Figures & Tables
Figures
- FIGURE 1
S-Curve for Modern Contraceptive Prevalence Rate in Kenya, by Countya
a From the 2014 Kenya Demographic and Health Survey.
- FIGURE 2
Human-Centered Design Methodology
- FIGURE 3
Two Models for Logistics Data Flow from Community Health Volunteers to Supervisors
Abbreviations: CHV, community health volunteer; USSD, unstructured supplementary service data.
- FIGURE 4
Supply Chain Design Mapping Process Showing Flow of Data and Commodities From National to Community Level, Kenya
Abbreviations: CHV, community health volunteer; KHIS, Kenya Health Information System.
Tables
- TABLE 1.
Participants Interviewed for Research on Designing Supply Chain Solution for Community Health, 2 Counties in Kenya
Samburu Central and East County (N=34), No. Wajir Central and WestCounty (N=27), No. County and subcounty health management team members 7 12 Health care workers including CHVs, CHV supervisors, health facility in-charges, nurses, and family planning coordinators 8 10 Project partners 2 2 Community members including WRA, matriarchs, husbands of WRAs, and community and religious leaders 17 5 Abbreviations: CHV, community health volunteer; WRA, women of reproductive age.
- TABLE 2.
Four Key Supply Chain Solutions Designed for Community Health, 2 Counties in Kenya
Supply Chain Solution Old Solution Problems Addressed 1. Paper-based stock record: redesigned to be highly visual, with circles for tallying, illustrations of the product and disease/condition Paper-based stock record used in Siaya County, Kenya, that was in English with no illustrations CHVs' low literacy levels
CHVs verbally reporting to supervisors
CHVs incorrectly recording data
Lack of standardized tool used by all communities to report on logistics data
2. cStock smartphone application: Redesign of the application that includes simplified navigation, context appropriate language, audio prompts, and visual cues Original cStock smartphone application designed for Siaya County, Kenya CHVs' illiteracy and language barriers
CHVs' lack of understanding of supply chain terms and concepts
CHVs' login challenges/user friendliness
3. CHV supervisor smartphone application: New cStock application for the CHV supervisors designed to be used to enter data for low literacy CHVs and to validate data plus allow for alternative supply arrangements during migration Informal processes already in place CHVs' with low tech capacity and low literacy levels had difficulty with data entry and data quality monitoring
Supervisors previously reporting on CHVs' behalf but in a nonsystemized way
4. USSD reporting system: Hybrid USSD and SMS reporting structure to be used by CHVs to report on supply chain data via a feature phone, eventually reiterated to be only USSD reporting SMS only system used in Siaya County, Kenya Some CHVs lacking smart phones
CHVs' challenges entering symbols for structured SMS option
CHVs' difficulty with case-sensitive SMS structure
USSD only option has a time-out feature
Abbreviations: CHV, community health volunteer; SMS, short message service; USSD, unstructured supplementary service data.
- TABLE 3.
Usability Testing Scenarios for Original Supply Chain Tools and 4 New or Redesigned Supply Chain Solutions for Community Health, 2 Counties in Kenya
Supply Chain Solutions Usability Testing Scenarios Original Tools New or Redesigned Solutions Paper-based stock record Printed original form used in Siaya County, provided CHVs with mock data and asked to fill out the form with minimal instructions Printed Excel prototypes of redesigned form, provided CHVs with mock data and asked them to fill out the form with minimal instructions cStock smartphone application Uploaded original cStock application onto researcher's phone. Provided CHVs with mock data and asked them to complete form with minimal instructions Developed and uploaded clickable prototypes onto researcher's phone.
Provided CHVs with mock data and asked them to complete form with minimal instructionsCHV supervisor smartphone application Not applicable Developed and uploaded clickable prototypes onto researcher's phone. Provided CHV supervisors with mock data and asked them to complete form with minimal instructions USSD reporting system Provided CHVs with mock data and job aids for SMS and asked them to follow instructions to send SMS Provided CHVs with paper prototypes for USSD and then moved to phone to enter an example SMS Abbreviations: CHV, community health volunteer; SMS, short message service; USSD, unstructured supplementary service data.
- TABLE 4.
