Enhancing community-based disease outbreak detection and response in East and Southern Africa

Project Location:
Ngorongoro (Tanzania)-Narok (Kenya) cross-border ecosystem and Morogoro municipality (Tanzania).
Project Duration:
14 months, from July 2015 to August 2016.
Project Summary:

Sectors of Intervention: Mobile health, epidemiology, One Health
Number of Direct Beneficiaries: Community Health Reporters (28), Integrated Disease Surveillance and Response strategy (IDSR) focal persons in participating districts (10) and District Medical Officers and District Veterinary Officers (6).

Number of Indirect Beneficiaries: Community members in the participating districts (1,627,312 people).

Date of Submission: June 8, 2015

 

Executive Summary
Early communication between sectors and neighboring countries, leading to faster detection and response to disease outbreaks, is a critical step to make a difference to emerging global public health threats. Infectious diseases have a significant impact on vulnerable populations and children across the world. Outbreaks of emerging diseases pose enormous challenges to affected countries. The negative impact of disease can be reduced by facilitating effective communication and early dialogues between countries.
The Southern African Centre for Infectious Disease Surveillance (SACIDS)[1], in partnership with EAIDSNet and InSTEDD proposes to implement a 14-month project, Enhancing community-based disease outbreak detection and response in East and Southern Africa. This work is based on a theory of change that aims at promoting community level One Health security that will progressively contribute to disease detection and response at community level and thence national, regional and global level. Our ultimate goal is to contribute to progressive reduction of disease spread of pandemic occurrences.
The project will promote a participatory disease surveillance model through completion and deployment of tools developed during EpiHack Tanzania 2014. These tools are those that will promote community active surveillance, facility-based surveillance and reporting and; feedback-two way communications. The project will improve capacities for neighboring communities to mobilize for action for streamlined and effective responses to disease in the Ngorongoro (Tanzania)–Narok (Kenya) cross-border ecosystem. Some work will also be carried out in Morogoro municipality where the SACIDS-NIMR hub is located. Beginning in the Ngorongoro-Narok ecosystem with focused interventions aims to provide a model that can be scaled up across the region, this project has the potential to revolutionize the speed and ability to respond to infectious disease and improve collaboration between animal and human health actors from the local to international levels. Mobile technologies are available and identifying and building on models that are feasible and effective will lead to their use for improved health across the spectrum of research and detection to resource mobilization, response and lifesaving interventions is critical to the general state of health of communities across Africa.
This project proposes a consortium led by SACIDS to develop innovative solutions which improve communication, collaboration, information sharing and speed of response to outbreaks by building cross-border local capacity.  
Problem Statement and Context
Surveillance of infectious disease is recognized as the foundation of human and animal health decision-making and practice. Complementing the international disease surveillance strategies with participatory engagement of local communities is expected to improve performance of disease surveillance systems in developing countries. However, there are a number of challenges facing human and animal health disease surveillance and response systems. Whereas the current disease surveillance systems and strategies are based on International Health Regulations (IHR 2005) and The World Organisation for Animal Health (OIE) Animal Health code which require flow of information from the grassroots/community to the global level, there has been relatively sub-optimal performance of such systems, particularly in some developing countries. The now wide use of mobile telephones offers the potential that disease surveillance reporting, including event reporting, could be timely and faster by using digital and mobile technology solutions. However, this needs to be conducted in a deliberate way where impacts and standard operating procedures are developed, adopted and promoted by local and national Governments, so as to avoid confusion of a multitude of parallel mobile reporting systems. To date, many mobile technology programs are implemented without sound evaluation and contingent on project funding and external actors with little buy-in from the ultimate end users, greatly limiting sustainability.
EpiHack Tanzania 2014 (see Annex I), an unprecedented meeting, brought together Information and Communication Technology (ICT) developers and health experts to jointly plan and develop digital solutions (prototypes) to health challenges facing the animal and public health sectors in Arusha, Tanzania from 8-12 December 2014. The event brought together 59 participants including developers (49%), public health experts (29%), animal health officials (17%) and other professionals (5%) from 14 countries and more than 20 different local and international organizations.
Through participatory problem identification, a list of challenges was developed and ICT developers were tasked to design prototypes aimed at solving identified challenges under close guidance of health experts. Major problems identified were: delayed submission and incompleteness of official disease surveillance data submitted by health facilities, failure to capture major disease events occurring at the community level, lack of feedback (two-way communication) to the disease surveillance data collectors and inability to trace individual humans and animals as well as their locations during disease outbreaks. Four prototypes that were developed by ICT developers during the EpiHack Tanzania 2014 are focusing on improving:
i)              facility-based disease reporting system;
ii)             Contact tracing;
iii)            community-based participatory disease surveillance; and
iv)             feedback (two-way communication between officials and data collectors)
This project, as described below, is the first step in concerted multi-disciplinary action to address these areas head-on, paving the way for improved disease surveillance and healthier populations in the targeted areas. It seeks to enhance and utilize digital and mobile technologies of SACIDS and InSTEDD platforms and those that are in operation in the countries represented at the EpiHack Tanzania 2004 event to address user challenges faced by the public and animal health systems. The work is based on hypothesis that by complementing the international disease surveillance systems and strategies with participatory engagement of local communities will improve performance of disease surveillance and response systems in developing countries.
