CommCare Application Proposal for ACCISS Study Nour Al-Sultan Michelle Iovino Bridget Muckian

1. CommCare Application Proposal for ACCISS Study Nour Al-Sultan Michelle Iovino Bridget Muckian Rachana Talekar Meaghan Tetro Spring 2019

2. Introducing Type 1 Tech Group Michelle Iovino Bridget Muckian Nour Al-Sultan Rachana Talekar Meaghan Tetro

3. Executive Summary • Diabetes is one of the most prevalent and costly chronic diseases worldwide. • Insulin has been around since 19221; but access to it remains limited, especially in low- and middle-income (LMIC) countries. • Data on insulin prices and availability remains inconsistent. • Health Action International (HAI) is improving access to insulin worldwide through its Addressing the Challenge and Constraints of Insulin Source and Supply (ACCISS) study.2 To increase access to insulin, HAI has partnered with Type 1 Tech Group, a team of mHealth consultants, to develop a CommCare application to monitor insulin prices and availability in many countries.

4. Background on Diabetes Prevalence and Insulin Access Information includes global context and local contexts within Peru and Tanzania (the initial application adopters)

5. Peru has one of the highest incidences of diabetes globally, with 1,130,800 adult cases and a 5.6% prevalence in 2017.5 Diabetes is a leading contributor to morbidity and mortality The number of people in the world with diabetes was at 425 million in 2017, with a projected rise to 629 million by 2045.3 In 2017, it was estimated that 4 million deaths were directly caused by diabetes3, and diabetes is the 7th leading cause of death worldwide.4 Tanzania had 897,000 incidences of adult diabetes cases in 2017, with a prevalence of 3.6%.6 All types of diabetes are caused by complications with insulin production, which regulates blood sugar. Hyperglycaemia, raised blood sugar, is common of uncontrolled diabetes. Death and serious complications from diabetes can be primarily prevented with access to insulin and blood sugar regulation.4

6. Insulin is essential for those living with diabetes People with Type I diabetes are incapable of producing their own insulin. People with Type II can make insulin, but their bodies don’t respond well enough to it, so they still need supplemental doses.7 Insulin comes in many forms: • Animal, human or artificially manufactured (analogue) • Rapid-acting, intermediate-acting, long-acting, etc.7 Barriers to insulin access include the cost of insulin itself as well as cost of other necessary supplies like syringes or blood glucose test strips: • Peru: 60% of population receives medication through Ministry of Health insurance; other 40% pay OOP in private sector, where insulin is significantly higher in price5 • Tanzania: price for 1,000 IU vial of insulin costs $3.208 (minimum wage ~$50/month9) • Other expenses include syringes and glucometer test strips

7. High prices and limited availability are two of many barriers to insulin access • Organisation for Economic Co-operation and Development countries + = Price Availability Barriers Data on: • Availability of insulin in the public sector11 • Availability of insulin in private sector11 • Availability of insulin in primary care institutions11 • Availability of insulin in private retail pharmacies11 is • Price of insulin drugs originating from the OECD is higher than for those imported from developing countries.10 • Per capita GDP is positively correlated with the unit price of insulin.10 In addition to insulin pricing and availability, barriers include: • Limited competition among Insulin suppliers10 • Insulin tariffs and taxes10 • Patient insurance (high out of pocket payments)10 Many High Limited

8. Little has been done to address barriers to insulin access Existing mHealth initiatives that address global access to insulin: World Health Organization (WHO) Essential Medicines Project Existing Applications & Platforms • Diabetes Self Management Apps14 • Blood Glucose Monitoring Apps14 • Diabetes Prevention Programs i.e Omada Health15 • In 2016, WHO piloted a smartphone/tablet-based app to survey the price and availability of specific medicines in 14 LMICs12 • WHO/HAI Project on Medicine Prices and Availability13 Quantitative and Qualitative Studies HAI ACCISS Study • Provides evidence and guidance related to access to insulin in LMICs via ACCISS toolkit2 • Gives recommendations for stakeholders interested in improving access to insulin2 • Studies, like cross-sectional surveys, of governments, pharmacies, and hospitals have been created and distributed to assess insulin pricing and availability globally11

9. Local Contexts for Mobile Application Adoption Information includes contexts within Peru and Tanzania (the initial application adopters)

10. HAI plans to address barriers to insulin access by piloting its CommCare application in Peru and Tanzania & Data will be collected at the household level in Peru Data will be collected at the health facility level in Tanzania Due to time limitations, Type 1 Tech Group exclusively worked to develop the household level application, although future efforts will be made to develop a facility level application. All app information included is for the household data level app.

