Step in Safely: Community-Driven Solutions to COVID-19 in Malaysia

An Interview with Dr. Helmi Zakariah, CEO of AIME

When COVID-19 reached Dr. Helmi Zakariah’s home country of Malaysia in January 2020, he was consulting in Brazil as CEO of Artificial Intelligence in Medical Epidemiology (AIME).  A trained physician, public health professional, and digital health entrepreneur, Dr. Zakariah found himself in high demand as the Malaysian government began to mount it’s COVID-19 response. He was asked to return home to his state of Selangor to lead the Digital Epidemiology portfolio for the Selangor State Task Force for COVID-19, and upon arrival immediately began to address the many challenges COVID-19 presented.

Like much of the rest of the world, the Malaysian economy struggled, and local businesses were forced to shut their doors as COVID-19 spread rapidly and governments prepared to respond. What became instantly evident was the urgent need for businesses to reopen and operate safely. In his new position, and with a vast array of skills in digital epidemiology, Dr. Zakariah set out to develop a system that would do just that. The solution: a QR-based contact tracing tool aptly named ‘Selangkah’ or ‘Step in Safely.’

Selangkah presented a seamless method for contact tracing for local businesses, who were able to obtain their own unique QR code and place it at the building entrance for customers to scan. Once scanned by a customer, the only required input field was a phone number, allowing for increased anonymity.

So how does it work? The platform relies on a machine-learning algorithm to sift through all positive COVID-19 cases and identify what is deemed a ‘close contact’. Those individuals are then notified of their exposure and are recommended to be tested. As Dr. Zakariah notes, “with contact tracing, it’s not only about how big your uptake is but how efficiently you sift through all of your data.” 

Despite early resistance from members of the Malaysian government, largely due to skepticism of whether businesses would use the platform, Selangkah was piloted with enormous success. In Dr. Zakariah’s home state of Selangor, the most populous state in the country home to 10 million people, a staggering 7.3 million utilized the system, with over 88.7 million total uses to date. When asked why he thought there was such a successful adoption of the platform, Dr. Zakariah explained that there is precedent for this type of information logging in Malaysia. “If you are visiting a friend in a condominium before you step in, you give your name and contact information for security reasons at the guard house. We just created a digital guestbook that was centralized. That makes it easy to be understood by the community.” All the data is shared with consent and individuals are not continuously tracked.

Upon successful pilot implementation, increased collaboration with the Malaysian government has allowed for the expansion of Selangkah. Not only has the tool been scaled and replicated nationally, but it has been adapted to collect additional safety data. For example, it now has survey capability; when the QR code is scanned a survey appears inquiring about other COVID-19 precautions taking place at that business. Data on mask-wearing, sanitation processes, and more are also now collected. “The idea is not for enforcement, but rather to measure public compliance,” said Dr. Zakariah. Additionally, Dr. Zakariah shares that the decision to scale the tool and utilize it for the purpose of resource allocation is indicative of a larger mindset shift within the government: “We have seen a lot less resistance from the government to new digital health solutions. They are seeing that some things work if you just give it a try.”

Dr. Zakariah ultimately attributes the success of Selangkah to three distinct, yet connected factors – data, cost, and community. “You can’t do this without data” Dr. Zakariah exclaimed, referring to mounting a strategic COVID-19 response. Good quality data that is truly representative of the challenge at hand is essential to allocate resources and take appropriate precautions to stop the spread of disease. Cost was another important element that led to the ubiquitous use of the QR system. “The cost for a shop owner is extremely cheap. It is one piece of paper. All you have to do is go to a website, register, and print a code,” shared Dr. Zakariah.

But perhaps the most important element to the platform’s success was the community-driven approach. “In the early stages there was less intervention by the government, it was really a crowd-sourced, community-driven solution that was later adopted by the government,” Dr. Zakariah said. Empathy and reassurance were essential tools that Dr. Zakariah equipped himself with to achieve local business buy-in, once that was acquired, everything else followed. “When you come up with a solution that is ‘people-centric’ you need to actually go to the ground level, the recipe for success is community first.”