Figure 1:A map showing project sites/ecosystems shared by neighboring countries of Tanzania and Kenya
In line with recommendations from health experts at EpiHack Tanzania 2014 and the momentum of the Big Results Now (BRN) initiative in Tanzania, we target the deployment of a new package of ICT tools conceived at the EpiHack Tanzania 2014 event in the Ngorongoro (Tanzania)-Narok (Kenya) cross-border ecosystem (Fig.1).  The ecosystem is specifically targeted for the following reasons:
(a)Will build on and leverage an already established community health reporter network in Ngorongoro district through previous (Rockefeller Foundation-funded project) and on-going Ecohealth project funded by the Canadian International Development Research Centre (IDRC).
(b)This ecosystem has maximum human-domestic-wildlife interactions and is contiguous with major wildlife ecosystems of Ngorongoro Conservation Area Authority, Serengeti National Park and Maasai Mara wildlife Reserve.
(c) It represents an inland cross-border ecosystem with maximum informal interactions of the local Maasai community in Tanzania and Kenya.
(d)Historically, the ecosystem has been affected by major disease epidemics in human and animals such as the Rift Valley fever (RVF, 2006/07), Contagious Bovine Pleuropneumonia (CBPP, 2010-2012), Contagious CaprinePleuropneumonia (CCPP) and Peste des Petits Ruminants (PPR, 2008 to date), just to mention a few examples.
This area is inhabited by 1,025,198 people and livestock population estimated at 3,458,027 heads (i.e. cattle, goats and sheep). The study area is high risk for human and animal disease epidemics. It is anticipated that the deployment of digital solutions for improved surveillance and reporting of disease events will contribute to earlier detection and response to such events as well as fostering inter-country collaborations. Some work will also be carried out in Morogoro municipality where the SACIDS-NIMR hub is located. The municipality is inhabited by 602,114 people. The total human population in the two project sites (i.e. Ngorongoro-Narok ecosystem and Morogoro municipality) is therefore 1,627,312 people.
Program Goal and Description
The goal of this project is to promote community level One Health security that will progressively contribute to disease detection and response at community level and thence national, regional and global levels. It is based on a Theory of Change summarized in Figure 2 and Annex II.
For this project, three out of four protoypes developed during Epihack Tanzania 2014 will be developed to beta/stable version tools.
Figure 2: SACIDS Theory of change-Community level One Health security model
The project will complete and deploy three integrated tools (Figure 3) developed from EpiHack Tanzania 2014 prototypes namely:
(a)Community health reporting:a tool to assist community health reporters collect signs of patients (animals and humans) within their community. Data, once collected, will be submitted to a central database, whereby the signs will be analyzed using a set standard case definitions to produce a related content that is used as feedback. The feedback will include possible diagnosis, recommended self-care actions, among other recommendations. The reporters will send data via either SMS (especially for prompt alert and action) or mobile app (especially for structured disease surveillance reporting as required by the official IDRS or national veterinary service practices).
(b)Ensure a Feedback Mechanism: This system will consist of a number of Application Programming Interfaces (API) to assist in sending feedback to a user. Content generated via community health reporting system coupled with artificial intelligence from One Health knowledge repository will support automated sending back of feedback to the data collectors (Figure 3).
(c) Official health reporting: This tool will use a programmed SIM card or mobile app to collect structured surveillance data required for official reporting.  This tool will be used by in-charge of health facilities and IDSR focal persons responsible for regular collection and reporting of disease surveillance data from health facilities to the national epidemiology sections of the ministry responsible for public and animal health.
Figure 3: Integrated development of ICT tools to support data collection and feedback on disease events occurring in human and animal populations
Program Objectives
1.     Work across animal and human sectors to fight epidemics in human and animal populations;
2.     Develop ICT tools to support data capture, reporting and feedback at health facility and within the community that feed into the official IDSR and veterinary national systems;
3.     Strengthen local cross border collaboration to fight epidemics.
Key program Activities
Objective 1: Work across animal, human and ICT sectors to fight epidemics
One of the most important take-away messages during EpiHack Tanzania 2014 was that “East Africa has very able experts, who if well mobilized can improve existing systems” (EpiHack Tanzania 2014 Report). This objective aims at fostering the relationships developed during EpiHack Tanzania 2014 and using the event as a springboard for continued momentum on improving health systems in East and Southern Africa. This will be achieved through:
●      Activity  1.1: Organize a Stakeholder workshop bringing together decision makers and those who will ultimately need to be owners and champions of the activities;
●      Activity 1.2: Establishing a coalition of Health (Animal and Human) experts and ICT technologists coined as the EpiHack Community of Practice (CoP),
●      Activity 1.3: Create a One Health Knowledge Repository.
