Earlier this year, the beautiful island nation of Kiribati joined the ranks of those battling COVID outbreaks. Until January 2022, Kiribati had recorded only two COVID cases throughout the entire pandemic – an incredible achievement made possible by both its remote location and a robust public health response.

But unfortunately, when the first international flight in 10 months arrived, it brought with it 36 positive cases which inevitably led to community transmission. Acting quickly, the government declared a state of disaster and the island of South Tarawa went into lockdown.

At BES, we had both a long-standing relationship with Kiribati and tried-and-tested tools to help track COVID outbreaks. When the Ministry of Health and Medical Services requested support from neighbours, we were more than happy to join the deployment team including DFAT, WHO, and SPC to respond to the outbreak.

From left to right, Dr Revite Kirition, public health physician SPC, Ms Margaret Leong, infection control specialist SPC, Dr Lamour Hansell, intensivist/anaesthetist SPC, Mr Tociro Kataki biomedical technician SPC, Mr Tebuka Toatu, laboratory specialist SPC, Carla Tolson, laboratory specialist CHS, Aislinn Healy health information systems project manager and registered nurse, BES.

Testing on arrival

Our greatest tool in this pandemic (from the BES toolbox) is our electronic medical record Tamanu. Designed specifically for remote settings in the Pacific like Kiribati, Tamanu is an offline-first system, with syncing capabilities allowing users to work seamlessly in settings with unreliable internet access. It is easy to use on both mobile and desktop, allowing health workers or anyone managing COVID testing to record patient information in a range of settings, including health clinics, testing centres, hotels, and in the field.

Upon arrival, our very own Project Manager Aislinn Healy got to be on the patient end of the COVID testing functionality for the first time. So here is how the process works: when you’re tested, you are given a COVID testing record, lab request ID number, and a QR code to access the result. When the test result is processed through Tamanu (allowing about 24 hours on the lab side), you can follow the link to easily see the result online – saving everyone time waiting on hold to confirm by phone.

Training and building local capacity

Of course, Aislinn wasn’t only visiting Kiribati to get her own COVID tests. Armed with tablets to be distributed amongst labs, and laptops on their way, Aislinn worked with the local teams to conduct training on how to enter PCR test results into Tamanu.

In South Tarawa, the most heavily populated area of Kiribati, PCR tests are being processed at three locations: the lab of the main hospital, a tuberculosis testing lab, and a COVID isolation facility set up in a shipping container donated by New Zealand’s MFAT. Kiribati’s Health Information Unit also designated a Tamanu officer, who was upskilled in all facets of Tamanu’s COVID testing functionality who can troubleshoot issues as they arise and continue training in-country as the rollout continues.

Unfortunately, the impacts of COVID were not limited solely to South Tarawa. To ensure that health clinics in the outer islands were also well-equipped to record tests and monitor outbreaks, Aislinn also travelled further afield to conduct training sessions.

Although getting to North Tarawa isn’t as easy as it looks, our team is familiar with the unique travel systems of the Pacific islands. Travelling on boats and wading through the water, tablets safely in bags, they made it to North Tarawa. Here, they trained nursing and health staff to use Tamanu to record rapid tests and results.

Training in the outer islands is really important, as it allows positive case data to be viewed immediately by the Response Team in South Tarawa. This way, they can make planning decisions in response to accurate, real-time data and offer support to any patients who need referral.

Tracking outbreaks in real-time

In the initial days of the outbreak, the Health Information Unit that provides daily case updates was receiving little to no information from the outer islands. Information coming in from South Tarawa was often a photo of their paper records, sent through an online messaging service, and manually entered into spreadsheets by the Health Information Unit.

Tamanu was able to streamline this process, with data digitally recorded at all COVID testing sites across the country including the main hospital, labs, hotels for new arrivals, and health clinics on outer islands.

Now, that information reaches the Health Information Unit immediately. Not only does that speed up the daily case number updates, but they can now also produce weekly test reports showing analysed data and test positivity rates. These reports make it easier to make informed decisions and direct resources as needed.

