The journey to national scale of Zanzibar’s digitally enabled community health program: an implementation report

Background: While high-quality primary healthcare services provided can meet 80-90% of health needs over a person’s lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced and managed Community Health Worker (CHW) programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation. Objective: In this implementation report we describe the design and roll-out of Zanzibar’s national, digitally enabled community health program. Methods: Since 2010, D-tree International has partnered with the Zanzibar Ministry of Health to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community Health Workers use a mobile app which guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources and continuous quality improvement. Results: The Zanzibar government has documented increases in health facility deliveries among pregnant women and reductions in stunting among children under-five since the community health program has scaled. Key success factors included starting with the health challenge and local context, rather than the technology; utilization of data for decision-making; and extensive collaboration with local and global partners and funders. Long-term sustainability has been a key focus of the program since


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Title
The journey to national scale of Zanzibar's digitally enabled community health program: an implementation report

Abstract Background
While high-quality primary healthcare services provided can meet 80-90% of health needs over a person's lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced and managed Community Health Worker (CHW) programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation.

Objective
In this implementation report we describe the design and roll-out of Zanzibar's national, digitally enabled community health program.

Methods
Since 2010, D-tree International has partnered with the Zanzibar Ministry of Health to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community Health Workers use a mobile app which guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources and continuous quality improvement.

Results
The Zanzibar government has documented increases in health facility deliveries among pregnant women and reductions in stunting among children under-five since the community health program has scaled. Key success factors included starting with the health challenge and local context, rather than the technology; utilization of data for decision-making; and extensive collaboration with local and global partners and funders. Long-term sustainability has been a key focus of the program since its inception, and the Zanzibar government and D-tree are currently implementing a transition plan to enable full government ownership and financing by 2026.

Introduction
The World Health Organization estimates that high-quality primary healthcare services provided can meet 80-90% of health needs over a person's lifetime 1 . However, in many low resource countries, this potential is severely hindered by a constrained health care system, tackling significant shortages of health workers and stock out of life saving medical supplies, all of which limit progress towards Universal Health Coverage (UHC) and damage trust among users 2,3 . There is a growing consensus that effectively designed and managed Community Health Worker (CHW) programs are a critical component of a well-functioning primary health system 4,5,6 . CHWs have significant potential to extend health services to people's homes, build relationships and meet individual health needs, improve access to service, and improve health system performance 7 . In addition, CHW programs have been shown to deliver a 10:1 return on investment due to increased productivity from a healthier population 8 . Despite this potential, scale-up and management of CHW programs has been slow and often underprioritized by governments 9 .
Digital technology has been increasingly recognized as a critical tool to improve both access to healthcare and the quality of healthcare delivery, including for CHW programs 10 . Mobile apps, which are designed to fit the local context and based on program guidelines, can support CHWs to register households and individuals in their communities, guiding CHWs through home-based visits following government guidelines. These tools, when integrated into broader digital and public health systems, can improve supervision, coordination and program monitoring through access to real-time client-level data.

Zanzibar's community health context
The islands of Zanzibar are a semi-autonomous region of Tanzania with a population of 1.9 million people. One in 33 women in Zanzibar will die of maternal complications in her lifetime 11 , 20% of children are stunted 12 , and Zanzibaris face a high burden of non-communicable diseases 13 . A key priority for the Zanzibar Ministry of Health is to strengthen its primary health system, including community health 14 .
Until recently, community health programs in Zanzibar were traditionally siloed by vertical health programs, funded by donors and implemented by NGOs with programs ending based on donor funding cycles and thematic areas of interest. This resulted in lack of coordination, duplication of efforts and hindered long-term sustainability. In 2018, the Revolutionary Government of Zanzibar (RGoZ) took the pivotal step of formalizing a government-led community health program, bringing together all previously siloed, donor-funded programs, under one national program, making the pivotal decision to digitize the community health workforce from the start.
In this implementation report we describe the design and roll-out of Zanzibar's national, digitally enabled community health program. Our aim is to share lessons learned, drivers for success and best practices to help other countries succeed in designing, scaling and sustaining digitally enabled community health programs.