Activity 1.1: Organize a Stakeholder Workshop
This activity aims to bring together key stakeholders who will be directly involved and beneficiaries of the proposed project. In addition to participants of the EpiHack Tanzania 2014, we seek to invite community health reporters, representatives from mobile operators and other like organizations to attend the workshop. This is aimed to create ownership of the tools that will be developed. Thanks to the Bill and Melinda Gates Foundation funding to Connecting Organisations for Regional Disease Surveillance (CORDS), this activity will be funded entirely by a project managed by CORDS. The stakeholder workshop will discuss and agree on:
●      Detailed implementation plan of the project funded by Skoll Global Threats Fund;
●      Key stakeholders who will own the project;
●      Refined high level requirements/outputs/goals of tools to be developed.
In line with the desire to share practices across borders and nations, actors from other networks around the world will also be invited to share their successes, ideas, and be potential participants in the EpiHack Community of Practice. This will also enable project success to have a further reaching impact, allowing networks from other regions of the world to test models proven successful in the context of this project. 
The workshop will also accommodate side meetings of participants interested to form EpiHack Community of Practice as well as ICT experts (Hack-a-thons) who will be interested to participate in the Open Source project through virtual community.
Activity 1.2: Establish EpiHackCoP
We aim to establish a virtual EpiHack Community of Practice (CoP) to foster sharing of experiences and technical advice on development and implementation of fit-for-purpose technologies to support health. SACIDS will lead the Forum with support from East African Integrated Disease Surveillance Network (EAIDSNet), Kenya Medical Research Institute (KEMRI) and University of Zambia (UNZA). This activity will rely on SACIDS’ close ties with health experts and people of influence within the region. Initial discussion and formation of the EpiHack CoP will be accomplished through organizing a side meeting during project stakeholder workshop. This meeting will further agree on frequency and virtual mode of conducting future meetings and discussions e.g. using instant messaging, group email and/or video chat platforms such as Skype, Google Hangout etc. Formation of EpiHackCoP will be crucial in aiding political buy-in and awareness within the region so as to fast track deployment of tools.
This CoP will initially target the Human, Animal and ICT experts and organizations represented during EpiHack Tanzania 2014, with the aim of using them as ambassadors to entice new members and establish ownership and policy buy-in their local communities, geared towards developing concrete next steps and plans towards deployment and implementation of digital surveillance tools.
The concept of Community of Practice (CoP) approach is one of the core values of SACIDS. It is used previously by SACIDS to bring together research apprentices and their supervisors and mentors to work together in defined themes. Our EpiHack CoP will be organized like a tree, including newer researchers and experts and allowing forum  for them to meet together, both physical and virtual,  as a ‘community’ to develop the expertise and ideas. An innovation of SACIDS community of practice is that we bring together experts from several domains with individuals who may be ‘experts’ in one area and more ‘learners’ in another area. These synergies are critical to the type of learning that will lead to the innovations and risks and ultimate discoveries that can change our ways of doing things for the better. Sustainability of the CoP will depend on constant engagement of CoP members through both physical and virtual meetings to be held within and beyond the project period.
The outputs include:
●      A Virtual One EpiHack community of practice comprising influential health experts and technologists;
●      A forum to exchange health data and information that is otherwise often regarded as sensitive which will save lives and help to contain disease spread;
●      A deployment template and plan for digital disease surveillance, detection and response
●      List of key stakeholders/organizations per country willing to be actively involved with helping disease surveillance;
●      An engagement plan to aid sourcing of new funds for in country implementation of developed tools;
●      A trans-disciplinary engagement involving medical, veterinary and ICT specialists as well as engagement of health practitioners, community leaders and other stakeholders.
Activity 1.3: Create a One Health Knowledge Repository
One of the most common challenges acknowledged during EpiHack Tanzania 2014 was the lack of targeted and timely feedback via existing reporting systems. In particular, feedback to persons collecting and submitting surveillance data is critical in order to encourage them to continue to report, as well as instigate quick action to prevent or mitigate the extent of possible epidemics. It was acknowledged that appropriate and timely feedback is one of the main motivating factors for community health workers and health officials to report syndromic and disease cases, which are at the cornerstone of public health management. The One Health Knowledge Repository is a decision making expert system that helps local communities, ministries responsible for human and animal health as well as regional animal and health desks (i.e. East African Community-EAC and Southern African Development Community -SADC) and international bodies such as the World Health Organization (WHO) and the World Organization for Animal Health (OIE), achieve access to data and information required to prevent, control or eradicate diseases transmissible between humans and animals. This is a better approach compared to the current system by ensuring that data is collected and used for public health excellence by streamlining the process and ensuring the necessary stakeholders are engaged, from the community to national and regional bodies.
The ICT technologists responded to this challenge by creating an innovative tool that will create targeted and relevant messages based on signs reported, in addition to an easy way to send feedback to the community and health officials. It is anticipated that language barrier will not be a major challenge as the Ngorongoro-Narok ecosystem is inhabited by Maasai communities that share the same Ma language and culture. In addition, Swahili language in popularly used as a national language in both Tanzania and Kenya. Provision of feedback relies heavily upon carefully designed and authored health related content that will be used as feedback messages and artificial intelligence and alerts of possible disease conditions occurring in human and animal populations. Creation of One Health knowledge repository will be achieved through:
●      Commissioning professional health related content authoring lead by a dedicated Epidemiologist and under guidance of health experts (from EpiHackCoP above);
●      Creation of a web-based database to store this content at SACIDS server .