The data from Tamanu also feeds into Tupaia, our data analysis and visualisation platform designed for low-income settings. Like Tamanu, Tupaia is open-source and offline-first, making it perfect for disseminating information in places with inconsistent internet connectivity.

On the live maps, decision-makers can see positive COVID cases broken down by district and sub-district. Colour-coded visuals help them to identify outbreaks as they happen, informing their next interventions and planning to prevent future spread of the virus.

Australian High Commissioner and Kiribati Minister for Health farewell the team

As it stands, Kiribati’s first COVID outbreak seems to have been contained. Cases only reached just over 3000, a testament to the rapid and coordinated response by the Ministry of Health. Given the success of Tamanu for tracking COVID-19 patients, we would love to roll out the software to support other patient interactions across the health system – although we hope future COVID outbreaks are few and far between.

To explore the live maps of health systems across the Pacific, visit Tupaia.org

To learn more about Tamanu, our EMR for remote settings, click here

BES is working with the United Nations Population Fund (UNFPA) Pacific Sub-Regional Office (PSRO), to support the ‘Transformative Agenda for Women Adolescents and Youth in the Pacific’. The Transformative Agenda (TA) programme invests in improving sexual and reproductive health in six priority countries: Fiji, Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu.

UNFPA is using Tupaia to build a real-time, regional map of reproductive health services and commodities. In Tupaia, data is coming in from multiple sources to populate visuals showing information important to planning reproductive health services. This allows regional bodies to target services and resources to the areas of the greatest need, with a focus on supply chain strengthening.

The programme seeks to reduce unmet family planning needs in the Pacific, with three identified programme outcomes: increased and improved supply of integrated sexual and reproductive health (SRH) information and services, particularly for family planning; increased demand for integrated SRH information and services, particularly for family planning; and a more conducive and supportive environment for people to access and benefit from quality SRH, especially contraceptive choice.

How does it work?

Every health facility across countries was surveyed initially to provide a baseline level of information on the availability of reproductive health commodities, equipment, medicines, human resources and services. This data was imported into Tupaia and is built upon yearly, when each facility is again surveyed during a National tour.

During these tours, our mobile data collection app Tupaia MediTrak is used to collect updated data from the health facilities, allowing graphs over time to show any progress as to the improvement of services, or to direct where further support would be of benefit. The data can be shown at facility level, or aggregated to give an overall view of how a district or province or country is tracking.

Included in this data collection process is an ongoing import of data into Tupaia on staff training. This includes information on which facilities have had staff attend trainings and what they have been trained on, to help address training gaps where they exist in provinces or facilities to ensure all women have access to a facility with sufficiently trained staff.

On Tupaia, you can see exactly what supplies each clinic has in stock

Through Tupaia, we have data coming into the reproductive health platform about family planning commodity availability for those countries that use the stock management system mSupply (Kiribati, Solomon Islands, Vanuatu, and Tonga) at the national medicines warehouse.

BES also supported the roll out of mSupply at the UNFPA central warehouse in Suva, Fiji. From this warehouse, Pacific Island Countries can order required family planning commodities, and now the warehouse is able to use the forecasting, tender and procurement functions in mSupply to ensure there is always sufficient stock to meet these needs.

What this means is that stakeholders can look at Tupaia and quickly identify the supplies that are available at each health facility across all six countries in the region. One facility may have condoms and IUDs but is running low on emergency contraceptives. Another facility nearby may have plenty of emergency contraceptives, but no services for pregnancy testing and insufficient condoms available.

The availability of country level stock status information from mSupply allows UNFPA to detect regional supply issues, country level supply issues and sub national bottle necks and provide support and advice as required. Next steps for this project include adding live information on the availability of items at the Fiji warehouse to Tupaia, so there is oversight at each country level on the availability of items within the Pacific.

