ALMANACH Somalia - Implementation of a digital Clinical Decision Support System / ICRC Somalia
Access to health care in Somalia is precarious for an estimate up to 70% of the population, especially for those living in the south-central region; among the most vulnerable are children under five years old. The mortality rate of children under five years old in Somalia is among the highest in the world. The leading causes of infant and child mortality are illnesses such as pneumonia (21%), diarrhoea (14%), and measles (5%), as well as neonatal deaths (29%). Owing to insecurity and displacement, over half a million young children have not been vaccinated in the last five years. Health infrastructure is small, dilapidated and concentrated mainly in towns; health, water and sanitation facilities that have been damaged by conflict or lack of upkeep put people at greater risk of contracting diseases.
To improve the quality of care for children between 2 and 59 months (< 5 years) old in the South-Central Somali region, the International Committee of the Red Cross (ICRC) and the Somali Red Crescent Society (SRCS), in partnership with the Swiss Tropical and Public Health Institute (Swiss TPH) are implementing the ALMANACH project in South Central Somalia. ALMANACH (acronym for ‘ALgorithm for the MANAgement of CHildhood illness’) is a novel (tablet based) digital health tool, designed to provide clinical decision support for health care providers in low- and middle-income countries. It is based on paper based guidelines from the World Health Organization (WHO), the Integrated Management of Childhood Illness (IMCI). The project objective is to enhance health care provision for children under five substantially. Targeted are the enhanced quality of care, patient oriented services and the strengthening of the health delivery system through a novel (tablet based) digital health tool, designed to provide clinical decision support for health care providers
The ICRC, in partnership with the SRCS and Swiss TPH launched the ALMANACH in Somalia on September 2020 at three primary health care facilities. By October 2022, ALMANACH has been implemented in 13 facilities and the aim is to extend the project to an additional 12 facilities in 2023. The emphasis on community sensitization as well as regular interaction with both the health workers and the communities has contributed to a successful beginning of the intervention, which has the potential to significantly improve the quality of care for children under 5 years. The application integrates well in the daily workflow and contributes substantially to better adherence to evidence-based diagnostic and treatment protocols, leading to targeted drug prescription, improved antibiotic therapy management, and ensuring key interventions such as malnutrition screening and preventive medication. Furthermore, ALMANACH enables remote monitoring of public health and epidemiological indicators. An automated backflow of aggregated clinical data enables health managers for example to detect disease outbreaks at an early stage and to improve the health provision system where most required.
A pre-post comparison, before and after implementation of ALMANACH, was conducted between early 2021 and end of 2022 to learn about changes in delivering health care in the health facilities implementing ALMANACH:
- the probability to be checked for need of Vitamin A was nearly 5 times greater once ALMANACH was implemented and used in the health facilities
- after the introduction of ALMANACH in the health facilities, patients were nearly 4 times less likely to receive an antibiotic treatment. And even more specific in the case of an Upper respiratory tract infection with an additional other infection: the risk to be treated with an unreasonable antibiotic treatment is 30 times less with ALMANACH than without ALMANACH
- health workers are much more proactive with ALMANACH to provide guidance to the patients’ caretakers on various health education messages such as the importance of breastfeeding, complementary feeding and home care treatment for sick children than without.
Further, health promoters, members of health committees and female community health workers regularly conduct home visits and information dissemination sessions to increase mothers and/or caretakers’ awareness of the ALMANACH.
Swiss TPH's involvement/tasks
Swiss TPH’ role was to provide the conceptional and technical expertise to develop the Clinical Decision support system (CDSS) termed ‘ALMANACH (ALgorithm for the MANAgement of CHildhood illness). It is based on WHO’s Integrated Management of Childhood Illness (IMCI) guidelines, which were enhanced and further expanded. It is tailored to the local context, which means it includes conditions relevant to Somalias epidemiological profile and takes into account both the Ministry of Health’s clinical guidelines as well as the resources available locally at the primary health care (PHC) facilities in terms of drug supply, equipment and staff.
ALMANACH is an easy-to-use digital tool for Android tablets and smartphones that enables health care providers to better adhere to clinical guidelines and thus better exploits IMCI’s potential. With a stepwise, user-friendly format, the ALMANACH’s algorithms guide healthcare providers to take a structured clinical history, perform relevant physical examinations and diagnostic tests, and finally provide diagnoses and evidence-based treatment recommendations. To use ALMANACH for decision support, no internet connection is necessary. Aggregated clinical data from ALMANACH consultations are uploaded to a Health Management Information System (DHIS2). Review of this data enables healthcare managers to monitor more closely clinical case management, trends of diseases like respiratory conditions as well as other outbreak-prone infectious diseases.
Schmitz T, Beynon F, Musard C, Kwiatkowski M, Landi M et al. Effectiveness of an electronic clinical decision support system in improving the management of childhood illness in primary care in rural Nigeria: an observational study. BMJ Open. 2022 Jul 21;12(7):e055315.