Use of RapidPro for remote collection of nutrition data during the drought emergency and COVID-19 pandemic in Zimbabwe

This is a summary of a Field Exchange field article that was included in issue 64. The original article was authored by Nakai Munikwa, Pauline Tsikayi, Desire Rwodzi, Mara Nyawo and Mathieu Joyeux.

Nakai Munikwa is the Nutrition Cluster’s Information Management Consultant, UNICEF Zimbabwe.

Pauline Tsikayi is a Nutrition Monitoring and Evaluation Officer with the Ministry of Health and Child Care.

Desire Rwodzi was previously a Nutrition Officer for Knowledge Management with UNICEF Eastern and Southern Africa Regional Office (ESARO).

Mara Nyawo is a Nutrition Specialist with UNICEF ESARO.

Mathieu Joyeux is a Nutrition Manager with UNICEF Zimbabwe.

Background

During the 2019 emergency response to Cyclone Idai in Zimbabwe, RapidPro software¹ was used to remotely collect nutrition data in two districts. In 2020, the COVID-19 pandemic limited the delivery of nutrition services and the routine collection of nutrition data. As a result, the Zimbabwe Ministry of Health and Child Care (MoHCC), with technical and financial support from UNICEF Zimbabwe, supported by the Nutrition Cluster, scaled up the use of RapidPro technology to 27 priority districts. RapidPro was intended to fast track the flow of nutrition data from frontline workers to national level, eventually feeding into the District Health Information System version two (DHIS2) system to ensure MoHCC ownership and to avoid duplication. This article describes the process of RapidPro implementation during the COVID-19 pandemic and the lessons learned.

Scale up of the use of RapidPro

Mapping exercise and selecting indicators

Prior to the scale-up of the RapidPro system, a mapping exercise of existing information management systems was conducted by Nutrition Cluster members. This aimed to avoid duplication of efforts, identify areas for potential integration and explore current information gaps. Identified gaps included a lack of near real-time nutrition data for use in emergency responses and a lack of data on the number of children admitted with moderate wasting and those reached with multiple micronutrient powders. A total of 27 districts were then prioritised for implementation of RapidPro based on drought impact according to key nutrition indicators.

High frequency indicators with the potential to provide trend data were selected at health facility and community levels from the routine list of indicators. Data on the status of health facility supplies was also collected. The frequency of collection of these indicators was increased from monthly to weekly during the implementation period.

Capacity building of health staff

The MoHCC and national level partners were already familiar with the RapidPro process and received short refresher trainings supported by UNICEF Zimbabwe. Trainings were then cascaded to priority districts, followed by health facility staff and village health workers (VHWs) using a training-of-trainers approach. Most trainings were carried out before COVID-19 movement restrictions were imposed. After restrictions were implemented, training was carried out via online platforms or, where this was not possible, in person following infection prevention and control protocols. Job aids were developed to assist in the use of the RapidPro system.

Data collection and validation

Once the RapidPro system was deployed, VHWs and health facility staff sent weekly indicator data via short messaging services (SMS) when prompted. Costs were covered at national level by MoHCC with financial support from UNICEF and its donors.

The data flow process (Figure 1) bypassed data analysis and validation at district and provincial levels. Raw data reached national level in near real-time when it then required cleaning, quality checking and analysis. Data was received and analysed by a monitoring and evaluation officer under the nutrition department of the MoHCC and an information management officer at UNICEF. Any incorrect data was passed back to health facilities or VHWs via SMS for checking and correcting. Data validation rules were developed to ensure the quality of reporting and results were regularly shared with interested parties.

Plans are now being made to further develop data validation mechanisms at district and provincial levels. This will improve efficiency by allowing district level staff to directly make changes when data discrepancies are evident.

Figure 1: RapidPro data flow from frontline workers to national level

Results

Reporting on RapidPro started in April 2020 in 655 health facilities and had  increased to all 684 facilities in the priority districts by October 2020. The proportion of health facilities correctly reporting data increased from 13% to 74% during this period.

Over 9,146 VHWs are now registered to provide reports using the RapidPro system. On average, 70% of VHWs send complete and correct responses and continuous district-level follow-up aims to ensure consist reporting.

Screening for wasting in Zimbabwe continued in the COVID-19 lockdown through mother-led mid-upper-arm circumference (MUAC) approaches (also known as Family MUAC). Training of mothers used a cascade approach whereby UNICEF implementing partners trained VHWs. Measurements taken by mothers were reported by VHWs via RapidPro. Over 2.5 million screening episodes² were reported by VHWs between April and October 2020 compared to the 1.1 million episodes recorded during the same period in 2019. Supplies of ready-to-use therapeutic food (RUTF) were closely monitored and only 4% of health facilities reported stock-outs during the reporting period.

According to MUAC measurements, 25,488 children with severe wasting and 91,543 with moderate wasting were reported at community level and referred to health facilities. Of those, 5,596 and 5,768 children were admitted for treatment of severe and moderate wasting respectively. This follows national trends in admissions which dropped in 2020 due to COVID-19 restrictions. The discrepancy between the number of children reported as wasted by VHWs and the numbers admitted for treatment at health clinics (verified using weight-for-height) is being investigated. Reasons likely include the double counting of children and highlight a need for further training and supportive supervision of VHWs.

Discussion and lessons learned

Building on the experiences from the use of RapidPro in the Cyclone Idai response, Zimbabwe was able to restart and scale up the use of RapidPro during the COVID-19 pandemic. This allowed for continuous monitoring of the nutrition situation in the 27 most drought-affected and nutritionally vulnerable districts in Zimbabwe. The Nutrition Cluster was able to monitor disruptions to essential nutrition services in near real-time (weekly), effectively monitor drops in the utilisation of services and support service delivery for children requiring treatment as well as regularly monitoring RUTF stock levels.

The assessment of existing information management systems prior to the implementation of RapidPro was important to avoid duplication of efforts, identify areas for integration and address gaps. Government leadership and ownership of the nutrition information systems was critical and improved communication between the MoHCC and partners. A systems strengthening approach ensured that RapidPro enhanced routine reporting systems and the health monitoring information systems (HMIS) rather than duplicating efforts.  Plans were also put into place to ensure that, in future, RapidPro data automatically feeds into the DHIS2. Capacity building of key cadres at all levels supported system functioning and on-the-job training and supportive supervision were highlighted as essential to facilitate accurate reporting.

The MoHCC National Nutrition Unit is currently restarting the sub-committee on information management, a technical body formed within the Nutrition Cluster, which will oversee the next steps for the RapidPro system. These include efforts to improve data quality in the 27 districts. The automatic link between the RapidPro system and the national HMIS (that uses DHIS2) will be completed before further scale-up.

For more information, please contact Mara Nyawo at mnyawo@unicef.org