In Tonga, the Reproductive Health team in the Ministry of Health can view the UNFPA reproductive health module described above, as well as other important data they need to support decision making and reporting – all within Tupaia. Tonga uses Tupaia to display Health Information System (DHIS2) data (such as contraceptive prevalence rate), and this data is captured at the facility level using Tupaia MediTrak. We thus have a growing workforce of people becoming adept at using the MediTrak data collection tool and using Tupaia to view a range of health data, so staff need only learn to navigate a single system to collect and view the data they need.

In Kiribati, the physical monitoring and the monthly review of mSupply reports have contributed to increasing the share of health facilities with no stockouts of any contraceptives from 2 per cent in 2019 to 67 per cent in 2020. Not just that, but data indicates the increased use of family planning commodities and a rise in couple-years protection.

The future of reproductive health in the Pacific

The long-term impact this project strives for is greater oversight as to the availability of reproductive health services in each of the participating countries. Countries will be able to use Tupaia to show where, for example, facilities offer family planning services, and where there are gaps in the family planning commodities available to support the offering of these services – and support Ministries of Health to plan to rectify these discrepancies.

The overall aim is to improve service availability to all women living in the 8 participating countries by ensuring they have the commodities, equipment and staff available to meet family planning and reproductive health needs.

Want to learn more about Tupaia? Visit our product page here.

Want to explore the data yourself? Check out tupaia.org

Kiribati’s health supply chain is on the right track – medicines availability has increased by 22% in the last year alone, with the number of urgent orders placed by clinics halving in the last two years.

Graph from our Kiribati dashboard showing medicines availability from July 2018 to Aug 2019.

Increasing visibility and availability of medicine 

Making sure the right medicine is available at the right time for the people who need it most, is what’s at the heart of a good supply chain. In remote island nations like Kiribati, where there are over 105 health facilities across 33 islands, this can be costly and resource intensive. 

Knowing where to direct resources and where supplies are needed is also extremely difficult. Until two years ago, Kiribati tracked all medical supplies from the clinic level using paper order forms and the Ministry of Health had almost no visibility over real-time supply chain issues. 

From late 2017, we began rolling out mSupply Mobile and Tupaia’s health mapping tools in Kiribati, to help address these issues and make the ‘boring’ job of administering health supply chain information easier for the dedicated staff who do it for a living.  

In the last two years, we have implemented mSupply Mobile in 42 facilities and 364 basic facility-level supply chain surveys have been collected: 146 of these have been submitted in the last year alone via crowd-sourcing. These form part of the >30,000 surveys collected using Tupaia across the region since 2017. 

With this information comes power! The power to predict which clinics need supplies and what medicines need to be mobilised, to avoid emergency orders that can be prevented.  

We already knew that we were seeing real success in Kiribati with a 22% increase in medicine availability in the last year (see graph from our Kiribati dashboard above). In the last Financial Year in Kiribati, medicines availability rose from 67.4% (July 2018) to 88.9% (June 2019). 

Reducing the need for urgent orders

Biribo Kararaiti, Head Pharmacist at the Pharmacy Department in Tarawa, also reports that they have simultaneously seen a healthy decline in the number of urgent orders being placed by clinics to the national stores each year.  

Urgent orders are placed by clinics when they run out of stock of important products before they are due to place their next regular order. Urgent orders are problematic for a number of reasons. They: 

• are expensive to fulfil as additional emergency transport needs to be arranged 
• place pressure on national authorities and make quantification more difficult
• increase the workload of pharmacy and warehouse staff, and
• tend to be a proxy indicator of the performance of a health supply chain – a lot of urgent orders suggests a lot of stock-outs at clinics, impacting patients. 

Reducing the number of urgent orders being placed by clinics saves substantial amounts of money and suggests that local systems are improving. 

Urgent orders have reduced from 435 to 226. As a % of the total number of orders placed, they have reduced from 31.70% to 16.47%. 