Methods
In this section, we present the stages of the evolution of Zanzibar's community health program, which are summarized in Figure 1.

Figure 1. Stages of the evolution of Zanzibar's community health program
Demonstrating the potential of a digital community health program D-tree International, a digital health NGO, began working with the RGoZ in 2010 on Safer Deliveries-a digitally enabled maternal and newborn community health pilot project aimed at increasing facility deliveries and improving postpartum care. This project has been described elsewhere 15,16 . Briefly, CHWs were trained and supervised, and equipped with a mobile phone-based app to enable them to register pregnant women, provide health education, screen them for danger signs and refer to a health facility, and link them with locally available transportation. This project supported 400 CHWs to care for over 80,000 pregnant women and their newborns, and demonstrated an increase in pregnant women delivering in health facilities from 50% to 75% (a 50% increase), led to increases in facility-based postpartum care visits from 20% to 80%, and increased communityfacility referral completion from 27% to 90% 15 . Clients reported receiving personalized, responsive, and compassionate care. They were empowered to provide direct feedback about the quality of facility-based services, which district health teams used to monitor and improve service quality.

Government adoption & policy development
Based on the success of the Safer Deliveries project and the recognition that a digitally enabled, government-owned community health system was critical to sustainably improve health in Zanzibar, RGoZ formally adopted this digital CHW program as part of the formal health system at the national level, unifying all community health programs through this single initiative, named "Jamii ni Afya" (Swahili for "Community is Health"). In order to formalize this program as a government initiative, the RGoZ updated its Community Health Strategy to make Jamii ni Afya a central pillar of community health. This strategy serves as a formal government document outlining how community health volunteers fit into the larger Zanzibar health system and specifying their roles, responsibilities, training, and required qualifications. Significantly, the revised Community Health Strategy specifies that community health volunteers will be supported with a digital health platform, as the Ministry of Health recognized the benefits of technology in the pursuit of its vision for a healthy population. The program uses the term community health volunteers to emphasize the engagement on a volunteer basis. However, to align with prior literature, we will henceforth refer to them as community health workers or CHWs.

Human-centered design & development
From January to June 2019, the Zanzibar Ministry of Health, D-tree and other community health stakeholders participated in a human-centered design process to co-create both programmatic and technical aspects of the Jamii ni Afya program. The approach was to fully define the health problem and local context first, then select the technology that is best suited to solve that problem. In this way, the program and technology design processes were conducted simultaneously, where program requirements-including health objectives, CHW workflows, supervisory systems, and long-term government management capacity-informed technology design choices. The Principles for Digital Development were applied throughout the process to ensure the resulting system was locally relevant, user-friendly, cost-effective, and sustainable 17 .
Jamii ni Afya leverages government guidelines and global best practices to guide CHWs using digital technology in delivering high quality, health education and counseling services in maternal and child health, nutrition, water, sanitation and hygiene (WASH) and early childhood development. The data generated from these interactions is used to further personalize health services by tailoring health messages based on the personal circumstances of the client, improve supervision, and support programmatic and policy decision-making at community, district and national levels.

