The journey to national scale of Zanzibar’s digitally enabled community health program: an implementation report (Preprint)

BACKGROUND While high-quality primary healthcare services provided can meet 80-90% of health needs over a person’s lifetime, this potential is severely hindered in many low-resource countries by a constrained health care system. There is a growing consensus that effectively designed, resourced and managed Community Health Worker (CHW) programs are a critical component of a well-functioning primary health system, and digital technology is recognized as an important enabler of health systems transformation. OBJECTIVE In this implementation report we describe the design and roll-out of Zanzibar’s national, digitally enabled community health program. METHODS Since 2010, D-tree International has partnered with the Zanzibar Ministry of Health to pilot and generate evidence for a digitally enabled community health program, which was formally adopted and scaled nationally by the government in 2018. Community Health Workers use a mobile app which guides service delivery and data collection for home-based health services, resulting in comprehensive service delivery, access to real-time data, efficient management of resources and continuous quality improvement. RESULTS The Zanzibar government has documented increases in health facility deliveries among pregnant women and reductions in stunting among children under-five since the community health program has scaled. Key success factors included starting with the health challenge and local context, rather than the technology; utilization of data for decision-making; and extensive collaboration with local and global partners and funders. Long-term sustainability has been a key focus of the program since its inception, and the Zanzibar government and D-tree are currently implementing a transition plan to enable full government ownership and financing by 2026. CONCLUSIONS Jamii ni Afya represents one of the world’s first examples of a nationally scaled digitally enabled community health program. This article outlines key successes and lessons learned which may have applicability to other governments and partners working to sustainably strengthen primary health systems.