To learn more about Selangkah, visit their Twitter @SELangkah_cvd19

An Interview with Ann Aerts, Head of the Novartis Foundation

As COVID-19 sweeps across the globe and inundates health systems, governments face ongoing pressure to respond swiftly to stop the spread of the virus. While this public health crisis revealed the fragility of many health systems and highlighted weaknesses in governance structures, COVID-19 also shed light on the transformative power of digital health tools. In fact, new opportunities emerged for governments to reshape investment in their digital health infrastructure.

So why has this specific health crisis been a wakeup call for governments on the power of digital? According to Ann Aerts, Head of the Novartis Foundation, it is because this is the first epidemic response that is fully data driven. “COVID has catapulted us into a digital world,” she explains, “and has also brought digital health to the forefront of health and care delivery; even the most skeptical have been convinced that the benefits of virtual care largely outweigh the risks of having in person consultations during the pandemic.” Now more than ever, Ann is seeing a shift in mindset within governments, recognizing the power of rapid access to digital data and its potential to inform better decision-making, health planning, and more appropriate allocation of resources.

While this shift in mindset is critical, for many governments, there remains a gap between acknowledging the power of digital solutions and tapping into their potential to improve health outcomes. COVID-19 made this painstakingly clear – as many governments still rely on paper-based systems for data collection, and a lack of digital literacy remains commonplace – it is extremely challenging for some to meet the digital demands of this crisis.

That is where the Novartis Foundation comes in. As an organization that spent the last decade supporting the adoption and implementation of digital tools, they have been thinking critically about the core components that truly enable a government to increase their health systems readiness to adopt digital and AI-driven solutions. In a recent report developed by the Broadband Commission Working Group on Digital and AI in Health; the Novartis Foundation, Microsoft and other partners provided a roadmap for governments to do just that. According to Ann, it ultimately boils down to having a strong Informational Communication Technology (ICT) national framework, intersectoral collaboration, and visionary leadership. “Health is really a political choice”, says Ann, “it is an opportunity to make digital and AI an essential part of every health system, just as essential as hospital beds are.”

The report highlights learnings from countries around the world, showcases their innovative AI-driven solutions, and guides governments on where to invest resources to transform their health systems and reap the benefits of digital and AI. It goes on to highlight how technological innovation skyrocketed during the pandemic, and spotlights new tools hitting the market. The scope of innovations is expansive – from AI-enabled symptom checker chatbots to systems that leverage real-time big data to produce COVID-19 risk maps – and the reach is far, impacting health and care delivery, and outcomes at all corners of the world.

The Novartis Foundation believes this report is one way to better equip governments with the steps they should take to allow their digital health systems to deliver health and care in the digital era. Transforming these systems will allow for better reaction, not only to respond to the COVID-19 pandemic, but for future outbreak response preparedness. Ultimately, Ann notes, “this COVID crisis highlights the critical role health authorities play to make the right policy and investment choices.”

Low- and middle-income countries (LMICs), given their dual disease burdens, the significant shortage of skilled health professionals and rapid urbanization, likely have the most to gain from AI in health. They also have much to lose; if their governments fail to take the necessary steps to strengthen their data strategies and digital infrastructure, and improve the digital skills of their people, they risk missing key opportunities to tap into impactful digital solutions. 

As the Novartis Foundation continues to promote and share the report findings, they are committed to finding other ways to highlight the role of digital in the COVID-19 pandemic. In partnership with the Harvard Global Health Institute, they hosted an 8-part webinar series that brought together experts from low resource settings to share how they leveraged digital in the fight against COVID-19, and the hurdles faced along the way. Ultimately, the message is simple: “countries need to invest in data and the use of data if they want to improve their populations’ health,” says Ann.

An Interview with Sathy Rajasekharan, Jacaranda Health

When the first COVID-19 cases began to spring up in Kenya, the government quickly responded with an array of infection prevention measures. While travel restrictions and curfews would help reduce the spread of the disease, there was a several-week gap that left pregnant women and new mothers confused on how to navigate care, while the Kenyan government created guidelines on how to safely provide care to those with ongoing needs.

