Context

As a baseline, the experimental work propagates evidence for development intelligence influencing the strategic visioning, steering designs and implementation of projects and programmes. More so, vigorous, untidiness and the unknown nature of results is what makes experimental work exciting. The experiment has attributes with ambivalent reactive insights advocating and sometimes imposing the need for review on each iteration prior to experiment scaling. However, same insights may initiate and develop an evidentiary argument to end an experiment progression, particularly if non-positive emerging results are observed against the set learning questions.  In many cases when an experiment scales, not all three dimensions of scaling are easy to achieve simultaneously. These dimensions are scaling-up, scaling-out, and scaling-deep, and these prospects normally form an integral part of innovation lifecycle. 

Reflecting on the Bophelo-Ka-Mosebeletsi (BKM) [1]mobile application developed by the Lesotho Accelerator Lab under COVID-19 Response Initiative in 2020, it is aways inevitable to analyse pathways to scaling experiments to fine-tune the supporting foundation for sustainable scaling. While it is essential to prepare the environment for conducive scaling, sometimes rapid changes on set learning questions derives a dynamic hypothesis, redirecting outcomes towards unforeseen scaling elements, which may eventually yield a weak foundation for sustainable scaling.

On a contrary, scaling Bophelo-Ka-Mosebeletsi (BKM) mobile application experiment attained an intended framework for voluntary scaling of the experiment by the implementing partners and beneficiaries. The entry point for the experiment was mainly to address issues of data for surveillance and disease control in communities. This included designed learning streams hypothesized through testing possibilities of utilising digital platforms at community level, leveraging on traditional Village Healthcare Workers programme. At the immediate strategic level, the experiment unearthed insights for key achievements including strengthening the government e-health and data strategies; provision of evidence for policy revision on segments of programme management, recruitment processes and the possible conversion of Village Health Workers into formal human capital within Ministry of Health.

Preparing the Environment for Scaling

Guided by the Strategy to Scale Social Innovation for Development [2] developed by the Accelerator Lab Network in partnership with Columbia University’s School of International and Public Affairs (SIPA), the emphasis to tackle development challenges from multiple and different angles is a precast to envision scaling, particularly when addressing complex issues such as the COVID-19 pandemic. The strategy also outlinesthe guidelines and recommendations to Accelerator Labs on scaling social innovation under four different sections: envisioning scale, providing supportive ecosystem for scaling, resources for scaling, and learning from scaling. Applying this toolkit helps to realise better and impactful outcomes beyond experimentation period. A more robust reference is also made from the interpretation obtained within Uganda Accelerator Lab’s publication,  “scaling social innovation for development” that highlights the importance of  environment preparedness for social innovation uptake and sustainability. 

To prepare the environment for BKM experiment, the Lesotho Accelerator Lab created a fulcrum of partnerships to secure the balance and the enduring support on the experiment uptake and sustainability. The Lab contributed less than $10,000 for the whole experiment from its resource pool, and this was complemented though the package of partnership support, including the following:

•  World Health Organisation (WHO) – As the custodian of the health mandate, WHO was the UN Lesotho’s focal point to the Ministry of Health for all health-related interventions emanating from the UN. The agency’s role was to prepare a playground and identify entry points for BKM digital solution on the already volatile implementing landscape during the pandemic. 

•  United Nations (Joint COVID-19 Response Project) – The Lab obtained further support from the joined UN Lesotho COVID-19 response funded under MPTF. Besides procurement of healthcare equipment and accessories, 1081 gadgets for BKM deployment were also acquire, of which 682 of the gadgets were used to train and allocated to Village Health Workers in Quthing and Mokhotlong districts. The remaining 399 gadgets are currently being used to expand the scope of BKM deployment, enrolling and training Village Health Workers Coordinators in Maseru and Leribe districts.

•  Econet Telecom Lesotho (ETL) – The mobile network operator provided free mobile network and internet access by zero-rating all traffic from BKM hosting infrastructure and all content access devices. The offer was during the experiment and beyond, as the experiment is currently being scaled under similar arrangements. UNDP penned a long-term agreement with ETL to execute this effect and the arrangement also includes other digital platforms supporting community data and reporting challenges which UNDP Accelerator Lab has developed. In addition, 1081 gadgets were procured through ETL assistance, with 25% discount off on the original selling price. The discount was also ETL’s contribution to support UNDP’s COVID-19 response based on the working MOU agreement which includes zero-rating of BKM application.

