Pakistan and Afghanistan report some of the worst health outcomes in reproductive maternal, newborn and child health (RMNCH) indicators, despite considerable investments in infrastructure and human resource development. Health systems of both countries suffer from inefficiencies caused by underperformance of health workers and lack of accountability and transparency, resulting in poor governance. An overview of the activities performed by Lady Health Workers (LHW), who are the main catalyst for provision of primary preventive, curative and rehabilitative MNCH and immunization services in rural areas of Northern Pakistan, found them to be highly underperforming, with only 33.8% of households reporting being visited by an LHW in Gilgit-Baltistan and 56.4% in Khyber Pakhtunkhwa.1,2
Over the past decade, digital health technologies have been increasingly leveraged to improve health service delivery and information systems from the community level to district and national levels by equipping health workers with supportive tools to provide better care in communities. Recognising these challenges, AKDN dHRC in collaboration with Aga Khan Health Services in Afghanistan and Pakistan and respective government health agencies launched the Hayat initiative in 2018.
Hayat is a novel mHealth application, which aims to empower health workers with technologies to improve coverage of and access to RMNCH services, immunisation and child growth services, by digitalizing health worker operations. The Hayat application has successfully been implemented in select regions of Afghanistan and Northern Pakistan and is being used by 612 health workers. Hayat is designed to primarily benefit children under 2 years of age and women of reproductive age in catchment populations of select areas of Gilgit-Baltistan and Chitral and in Bamyan and Badakhshan in Afghanistan.
Since its launch, Hayat has demonstrated immense potential in achieving higher utilization of services by the population by improving transparency and accountability mechanisms linked with health worker performance and creating a demand for services by generating awareness and interest through the awareness sessions. Image I details the progress of Hayat during the Transition to Scale Phase III (TTS3), from December 2019 to December 2020:
Image I: TTS3 Progress - Dec 2019-Dec 2020
*Basic vaccinations include the BCG, Polio, Pentavalent and Measles vaccines under the Hayat project.
Implementation of Hayat has improved health worker capacity to diagnose and track diseases; collection and timely provision of data to inform clinical decision-making; access to timelier, actionable public health information; and has increased transparency, accountability and overall governance to ultimately improve health outcomes. The close-to-real time monitoring through the digitized system, along with the comprehensive database, enables government stakeholders to identify gaps and challenges, which allows them to allocate appropriate resources in a timely manner. Hayat’s training sessions have empowered and built capacity of health workers, many of whom often lack digital literacy due to limited exposure in remote settings.
Progress and Impact:
Increasing Awareness
The qualitative assessment found that Hayat had a positive impact on generating awareness in the field, reaching a larger audience of both genders, creating an easier communication channel with patients and creating demand for services. Prior to Hayat, a health worker would rely on conventional method of health education – verbal communication, which often lacked impact, as the participant would quickly lose interest. Awareness sessions are now met with greater interest in the field. Hayat has experienced high involvement of male family members in awareness sessions, which consist of gender-sensitive audiovisual content. Conservative sociocultural norms previously limited health workers from educating male family members when they would relay health education orally during their house visits, but with Hayat they feel more confident about including male counterparts in the sessions and discuss taboo topics.
Greater Coherence
Furthermore, with the usage of Hayat, the health workers under, Extended Program on Immunization (EPI) and Lady Health Worker (LHW) Program are now working with greater coherence. For example, using the app a lady health worker is now able to inform a vaccinator about child births within their village, helping reduce the number of zero dose children and tracking defaulters.
Supervisory Module
Another milestone was the launch of the supervisory module in Pakistan in response to the growing needs and to provide a comprehensive, complete solution for data validation. The EPI, KPK and the LHW Programme, KPK requested to expand Hayat's digital health services and develop a supervisory module for Lady Health Supervisors (LHS) and District Superintendents Vaccination (DSVs) and Tehsil Superintendents Vaccination (TSVs) to facilitate remote data validation and auditing. Resultantly, a supervisory version was developed and implemented, thereby digitizing the entire reporting chain of EPI in target regions.
COVID-19 and Hayat: Leveraging data generated through the app, Hayat help spread awareness regarding the COVID-19 pandemic among isolated populations. Key messages for preventive measures against COVID-19 were delivered to frontline health workers and catchment populations. The digital literacy of health workers acquired through the use of smart phones during implementation proved immensely useful during the pandemic lockdown as health workers used it to disseminate essential disease information and preventive measures to reduce harm, risk and spread of COVID-19 within their communities.
Hayat’s Sustainability: Hayat has been able to successfully engage government stakeholder to absorb Hayat into the government’s budget in terms of sustainability. The concept note for Hayat was incorporated into the KPK government’s PC-1 budget document and respective departments have provided Letters of Support (LoS) indicating their commitment moving forward. Similarly, the Government of Gilgit-Baltistan has shown interest to also absorb Hayat into their provincial health programme offering.
Currently, a no-cost extension (NCE) has been granted by Grand Challenges Canada and Aga Khan Foundation Canada until June 30, 2021. The endline survey was initiated in 2020 in both countries, after which in-depth analysis and reporting on project results is to take place.
The Hayat project is undertaken with the financial support of Grand Challenges Canada and the Government of Canada, through Global Affairs Canada (GAC) and the Aga Khan Foundation Canada.
1Gilgit-Baltistan MICS 2016-2017
2Khyber Pakhtunkhwa Health Survey 2017
