mTrac

Launched: December 2011

mtrac logo




Health information is an important building block in any health system. To be effective, information must be reliable and produced, analysed, and disseminated in a timely manner. These data are used to inform decision-making that improves programmes and health systems performance that ultimately impact the health status of a population.

Health management information systems (HMIS) often provide historical accounts or audits that identify gaps and failings long after they needed to be addressed. mTrac is used to course-correct mid-process as challenges arise.

Like many other countries, Uganda uses DHIS 2, a health management information system that helps governments manage their operations, monitor processes and indicators, improve communication, and visualise data. Health centres were required to hand in paper-based surveillance data forms to their District Health Office on a weekly basis, travelling great distances and at great expense. These reports were inefficient, time-consuming, and regularly delayed by the poor transport network within Uganda. One Nursing Assistant at a health centre level 2 had this to say in relation to the reporting issues:

I used to cry whenever it came to submitting weekly surveillance data to the District Health Office because I had no information records from which I could get the information. I wasn’t collecting that information because I knew I couldn’t be able to transport it to the district and neither did I have airtime to call the district every week.

These delays in weekly information caused significant bottlenecks in the drug supply chain. Though there is no shortage of medicine at the national level, supplies weren’t reaching local clinics when they were needed so people seeking treatment at clinics were finding that essential medicines were not always in supply.



Approach

In partnership with UNICEF, WHO, and DFID, the Ministry of Health decided to change the face of health service delivery in Uganda with mTrac. mTrac is a mobile phone-based health information systems strengthening tool that facilitates the flow of relevant and timely data into Uganda’s national health management information system (HMIS) using SMS.



HMIS

The health management information system was the entry point for mTrac. DHIS 2’s Form 033b: Health Unit Weekly Epidemiological Surveillance Form was selected for the relevance of information collected, the importance of timely follow up and action, and historical challenges health facilities faced in sending the form in on a routine basis. The form collects critical data on morbidity and mortality for specific diseases, the out patient department, eMTCT, malaria, and inventory of tracer medicines and HIV testing kits. This information was broken into separate strings sent over SMS using code words that mTrac processes and interprets. As a result, records assistants, HMIS officers, and nurses throughout Uganda use their own mobile phones to send 8 coded SMS messages to a toll-free short code each Monday. Health care workers can also submit alerts should they diagnose a notifiable disease during the week. 

Similarly, village health teams (VHTs) in selected Integrated Community Case Management districts provide information at the community level. VHTs are composed of volunteer health workers who provide first line healthcare service to families in their communities. VHTs submit weekly data through SMS on their existing HMIS paper form 095, the VHT register. The data submitted includes the number of identified cases of malaria, incidence of severe malnutrition, and cases referred to the nearest health facility, as well as stock of artemisinin-based combination therapy for malaria and Amoxicillin for bacterial infections.

mTrac either repeats the data back to the user to check the accuracy of the submission, or sends an error message with a prompt to correct the error. The entire process can take as little as five minutes. Data are transmitted through mTrac to a central server, where they are tabulated, aggregated, and graphed on a customised dashboard for District Health Teams (DHTs) and selected national stakeholders to review, verify, and approve. For early detection of outbreaks, mTrac sends alerts to District Health Teams and appropriate health centres when an SMS report includes incidence of a notifiable disease. To ensure adequate supply of medicine, mTrac sends alerts when an SMS report indicates a drug stock out.The dashboard also includes a mechanism for District Health Teams to communicate with those who report in over SMS. They may need to contact a health worker to verify or correct suspicious data or follow up on missing reports.

Once the Health Facility Reports are approved, data are automatically updated in the DHIS 2 database and then used to generate reports and share information via email to Ministry of Health Departments, District Health Offices, and partners. Accurate and timely data are collected, compiled, transmitted, reviewed, approved, and shared on a weekly basis. mTrac extends the national reach of DHIS 2 all the way down to the facility level.

The mTrac system provides basic data analysis in each district. District biostatisticians and HMIS officers are able to view trends in drug stock levels, disease incidence and health facility reporting performance. Armed with this trend data, district teams are able to make more informed management decisions such as re-distributing drugs and initiating responses to disease outbreaks.

With the introduction of mTrac, many of the logistical issues affecting health centre’s weekly reporting were addressed, leading to reduced drug stock outs and early detection of outbreaks.

 

Early detection of outbreaks

mTrac facilitated the quick response, isolation, and treatment of symptoms to contain the following outbreaks:

  • Ebola Virus, Kibaale District, July 2012
  • Cholera, Ntoroko, October 2012
  • Marburg Virus, centred around Kabale, November 2012

Before mTrac, it was very difficult to contact frontline health workers to provide them with critical, real-time information during emergencies. But with mTrac, the MoH national response team can quickly prepare a series of SMS messages to alert health workers of each outbreak, the case definition (symptoms), isolation procedures, the location of the nearest isolation facility, and the hotline to the national response team to report suspected cases. The Ministry of Health and DHTs were able to respond to the cholera outbreak in a matter of hours. And during the Marburg outbreak, the Ministry of Health sent a total of 9,900 SMS messages to 825 health workers, DHTs and VHTs across 5 districts. The ability to communicate directly to health workers ensures that they have the information they need to respond to imminent public health emergencies and minimise the impact on the Ugandan people.


