Less than a decade ago, approximately three percent of infants born in the Kingdom of Eswatini were human immunodeficiency virus (HIV) positive. Gender inequalities, biases and stigma have led to women shouldering a heavier burden of disease, as women need a husband’s consent to access sexual and reproductive health services. These realities continue to put young women, and their children, at risk of contracting a life-threatening virus – transmission of which, even to unborn and breastfeeding infants, is preventable.
For decades, HIV has threatened the lives of millions around the world. Without treatment, HIV can lead to acquired immunodeficiency syndrome (AIDS), currently the leading cause of death in Eswatini. This small nation, bordered by South Africa and Mozambique, has one of the highest HIV prevalence rates in the world – about 27 percent.
The Government of the Kingdom of Eswatini and the Ministry of Health is actively engaged in projects to reduce the spread of HIV, especially among women and children. Still, as recently as 2018, there were an estimated 23,000 people ages 15-24 were living with HIV. More than 15 percent of the country’s women were HIV positive that year, as compared to roughly three percent of men.
Turning the Tide
In a nation like Eswatini, where most people live in remote, rural areas and seasonal migration for work in neighboring South Africa is common, regular touchpoints between patients and clinicians are harder to guarantee. Without the infrastructure often taken for granted in the First World, client needs and locations may be quickly lost in a sea of paper-based administrative processes.
Recent enhancements to the country’s client management information system (CMIS), as supported by the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) have changed all of that.
FEI Systems served as a proud partner of USAID on the Eswatini CMIS (ECMIS) project from March 2019 to March 2022. Our contributions to the nation’s electronic medical record (EMR) platform helped facilitate greater HIV treatment compliance, reduce the spread of the virus and connect frontline healthcare workers with more than a million clients living even in the most remote areas of the country. All of this was done in support of the nation’s National Strategic Plan (NSP 2018-2022) goals and the Government of the Kingdom of Eswatini’s vision of an AIDS-free generation in 2022.
After three years of our involvement in the project, the CMIS is now actively used at 219 of the national healthcare facilities, both urban and remote, to help facilitate the care of more than 1.3 million registered patients (not all with HIV-positive status). We enhanced the system to allow for the offline upload of data, with an automated sync triggered when internet connectivity is restored. We strengthened security and ensured HIPAA compliance of client data storage. We trained Ministry of Health workers on how to use the system, and linked 93 percent of the national HIV and tuberculosis testing sites to the platform.
“You are showcasing the power of technology to bring services to people. It is a real-world example of the U.S. government’s goal to help drive equity between and within countries by catalyzing investments in infrastructure.”
CMIS 2.X Enhancements and Rollout
With more than 20 years of experience providing health information technology solutions that serve local, state and federal agencies, we have come to understand the true value of data for informed decision making. We also recognize that our clients and partners often require training to know how to access, manipulate and analyze data in an effective way.
The CMIS 2.X, as enhanced by FEI Systems, was rolled out to 219 healthcare facilities in our three-year involvement on the project. This fell short of the targeted 313, because of a lack of infrastructure and equipment. But, for the facilities using the new system, 95 percent of staff showed competency in data input. Our team left a detailed framework for training clients to use the system.
The purpose of the CMIS is to collect, store and manage patient-centered information, including patient identification attributes, demographics, clinical encounter information and observations. But all this must be done with the client’s needs in mind. The system must be able to securely store client identification and treatment data, but also allow certain pieces of information to be shared for reporting purposes.
Key enhancements for the CMIS 2.X included:
- Fingerprint scanning at ART facilities, so access to client records can only occur when client is present
- Application-generated reports and dynamic dashboards for filtering data for required reporting
- Making CMIS HIPPAA compliant
- CMIS interoperability with other healthcare data platforms, including the laboratory information system (LIS), electronic logistics management information system (eLIMS), and International Statistical Classification of Diseases, version 11 (ICD-11)
The CMIS 2.X allows timely, secure access to up-to-date patient information, which plays a vital role in the provision of effective clinical care. To streamline buy-in, and enhance the CMIS in a way that would benefit all key users, we met with frontline healthcare workers and Ministry of Health program staff to best understand their unique needs for an updated CMIS. Ultimately, we trained 3,633 healthcare workers across all four regions of Eswatini on the new system and how to register clients and capture client data. We also administered competency tests prior to CMIS rollout to ensure clinical, and non-clinical staff were prepared prior to a launch.
