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How Zanzibar Built a Health System Fit for the Digital Age

This week is the first Digital Health Week, organized by the Transform Health coalition to raise awareness and champion the potential of digital technology to revolutionize health systems and advance countries toward their universal health coverage (UHC) goals. As advocates come together, it is important that we recognize and celebrate examples of country successes so others can learn lessons and adapt their future efforts to meaningfully transform health systems.

More than five years ago global leaders made a commitment to deliver UHC by 2030, and although there have been improvements in some areas, more than 400 million people around the world still lack access to essential health services—jeopardizing the achievement of our global commitment to help everyone live longer, healthier lives.

One hopeful development has been the recognition that digital technology can support governments in transforming their primary health systems to be more responsive, people-centered and data-driven. Digital health approaches have been endorsed by the World Health Organization as a key way to improve the quality of health services, especially when delivered at the primary level, expand access to care for marginalized communities and dramatically increase the availability of data to inform evidence-based planning and decision-making at all levels of the health system.

Zanzibar is a strong example of how digital health can strengthen a national health system. D-tree has worked alongside Zanzibar’s Ministry of Health for almost a decade of planning and development, and in August 2021, the Ministry brought its digital community health program, called Jamii ni Afya, to full national scale. In successfully rolling-out Jamii ni Afya at national scale, Zanzibar is delivering essential health services to all of its 1.6 million citizens. With this accomplishment, Zanzibar has taken a huge step forward to advance UHC and become one of the world’s first examples of a government-led digital health initiative succeeding at this scale.

Jamii ni Afya connects every household in Zanzibar to a dedicated community health volunteer (CHV) who is trained and equipped with a mobile app. As CHVs visit with clients, the app provides step-by-step guidance so CHVs consistently provide high-quality services based on government standards.

The app also generates and captures data during every visit that is reported back to the broader Jamii ni Afya system and integrated into Zanzibar’s national health reporting systems. This formal linkage not only enables CHVs to refer clients to services at health facilities, but also enhances the ability of supervisors and managers to make evidence-informed decisions. Rather than waiting for paper records to be reported or relying on household surveys, now decision-makers have population-level data available to them in real-time.

Many countries have tried to incorporate technology in small projects, but struggled to institutionalize them into their broader health systems. So, how did Zanzibar’s Ministry of Health succeed where so many others have faltered?

Mobilizing a Coalition toward a Shared Vision

With Jamii ni Afya, Zanzibar’s government recognized that technology and health data are not the end goal or solution to health challenges—but rather central pillars of a larger transformation that they needed to lead themselves. To achieve full national scale and integrate Jamii ni Afya into the health system, the Ministry of Health organized a coalition of partners around a shared vision of a digitally enabled health system—a feat that took almost a decade of collaboration and continuous engagement to build the trust, relationships and skills needed to sustain the initiative long into the future.

Importantly, this early focus on building a shared vision created the foundation to overcome many of the common challenges that community health and digital health programs both face when attempting to scale up. By bringing together non-governmental organizations, multilaterals and funders committed to this vision, the Ministry kept everyone focused and reduced the fragmentation between organizations that can derail these projects from the start.

Fostering an Enabling Policy Environment

This strong coordination, led by the government, also fostered an enabling policy environment supportive of the program. When the Ministry of Health revised the National Community Health Strategy in 2018, the roles of CHVs and oversight responsibilities for Council Health Management Teams were codified in national policy, providing a clear mandate for the program’s long-term institutionalization. This process engaged staff from every level of the health system and focused on building the skills needed to fully operationalize Jamii ni Afya.

Having a clear policy and political commitment meant Ministry staff felt confident in overseeing the program and helped ensure that adoption of the system was built from the ground up. And, having the program explicitly included in national policy qualified the program to receive direct government funding and multilateral funds, further expanding the Ministry’s options to financially sustain the system.

Training & Building Skills by Design

Finally, there was a deliberate focus on building the skills necessary for government to operationalize and manage Jamii ni Afya. As the program was introduced, the Ministry of Health and district health management teams stepped up, by raising awareness in their communities, recruiting and training CHVs and supervisors and managing the program’s performance.

The Ministry seconded staff to D-tree early on so they would be integrally involved in every aspect of program design, planning, technology development and rollout. These opportunities provided valuable experience in managing and operationalizing every aspect of Jamii ni Afya that could be brought back to their teams at the Ministry. And, likewise, a long-term Senior Digital Health Advisor was seconded from D-tree to the Ministry of Health to supplement their teams and coordinate Jamii ni Afya within Zanzibar’s digital health and program landscape.

On their own, none of these three elements appear particularly unique, but they are powerful drivers when intentionally brought together. While it is easy to be skeptical when looking at the proliferation of short-term digital health implementations over the past decade, Zanzibar’s success shows that there is a path governments can follow to harness data and digital technology for stronger health systems.

We are at an exciting inflection point in the history of digital health—where the tools and examples exist to break down historic barriers to health access and to leverage the power of digital technology to make affordable, high-quality healthcare available to all.

Now, the question becomes, how can we learn from the success in Zanzibar to support more countries and governments to achieve their UHC goals by 2030?

This is the final post in a series highlighting Jamii ni Afya, one of the world’s first digital community health programs to reach full national scale. Learn more about Jamii ni Afya’s journey to connect every community in Zanzibar to essential health services and contact us to get involved.

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