well as for scale-up and sustainability, through incorporation of other disease conditions and integration with government\u0026rsquo;s Unified Community System (UCS).\u003c/p\u003e","manuscriptTitle":"Using digital technology as a platform to strengthen the continuum of care at community level for maternal, child and adolescent health in Tanzania: Introducing the Afya-Tek program","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-28 16:01:27","doi":"10.21203/rs.3.rs-4127585/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-25T06:54:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-23T06:48:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-23T06:48:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-03-19T05:53:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"caf83ee1-054f-44cf-aa85-f0c0e1ef2e02","owner":[],"postedDate":"March 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-05T15:58:40+00:00","versionOfRecord":{"articleIdentity":"rs-4127585","link":"https://doi.org/10.1186/s12913-024-11302-7","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-07-30 15:56:51","publishedOnDateReadable":"July 30th, 2024"},"versionCreatedAt":"2024-03-28 16:01:27","video":"","vorDoi":"10.1186/s12913-024-11302-7","vorDoiUrl":"https://doi.org/10.1186/s12913-024-11302-7","workflowStages":[]},"version":"v1","identity":"rs-4127585","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4127585","identity":"rs-4127585","version":["v1"]},"buildId":"cTy_lsJlmDsVRNrSptgXS","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}