Introducing Notify Health + Nigeria scoping visit report

Welcome to the inaugural Notify Health newsletter! We are thrilled to introduce you to our program and share insights from our recent scoping visit to Nigeria.

Our programme

Notify Health aims to send reminder messages to caregivers about their child's routine immunisations. This intervention excites us due to its strong evidence base, low cost, and potential for technology-driven, large-scale impact. In a few years, we could send reminders to caregivers of millions of newborn children every year across several countries, increasing coverage of crucial immunisations and saving many lives.

We also love the many opportunities for growing the impact of this intervention over time, for example, facilitating uptake of the malaria vaccines as they roll-out, adding information on other important health behaviours, or providing automated, two-way communication.

Here are the key steps we plan to follow:

• Enrolment/Database Creation: We compile a database of children's names, birthdates, and caregiver phone numbers. This is done by photographing paper-based immunisation registers in facilities and manually entering the data into our system. In the future, we see large potential for automating this entry process e.g. using AI-based systems.

• Localised Reminder Design: We craft reminder messages tailored to the local context, including content creation, translation, and recording in local languages. These messages are then sent via the most effective method for each population segment (SMS, automated phone calls, or WhatsApp).

• Automated Messaging: Reminders are sent at the optimal times before a vaccine is due, through an automated, mass-messaging IT system.

We are planning to launch our programme in Nigeria due to the large impact and cost-effectiveness potential from high childhood mortality rates, large population and potentially solvable drop off in vaccinations across the routine schedule.

Roughly every third child that starts the routine immunisation schedule at birth in our focus states drops out in their first 14 weeks of life along the journey to the Penta-3 vaccine. Around 50% of caregivers say this is because of a lack of knowledge or forgetting about the schedule (MICS 2021, p 200/201). These are reasons our intervention is well suited to address.

Co-founders Daniel and Sam with the Kogi Ministry of Health including Honourable Commissioner Dr Abdulazeez Adams

Scoping visit

We spent four weeks in Nigeria to understand the vaccination landscape and identify the best state for launching our pilot program. During this period, we visited Nasarawa, Ogun, and Kogi states. We met with high-level government officials in the Ministry of Health in each state, engaged with six promising local partner organisations that we selected from 56 applications, visited over 20 primary healthcare facilities, and spoke with dozens of mothers and healthcare providers.

Highlights

• Positive Government Reception: The Ministry of Health in each state welcomed us warmly, expressing interest in collaborating on our pilot program.

• Consistent Data Collection: Essential data, such as children's birthdates and caregiver phone numbers, are recorded in the facility paper immunisation registers across the states. The current data quality looks very promising as a starting point.

• First Reminders Sent: In an initial alpha test, we manually called caregivers of children due for immunisations, assisted by primary health center staff.

• Mass Messaging System Testing: We started setting up and testing possible solutions for the mass messaging system, with the first SMSs successfully sent to our own Nigerian phone numbers.

• Affordable SMS Costs: Sending SMS messages in Nigeria is very economical, costing only 4 Naira per message (about ¼ of a US cent), even before bulk discounts.

Example of the national immunisation register used throughout Nigeria which will be the primary source of enrolments for our intervention

Key uncertainties

• Phone Number Quality: The reliability of phone numbers in the registers is uncertain, with issues such as whether the numbers belong to the primary caregiver and potential challenges women face in maintaining consistent contact (e.g. battery, signal).

• Cost effectiveness in areas with lower population density: due to low price of messages, the driving cost of the the programme is in digitising records. We are unsure of the effect of lower density areas on the digitisation costs (e.g. through increased travel time between facilities). The three states we are considering all have population densities <1/6 that of Bihar (the state in India where the non-profit Suvita cost-effectively runs their SMS reminder programme by digitising paper records)

• Defaulter Tracking System: Some healthcare workers told us of an existing robust system where health facilities call caregivers who miss immunisation appointments and follow up in the community needed. However, we are unsure of the consistency and quality of this system.

• Rural Data Collection: Safety concerns prevented us from visiting very rural facilities, so the state of phone number recording in these areas remains unknown.

Co-founder Daniel discussing vaccine supply in a Local Government Area (LGA) coldstore

Next steps

Having returned from Nigeria, we will now consolidate our learnings to decide which state(s) to contract a partner for a needs assessment. This assessment will help address key uncertainties and inform the design of our pilot. Immediate plans include:

• Contract local partner organisations for on-the-ground implementation and obtain ethics approval and memorandum of understanding (MoU) with state(s)

• Design the needs assessment plan including focus group design and interview guides. Also further outline the pilot planned for the end of this year

• Set up an MVP of the mass messaging system ready for beta testing with 50 - 100 caregivers during the needs assessment

Call to action

If you share Notify Health’s vision of a future where all children thrive,

free from preventable disease, you can contribute!

• Volunteering: We are looking for a range of volunteers from those looking to gain experience working in a newly founded organisation to people with expertise designing programmes, M&E approaches and the technical side of SMS/automated voice mass messaging systems. Reach out to info@notifyhealth.org if you are interested.

• Sharing: Please share this newsletter with your network to raise awareness.

• Feedback: Share ideas and feedback about what we do at any time. We always strive to improve!

Finally we would like to thank the team at Charity Entrepreneurship for making Notify Health possible and in particular Samantha Kagel and Steve Thompson. We also thank all of the experts and mentors who have generously given advice with a special thanks to Fiona Conlon and Patrick Stadler.