Interoperability
The Jamii ni Afya mobile app is built on the Community Health Toolkit (CHT), an open source global goods platform developed to support community health workers globally. This platform was selected by the Zanzibar government due to the following reasons: it is open-source and uses wellknown components and frameworks; it has a growing community that can be leveraged for support; it can be hosted in a local datacenter; the skills required to configure health worker tools are found among Ministry ICT staff and easily available in the local market. In addition, CHT runs on low-end Android smartphones and has offline functionality, which is critical in Zanzibar where network connectivity is not guaranteed. Developers from D-tree and the Zanzibar Ministry of Health led the mobile app development process, including system requirements and specifications. The system was designed to ensure interoperability with the broader digital health ecosystem in Zanzibar. The CHT is integrated with the government's health management information system (DHIS2) and provides data for the Community Health Information System. Jamii ni Afya is referenced in the Zanzibar government's first-ever digital health strategy, which works to coordinate and optimize government resources for digital health in Zanzibar. It is integrated with the Zanzibar Health Interoperability Layer (based on OpenHIM) and can thus integrate with an up and coming Electronic Medical Records system. There are plans to integrate with the future client registry system and a healthcare worker registry.
National roll-out Jamii ni Afya was introduced in phases from July 2019 to August, 2021 to all of Zanzibar's 11 districts. Throughout the rollout, the Zanzibar Ministry of Health played a central role, from recruiting and training CHWs and supervisors, raising awareness in communities, and coordinating supportive supervision for health workers. The standard implementation approach used to scale up the project included community sensitization, recruitment and selection of CHWs and health facilitybased supervisors, 10-days of training on the overall program and mobile app, intensive mentorship for a 3-week period, followed by ongoing monthly supervision and semi-annual refresher trainings.
Monitoring, supervision and data-driven decision making As a byproduct of program implementation, Jamii ni Afya collects rich data on enrollment, health utilization, and health outcomes. This data is made available on program dashboards, which are used by district health management teams to monitor program progress and CHW performance, track health trends, and identify challenges. Supervisors have a mobile app which displays data on the CHWs they supervise, enabling tailored and prompt follow-up and support. In addition to using data for program monitoring and supervision, we conduct analyses that provide additional insights into successes and areas for improvement and evaluate the impact of specific components of the program on key outcomes 16,18 . We also develop and embed prediction models built using machine learning to tailor our program to individuals and communities 19 . Insights from monitoring and evaluation are used to inform ongoing system improvements. With Jamii ni Afya established as a fully scaled national government program, there is also increasing interest to leverage the resulting data for other purposes. For example, the Zanzibar government is exploring how Jamii ni Afya can collect household socio-economic during routine visits which can inform subsidies for the upcoming Universal Health Insurance program.

Sustainability planning
Zanzibar government leadership has been critical to Jamii ni Afya's success and instilled trust in the population for the long-term sustainability of the program. By establishing Jamii ni Afya as part of a national strategy, the government has been able to formally assign oversight and implementation responsibility to government staff so that running the program becomes part of their job description and regular responsibility. The government directly pays the salaries of Jamii ni Afya CHW supervisors (210 individuals), who health care providers working at health facilities and are 100% dedicated to community health. In addition, one person in each of Zanzibar's 11 districts acts as a District Health Promotion Focal Person for Jamii ni Afya. These government employees are responsible for district level coordination of the program which has been critical for program oversight, government commitment and ownership.
The Zanzibar Community Health Strategy Costed Operational Plan developed by the Zanzibar Ministry of Health in 2022 found that the annual operating cost for Jamii ni Afya is TZS 6.4 billion (approximately USD $2.73 million), which is equivalent to USD $1.70 per capita. Currently, the government is spending $0.30 per capita on Jamii ni Afya salaries. The remaining costs are paid by donor funds, which funds equipment and working tools, CHW stipends, training, meetings, technology, and hosting costs. The Zanzibar government has committed to increasing their funding commitments by 25% each year for the next four years, until they are fully funding the program by the end of 2026. Of note, the cost per capita is the cost of the entire community health program, which includes the digital health system. We have not isolated the digital system costs since technology is fully integrated in the community health program and cannot be viewed as a standalone cost.

