1. Evolution to scale
Lessons learned from the Safer Deliveries program in Zanzibar, from pilot to scale
The Safer Deliveries program has been working in Zanzibar since 2011 to improve rates of facility deliveries and postpartum care with the goal of reducing maternal and neonatal deaths. From 2012 to 2014 we received funding to show the proof of concept that our model could achieve results at some scale. 1

2. 50% increase 8x increase PHASE II SUCCESS
in facility deliveries among 14,000 deliveries (50%  75%)
8x increase
in post-partum follow-up (10.9%  88%)
We saw facility delivery rates increase from 50% to 75% among 14,000 women registered in the program. Postpartum follow up rates increased 8-fold, from 11 to 88%.
Like many projects, we did this by closely supporting health workers and their supervisors to ensure program success.

3. PROGRAM MODEL Register pregnant women Birth plans
Counsel mothers and families
Screen for danger signs
Refer & follow up
Coordinate transport
Pay for transport
Monitor mother and baby
In brief, this program supported Community Health Workers to use basic feature phones to register and support pregnant & postpartum women and their families. This is similar to many maternal health CHW programs, but with a strong focus on birth planning and transport coordination.
225 CHWs in 6 out of 10 districts in Zanzibar
Program ran from

4. CHALLENGES Software functionality Transport cost sustainability
Administrative burden
Mentoring & follow-up
Limited dashboards
When the program was developed, we designed a mobile app using CommCare running on a basic feature phone. The app supported CHWs but the interface required that they move in and out of forms to provide different functions such as registering a woman, initiating a referral and coordinating transport. When our team wanted to modify the app, we had to engage an experienced programmer to help support these changes as our team of health professionals could not easily make changes more than simple edits to the protocols.
As I mentioned, the program paid for transportation for women to reach a health facility during labor, which increased overall program costs.
In order to effectively support the CHWs trained, there was a large administrative burden on the program team, who provided in-person mentorship visits after training and spent a great deal of time managing the mobile money systems and following up with health workers and their supervisors.
In addition, our dashboards had some data but did not provide a variety of data visualizations to support tailored program monitoring.
While the program was very successful, it was cumbersome for our team to maintain, manage and sustain. This is not uncommon from many digital health programs, and what we often see is that these programs are successful in the beginning when there is intensive support, but after this support decreases and the program scales, health worker activity slowly declines as systems have not been put in place to maintain high levels of engagement over time.

5. PHASE III Easy to Maintain Easy to Manage Focus on Sustainability
New software platform
Easy to Manage
Supervisory system
Field-based mentorship
Performance & accountability systems
Dynamic data analytics
Focus on Sustainability
Cost effective
Ministry planning & integration
We received funding to scale the program up – we are doubling the number of health workers and scale with essentially the same annual operating budget.
Support 400 CHWs in 9 out of 10 districts, serving 80% of pregnant women.

6. MAINTAIN

7. EASY TO MAINTAIN APP

8. EFFECTIVE USER INTERFACE

9. MANAGE Support management of the system at scale:
-system to mentor newly trained CHWs
-system to support supervisors
-pay for performance for CHWs & supervisors to promote motivation and accountability
-real time data for decision-making: supporting program managers to review programmatic indicators, tailor resources and support with heat maps, and monitor CHW performance

10. MENTORSHIP SYSTEM

11. SUPERVISORY SYSTEM
SS Supervisor app

12. MOTIVATION & ACCOUNTABILITY

13. DATA FOR DECISION-MAKING

17. SUSTAIN
Throughout the past 5 years, we have continued to build on a strong relationship with the Zanzibar Ministry of Health. In this phase of the program, we have a strong focus on reducing reliance on the NGO management and transfer of responsibility to the Ministry and government staff.
We have a formal MOU with the Ministry of Health, and the Safer Deliveries program has been incorporated into the plans of action in all 10 districts in which we work.

18. CITIZEN FEEDBACK

19. Other: in all district plans of action; MOU with Ministry; focus on building capacity of district teams to manage the system

20. SUSTAINABLE TRANSPORT
Estimate costs
Transportation & facility expenses calculated by app
Link with savings groups
Pre-programmed in app
Access to short term loans
Pre-arrange drivers & prices
Community drivers & prices pre-programmed in app

21. KEYS TO SUCCESS
Maintain
Manage
Sustain

22. Thank you!
Erica Layer
Program Director
@ericahlayer