The CMIS 2.X also improves client communication, adherence to treatment programs and access to medical records. This included SMS text messaging in Siswati and English to clients from healthcare clinics with appointment reminders, announcements or other information.
Prior to our involvement in the project, the CMIS experienced high periods of downtime due to instability of the Microwave during the rainy season. Our scaling up the APN network and reducing reliance on the Microwave network, we were able to reduce downtime on to 1 percent. APN rollout priority was given to CMIS live sites, with targeting of ART sites and high-volume facilities. The use of the APN connection is aimed to improve data quality as it will allow all sites to access the centralized database, real-time tracking and tracing of clients uniquely.
Finally, CMIS Lite, a mobile web-based evolution of the CMIS system, was launched in November 2021. It is expected to improve retention and clinical outcomes for community-based outreach services, as it allows providers to efficiently collect the data needed to inform what health services patients need and manage subsequent care, even in the most remote areas of the country.
COVID-19 and Civil Unrest Disrupt Implementation
In any major project of this scale, there are inevitable challenges and roadblocks to respond to and learn from. In our more than 20 years of experience providing health IT solutions, we have learned to adjust to countless interruptions in implementations for our partners and clients. But the challenges for this project proved as unique as the country we were serving.
Like in much of the rest of the world, the rapid spread of the novel coronavirus, Sars-CoV-2 (COVID19), caused a great deal of uncertainty in the nation, as the government sought to adequately respond to the crisis. Vital healthcare resources were allocated to prevention and treatment efforts, putting implementation, reflection and review activities for ECMIS on hold. Capacity limits also affected training sessions.
By mid-year 2021, as the pandemic started to come more under control, a period of heightened civil unrest put the future of the ECMIS project in jeopardy. FEI staff were forced to hide vehicles and stay out of the field, out of fear for their safety. Equipment used in CMIS functionality was vandalized or stolen during violent riots, and many clinics were shut down during protests. This era of instability had a large impact on our work and slowed the completion of tasks.
Finally, at the start of the project, FEI was contracted for three years of enhancement work on the ECMIS for $12,5586,071. By project end, $10,096,389 had been awarded – a roughly $2.5 million deficit, making fulfillment of the entire scope of work a significant challenge.
Moving On
At FEI Systems, we are honored to have played a role in the successful HIV/AIDS prevention efforts conducted by in Eswatini from March 2019 to March 2022. We made continuous improvements to the country’s CMIS to empower providers to better log, track and manage the delivery of health services to patients, no matter their location. We built systems that keep data secure as it is shared across government departments, expanded network connectivity and trained end-users on how to maximize use of the platform.
Today, more than 3,000 clinicians have been trained on the CMIS and it is being employed at more than 200 health facilities throughout the nation to track care, monitor medications prescribed and taken and record appointments made or missed by clients. This data gives program directors a comprehensive view of compliance to HIV/AIDS treatment programs, thereby informing new efforts to limit the spread of the disease. Our developmental support, as part of our partnership with USAID, has even allowed providers to collect and report treatment data into the CMIS offline, greatly expanding use of the system for frontline healthcare workers in the nation. Additionally, the rollout of CMIS Plus will give providers access to the same CMIS application dashboards in both large, urban medical facilities and community outreach sites.
Our health information technology infrastructure enhancements played a small, though integral, role in the progress the Kingdom of Eswatini has had in the fight against the HIV/AIDS epidemic in recent years. We were proud to partner with USAID to assist the country in making significant strides towards an AIDS-free generation in 2022.