11. Peru is accessible for pilot testing at the household level 32.2 million residents16 84% of Peruvian adults own a mobile phone17 58% of males & 47% of females18 More than 80% of rural Peru has access to cell phone network coverage (3G & 4G networks)19 Adoption of broadband internet is low in Peru compared to surrounding South American countries16 • ~50% of households access broadband internet in Lima, utilization even less outside urban areas16 • Limited internet usage is due to lack of infrastructure & high price where it is accessible16 Past successes in development of public health surveillance system based on cell phones to collect data (female sex workers study)20 Basic Phone Usage17 43% Mobile Internet Penetration16 30% 41% Smartphone Usage17

12. Tanzania is accessible for pilot testing at the health facility level 54.2 million residents24 Cell phone ownership in Tanzania is 81% among males & 73% among females29 The major telecom operators include Vodacom, Airtel, Tigo, Halotel, TTCL, and Zantel, Smart. Vodacom has the highest market share24 3G(61%) and 4G/LTE(28%) networks are available24 2G(90%) has the highest coverage in the country24 By December 2018, 43% individuals were subscribed to a mobile tariff or service – i.e. via a SIM card (unique subscribers) with 81% Voice Telecom Penetration among Tanzania’s major Operators25 mHealth projects implemented in partnership with mobile operators include: Vodafone Moyo, Tigo’s CCBRT partnership24 Basic Phone Usage 26 62% Mobile Internet Penetration 24 18.5% 13% 26 Smartphone Usage

13. Comparisons of price crowdsourcing applications available worldwide Global Peru Tanzania 13 registered mHealth apps AhorroMED - Mobile application overseen by Ministry of Health that tracks presence and price of medicines22 C@reNet - SMS reminders to diabetic patients to reduce risk behaviors, test glucose, and adhere to medication23 No digital crowdsourcing for medicine prices and availability previously conducted. Other type of crowdsourcing app: Tigo Kilimo: - Tigo provides market price information weather forecasts for 26 regions of the country through 4 channels: USSD, push SMS subscription, IVR and a helpline24 • In 2016, WHO piloted a smartphone app to survey the price and availability of specific medicines in 14 low- and middle-income countries.28 • The app allowed information to be transferred directly via a global database.28 • Challenges: Limited connectivity to Wi-Fi. 28

14. Our proposed solution: CommCare application to monitor household’s access to insulin price across the world

15. Overview of the CommCare application to monitor insulin price and availability at the household level Application Goals5 Application Uses5 • Surveillance data collection • Providing regular information on insulin prices and availability • Measuring changes over time • Measuring impact of interventions • Providing information to stakeholders and pharmacies • MoH, NGO, or University staff will capture data, collected through phone interviews, about types of insulin found in health facilities in Tanzania and households in Peru • MoH, NGO, or University staff will automate data analysis using the dashboard Conditions for Use5 Primary Actors5 • Distribute study brochures in diabetes clinics at health facilities to enroll participants • Randomly select 40 people using insulin with Type I or Type II diabetes from each study region • App needs to accomodate 400 people (40 people per region, up to 10 regions) • Train data collectors 80% • Ministry of Health (MoH) Staff • NGO or University Staff • Families in Households • Patients in Health Facilities • HAI Team • Trained Data Collectors

16. Use Case for Household Application Identify Region and Groups to be Interviewed Revise Data After Conducting Validation Interviews • Pilot Regions: Peru and Tanzania • Groups: Participants in each region are randomly selected for monthly or quarterly data collection. Frequency of collection depends on individual country’s capacity. Conduct Data Analysis • Examples: • Mean % availability of insulin, per region • Median prices and price range of available types of insulin • Mean % availability of syringes and test strips per region Capture Data from Interviews • Availability of insulin at home • Price of insulin • Place of purchase • Type of Insulin • Brand and manufacturer • Strength (IU) • Packaging Monitor Outcome Measures and Trends • Track changes on insulin price and availability over time through dashboard • Provide feedback to pharmacies on their insulin prices compared to others • Measure compliance with existing price regulations Country’s Data Collectors: • NGO staff • University staff • Ministry of Health staff • Dependent on country’s needs & capacity Buy

17. Application Process Maps

18. Workflow Process Map: actions performed by users and developers

19. High-Level Application Process Map

20. Process maps for each of the application’s six forms were created to better visualize data collection methods at the household level

21. Participant Information: Recruitment Form

22. Participant Information: Remove Participant

23. Household Data Collection 1: Visit Registration Form

24. Household Data Collection 1a: New Respondent Info

25. Household Data Collection 2: Insulin Availability and Price

26. Household Data Collection 3: Syringe Availability

27. Household Data Collection 4: Availability of Glucometer Test Strips

28. Household Data Collection 5: Blood Glucose Level Monitoring

29. Application Demonstration

30. User Guide document demonstrates how to access and use the application step-by-step

31. Two dashboards will be utilized to monitor key indicators by: 1. Health Action International 2. Individual Country Leadership Dashboards

32. HAI will utilize one dashboard that monitors global-level data to show trends over time • Users: Health Action International researchers • Monitor trends in insulin price/availability in countries around the world • Data source: survey data collected by country-level enumerators and exported from CommCare HQ • Decisions: inform local government officials or international policy makers about issues around insulin • KPIs: • Cost per one insulin unit over each quarter • Total consumption of insulin by brand, manufacturer, type, originator/biosimilar • Ex. Average of 5,000 units of originator insulins present in Peruvian households between 2016-2017. • Total average number of insulin delivery type present in households each quarter in one year • Ex. Average of 600 participants used insulin pens in quarter 2 of the year 2016.

