On October 27th, 2014 JSI hosted the third in a series of interactive sessions the Principles for Digital Development. This meeting focused on the Principle 3: Design to Scale. It began with a discussion of how to design for scale from the very start, transitioned to a discussion of the importance of considering the implications of design beyond the immediate project, and then concentrated on designing solutions that are replicable and customizable in other countries and contexts. Joy Kamunyori (JSI) facilitated the meeting. Kate Wilson (PATH), Marion McNabb (Pathfinder International) and Sarah Andersson (JSI) presented. More information about the principles can be found here: http://ict4dprinciples.org/

1. Designing
for Scale
Case Study: Designing a mHealth system for
the community health supply chain in Malawi

2. Malawi Context
• Community Health Workers (called HSAs) in Malawi live and work in hard to
reach areas (>8km from health center)
• HSAs are one of the lowest paid cadre in Malawi Civil Service
• Supervised under the District Health Management Team
• Previously HSAs did not manage products, only focused on prevention activities
• Recently HSAs have been trained to
treat common diseases such as
malaria, pneumonia and diarrhea
to children under 5 years and
provide family planning to women.
• HSAs can now manage up to 17
products that they store in a drug
box in their home.
• HSAs collect medicines from the
closest health center (>8km).

3. Problem Statement
Key Quantitative Baseline Assessment Data 2010
• 27% of HSAs who manage health products had four CCM tracer
drugs* in stock on day of visit
• 43% HSAs submitting reports that contain logistics data to HC
• 14% of HCs reported passing HSA information to higher levels
*cotrimoxazole, artemether lumefantrine 1x6 and 2x6, ORS
• Poor availability of medicines
• Irrational drug management process
• Lack of visibility of HSA logistics data due to low
reporting rates and poor movement of data
• Lack of coordination in drug management at all
levels
• Weak linkages between community and health
facilities
• HSAs would travel long distances to collect
products only to find there were no products

4. Solution
• 94% of the HSAs surveyed had basic GSM mobile
phones
• 80% of HSAs and health facility (HF) staff had
continuous network coverage at their place of work
• all districts surveyed had computers and access to
the internet
Mobile based system
to manage reporting
and resupply process

5. Ecosystem
• Different MOH departments involved:
Pharmaceuticals Department and Child Health
Unit
• Different implementing partners support
different districts
• Project only had resources for piloting in 6
districts and did not have the resources to take
the system to scale
• Multiple partners piloting different mHealth
solutions for supporting service delivery at
community level, no common vision
• Infrastructure and capacity for data hosting,
software development and maintenance is low
in MOH and in Malawi
• Supply chain information systems was only
automated above district, but not networked,
relies on data being transferred by flash drives

6. Designing for Scale
• Design for scale from the start, and assess and mitigate
dependencies that might limit ability to scale.
• Employ a “systems” approach to design, considering
implications of design beyond an immediate project.
• Be replicable and customizable in other countries and
contexts.
• Demonstrate impact before scaling a solution.
• Analyze all technology choices through the lens of
national and regional scale.
• Factor in partnerships from the beginning and start early
negotiations.

7. Group Discussion
What considerations would you make when
designing the system and the pilot to ensure
it can be taken to scale?
1. Technology and Infrastructure
2. Institutional Stakeholders (policy makers and
implementing partners) and System Users
3. Data Use, System Monitoring and Evidence
Generation

8. Overview
cStock is a RapidSMS, open-source, web-accessible logistics
management information system for community-level health
products in Malawi.
• Uses basic GSM phones already owned by HSAs
to report data via SMS on a toll free phone line
• HSAs in Malawi only manage up to 17 products
but generally manage about 7 or 8, so SMS
reporting for all products in one message was
feasible and not too burdensome
• Data is cloud hosted
• inexpensive, secure, reliable and easy to
manage option for a small scale system like
cStock in a country like Malawi
• did not require recruiting/training IT
support staff and procuring/maintaining a
server

9. District, Zonal
and Central staff
access HSA
logistics data via
dashboard
Health Facility
supplies the HSA
based on SMS
message
HSA sends SMS
with SOH each
month
The database calculates –
Months of Stock and resupply
quantities, reporting rates,
number and duration of stock
outs, displays on dashboard
Data and Product Flow

10. Reports & Dashboard
A web-accessible dashboard
with simple, easy-to-use
reports, shows stock levels,
reporting rates, and alerts
for central and district level
managers

11. S
s
In addition to cStock, SC4CCM introduced District Product Availability Teams
(DPATs) that use cStock data to monitor and improve supply chain
performance
Connecting to the Health System
DPATs have
proven to be
an important
complement to
cStock. DPATs
“demand”
updated data
that cStock
“supplies,”:
motivating
HSAs to
continue
reporting.

13. Operationalizing MOH ownership of the system
• Formation of a taskforce (MOH chair) with all stakeholders dedicated to
institutionalization of cStock and DPATs
• Formation of national team of implementing staff to monitor implementation,
monitor the dashboard and provide follow up support to users
• Finding champions in MOH by having central level advocates and trainers in
every districts
• Capacity building of MOH to provide management and leadership, currently have
a secondee in MOH
• Development of comprehensive, five year transition plan with cost estimates for
resource mobilization, in the short term, and eventual transition to MOH budget
Scale Up And Institutionalization
Partnering to Scale builds broader ownership and capacity
that lasts after project ends
• As of last week all 29 districts (3059 HSAs) have been trained with funding from
WHO, Save the Children, UN Foundation, USAID and SC4CCM

14. Designing cStock for Scale
• Kept the design simple and suitable for the context
• Used GSM for data transmission so HSAs could use their
personal phones
• Collects minimal data so as not to overburden
• Appropriate for the skill level of the HSA
• Revisited some of design early in the pilot when users had
experience to draw from
• user centered approach to build local ownership
• Used cloud hosting as it was cheap, reliable and easy to
manage
• capacity for data hosting was low and as cStock only requires a
small data hosting space was not worth investing at this stage

15. Designing cStock for Scale
• Engaged partners and MOH from the outset
• continued to provide updates and data throughout pilot and
encouraged partnering for scale up to broaden ownership
• Created a open source system that can be interoperable with
other systems
• have supported partners to integrate cStock into their newer
mHealth systems for HSAs
• Combined the mHealth solution with interventions that take a
systems approach which ensured the data was valuable and
used to improve the system
• Developed a transition plan well before the end of the project
and help set the ground work for sustainability

16. ore information on cStock visit:
://sc4ccm.jsi.com/cstock/