Implementation results
Since August 2021, Jamii ni Afya has been operating at full national scale. 2,300 CHWs and 210 Supervisors have been trained to support every household in Zanzibar. As of March, 2023, more than 1.5 million people had been registered to the system, representing nearly 80% of the Zanzibar population, and over 320,000 pregnant women and children under-five have received health visits.
Both the current Jamii ni Afya and prior Safer Deliveries programs' focus on education and promotion of health-seeking behavior for maternal and child health and have played a role in positive trends in key health outcomes. The percentage of women delivering in a health facility increased from a baseline of 64% 11 to 85% among women registered in the program in 2022, a 33% increase. In addition, rates of stunting reduced from 30.4% in 2015 to 17.6% in 2022 11,20 . While we cannot attribute these reductions to Jamii ni Afya, we are confident that the program's focus on education and promotion of health-seeking behavior for maternal and child health played a role in these significant changes. To directly quantify the Jamii ni Afya's impact on early childhood development outcomes, our team implemented a nationally-representative baseline survey in 2018 with a postimplementation survey planned for late 2023 21 .
There were many factors that led to the success of Jamii ni Afya as a nationally scaled, digital community health program. Briefly, a key element was designing the program by starting with the health challenge and local context, rather than the technology. Only when the health challenge was defined and a clear vision for what was possible was conceptualized did we bring in technology, which enabled us to focus on the need, rather than the technology solution. In addition, we leveraged the Principles for Digital Development to guide the technology design process. We also heavily focused on utilization of data for decision-making, which amplified the value of the program beyond service delivery, and demonstrated how population-level data could add tremendous value to planning, budgeting and policy-making at the local, district and national level. Finally, extensive collaboration with local and global partners was critical to the success of Jamii ni Afya. The project team engaged with global technology partners, health experts, evaluators, data scientists and data governance coalitions. Within Zanzibar, collaboration with health experts, universities, political strategists and communication experts helped to shape the program and support its sustainability. Collaboration with long-term and flexible funders was also key to Jamii ni Afya's success, enabling the project to adapt based on evolving needs and understanding throughout various stages of maturity.
The current focus on Jamii ni Afya is full transition to the Zanzibar Government. Working with partners, the government has developed a transition plan which outlines the financial, technology and operational aspects of the program that will be fully absorbed by the government by 2026. D-tree and partners are supporting skills transfer and systems development to enable this transition, recognizing that financing and management of a nationally scaled digitally enabled community health program is a major undertaking, and strong accompaniment from non-governmental organizations is critical to the effective handover of such a system.