33. *To be updated quarterly* Slicer allows user to choose indicators displayed on total insulin types graph Total consumption of insulin types by country. The indicator displayed can be changed via the slicer on the right. Total number of data points collected for each country Average Insulin Price for Households by Country Total types of insulin delivery methods used worldwide

34. Countries will utilize another dashboard to monitor individualized data to show trends over time • Users: Ministry of Health researchers in any one specific country • Monitor trends in regional pricing and availability in their own country • Data source: survey data collected by country-level enumerators and exported from CommCare HQ • Decisions: guide regional/country-wide policy and allow local researchers to engage and collaborate with HIA • KPIs: • Average insulin price per 10 mL of 100 IU (in USD) by region • Brands available in-country • Individual manufacturer market share percentage • Reasons for lack of availability

35. Regional Insulin Trends for Country X Each manufacturer’s market share in country Average insulin price for each region *To be updated quarterly/monthly* Slicer allows user to view insulin brands for region/entire country Slicer allows user to view reasons for region/entire country Slicer allows user to view insulin brands for region/entire country

36. End Game Strategy Plan for scalability and sustainability

37. Application will be scaled up to be present in all LMICs across the world • Adopted first by NGOs or Universities within a country. • NGOs /Universities will advocate to their country’s Ministry of Health. • App users are identified through existing partnerships with the ACCISS study. • Adoption by Ministry of Health will ensure long-term sustainability. Data from pilots will be used to demonstrate value • We suggest supplying materials or other forms of support to these NGOs in how to use the data for advocacy • Considerations made to ensure long-term sustainability: • 40 respondents per region with data collected via phone instead of in person, so there is less demand • No funding provided by HAI that needs to be replaced (with the exception of the current pilot countries) • Ability to have the app translated into local languages

38. Factors that will facilitate the scale up and sustainability of our app Resources: Internet Personnel Training Partners & Stakeholders: HAI MoH Pharmacies Insulin Manufacturers NGOs and Universities Health Outcomes: Indirectly increase access to insulin worldwide to improve diabetes outcomes

39. To log in to the ACCISS Household Data Application: Application Barcode: Application Code: Username: Gh804test Password: Type1TechGroup 2VWbFoo

40. Index Background on diabetes prevalence and insulin access…………………………………………………..4 Demonstration……………………………………………………………………………………………..29 Executive Summary……………………………………………………………………………………………2 Local contexts for mobile application adoption…………………………………………………………...9 Login information…………………………………………………………………………………………….36 Overview of application……………………………………………………………………………………..14 Process maps………………………………………………………………………………………………….17 References………………………………………………………………………………………………….38