•  National University of Lesotho (NUL) – The Lab partnered with software developers from NUL to design and develop proof of concept from scratch. The NUL team in collaboration with software development capacities inherent within the Lesotho Accelerator Lab developed a working prototype which was later improved and used as an experiment in partnership and under the guidance of the  Ministry of Health.

Outlining the Three Dimensions of BKM Scaling (Scaling-Up, Scaling-Out, Scaling Deep)

a) Scaling Up: “Which involves institutional and policy changes to further the innovation”

•  Incorporation of community health element within National Health Strategies - BKM provided evidence for possible use of digital technologies by Village Health Workers, and the insights harvested from the two pilot districts of Mokhotlong and Quthing indicated high appreciation on the use of digital technologies by the Village Health Workers. This highlighted the significance of community health data for incorporation into broader ministerial guiding frameworks, encouraging a course of revision on the existing e-Health Strategy (draft) to incorporate the community health elements with specifics to the Village Health Workers unit’ activities within communities.

•  Revision of Village Health Workers recruitment criteria within Primary Healthcare Policy - To align with insights of the experiment, Ministry of Health revised the Primary Health Policy that governs implementation of Village Health Workers unit. The policy strengthens aspects of programme management, the recruitment process with review of entry academic requirements for Village Healthcare Workers from “No Education requirement” to a minimum of “Grade-10 or Form-C”.  Other sections that were reviewed under the policy included the age requirement, reducing it to 65 from no age limit. Additionally, the observation from rolling out the experiment was that some Village Health Workers profiles did not suit the capacity to utilise digital technologies e.g., Some Village Health Workers were over the age of eighty (80), with no formal education and digital skills, while some had eye health challenges due to advanced age. 

•  Strengthening Human Resource Management Component– Since the Primary Healthcare Unit did not have proper documentation of Village Healthcare Workers, it was difficult to trace communities that had active and non-active Village Healthcare Workers. The Key Performance Indicators used to collect evidence on BKM digital platform ensured that Ministry of Health has evidence of day-to-day activities performed by Village Healthcare Workers, ensuring that stipends are paid to the right personnel, efficiently.

•  Development of new policy prospects – BKM experiment insights encouraged proposal to develop the Community Health Strategy and Policy. The proposal forms part of the scale-up in collaboration with UNICEF, where the ministry has endorsed BKM as the ultimate Community Health Information System (CHIS) integrated into District Health Information Software 2 (DHIS2) to cover all community-based services. The new policy will come with controls to ensure that all development partners collaborate and utilise BKM as the unified community-based digital tool for data collection and analysis. This implies that all development partners in the health sector have to merge efforts earmarked for digital support in community. Any new proposals on digital developments at community can only be for the review of existing digital needs, advocating for updates or upgrades of the existing BKM platform.

•  Leveraging on Digital Public Goods Alliance as Guided by UNDP Digital Strategy – As the Lab scales BKM digital platform, sustainability, performance, and security play an integral role to ensure smooth implementation and improved user experience and acceptance. The application is currently under development from 2023 till 2024 to incorporate all community health activities. The new BKM digital platform is now being developed over Open-Source Smart Register Platform (OpenSRP)[3] architecture, designed to support health systems delivering Reproductive Maternal Newborn Child Health + Adolescent Health (RMNCH+) services with community-based outreach. OpenSRP is one of the solutions listed under Digital Public Goods Alliance, and leveraging the new BKM mobile application on OpenSRP architecture will not only solve security and scalability issues but will also improve interoperability requirements with the national e-health database, District Heath Information System (DHIS2). The Lesotho Accelerator Lab also anticipates reflecting the Lesotho community health landscape onto the new version of BKM, and the outcome will be shared as an open innovation to the open-source community, enabling other countries with similar health landscape attributes as Lesotho to utilise the new open platform.

b) Scaling Out: “Which includes achieving greater numbers through adoption of the innovation”

•  Increased number of Village Healthcare Workers using BKM digital platform - There is a network of around 9,265, (Village Health Workers Verification report, 2020) Village Health Workers in the country, inclusive of Supervisors and Coordinators.  From this number, UNDP enrolled and trained 682 Village Health Workers on BKM from the Mokhotlong and Quthing districts. With new collaboration with UNICEF, additional 800 Village Health Workers will be trained and allocated gadgets from Maseru, Leribe and Mohale’s Hoek districts. Plans are underway in collaboration with World Bank to expand training of Village Health Workers nationwide covering all ten districts of the country. 