Human-Centered Design Insights Generated From Research on Community Health Volunteer Use of Supply Chain Tools, 2 Counties in Kenya
Relevance to Design Illustrative Quotes Behavioral Insights Nomadic migration has dramatically declined due to the need for education, health, and demarcation of land. Migration was less of an issue than originally assumed and some simple design considerations were required for resupplying CHVs during migration. “People move in search of pastures and water. They move within the sub-county and rarely outside.” —County Health Management Team member, Wajir
“Communities here no longer migrate, land is being partitioned and allocated to the community.” —CHV, SamburuIn some communities, only men move with their animals, leaving their women and children behind. As women and children were left behind, CHVs will also remain. “I usually migrate and leave my wives in this home. When I migrate I take 1 wife …, I usually take the wife that doesn't have any young children. I haven't migrated for 5 years.” —Husband of women of reproductive age, Samburu Members from the community do visit nearby centers to trade and get basic supplies. In many situations, CHVs within these nomadic communities will have access to health facilities to collect supplies even if migrating. Mobile phones are the main mode of communication between the people that move and the ones that are left behind. The use of mobile phones is increasingly common and important for these communities. Supply Chain Insights Health facilities, which will be or are responsible for resupplying CHVs, have stock-outs and overstocks. Stock imbalances at facilities will result in stock imbalances with CHVs. “Sometimes they make a blind order when they are in town.” —Subcounty Pharmacist, Samburu Health facility staff do not routinely use data (demand data) to calculate supply requirements. Health facilities need to have access and include CHV data in calculating their requests. Insufficient county level budget allocations result in an undersupply of commodities to facilities. A current lack of data visibility does not support transparency and accountability. “There is too little allocation of funds to commodities, and this is demoralizing to health care workers” —Subcounty health management team member, Samburu Family planning products are supplied to the counties from the national medical stores even though demand is low, resulting in overstocking and expiries. When counties do not request commodities, it can result in national level programs pushing out commodities. “The uptake of FP is not high. We do not have supply chain issues for FP. We are generally overstocked rather than understocked” —Subcounty health management team member, Wajir Information System Insights Lack of standardized supply chain reporting forms has resulted in ad hoc processes. Standardized recording and reporting of supply chain data is critical for making data available to higher levels. “I record commodities like condoms in a notebook, but other reports I do are MOH 513, 514, and MOH 100.” —CHV, Samburu Service-related forms were in place but poorly used due to their complexity and unavailability. Reporting forms must be suitable for low literacy CHVs to ensure complete and timely reporting. “Some of the CHVs know how to read and write. The ones that don't know how come to me, and I do it for them (reporting) like their end of month report.” —CHV supervisor, Wajir Some county and subcounty level but very few facility-level staff have skills to visualize and analyze data. Facility staff need to be trained to use the data reported by CHVs to inform resupply and ensure CHVs get the commodities they need. Human Resource Insights CHVs have inadequate supervision due to lack of logistical support for supervisors to travel. The use of mobile phones is one way to overcome some of the challenges associated with providing one-on-one supervision. “I do supervision based on priority or challenges like availability of motorcycle or fuel. It's only my own initiative. I just support myself.” —CHV supervisor, Samburu Lack of support throughout the system demotivates CHVs, leading to high attrition. If CHVs are demotivated, it is essential to design a solution that makes their job easy and more rewarding. Also, take into consideration that if attrition is high, supply chain tools must be simple so new staff can be easily trained. “We started with 20 CHVs but only 2 of them are active.” —CHV, Wajir Service Delivery Infrastructure Insights Mobile clinics are designed to be located at strategic points such as the watering points; however, they are not operational or fully utilized due to inadequate funding and support. Mobile clinics are being strengthened and could possibly resupply CHVs in the future. “The nomadic clinics go to static settlements where there are no dispensaries. If they were designed differently, they would reach the nomads.” —Subcounty health management team member, Wajir Meetings are held regularly and with high turnout throughout the system in one county but not the other. Monthly meetings should be strengthened as part of the supply chain strategy to improve communication, data use, and local problem solving. “During the monthly CHV meeting we plan and schedule all activities of the month since it is a challenge to send SMS in between.” —CHV supervisor, Samburu Connectivity Insights Lack of connectivity and lack of power to charge phones hinders CHVs' communication among themselves and with their supervisor. The design must consider that CHVs will likely not have their phones charged and have network at all times. Therefore, use of phones should be limited as much as possible to one report per month. “Most [CHVs] have feature phones because of the battery life. Some use solar powered charges. They send 1 rep to town to charge all the phones.” —Partner, Wajir Few CHVs had smartphones issued by partners, but struggled to use them for anything other than voice communication with family and friends. Smartphone availability is increasing but capacity among CHVs to use them is still low. cStock should be designed for the future of smartphones. “There is no connectivity here in the hospital, not even Safaricom or Telkom. If you want Telkom you go for about 500 meters to access it, for Safaricom you have to go to that hill (about 1 KM).” — Health facility in-charge, Samburu
“Although CHVs have smartphones we usually (and they prefer too) sending SMSs”—Health facility staff, SamburuAbbreviations: CHV, community health volunteer; MOH, ministry of health; SMS, short message service.
