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How digitizing the largest voluntary workforce in the world can transform healthcare in ​​Madagascar

(© UNICEF/UN0790142/Ramasomanana) Emilienne during a consultation at her home.

“It’s a way to take care of my community,” says Emilienne, passionately describing her motivation to ​​serve as a community healthcare worker in Saint Augustin, a small municipality in Southwestern Madagascar.

While many of her friends have retired, 70-year-old Emilienne leads the women’s group in her community. Although she struggles with her own health, her youthful eyes light up when speaking about her work. “I usually go to people’s homes just like a friend to do medical check-ups,” she says. “Sometimes I bring them to my place.” She is the sole inhabitant of a two-bedroom house – one bedroom used for living and the other one to see patients. Colorful health information posters hang across a wall. Pinned to it is a calendar and a weekly timetable. Stacks of papers, a calculator and some medical tools are neatly stacked on a small table.

Despite the fulfillment she experiences as a health worker, Emilienne also faces many challenges in her work. One of the most significant obstacles is raising awareness amongst the neighbors to go to health centers. Most people in her community are preoccupied with work, which means that they do not have time to go to health centers to receive vaccinations or treatments. This situation is particularly challenging for children who need vaccinations.

According to this year’s State of the World’s Children, vaccination coverage dropped sharply during the COVID-19 pandemic, leaving millions more children unprotected against some of childhood’s most serious diseases. Millions of children continue to miss out on their most basic vaccines—leaving them vulnerable to vaccine-preventable disease. When families and children are not able to seek the care they need, other community health workers like Emilienne ​must ​go from door to door to inform people about the importance of seeking medical attention including routine vaccines that help prevent outbreaks like measles, whooping cough and pneumonia. About 35 percent of children in Madagascar are zero-dosed children, or children who have not received any vaccines, making it the country with the sixth-highest rate of under-vaccinated children.

Frontline health workers can help children get the protection they need. “I also take children to health centers for vaccinations while their parents work,” she says. This process can be time-consuming, costly, and challenging, particularly for older health workers like Emilienne. ​​

However, digital tools can significantly improve their work. Digital tools can enable them to report to health centers faster and more easily, including the number of cases treated, the medicine used, and general information about patients. ​Workers can notify the entire community at once about available services. ​Vaccine delivery can become more systematic and less cumbersome​ with automatic reminders to the neighborhood​, and health workers can more easily deliver high-quality care and respond to emergencies in hard-to-reach places. “All I would need is training and electricity,” Emilienne says, pointing to two big challenges in the uptake of digital tools.

(© UNICEF/UN0790130/Ramasomanana) Emilienne is the leader of the women’s group in her community. Together, they regularly do awareness-raising sessions and help community members access healthcare.

Thanks in part to support from ​​Twilio, UNICEF launched the Digital Health Centre of Excellence (DICE) to help frontline health workers access digital tools and the training needed to advance care in their communities. Through DICE, UNICEF can provide support to governments in establishing digital health and information system solutions. This includes ensuring equitable coverage of quality health services, such as vaccines, maternal and child health, and nutrition through increased use of data and evidence.

Emilienne believes that digital tools can revolutionize the way health workers operate in her community. Telemedicine, for example, allows patients to consult with healthcare professionals from the comfort of their homes, reducing the need for travel and wait times. This can be particularly beneficial in Madagascar, where many communities lack easy access to medical facilities.

For Emilienne and other health workers, digital tools can also help to reduce the burden of paperwork. Currently, health workers must fill in forms and reports manually, which can be time-consuming and prone to errors. With digital tools, health workers can submit reports electronically, reducing the time and effort required to complete paperwork. Digital records can also translate into ease of access to medical documents and would allow health workers to track medication usage and dosages and ensure that patients receive the correct treatment. This process can significantly reduce medical errors, which can have a detrimental impact on patients' health.

Well-designed digital tools alone aren’t enough to see improvements for community health workers.​​ Madagascar has begun to educate community health workers and UNICEF staff on the implementation of digital health systems. Since the training began in 2022, over 100 staff including frontline health workers received this training.

Emilienne's story demonstrates the critical role that health workers play in communities worldwide. Through the multi-year partnership with Twilio, DICE has enabled the digitization of community health programs not only in Madagascar but also in Iraq and Zimbabwe. This work is essential in improving the health and well-being of communities, particularly in areas where healthcare access is limited. As Madagascar and other countries ​continue​ to invest in their health systems, embracing digital health tools will be crucial to ensuring that all citizens have access to the care they need and deserve.


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