•  Increase in the number of healthcare facilities – The initial pilot stage of the application covered 11 healthcare facilities in two districts of Mokhotlong and Quthing. With the new rollout plan outlined by the Ministry of Health, this number will increase to include all 274 healthcare facilities in the country, through partnership with UNICEF and World Bank. From this, additional 230 Village Health Workers’ Coordinators from nine districts will be trained, with exclusion of Village Health Workers from Maseru district already trained earlier in 2023. This training will be followed by national training of all 9,265 Village Health Workers in the country, excluding the already trained Village Health Workers Coordinators.

•  Increased number of functional modules incorporated into BKM digital platform – In the pilot phase, BKM ran a single COVID-19 Surveillance and Disease Control Module for data collection and analysis. The new platform will incorporate more than ten (10) functional modules including the Village Health Workers Programme Management module, Village Health Workers Household Register, Village Health Promotion Logbook, Community Health Register, Village Health Workers Registry, Under-Five Register, Maternal Health, Village Health Workers Stock Card Manager, Combined COVID-19 and TB Detection register, Nutrition and environmental Health, Risk communication and community engagement (RCCE) for COVID-19 and other health related issues.

•  Increased partnership base to support BKM uptake – With additional partnerships mobilised including UNICEF and World Bank in the year 2023, BKM is the pride of Lesotho Accelerator Lab as the most successfully scaled experiment with support from wider collaborative effort. The two organisations form part of the already established partnership-base, and more partnerships are envisaged to be mobilised after the endorsement of reviewed Primary Health Policy that has identified BKM as the de facto Community Health Information System (CHIS) for all community health related activities within Ministry of Health.

c) Scaling Deep: “Which is impacting culture through innovation that alters behaviours and norms, or a combination of all or some of the types of scaling”

•  Ownership, sustainability and building internal capacities – The new software development exercise took into consideration sustainability needs to ensure that technical level teams are well capacitated and own the solution. To achieve this, all Ministry of Health’s ICT staff were engaged in the software development exercise of BKM digital platform, working with experienced developers from National University of Lesotho. The decision seeks to achieve skills transfer to the Ministry’s technical personnel and further improve take-up of the solution, even upon non-ICT units within Ministry of Health. The ministry has expressed the need to adopt this practice with a possibility of including it within its guiding frameworks.

•  Enabling social interactive platforms to enhance Village Health Workers digital skills – The controversial part of the experiment’s requirement was also to allow Village Health Workers to use the allocated gadget for personal use, including engaging in social medial and internet. While this was intolerable from the ministry’s side initially, the Lesotho Accelerator Lab believed that this aspect would help to improve Village Health Workers’ digital skills set by exposing them to various and interesting digital platforms to diffuse technology intimidation. The ministry believed that uncontrolled use of the gadget will dilute outcomes of the objectives with substandard work from Village Health Workers. With the average age of about 56 years for all Village Health Workers trained in the first cohort in Quthing and Mokhotlong districts, and with careful consideration to only 10% of Village Health Workers below 40 years, and a hefty 40% that was above age of 55 with no prior record of interacting with digital activity, opening the gadget for further frequent technology practice assisted in sharpening their thinking and appreciation of technology use. While BKM took into consideration the need for human centered design approach to use colour themes denoting interface elements, other techniques were also used to influence digital inclusion to accelerate the solution acceptance by beneficiaries.

•  Financial Inclusion Sensitisation – While this was not the primary intent and the objective of the experiment, KPIs were developed to measure this dimension. Village Health Workers were allowed to utilise Econet Telecom Lesotho’s provided sim-cards to access financial products provided over mobile money platform, Ecocash, to transfer money and pay bills. In addition, Ecocash also provides products for community saving schemes as well insurance (Ecosure). Upon assessment and data analysis, 35% of Village Health Workers reported to have been engaged in mobile money financial activities within the period of six months after training on BKM platform.