Digital health tools can strengthen national health systems. But to be effective, they must be designed and implemented in partnership with users. A new supervision system, developed using human-centered design principles, is contributing to a culture of care.
Design and Development
User advisory groups (pictured above) collaborated to develop Tanzania's digital facility supportive supervision system, AfyaSS. Photo: PATH.
To enable a strong health system, health workers must be able to monitor the performance of their facilities. Until recently in Tanzania, this process was fragmented and paper based. Health managers and frontline health workers had limited visibility into how their hospitals and clinics were performing against health system targets, with few opportunities to track progress and understand where improvements were needed.
In the past, health facilities were subject to frequent supportive supervision visits by different actors, for a range of purposes—including implementing partners, donors, representatives of the Ministry of Health, and officials from the President’s Office Regional Administration and Local Government. These visits were often uncoordinated and resulted in health facilities receiving numerous paper feedback reports and checklists that were hard to manage, track, and put into action. Supervisory visits sometimes didn’t happen, or the findings wouldn’t be shared back with health facilities, leading to broken feedback loops. As a result, supervisors and health workers were often unaware of the feedback delivered during past supervision visits and struggled to monitor progress and implement improvements.
Under the Data Use Partnership, the government of Tanzania partnered with PATH to digitalize this performance monitoring process. A cornerstone of the Data Use Partnership has been the development of a digital facility supportive supervision system used by health managers, district health officials, and frontline health workers to systematically link performance data and supervision recommendations. AfyaSS, as the system is called, uses a single dashboard to consolidate supervisory checklists, feedback forms, recommendations, and action plans across all health areas. In the past, different health areas used different checklists to monitor performance data, which made it difficult to track a health facility’s overall performance. Consolidating these into a single, shared checklist made it easier to evaluate and strengthen service delivery.
AfyaSS was designed using a human-centered design approach. Beginning in 2018, the government of Tanzania and PATH embarked on a participatory design process that included a desk review of existing guidelines and paper-based and digital tools, field visits, stakeholder workshops, and user advisory groups to identify common challenges and system requirements of the future AfyaSS.
The government employed user advisory groups composed of key health actors, software designers, and engineers to map the previous paper-based systems and redefine workflows in support of health system strengthening. It also used an iterative design process to elicit feedback, applying phases or sprints to validate system features with the user advisory groups.
Health actors, for example, revealed that supervisory visits would often only focus on malaria-specific indicators or maternal and child health, rather than looking holistically at a facility’s performance. Based on that feedback, they reviewed multiple health area– specific checklists and helped consolidate them into a single, synthesized digital format.
Input from users also indicated that health managers often struggled to verify if a supervision visit occurred. Supervisors sometimes falsely reported visits, and paper-based systems did not allow for any means of accountability. In response to this persistent challenge, AfyaSS was designed to include geotagging features that log the start and end locations of a visit, prompting users to begin their evaluation when they are in the vicinity of their assigned health facility. These quality control measures help to validate supervision visits and promote accountability.
“The technology is what makes the supportive supervision system appealing and pushes us to make sure we’re frequently logging in to see the supervisions conducted, action items, and [to] follow up to see if the issues were resolved.”— Dr. Charles Migunga, Regional Quality Improvement Focal Person, Arusha
AfyaSS ensures that health workers at the facility level, managers at the regional level, and policymakers at the national level have reliable, real-time access to information on the performance of Tanzania’s health system. AfyaSS includes checklists for different health areas, system notifications to remind health workers about facility targets, dashboard features to monitor progress toward health system goals, and action plans linked to data from previous visits. Offline components allow for use of the system in remote areas with limited connectivity. Together, these features enable health workers to act on the performance data made available to them.
The impact of using human-centered design
As a result of the human-centered design process, AfyaSS is helping to contribute to a culture of care that is focused on addressing user pain points and data-driven quality improvement. AfyaSS has been rolled out to all 26 regions in Tanzania and is actively in use in 24, with plans to continue training users and implementing change management strategies to increase system use.
Understanding the needs, desires, and behaviors of all key stakeholders and delivering an appropriate solution has been instrumental in improving its uptake and adoption.