Improving health supply chains 

We have helped the Kiribati Pharmacy Division reduce urgent orders and improve their health supply chains in several ways: 

• They are able to see live stock levels at each health clinic, so they can get a sense of whether the regular order is accurate or needs to be adjusted.
• Tupaia heatmaps of medicines availability are used to efficiently plan annual tours that focus on the areas with low availability and provide additional training and support to ensure local nurses are managing stock effectively.
• Being able to quickly see which stock is available at nearby facilities, means nurses are able to request urgent items, instead of placing expensive orders to the national store. We know that nurses are doing this using our technology and via the messaging app we have simultaneously implemented to build social networks of health workers across the country. 

We hope to continue working with the Kiribati Pharmacy Division to improve medicines availability and expand the benefits of eHealth to other areas of their system – the results we are seeing are extremely positive. 

To better understand how it works we spoke to our International Programs Manager, Kahlinda Mahoney who recently held training with health workers in South Tarawa last month.  

How is health information collected in Kiribati? 

A monthly survey (called MS-1) is completed by each health facility in Kiribati. It captures information on what type of health cases have been seen over the month and what type of care has been provided by the health facility. 

This information helps the Health Information Unit (HIU) within the Ministry of Health and Medical Services (MHMS) to track the occurrence of disease and monitor instances of care. For example, information collected through MS-1 reporting helps the HIU to track the annual number of births in Kiribati or calculate the rate of diabetes. Without this information, there’s no real accurate way of monitoring health and health care services across the country. 

What are the current challenges with health reporting and data collection? 

Previously, MS-1 forms have been submitted manually, on paper. It can be very tricky, logistically, for the nurses from each of the 106 health facilities across Kiribati’s 84 islands to deliver a paper form. Surveys can be up to 15 pages in length and can take days/weeks to reach the hospital on South Tarawa. Even once the form arrives at the HIU, staff members then enter the details from each page into the MS-1 database. That’s over 1,500 pages of information that need to be manually entered into the database every month! This takes a lot of time, and naturally, it can lead to errors in transcription. 

How does Tupaia’s monthly online survey (MS-1) help streamline the reporting process?  

Now, instead of filling out a form by hand, the nurses in each health facility can simply enter the information as responses to survey questions in the Tupaia app on their facilities mobile tablet. The answers are sent directly to the MS-1 database within the HIU – no transcription is required! This saves time and allows everyone to spend their time on more meaningful tasks than data entry. 

Building and implementing new systems can be challenging. Where there any hardships along the way that you and/or the team had to overcome? 

This project is in its very early stages, so a lot of the challenges still lie ahead. That said, the new system is now live and we have overcome a number of enormous issues already. 

Kurt Johnson (one of our Software Developers) and I worked closely with the HIU to understand their needs to make the transition from paper to electronic forms as seamless as possible.  

One of the major challenges was building the infrastructure within Tupaia MediTrak app to allow survey answers to feed directly into the MS-1 database – this was no small task! Kurt developed the MS-1 form series which is what allows us to visualise the data collected from monthly surveys in within the app.  

There was a scary moment back in April when it looked like the MS-1 integration wasn’t going to be possible – the information wasn’t transferring despite our troubleshooting efforts. In the end we found the culprit! A rat that had chewed through a cable where one of our servers were located. Thankfully, the cable was replaced and we were back on track. 

Who is involved in the pilot and how is it being rolled out? 

Once the technical side of the set up was complete, I came to Kiribati to test the process ‘on the ground’, update the software in each clinic and conduct training on the use of Tupaia to the nurses working in South Tarawa. We had a great training; they were quick to pick up the skills to adopt the new mobile reporting process within the app. 

 Kantabu Moantewa, one of our Data Collection Officers’ helping to roll out MS-1 reporting in Kiribati describes how the pilot is working and what the next steps are. 

“The MS-1 reporting in Tupaia is going really well for us at the moment. We are first piloting the technology within the health clinics in South Tarawa. After using it for two months, we’re finding it saves a lot of time and money that used to be involved with using paper-based forms.” 

Once the pilot project is completed we will be looking to roll out to other islands in the region, including Kiritimati (AKA Christmas Island) and Phoenix Islands (Rakawi). 

www.medqualityassurance.org