Integrated e-Diagnostic Approach (IeDA) in Burkina Faso and Mali

Nearly 1 in 10 children dies before the age of five in Burkina Faso, mostly from preventable and/or treatable conditions such as malaria, pneumonia, diarrhea and malnutrition. Indeed, despite having life-saving commodities for these diseases (antibiotics, oral rehydration salts, zinc, antimalarials, etc.), the low quality of care results in many children not receiving the treatment they need. In order to improve the diagnosis and treatment of sick children, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) developed the Integrated Management of Childhood Illness (IMCI) strategy, which provides an evidence-based protocol to guide healthcare workers through the management of sick children under five. However, despite significant investments by governments and donors, the correct use of IMCI is still very low. In the case of Burkina Faso, a report by the Ministry of Health showed that only 10% of healthcare workers used the IMCI paper forms, resulting in only 15.4% of children correctly diagnosed. Healthcare workers find the current paper-based job aid to support IMCI implementation cumbersome and time consuming. As a result, healthcare workers end up simplifying the protocol (or not using it at all) and fail to correctly manage and treat sick children. This situation is exacerbated by the low levels of skilled health workers (most are not medical doctors, nor nurses), the physical isolation of health facilities (most of them in rural areas with poor road access and electric supply), poor supervision, poor quality of patient records and the subsequent absence of accountability, performance management and continuous medical education. The low adherence of healthcare workers to IMCI drives low quality of childcare and undermines the reduction of child mortality through healthcare services.

Integrated e-Diagnostic Approach (IeDA) was developed in 2013 with the Ministry of Health of Burkina Faso to significantly improve the performance of primary healthcare workers in using national guidelines for the management of sick children. IeDA is integrated with DHIS2, the health management information system deployed in Burkina Faso by the Ministry of Health (MoH), and sends regular data to that system.

IeDA improved quality of care at the primary healthcare facility, as well as supervision and decision making at district and central levels through the four components described below:

• Digital Job Aid, through REC (Registre Electronique de Consultation in French). REC is used by healthcare workers to perform consultations to children under-five. It is built on a  decision algorithm. Healthcare workers are guided through the IMCI clinical protocol (WHO) and introduce the relevant data into the tablet, which provides the diagnosis and treatment adjusted for age and weight. The REC also provides audio, visual and text-based support to healthcare workers which reduce errors and help improve workers’ skills. The system is in full compliance with the national policy and protocols for IMCI.
• Coaching and Quality Improvement. The electronic job aid is complemented with a coaching application and quality improvement methods to help healthcare workers improve their performance. Through regular visits from coaches and the provision of performance data to healthcare workers through a dashboard on the tablet device, areas for improvement are identified and healthcare workers are supported to develop solutions to their challenges.
• Continuous Learning. Terre des Hommes has implemented a Continuous Learning module on the tablet device, with a learning app through which healthcare workers perform regular quizzes and receive training in those areas where they need more support. This way, in addition to supporting the consultation process, the digital tool improves the knowledge and skills of healthcare workers using adult-learning techniques.
• Data use. Data from the digital job aid is sent to the servers (through the mobile network) and analyzed in order to produce a Quality Assurance (QA) dashboard with 10 key indicators. The dashboards are used by district management teams to monitor the performance of the healthcare centers in the district and provide them with the necessary guidance and support. At the central level, the data is sent to DHIS2 which gather each month 60 indicators from the REC.

To date, IeDA has been deployed in 1200 clinics (including 40 in Mali) and supported nearly 6,000 healthcare workers to deliver over 6 million consultations to children under five. The approach is used in over 90% of consultations performed in the 1200 facilities. Final results from the evaluation study by the London School of Hygiene and Tropical Medicine show an improvement of healthcare workers’ performance, high acceptability by healthcare workers and district managers.

IeDA does not only improve the recording of data but also the quality of the medical consultation and the prescription, and does so in the peripheral health centers the least equipped but the most frequented of the health system. In addition to offering a digitized patient record and an a diagnosis aid, IeDA has the specificity to make possible to close the information loop by enabling district management teams to identify the profile of consultations conducted in each health center and by each agent, spot outliers and conduct targeted supervisions on centers the most likely to commit misdiagnosis or enter wrong information. Thus IeDA offer the opportunity to the health worker of an individualized and remote support, over time.