41. References • The British Diabetic Association. (2010). First use of insulin in treatment of diabetes on this day in 1922. https://www.diabetes.org.uk/about_us/news_landing_page/first-use-of-insulin-in-treatment-of-diabetes-88-years-ago-today. Accessed April 7, 2019. • Health Action International. (2019). About ACCISS. Retrieved from http://haiweb.org/what-we-do/acciss/about-acciss/. Accessed April 7, 2019. • International Diabetes Foundation. (2017). Diabetes facts and figures. https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. Accessed March 20, 2019. • World Health Organization. (2018). Diabetes. https://www.who.int/en/news-room/fact-sheets/detail/diabetes. Accessed March 20, 2019. • Health Action International. (2019). Monitoring Household Availability and Price of Insulin (In Peru). • International Diabetes Foundation. (2017). IDF Africa Members: Tanzania. https://www.idf.org/our-network/regions-members/africa/members/27-tanzania.html. Accessed March 20, 2019. • American Diabetes Association (2015). Insulin basics. http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/insulin/insulin-basics.html. Accessed March 19, 2019. • Health Action International (2016). Insulin prices profile. http://haiweb.org/wp-content/uploads/2016/04/ACCISS-Prices-report_FINAL-1.pdf. Accessed March 19, 2019. • World Health Organization (n.d.). Tanzania making steady progress in access to essential medicines and health products as new challenges emerge. https://www.who.int/medicines/about/country-stories/tanzania-overview/en/. Accessed March 19, 2019. • Helble, M., & Aizawa, T. (2016). International trade and determinants of price differentials of insulin medicine. Health Policy and Planning,32(1), 1-10. doi:10.1093/heapol/czw085. Accessed March 17, 2019. • Liu, C., Zhang, X., Liu, C., Ewen, M., Zhang, Z., & Liu, G. (2017). Insulin prices, availability and affordability: A cross-sectional survey of pharmacies in Hubei Province, China. BMC Health Services Research,17(1). doi:10.1186/s12913-017-2553-0. Accessed March 17, 2019. • World Health Organization. (2016). Surveying insulin availability and pricing: Vital to treating diabetes. https://www.who.int/medicines/areas/access/webstory_diabetes/en/. Accessed March 17, 2019. • Beran, D., Ewen, M., & Laing, R. (2016). Constraints and challenges in access to insulin: A global perspective. The Lancet Diabetes & Endocrinology,4(3), 275-285. doi:10.1016/s2213-8587(15)00521-5. Accessed March 17, 2019. • Healthline. (2018). Best Diabetes Apps of 2018. https://www.healthline.com/health/diabetes/top-iphone-android-apps. Accessed March 17, 2019. • Omada Health. (2019). Digital Therapeutics for Chronic Disease | Omada Health. https://www.omadahealth.com/. Accessed March 17, 2019. • World Bank. (2017). Population, total | Data. https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PE. Accessed April 7, 2019. • Poushter, J., Bishop, C., & Hanyu, C. (2018, June 19). Social Media Use Continues to Rise in Developing Countries. https://www.pewglobal.org/2018/06/19/2-smartphone-ownership-on-the-rise-in-emerging-economies/. Accessed March 25, 2019. • GSMA Connected Society & Connected Women. (2017). Accelerating affordable smartphone ownership in emerging markets (p. 21). https://www.gsma.com/mobilefordevelopment/wp-content/uploads/2017/07/accelerating-affordable-smartphone-ownership-emerging-markets-2017.pdf. Accessed March 18, 2019. • GSMA Intelligence — Help — Technologies, families & generations. (n.d.).https://www.gsmaintelligence.com/help/74/. Accessed March 18, 2019. • Curioso, W. H., Karras, B. T., Campos, P. E., Buendía, C., Holmes, K. K., & Kimball, A. M. (2005). Design and Implementation of Cell-PREVEN: A Real-Time Surveillance System for Adverse Events Using Cell Phones in Peru. AMIA Annual Symposium Proceedings, 2005, 176–180. Accessed March 18, 2019.

42. References (cont’d) 21. GSMA. (n.d.). mHealth Tracker. https://www.gsma.com/mobilefordevelopment/m4d-tracker/mhealth-deployment-tracker/. Accessed April 7, 2019. 22. Herramienta para consultar precios de medicamentos. (n.d.). https://www.gob.pe/552-herramienta-para-consultar-precios-de-medicamentos. Accessed March 25, 2019. 23. Fogarty International Center. (2012, February). Managing diabetes with mobile health tools in Peru. https://www.fic.nih.gov/News/GlobalHealthMatters/jan-feb-2012/Pages/mhealth-diabetes-manage.aspx. Accessed April 7, 2019. 24. GSMA Intelligence. (n.d.). GSMA Intelligence - Research - Digital transformation in Tanzania. https://www.gsmaintelligence.com/research/2019/03/digital-transformation-in-tanzania-the-role-of-mobile-technology-and-impact-on-development-goals/742/. Accessed April 6, 2019. 25. TelCom_Statistics_December_2018. Tanzania Communication Regulatory Authority. www.tcra.go.tz/images/documents/telecommunication/TelCom_Statistics_December_2018.pdf. Accessed April 6, 2019. 26. Silver, Laura, and Courtney Johnson. (2018). Basic Mobile Phones More Common than Smartphones in Sub-Saharan Africa.” Pew Research Center's Global Attitudes Project, Pew Research Center's Global Attitudes Project. www.pewglobal.org/2018/10/09/majorities-in-sub-saharan-africa-own-mobile-phones-but-smartphone-adoption-is-modest/. Accessed April 6, 2019. 27. Ewen M, International HA, Kaplan W. Prices and availability of locally produced and imported medicines in Tanzania Report of a survey conducted in August 2013. 2016;(December). 28. Surveying insulin availability and pricing: vital to treating diabetes. World Health Organization. https://www.who.int/medicines/areas/access/webstory_diabetes/en/. Published August 30, 2016. Accessed April 30, 2019. 29. GSMA(n.d)The Mobile GEnder Gap Report 2018 Retrieved from https://www.gsma.com/mobilefordevelopment/wp-content/uploads/2018/04/GSMA_The_Mobile_Gender_Gap_Report_2018_32pp_WEBv7.pdf