Better distribution of essential medicines

mTrac has also standardised drug management and operations. A Medical Records Officer at Mukono Health Centre observed:

“We don’t have to spend money on fuel to drive to National Medical Stores just to enquire about drugs. We simply SMS and this triggers an immediate response that culminates in delivery of medicines to the health facility...” so that more patients can be treated with available medicines.



Health Service Anonymous Hotline
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In addition to health worker reports, mTrac supports an anonymous hotline for community monitoring and accountability. The anonymous hotline is an avenue for Ugandan citizens to provide feedback about the quality of health services in their area and communicate directly with District Health Teams and the Ministry of Health. Individuals type a message with detailed information and then text it to short code 8200. mTrac replies with an automated confirmation, and the message is reviewed by a dedicated team at the Ministry of Health who categorises them by district and issue area (e.g. general complaint; stock-out of essential medicine; health staff negligence; fraud, drug theft, or impersonation of health workers; health worker absenteeism) before they’re made available to District Health Teams on the mTrac dashboard. District health teams are first in line to follow up and investigate based on the information provided. Incidents can also be forwarded to appropriate third parties like the National Medical Stores and the Medicines and Health Medicines Delivery Monitoring Unit when the issue falls outside of DHT’s scope. Follow-up actions are tracked on the dashboard.

Since 2012, the hotline has received 14,588 actionable reports. The Health Monitoring Unit has responded with the following:

  • Visits to 1,268 health facilities, contributing to the prevention of maternal and newborn deaths 
  • Investigations of  2,066 criminal reports. One hundred cases were referred to the courts, which led the recovery of stolen equipment and medicines valued at $408,488 in 2013 alone.

The hotline provides districts with the opportunity to receive feedback and respond to health service delivery issues raised by citizens, which has generated a lot of discussion within districts. Some districts are printing the anonymous messages on a weekly basis, sharing them with the District Health Management Team and partners, investigating, and resolving issues like disrespect from health workers, health worker absenteeism, and stock outs. They use the information to improve their image since they are seen as being responsive to the concerns of the community.



Rapid Surveys

In preparation for a new vaccination campaign, the Uganda National Expanded Programme on Immunization (UNEPI) used mTrac to conduct a series of rapid SMS surveys. Pneumococcal Conjugate vaccine (PCV) requires a cold chain supply, so UNEPI wanted to assess vaccine supply and cold chain functionality to resolve issues that would impact the effectiveness of vaccination efforts.

On April 26, 2013, health staff at 3,240 facilities received the following poll:

"Does your Health Unit have a cold chain fridge for vaccines? Please answer YES / NO. If you have a fridge but it is not working, please tell us about it.”

Within two days, UNEPI had actionable data from 1,862 facilities (57.5% of the total target), identifying 194 facilities with resolvable issues like gas stock-outs or minor mechanical issues.

Even where cold chain fridges were functioning properly, a follow-up mTrac rapid survey on supply showed that stock-outs would also inhibit the success of the PCV campaign. On May 19, 2013, a second poll was sent asking health workers:

"Do you have any stock-outs of key vaccines, YES or No. If Yes, please tell us which you have no stock."

Tapping into the mTrac database of over 16,000 registered health workers, UNEPI was able to survey thousands of health facilities and analyse results within 48 hours at cost of less than $150 USD per poll. With the appropriate information, UNEPI was able to respond to these actionable data before the launch of the PCV campaign. As a direct result of these rapid surveys, the MoH, UNICEF, WHO and partners conducted an urgent review with the National Medical Stores that identified drivers of vaccine stock-out, provided a cold chain consultant, and streamlined vaccine distribution. In addition to a successful PCV campaign, these actions led to a remarkable increase in immunization coverage of DPT1 from 52% to 98% over the course of one year. 

This work around supply also reduced stock-out of ACTs for malaria from 60% in 2012 to 13% in 2014 with an estimated 132,000 children under 5 treated per year.



Family Health Days
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mTrac was originally designed to improve reporting on disease surveillance and supply of essential medicines, provide a mechanism to receive feedback from the community, and identify issues with healthcare delivery, but mTrac has expanded since its inception in December 2011. The Ministry of Health (MoH) is now using the platform for other critical life-saving measures in a partnership with UNICEF and faith-based organisations. Family Health Days were designed to reach populations living in hardship areas where access to healthcare is limited. A free and integrated package of health interventions is provided on a quarterly basis following religious services. Interventions include deworming, antenatal care for pregnant women, birth registration and immunisation for children under the age of 5, counselling and education on health lifestyles for youth, and blood pressure checks for fathers accompanying their spouses. Through Family Health Days, traditional barriers to healthcare, such as long distances, have been eliminated.

mTrac is supporting real-time data collection within Family Health Days campaign, which has been implemented in 28 districts. mTrac data have been used to improve planning and decision-making, including in Yumbe district where the DHT was able to successfully address supply issues and enable support access to much-needed healthcare services across the country.


By 2013, mTrac was fully operational nationwide, making it the first and only mobile phone based health information system strengthening tool operating at that scale anywhere in the world. mTrac now reaches all 112 districts, over 5,000 health facilities, 16,000 health facility workers, and over 5,000 community health workers in Uganda.

mTrac demonstrates the impact that mobile health technology can have in a resource-constrained environment. Future use cases include medicine adherence reminders, referral management, and appointment scheduling but these are just a few of unlimited possibilities. mTrac will continue to play a role in the monitoring and delivery of health services in Uganda.


mTrac is preparing to transition from RapidSMS to the RapidPro framework.