Jamii ni Afya in Zanzibar

The World Health Organization estimates that high-quality primary healthcare (PHC) services provided at the community and the lowest health facility levels can meet 80-90% of health needs over a person’s lifetime (WHO, 2018). However, in Zanzibar, this potential has been severely hindered by an underperforming and fragmented PHC system, limiting progress towards Universal Health Coverage.

Both supply and demand factors have permitted this problem to persist, which overwhelmingly affects disenfranchised populations – especially women and young people. Zanzibaris lack access to quality community and facility-based PHC services, misconceptions around healthcare are common, and women and young people have limited agency when making decisions about their own healthcare. On the supply side, primary healthcare workers have limited training and supervision and often do not follow standard protocols nor deliver personalized care.

Further, when people are referred between the community and health facility, there has been no coordination or follow-up, which often results in incomplete care and a loss to follow-up. Finally, a lack of data and transparency around health service delivery, health outcomes, and the client experience when seeking care hinders evidence-based decision-making and effective supervision that otherwise could lead to tangible improvements.

These system-level challenges have resulted in severe health outcomes. One in 33 women in Zanzibar dies of maternal complications (MOHCDGEC et al., 2016). One in five children is physically stunted, and one in ten has significant delays in development (MOHCDGEC, 2018; Nelson et al., 2019). Tackling these and other challenges is an imperative laid-out in the Sustainable Development Goals, particularly Goal 3: “Ensure healthy lives and promote well-being for all at all ages,” which includes improving maternal mortality ratios, births attended by skilled deliveries, and under-5 and neonatal mortality rates.

In Zanzibar, too many women and children experience poor health or die prematurely because of persistent barriers keeping them from getting the care they need. Digital technologies have an unprecedented potential to overcome these barriers and improve the access to and quality of essential health services for all Zanzibaris. Learning from over a decade of implementation with digital technologies to support frontline health workers and meaningfully improve health outcomes, Zanzibar’s Ministry of Health launched Jamii ni Afya (Community is Health), a comprehensive, government-led, digital community health program connecting families, community health volunteers and the health system to ensure everyone has access to essential health services.

In August 2021, Jamii ni Afya achieved full national scale, bringing digitally enabled healthcare to every household and making Zanzibar one of the first examples of a government-led, digital community health system achieving national scale anywhere in the world. The program has been written into national policy with strong commitment from the government to institutionalize and sustain it as a critical part of the broader health system, serving as a model for governments looking to scale-up similar programs around the world.

Jamii ni Afya formalizes the role of community health workers—called community health volunteers (CHVs) in Zanzibar—and equips them with digital tools to provide step-by-step guidance to deliver high quality, standardized care based on government protocols, automate data collection and link referrals made in the community to primary health facilities. As a patient’s care needs change, CHVs receive tailored guidance to provide the most appropriate and personalized care possible. For CHV supervisors, Jamii ni Afya provides valuable information to monitor and improve the performance of health workers and the coverage of health services. At the national level, data aggregated from the system also supports the Ministry of Health to make informed decisions based on a real-time understanding of the state of community health.

With a comprehensive digital system connecting communities, health facilities and the national health system, Jamii ni Afya helps women deliver in health facilities with skilled birth attendants, creates an effective referral system for mothers, children and adolescents to receive timely care and supports parents and caregivers to build nurturing home environments for young children—all proven changes we know can save lives and improve the wellbeing for thousands of people every year.

Now that Jamii ni Afya is operating at full national scale, the government has committed to full financial, programmatic and technology ownership of the program. D-tree is working hand-in-hand with the government to foster a smooth and effective transition, strengthening the capacity of government stakeholders at the community, district and national levels. To support full government ownership of Jamii ni Afya, D-tree and the Zanzibar MOH partnered to develop a transition plan which documents clear milestones over a four-year period in the areas of financial sustainability, program & operations management, and technology & data management.

Jamii ni Afya is transforming how people access care by connecting every household to community health volunteers in the world’s first government-led, digital community health program at full national scale. 90% of Zanzibar population is registered in the programme. Incorporated into national policy through its inclusion in the MOH’s National Community Health Strategy 2019-2025, the solution has been fully endorsed by the President and the Minister of Health and will help driving the implementation of the Universal Health Insurance, and other financial services. The wealth of data has generated two important initiatives:

1. the development of a national digital health data governance to ensure proper use of data, and
2. the exploitation of data to strengthen health services’ output (e.g. identification of pregnancy at high risk) and healthcare workers’ performance.