At the same time, providers looked for ways to circumvent the healthcare service disruptions that were making it difficult to communicate with patients and deliver essential services. Fearing that maternal care would become jeopardized, it was clear a solution was needed quickly.

For Jacaranda Health, a non-profit organization that uses digital tools to improve maternal and child health outcomes, it was clear they were well positioned to overcome some of these challenges. Sathy Rajasekharan, Jacaranda’s Executive Director (Africa), explained that prior to COVID-19, the organization was already using a contactless approach to connect new and expectant mothers to care at public hospitals at the right time and place.

One of Jacaranda’s flagship products, the PROMPTS digital health platform, uses an AI-based triage tool to prioritize urgent health-related messages from mothers. These messages are then filtered to clinically trained help desk agents, who identify and refer high-risk mothers for care. Better yet, the platform is integrated into some health systems, enabling the help desk to link women to the care they need, while also alerting the clinics to the incoming patient. 

As these novel needs arose, Jacaranda’s help desk agents were able to adapt and provide mothers with timely responses to their questions. This approach meant that, within hours, mothers obtained a response, and when necessary, high-risk mothers were identified and immediately referred to receive emergency care. Sathy noted that while chatbots are a valuable information-sharing tool, they often serve as a step toward human interaction, rather than replacing it. “A COVID chatbot is a way to get them information quickly, but every mother has a unique question and so we have help desk agents ready to follow-up and provide that unique guidance,” he explained.

In the midst of the COVID-19 pandemic, tools like PROMPTS are more critical than ever. As cases started to spread and healthcare services were still adapting to guidelines and precautions, the over 200,000 users could quickly turn to the platform to get answers to their pressing questions. Sathy explained that as the virus spread, they started to see a new set of questions that were COVID-19 specific, such as  ‘how am I supposed to access services at night?’ and ‘can I deliver at home?’.

For emergency cases, the help desk agents will often call the mother directly and assist them in finding the closest facility to attend. They will also follow-up with the mother in order to verify whether she attended her appointment. In recent months, on average 95% of women who were referred to seek urgent care by PROMPTS did seek care at a facility.

On the provider side, Jacaranda’s Emergency Obstetric and Newborn Care (EmONC) mentorship program, which trains nurses in obstetric care skills, has since transitioned online. The Jacaranda team recognizes that despite the pandemic, the need for training on essential life-saving maternal health skills remains. Virtual platforms have enabled them to continue their work safely, reaching over 120 in-facility EmONC mentors across 70 government hospitals. Sathy recognizes that while there are limits to who the online training can reach, “people are really getting behind these digital solutions, recognizing the need for them, and seeing the potential role they can play in the current situation.”

As COVID-19 continues to disrupt ongoing healthcare provision, it is clear that digital solutions can play an instrumental role in bridging the gap. Now, Sathy says, he is seeing a shift in the acceptance of digital solutions – “there has been a widespread recognition that teleconsultation, telemedicine, telesupport – is incredibly helpful at this time – and so we are seeing an acceleration in people’s responsiveness to test these solutions.” A change in attitude could mean that in the future, barriers to the uptake and engagement with digital solutions could decrease. 

The acceptance of digital health tools has already begun to translate to an increase in demand. This has meant new opportunities for Jacaranda; including a partnership with local start-up M-Shule, a mobile-learning system, to create an e-learning platform for our EmONC mentors; and Health-E-Net, a telemedicine provider, to help to accelerate referrals for high-risk mothers.

While challenges remain in integrating digital health tools into existing workflows, Jacaranda’s success has in large part been due to the unique position they were in when the pandemic hit. Sathy shares, “I think what’s important is that we had the infrastructure present; it was very maternal and newborn health specific, but we adapted that data and data sourcing to be able to respond to more holistic challenges that we were seeing, with the end goal of maintaining essential services for mothers and babies.”

To learn more about Jacaranda Health, follow them on Twitter @Jacarandakenya and LinkedIn