Outputs include
●      List of standard case definitions for major and priority endemic and epidemic-prone diseases prevalent in participating countries;
●      List of recommended action per targeted user (community, health official, livestock extension officers etc);
●      A one health training manual and content for community health workers;
●      A multilingual Web based interface to database to host this content at SACIDS server;
Objective 2: Develop ICT tools to support data capture, reporting and feedback at health facility and within the community 
One of the major outcomes of EpiHack Tanzania 2014, was four prototypes of tools and/or applications that were geared towards improving health systems and their ability to detect and respond to disease outbreaks. This proposal seeks to improve on these prototypes and develop them into functional tools (stable versions) that will be deployed and integrated into national disease surveillance systems. The tools selected for full development focus on the areas of Community Surveillance, Official Reporting and Feedback Mechanisms. Building on SACIDS’ experience in surveillance with Mobile technology, this project will develop appropriate tools to support surveillance of diseases and disease events relevant to East and Southern African regions.
We propose the following activities to be carried out under this objective:
●      Activity 2.1: Establish design and implementation team;
●      Activity 2.2: Mobile Operator engagement and Acquiring Infrastructure;
●      Activity 2.3: Setting up Application hosting Infrastructure;
●      Activity 2.4: Development of Tools.
Activity 2.1: Establish a Design and Implementation (D&I) team 
We envisage the development of these tools to be based and inspired by the spirit of open source community development. In order to speed up and champion the development, it is essential to recruit and have dedicated persons working on the project on a daily basis under the oversight of SACIDS. We already have two dedicated ICT programmers, one epidemiologist and one technology transfer experts who will kick start the process immediately after project approval. The project will recruit two more ICT programmers and one epidemiologist so that the D&I Team has full capacity to implement the project. These individuals will take charge of enticing the open source community in particular developers who participated in EpiHack Tanzania 2014 to contribute to these projects.
This activity will involve engaging the EpiHack Tanzania 2014 developers team together with the dedicated programmers (some may be EpiHack ICT developers), with the purpose of agreeing on the structure, frameworks, versioning tool, programming style and language etc. to be used in development of the open source project. The outputs include:
●      Open source projects established and actively maintained;
●      Refined requirement analysis and roadmap for development of the tools.
Activity 2.2: Mobile Operator engagement in infrastructure integration
During EpiHack Tanzania 2014 it became clear that mobile operators have a crucial role to play in respect to aiding deployment and sustainability of projects. As our ICT tools will utilize mobile operators infrastructure, it is imperative to foster close integration with mobile operators to push forward our agenda. Currently SACIDS, through a project funded by IDRC, has initiated communication with major mobile operators in Tanzania i.e. Vodacom, Tigo and Airtel. It has been found that we would need to engage the mobile operators through Value Added Service (VAS) companies for such inter-connectivity. This activity will involve integrating our infrastructure with major telecommunication companies for Unstructured Supplemented Service Data (USSD), SMS, and Internet and voice services.The IDRC-funded project will support acquisition of USSD and SMS shortcodes as in kind contribution to this project. Identification and engagement of mobile operators as well as acquisition of USSD and SMS shortcodes in Kenya (Narok project site) will be carried out at later stage of the project after establishing local agreement with the Government of Kenya.
The outputs include:
●      Acquiring USSD and SMS shortcodes for mobile apps integration in Kenya;
●      Acquisition of shortcodes for Tanzania- supported by IDRC-funded project managed by SACIDS;
●      Interconnection with mobile operators infrastructure for SMS and USSD services in participating two countries (Tanzania and Kenya);
●      Zero rated and/or subsidized cost for internet, SMS and USSD services in participating countries.
Activity 2.3: Setting up Application hosting infrastructure
SACIDS is well aware through extensive experience that health data is a contentious subject. Most countries do not want health related data and/or information of their people to be hosted in another country. Initial discussion and agreements with the Government of Tanzania and Kenya will be carried out to allow hosting of health related data at SACIDS server.
SACIDS has a well-equipped server room for hosting application data, which is currently being used to host health data for the Tanzanian Ministry of Health and Social Welfare. This facility will be the nucleus of a SACIDS-NIMR (National Institute for Medical Research) hub for the project.
Activity 2.4: Development of Tools
This activity involves the iterative design of the selected tools. It will involve completing development, testing, analyzing and refining tools from EpiHack Tanzania 2014 prototypes. This will begin by actively engaging participants of EpiHack Tanzania 2014 and other programmers within East and Southern Africa who wish to be involved in establishing and agreeing on a roadmap, protocols and other design principles/guidelines required for collaborative programming. This will be lead by the D&I team. Based on the design principles and wireframe, development and programming will commence. This will be achieved through:
●      Conducting ICT developers Hack-a-thons (physical and virtual meetings) to fast track development;
●      Hosting developer-users (health experts, community workers etc) physical and virtual meetings for tools validation and ownership.