- TABLE 5.
Results of Usability Testing of 4 Prototype Supply Chain Solutions for Community Health, 2 Counties in Kenya
Supply Chain Solution Positive Results Negative Results Changes Made in Final Iteration Paper-based stock record (Paper prototypes) Most pictures worked well in assisting the CHV to identify the commodity and the symptoms it treats
The circles used in counting the commodities helped those who could not write numbers
When supply chain terms were explained in Swahili, it increased understanding of the action that CHVs needed to do in reporting
If there was a color picture of the actual commodity, this helped CHVs to identify it
Some CHVs had challenges identifying some icons (e.g., family planning method and the avoiding pregnancy icon)
CHVs found it difficult to find where to enter their names
CHVs were familiar with reporting data horizontally (rows) rather than vertically (columns)
Users generally ignored the “units” column and counted based on what they were used to
Some users found the shading of circles difficult, making it difficult to total and some recorded by using tally lines through each circle
CHVs with low literacy could not identify different columns with supply chain terms
Some CHVs entered their age as opposed to the year which the report is being submitted
Changed icons that were confusing to users
Moved CHV names and their details to the left of the document
Changed Month, to Month of Report and Year of Report to clearly define purpose of cell
Included clear visual distinction between commodities such as a gray bar between commodities and the alternate shading of horizontal rows
Used horizontal rows instead of columns for each commodity
Included colloquial or familiar terms for some commodities (e.g., dewormers for albendazole)
Added Swahili translations in brackets under existing supply chain terminology to aid in the translation of often confusing supply chain terminology
Redesigned cStock smartphone application (Paper then clickable prototypes) The audio was the most appreciated feature by the CHVs as it helped identify the commodities
The icons allowed for CHVs to identify commodities based on look rather than text
The CHVs were also able to identify icons that they had previously seen in the paper recording tool
The back and next arrows were understood by some of the CHVs
They were able to scroll down the months when selecting the period for reporting
CHVs found some of the icons confusing because they were not representative of reality
Some CHVs clicked the icons and not the buttons when selecting which reports to send
Most CHVs had difficulty identifying the fields to enter their data
Some users understood the arrows to mean “next,” but other users did not
Changed the receiving and dispensing icons based on user feedback
Added audio for most icons
Changed the icon for audio from a speaker to a person speaking
Changed commodity icons to reflect the commodities' actual look
Changed icons to match the revised paper tool
Included navigation arrows, as well as buttons with “next and back” to allow multiple paths to navigate the app
CHV supervisor smartphone application (Paper then clickable prototype) Supervisors appreciated the prototype
The user experience was easy, and they were able to generally follow it with ease
The tech was easy to use, even at various levels of technology literacy
Some supervisors were not able to relate how the dashboard related to the paper-based resupply worksheet
The validation section of the app was confusing due to unclear wording
Most CHVs found the section added for additional CHVs (CHVs that migrate into your area) confusing
Made it clearer that resupply values were the total amounts received from the facility
Changed column heading for the checkboxes in the validation page
Relabeled additional CHV section in dashboard to articulate that those are CHVs who have migrated to the area
Hybrid USSD and SMS reporting system (Paper prototype) A large number of the CHVs interviewed had a feature phone as their main phone
This prototype was the most difficult for all CHVs, both literate and low literate
CHVs were not able to switch from USSD to SMS. They entered data on the dial pad and not the SMS
Needed to be redesigned to only USSD and significant tests were done to ascertain its usability in these communities
Abbreviations: CHV, community health volunteer; SMS, short message service; USSD, unstructured supplementary service data.
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