Discussion
This article outlines the evolution of Zanzibar's national, digitally enabled community health program. Since 2010, the program grew from a small pilot to a nationally scaled, government-owned initiative that is set to be fully institutionalized within the national health system. During this time, we have learned many lessons and best practices that may be relevant to governments and practitioners designing, scaling and institutionalizing digitally enabled community health programs.
Community health programs have traditionally been driven by vertical health programs (i.e. HIV/AIDS, family planning or maternal health) and focus on specific health service delivery 22,9 . With Jamii ni Afya, we focused on designing a strong community health system, independent of the types of services being delivered, which serves as a strong foundation on which to add service delivery areas. The Zanzibar Community Health Strategy is a critical document which not only formalizes Jamii ni Afya as a government initiative, but also outlines critical systems-level criteria to guide the program. This includes defining the supervision structure, selection criteria, training and stipend payments, which is aligned with WHO guidelines for community health 10 .
Just as it's important to invest in building strong foundations in community health system, it is critical to design digital health initiatives that are integrated and harmonized with the broader digital health ecosystem. A recent article by Karamagi et. al describe the alarming lack of coordination, integration, scalability and sustainability of digital health interventions in sub-Saharan Africa 23 .
Through the design of Jamii ni Afya, we were intentional to ensure that the digital system was interoperable with other digital health systems such as DHIS2 in order to enable the transfer of data between systems. The Jamii ni Afya team was also closely involved in the development of the Zanzibar Digital Health Strategy, which features Jamii ni Afya as a core digital health intervention.
Jamii ni Afya was among the first systems to adopt the Zanzibar Health Interoperability Layer which lays the foundation for seamless data exchange across systems. These intentional design decisions, coupled with integrating the program into government policy, have set the stage to ensure long-term coordination and synergy with the evolving digital health landscape in Zanzibar.
Having the right leadership is recognized as a critical lever to accelerate the institutionalization of a product or service 24 . Strong leadership, ranging from the highest levels of government to local community leaders, may be the single-most important success factor for Jamii ni Afya. Extensive work was done early on to establish buy-in and trust at the community level. Community sensitization was built into the national roll-out plan, leveraging shehas (ward leaders) to champion the initiative within their communities. Sensitization activities were led by district and national-level government staff who introduced the program as a government-led initiative, and CHWs have official government-issued identification cards that provide increased credibility. These initiatives were critical in building public trust and ownership of Jamii ni Afya from the beginning, resulting in 90% of the population being registered in the program. We also focused on high-level political support to champion this initiative and set the stage for full government ownership and sustainable financing. In February 2023, the Zanzibar Minister of Health presented Jamii ni Afya to the Zanzibar President who pledged his commitment to champion the institutionalization of this initiative. While this support is encouraging, one lesson learned is the importance of high-level political engagement early on. The Jamii ni Afya team initially focused on community, district and departmental support within the Ministry of Health in order to build buy-in and support, and only after the program was established, began lobbying higher levels of government for their support. Earlier engagement with these higher levels may have expedited the institutionalization process.
The evolution of Jamii ni Afya has lasted nearly 13 years and is now in a strong position to be institutionalized within the Zanzibar health system. Each stage of the project -beginning with a small pilot to demonstrate the potential of this model, gaining consensus for government adoption, integrating the program into government policies -was critical to build demand and formalize Jamii ni Afya as a government initiative. Often, donors expect that health systems strengthening initiative, including digital health, should be conceptualized, piloted, scaled and institutionalized within a short period of a few years. However, our experience is consistent with other research and shows that significant digital health systems transformations take time and require funding and partnerships to accompany governments on their journey to scale 25 .
One of the most significant challenges for Jamii ni Afya's institutionalization is sustainable financing, which is a common challenge for community health programs across many low and middle-income countries 26 . The Zanzibar government has committed to full institutionalization of Jamii ni Afya by 2026 which is an ambitious target and will require substantial political commitment and innovative solutions. The Jamii ni Afya program team is currently working on a number of strategies to support the government to fully finance the program within four years. One way is to increase demand for the program outside of the health sector. Jamii ni Afya champions are in discussion with the Zanzibar Ministry of Finance, Ministry of Social Welfare, Ministry of Agriculture and Ministry of Education to discuss how existing or new data from Jamii ni Afya could be valuable to them, or the potential of expanding the package of services delivered by CHWs. By extending the value of the program outside of the Ministry of Health, additional government entities can contribute towards operating costs, thus reducing the burden on any one particular Ministry and reducing duplication of efforts. We are also in the process of integrating Jamii ni Afya into the government's upcoming Universal Health Insurance scheme which will be rolled out in the next 1-2 years. The Jamii ni Afya digital platform can be leveraged to collect data on household economic status, feedback on health facility quality, and CHWs can support registration of households into the program. In turn, the community health program can be partially financed by revenue generated through the health insurance scheme. It has been reported that many national health insurance schemes fail to adequately engage the informal sector 27 . Leveraging CHWs to support these efforts in Zanzibar could both increase participation among the informal sector and support operational costs for the community health program. There is also increasing support from multi-lateral donors who are increasingly investing in digitally enabled community health systems and provide funding directly to governments to decrease financial reliance on non-governmental partners. This multipronged financing approach is aligned with a recent review that found that an adaptive mix of health financing mechanisms is necessary for low and middle-income countries 28 .
In conclusion, Jamii ni Afya represents one of the world's first examples of a nationally scaled digitally enabled community health program. This implementation report outlines evolution of this program, from pilot to national scale and institutionalization. While Zanzibar has a relatively small population is geographically isolated, the challenges they face are similar to many other settings. The authors hope that the experiences and lessons learned described in this manuscript will be helpful to others working to implement digitally enabled community health systems at scale. In addition, given the maturity of Jamii ni Afya, the relatively small size of the Zanzibar population and the significant health need, there is an opportunity for Zanzibar to become a digital health implementation research hub in order to test new and promising innovations, research various implementation models, and develop best practices that can be applicable in other settings.