During the stakeholder workshop and EpiHackCoP workshop (activity 1.1, 1.2 respectively), the requirements will be refined, approved and documented. All developed tools will be open source and data will not be used for commercial purposes.
The outputs include
●      Refined requirements/wireframe of tools to be developed;
●      3 developed tools for enhancing disease surveillance and response.
Objective 3: Strengthen local cross border collaboration to fight epidemics
The first two objectives of this project lay the groundwork for active deployment, testing and sustainability of these tools in the field. Objective three focuses on ensuring the tools are adopted, used, operational and supported for active and passive surveillance. This is proposed to be achieved through five primary mechanisms:
●      Activity 3.1: Communication and engagement of key stakeholders;
●      Activity 3.2: Training;
●      Activity 3.3: Technical support and facilitation of the tools in the field;
●      Activity 3.4: Periodic expert reports and recommended intervention plans.
Activity 3.1: Communication and Engagement of key stakeholders
SACIDS will engage the communities in the project sites in order to ensure that prototypes developed are relevant to their needs.
Community engagement will be through:
●      Organizing local meetings between community/village members and  health experts from local district/county authorities i.e. District Medical Officer (DMO) and District Veterinary Officer (DVO) in Ngorongoro and Morogoro Urban districts-Tanzania; Narok County Veterinary Services officer and Director of Narok Public Health services of the Health and Sanitation department etc. in Narok county (Kenya).;
●      Engagement of local leaders or focal people in each project sites to identify the Community Health Reporters (CHRs) that will be acceptable to work in communities;
●      Local capacity building by engaging local partners to participate in the full life cycle of new system design — rapid prototyping, design, development, quality assurance and field support in the local language, culture and context — thus creating a long-term asset for the countries where the project will be implemented;
Different communication and dissemination pathways will be explored such as:
●      Through various media houses as well as well as via SACIDS and InSTEDD webpages and social media. Such dissemination will be about the developed prototypes (including the creation of a web page under the current SACIDS website to publicize the technology developed so as SACIDS showcases its technologies developed);
●      Preparation and production of dissemination materials including posters and newsletters. In order to ensure that wider dissemination is achieved, a simple and plain language will be used during production of dissemination materials.
●      The program will also collect success stories on a quarterly basis and will disseminate them among program stakeholders.
●      SACIDS and partners will document best practices and incorporate them into the project’s strategy to improve performance and impacts.
Activity 3.2: Training 
The training will involve users of the developed ICT tools in participating districts of Ngorongoro and Morogoro (Tanzania) and Narok (Kenya). We will build on lessons learnt from previous projects funded by Rockefeller Foundation and IDRC in identifying, recruiting,  training and sustained use of Community Health Reporters (CHRs) in community disease surveillance and reporting. Usually, a CHR should be a person with integrity and respect in the community so that s/he is acceptable to work in her/his community. In addition, s/he has to have knowledge on how to use mobile phones including ability to read and write. With previous trainings, it was also learnt that supporting trained CHRs with airtime and solar chargers is important so that their phones could be used to capture and report disease data any time. It has also been learnt that in order to keep CHRs motivated, it is important to provide regular feedbacks related to data they submit. For the prototype aiming at improving official reporting, training will be carried out for in-charge of grassroots health facilities, IDSR focal persons, DMOs and DVOs in respective project sites.
Outputs of this activity include:
●      Trained community health reporters (28);
●      Trained local IDSR focal persons/ in-charge of health facilities (10);
●      District Medical Officers and District Veterinary Officers (6);
●      Fostered relationship between community health reporters, IDSR focal persons and district health official.
Activity 3.3: Technical Support and Facilitation of tools
This activity aims at ensuring that data will be flowing constantly from reporters to the hosting application and that relevant feedback will be sent back to the reporters. This involves close follow-up with community reporters and health officials to ensure everything is running well. In some cases, it also involves providing airtime to enable reporters to report.
The activity also includes periodic visits to project sites to foster interactivity and maintaining the link between community health reporters with health officials in the area. These visits will also be used to receive feedback from users on the suitability and challenges of the tools used. In addition the epidemiologist and district health officials will be assisting on relevant refreshers courses to community health workers.
Outputs include
●      Timely reports to the system;
●      Timely feedback of submitted data;
●      Well engaged community and community health reporters.
Activity 3.4: Periodic expert reports and recommended intervention plans
In addition to aligning user requirements for tools development, the project Epidemiologist will be charged with constant analyzing of submitted data, and producing reports and high level policy briefs in respect to recommended actions and steps for intervention. It is expected that a Newsletter summarizing disease events reported from project sites will be produced and shared on regular basis, at first on monthly- but later on a weekly-basis. Information and data collected will also be used to produce and publish manuscripts in open access peer reviewed journals.
The outputs include
●      Periodic (initially monthly for 2 months, then weekly after month 9) reports on health status.
●      At least three scientific manuscripts will be submitted to open access journals for publication
Ethical Clearance
In order to implement anything that falls within the realms of research involving human or animal subjects, we are required to apply for ethical clearance. The process is straight forward, mainly filling out a form and attaching relevant tools and documentation to declare what we will be done at the project sites. In Tanzania, medical research ethical clearance application is made to the National Health Research Ethics sub-committee operating under Medical Research Coordinating Committee (MRCC) hosted by the National Institute for Medical Research (http://www.nimr.or.tz/ethical-guidelines/). For research activities in wildlife areas, clearance is applied to the Tanzania Wildlife Research Institute (TAWIRI). A similar process should be followed in Kenya. Submitting ethical clearance is critical as it ensures that national and local government is aware of and supportive of our work.
Potential for Impact
To contribute to the targeted communities within Tanzania and Kenya health and development and increase the impact of the program, project activities complement the strategic initiatives, related to fostering of mHeath and cross-sectoral collaboration, in the two countries.  This program will lay the groundwork for the scale-up of use of ICT tools that will first be piloted in three project sites (Morogoro, Ngorongoro and Narok) through field test, with results that will serve as a testimony to its feasibility on a large scale.
Government partners: The project will directly complement government’s efforts toward improving health and the improvement of data collection, use and cross-sectoral collaboration via mHealth. It reflects the current Poverty Reduction and Growth Strategy Paper (PRSP), whose goal is to improve human development while focusing on achieving the Millennium Development Goals as well as enhanced economic growth through the Big Results Now (BRN[2]) initiative. This program will work with local and national level government officials to help transform the broad agendas into actionable initiatives. Finally, the project will promote the transparency and accountability to all users of health data, including those affected by epidemics at the community level.
Sustainability
As one of SACIDS’ core principles, sustainability is considered in all aspects of project design.  While we recognized that full sustainability is not always achievable, we actively take steps to maximize sustainability.  This project has integrated sustainability with the following consideration and approaches:
●      Partnership with the National Health System.  The project will work closely with the District Health (Animal and Medical) office and community health worker level of the national health system.  Health care workers who benefit from the project’s training can continue to serve with their improve capacity well after the project ends.  Likewise, District Health Management teams will benefit from increased technical capacity, as well as supervision, monitoring and evaluation and project management skills from close partnership with the project team.  These skills will help them continue to benefit the areas they serve with quality programs.
●      Targeting of Community-Level Capacity.  In an era characterized by high brain drain of medical professionals from rural to urban areas, Community Health Workers (CHW) are recognized as one of the best available options for keeping human resources and training investments in the most underserved communities.  As a result, the project will not only work with CHWs (in this project, referred to as Community Health Reporters- CHRs) but will also focus on selecting those CHRs that are highly dedicated in service to their community and likely to continue their activities even after any formal end to supervision or motivation.
●      Systems Approach.  The project also brings a focus on bolstering the gamut of components within the health (human and animal) system, with the goal of making the system more successful and sustainable.  During its 12 month period, the project will ensure constant training and supervision as well as equipment needed to roll out and use these systems locally.
●      Integration of Behavior Change.  By working directly at the community level the project provides lasting benefits to communities.  For example, a CHR who receives feedback when reporting data and sees the positive health benefits is more likely to continue using this system.
Monitoring and Evaluation Plan
A comprehensive Monitoring and Evaluation (M&E) system is the backbone of sustainable project performance. The information needs of the donor, Governments and community based partners will be identified and SACIDS will develop an effective M&E system to meet these needs in a timely manner. SACIDS will develop data collection and analysis methods, data flow, reporting and communication maps. In addition, SACIDS will develop a simple prompt system to promote learning to action discussions.
Within a month of the baseline, SACIDS will develop an M&E Operating System. The M&E system will include individual responsibilities for monitoring, forms for data gathering, reporting format and schedules. SACIDS will monitor the progress of output indicators through field data collection. SACIDS will also hold quarterly review meetings that will be an important forum for sharing progress and addressing challenges with the participation of all stakeholders and collaborating organizations.
Baseline
During the first three months of the project’s first year, SACIDS will conduct a comprehensive baseline study to establish benchmark values for performance indicators measured throughout implementation. It will include interviews with community health reporters who will be involved in the project using both quantitative and qualitative methods to document their current needs and technology capacities; level of access to essential health and lab services; knowledge, attitudes and behaviors related to the success of the project. Data collection will be participatory and include both quantitative and qualitative components. The baseline will coincide with staff recruitment, materials acquisition and contract signing so that it will be complete prior to the scheduled start of activities. It will also serve as an opportunity to identify mobile technologies currently being used, systems they are currently or need to in the context of this project feed into, and the shortfalls of past attempts so they can be avoided.
Performance Monitoring and Reporting
Project M&E tools will track against indicator targets, including ‘time to detect’ disease outbreak, which will be developed during the first three months of the project and serve as a Performance Monitoring Plan (PMP). SACIDS will monitor gender sensitivity and responsiveness through periodic participatory gender audits, which include feedback loops informing needed modifications to ensure compliance. These methodologies will also increase local ownership over data collection, use and analysis.  The project will regularly monitor disaggregated indicators presented in the PMP to improve project effectiveness, test validity of the project strategy and rationale and provide an evidence for project decision-making.
A progress report will be prepared and submitted to Skoll Global Threats Fund during the 6th month of project implementation. The report will summarize progress, documenting short-terms lessons learned, challenges, constraints and solutions. The reports will: (1) facilitate accountability of resources and results; (2) assess progress and performance; (3) provide management with information to make evidence-based decisions in implementation and improve effectiveness and impact. An End-of-Project report will be prepared and submitted to Skoll Global Threats Fund just after the project conclusion.
The timeliness enabled by the use of ICT will enhance SACIDS’ ability to track the indicators in or near real-time and create a system of data integrity within the routine monitoring and assessment of data. This timeliness of data collection allows SACIDS to adapt to changing conditions and make mid-course corrections as necessary in their project management.
Stakeholder analysis and engagement plan
SACIDS’ program applies the principle of subsidiarity and focuses on the creation of capacity at the local level.  SACIDS has a long history of strengthening health systems, helping develop health worker capacities to acquire and manage accurate data while providing both technical and managerial oversight to ensure sound programming.
Community Health Reporters (CHRs) 
CHRs in the targeted areas will be the main implementing partner for the project.  They are dedicated to ensuring access to quality medical services. With support from SACIDS, they will be engaged in the development of the initial tools, providing feedback on their feasibility, and ultimately providing the day-to-day implementation of project activities. SACIDS will organize trainings, carrying out joint supervisions of facility-staff, and distributing supplies as needed to their benefit.
The national health systems 
National health system officials are also key partners in the project. Project data collection, feedback and use will be provided through the national health system, specifically the facilities, providers and leadership teams of the targeted districts.   These facilities will benefit supplies and trained staff needed to implement the project. To ensure ownership and sustainability, SACIDS will also work closely with local District Health Management leadership to integrate project activities, such as supportive supervision, into their routine activities.  As such, this type of supervision visit will be carried out jointly during the early part of the project, with a gradual phase-over to increased independence from the health system.  District and Provincial/County/Regional leadership as well as ministries responsible for Health (MoH) and livestock development will also be briefed on project activities. The district health management leadership will also be periodically involved in the monitoring and assessment of project success.    SACIDS has experience working with all of these levels of the health system through its extensive ongoing programming.
Program Management Plan
The proposed project will be managed by Southern African Centre for Infectious Disease Surveillance (SACIDS) through its secretariat headquartered at Sokoine University of Agriculture (SUA). Key partner institutions which will be involved in project execution are:
Innovative Support to Emergencies, Diseases and Disasters (InSTEDD)
Provides design and development experience to help drive the initial stages of the prototypes, then handing off the development and deployment to SACIDS. InSTEDD will also provide some communication and technical assistance throughout the project.
East Africa Integrated Disease Surveillance Network (EAIDSNet)  of the East African Community
Coordination of selected sites in East African countries where piloting of deployment of prototypes will be carried out.
Kenya Medical Research Institute (KEMRI)
Coordination of technology deployment sites in the south western region of Kenya (Narok district)
Project funds will be deposited into Sokoine University of Agriculture’s Research Grant Account and allocate a special financial code for this project OR preferably deposit into a special SACIDS operated account opened by Sokoine University of Agriculture specifically for this project. The funds will be managed under the overall guidance of the university system, compliant with globally accepted accounting procedures (GAAP) for accounting and auditing of external donor funds and in a manner that is acceptable to the Skoll Global Threats Fund. All financial transactions will be managed by SACIDS Accountant and all operational costs will be honored by direct payments from Sokoine University of Agriculture.
Key Project Implementation Team
The following will constitute Team members dedicated to the implementation of this project:
Name
Role
Affiliation & Contact Email
1.Prof Esron Karimuribo
Project Leader & guide epidemiologist
SACIDS at SUA (Tanzania)
2.Dr Leonard Mboera
Coordinate deployment of developed prototypes
SACIDS at NIMR (Tanzania)
3.Eng Eric Beda
Coordinate tool development & guide programmers
SACIDS at SUA (Tanzania)
4. Scott Teesdale
Mentor and collaborate with SACIDS to supervise completion of prototypes
InSTEDD
E:steesdale@instedd.org
5.Dr Robert Karanja
Coordinate deployment of tools  in  Kenya (Narok district)
KEMRI (Kenya)
E: RKaranja@kemri.org
Project Phases
The project will be implemented in two phases, because of the uncertainty in approval of deployment in Kenya. Phase I will involve design and development of tools as well as deployment of these tools in Tanzanian field sites of Morogoro and Ngorongoro districts. In this phase, we will engage with relevant authorities in Kenya to seek approval of deployment of developed tools in Narok county, Kenya. Phase II will involve extending deployment of developed tools for official disease surveillance, feedback and community participatory surveillance in Narok county in Kenya.
The human population of Ngorongoro district, according to the 2012 national census, was 174,278 with human density recorded at 12/km2.  Phase I of the project will involve deployment and testing of developed tools in the Ngorongoro district where a total of six IDSR-focal persons at six health facilities and 20 Community Health Reporters (CHRs) will be identified and trained to participate in data collection and reporting of disease events. A total number of four IDRS-focal persons at four health facilities and eight CHRs from Narok County will be identified and trained during Phase II in Kenya. Phase II will strategically involve those wards in the Narok South area that are neighboring Ngorongoro district wards of Olodonyonyosambu, Enguserosambu, Ololosokwan and Soitsambu. The Narok South constituency population is estimated at 176,764 with population density of 35.6/km2 (2009 census).
Narok is an extension of the Ngongoro Maasai community, they share the same ecosystem and challenges in disease burden and surveillance in human and animal populations. Thus Phase II aims at testing and assessing whether cross-border sharing of disease surveillance information/data could trigger joint and/or collaborative response efforts in human and animal populations in neighboring countries or not. The major indicator for moving to Phase II will be official approval of project implementation in Narok county by relevant medical and animal health authorities in Kenya.
Project Timeline and Workplan
Project implementation during Phase I and II will be guided by the following project timeline and workplan:
Activity
Output
Lead
Project Month
1-2
3-4
5-6
7-8
9-10
11-12
13-14
Pre-funding period
Contract Signing
Mark Rweyemamu and Filomena
Transfer of Funds
Mark Rweyemamu and Filomena
1.1 Organize stakeholders workshop
List of key stakeholders
Esron
Implementation plan
Facilitator (TBI)
Refined high level requirements
Facilitator (TBI)
Launch open source project for the tools
Eric
Mid-term review meeting
Esron
1.2 Establish EpiHackCoP
List of members and respective commitments towards EpiHackCoP
Eric
CoP Forum
Eric
EpiHackCoP meetings1
Esron
P
V
P
V
v
1.3 One health knowledge repository
List of standard case definitions for diseases
Leonard
List of recommended action per targeted user
Leonard
One health training manual
Esron
Multi-lingual web based interface
Eric
2.1 Establish design and implementation team
Project staff in place
Esron
Work space refurbished
Esron
Roadmap for tools development
Eric
Open source project  in place
Eric
Monitoring and Evaluation plan
SACIDS secretariat
M&E Reports
SACIDS secretariat
2.2 Mobile operator engagement and acquiring infrastructure
USSD and SMS shortcode in Tanzania in place
Eric
Letter of approval from VAS company for subsidized SMS and USSD service costs
Eric
Interconnection with mobile operator infrastructure
Eric
USSD and SMS shortcode in Kenya in place2
Eric
Letter of approval from VAS company for subsidized SMS and USSD service costs in Kenya2
Eric
Interconnection with mobile operator infrastructure in Kenya
Eric
2.3 Setting up Application hosting infrastructure
Agreement to host surveillance data from Ministry of Health and Livestock in Tanzania
Leonard
Agreement to host surveillance data from relevant human and animal health authorities in Kenya
Leonard
Hosting infrastructure in place at SACIDS
Eric
2.4 Development of Tools
Refined requirements
Eric
3 tools developed
Eric
One Health repository API
Eric
IT meetings / Hack-a-thons
Eric
3.1 Communication and engagement
Engagement plan in place
SACIDS  Communications@ Secretariat
Project visibility material produced
SACIDS  Communication Officer
Proceedings and/or minutes of engagement with key stakeholders
Esron
Published and/or broadcasted resources in mass media
SACIDS  Communication Officer
Archive of success stories and best practices
SACIDS Secretariat
Letter of support from government of Kenya
Leonard
3.2 Training
List of potential trainees3
Eric
T
K
Equipment procured3
SACIDS Procurement Officer
T
K
Trainees trained3
Eric
T
K
Disease incidence database in place
Eric
3.3 Technical support and facilitation of tools
Timely disease incident reports
Epidemiologist (TBI)
Back to office field reports
Eric
3.4 Periodic expert reports and recommended intervention plans
Analyzed and summarized disease incidence reports
Epidemiologist (TBI)
Publications in peer reviewed journals
Esron
1EpiHack CoP meetings will be either Physical (P) or Virtual (V)
2Mobile operator and Mobile Value Added Service (VAS) company integration for SMS and USSD in Kenya will depend on approval of project implementation in Kenya by relevant authorities 
3Identification of trainees, procurement of equipment and training will be carried out in Tanzania (T) and Kenya (K) in different phases dependent on approval from relevant authorities in Kenya
Annex I: EpiHack Tanzania 2014 report
 (submitted)
Annex II: Support Letter from Tanzania Ministry of Health (submitted)
Annex III: Support Letter from Tanzanian Ministry of Livestock Development (submitted)

[1] In this document, SACIDS refers to a consortium of academic and research institutions operating in southern Africa to improve disease surveillance in human and animal populations. For this project, key SACIDS members which will be responsible for project implementations are Sokoine University of Agriculture (SUA) and National Institute for Medical Research (NIMR)

[2]BRN stands for the Big Results Now, a Malaysian Model of development that has been adopted recently (2013-14) by the United Republic of Tanzania as an effort to transition of the country from low to middle-income economy. BRN initiative focuses on selected six priority areas affecting national economy which are:  health, water, education, energy and natural gas, transport and mobilization of resources and; agriculture.

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Project Members:
Prof. Mark Rweyemamu , Dr Filomena Namuba , Prof. Esron Karimuribo , Mr. Eric Beda Leonard Mboera, Scott Teesdale, Dr Robert Karanja