By Javan Waita, PS Kenya and Martin Dale, PSI
As of early December 2020, Kenya has documented over 80,000 COVID-19 cases, with approximately 1,500 deaths. The COVID-19 pandemic has presented significant challenges to the health system, particularly with regards to upskilling of health workers on how to respond to the new disease. Government response has been primarily focused on ensuring that the public sector is well prepared to curtail the spread of the pandemic. However, given that about 50% of Kenyans seek health care in the private sector, it is critical to ensure that health providers in this sector are also well prepared to manage COVID-19. Population Services Kenya (PS Kenya) and Population Services International (PSI) partnered to take on the challenge of upskilling private sector health workers, with support from Unilever and UKAID through the HBCC Unilever Project a 500M GBP investment which aims to reach over 500 million individuals across 37 countries with critical messages, services and products to prevent the spread of COVID-19.
In pre-pandemic times, PS Kenya and PSI often provided in-person trainings for healthcare workers to update their skills in delivering health services. However, in a world of physical distancing, we had to rethink this model. Working closely with the Ministry of Health, we have designed and implemented a remote capacity building solution using existing digital platforms to deliver certified COVID-19 training to over 1,000 private sector health workers. This solution presents a good opportunity to address the current skills gap associated with COVID-19, but also offers a cost-effective path to broader support of health providers at scale in the long-term.
A familiar remote learning environment
Internet penetration currently stands at 87% in Kenya, with two-thirds of users connecting via smartphones. Nine out of 10 mobile internet 
users in Kenya have WhatsApp.(including the majority of the 3,000 private sector health providers affiliated with PS Kenya), hence this was seen as an appropriate channel to deliver COVID-19 related remote capacity building, targeted at private sector providers more broadly. In order to automate the interactive learning experience, we adapted the official Ministry of Health COVID-19 training curriculum to run using chatbot software, tailored for WhatsApp, hence delivering a learning experience through a channel that is familiar to the target audience. The training was packaged into discrete modules focused on COVID-19 Epidemiology, Infection Prevention & Control, Occupational Health & Safety, and Case Management. Emphasis was placed on training regarding preventive measures aimed at protecting health workers and their clients. The training is delivered in a manner that allows providers to learn at their own pace, interact with audio and visual content, and access online links for further reading. No orientation is required for use of the platform—simply ‘click’ and train.
Target audience reach
The WhatsApp-based remote learning solution was launched in August 2020, with the clickable link to join the WhatsApp platform mainly distributed to private clinics and pharmacy staff affiliated with PS Kenya through WhatsApp groups. At end of November 2020, approximately 2,500 private sector providers had accessed the platform to embark on training, with over 1,000 providers completing the full COVID-19 curriculum, thus receiving a certificate and recognized contribution towards their Continuing Professional Development (CPD) learning hours from the Ministry of Health. Many providers continue to undertake the training. With regards to the profile of the providers accessing the platform, they were equally split in gender, with 80% of them aged between 20-39 years. Eight out of 10 of the providers either Clinical Officers or Nurses, with the rest consisting of medical doctors, laboratory staff, facility managers and pharmacy staff.
Provider knowledge improvement
In order to measure the knowledge improvement associated with the training, providers undertook a pre-test within the platform to determine 
their base level of knowledge on COVID-19 prior to interacting with the learning material. Once completed, they undertook a post-test to establish improvement in knowledge from baseline. As per the illustration (see right), there was a significant improvement in provider performance following the training, with 5 out of 10 providers scoring above 80% following the learning as opposed to 1 out of 10 prior to the learning. We are looking into ways to further strengthen the performance of providers based on their insights and experiences with the app.
“It’s the way to go for now, as it is easy and convenient”
The WhatsApp learning platform also gathered feedback on user experience. We additionally gathered qualitative insights from a sample of theproviders. Feedback on the learning experience has been overwhelmingly positive. Given that ‘time is money’ for these providers working in the private sector, they appreciated the flexible and convenient approach to learning using WhatsApp. One provider expressed: “The platform enables me to learn as I work, unlike other training modalities where we have to leave our facilities for a week and go to learn.” The availability of the course on WhatsApp, a platform providers regularly use to socially connect also contributes to the ease of use— a provider noted “I use WhatsApp for my social communications, it’s easy to learn as you chat with your friends too.”
Based on platform-generated feedback from approximately 250 of the providers who have completed the curriculum, both the training content and learning approach using WhatsApp was well received. Nine out of 10 of the providers offering feedback reported that the training content either met or exceeded their expectations. As per illustration 1, the majority of our providers highly rated the learning approach using WhatsApp. Providers noted an interest for further learning using this approach, particularly on Sexual and Reproductive Health, HIV/TB, Non-communicable diseases, and Maternal & Child Health. In addition, providers appreciated the use of videos, expressing the need for more video-based content to be incorporated into future learning. The main area of improvement cited by providers was regarding the issuing of the certificate, which they felt should have been automated at the end of the training rather than sent at a later date. Some providers also noted that the provision of data bundles would have also been a good incentive to drive participation.
A cost-effective pathway to health provider stewardship and support at scale?
Using in-person training as a comparator, we undertook crude comparative analysis to establish the cost effectiveness of the WhatsApp learning approach (see illustration). The WhatsApp learning approach presents a more cost-effective approach in comparison to in-person training, even when including the platform set-up costs. This is due to the high accommodation, per diem and conferencing costs associated with in-person training. The cost effectiveness further improves once the platform set-up costs have been accounted for. The cost of training each additional provider reduces to approximately $7 for the next 1,000 providers, accounting for WhatsApp transaction costs as well as project management and technical support.
Forward look
Given the positive feedback from providers regarding the learning approach, as well as cost effectiveness, there are plans underway to cascade the training to public sector workers, taking a mixed health system strengthening approach. In addition, PS Kenya and PSI are considering wider use of this approach as a means of scaling stewardship and support across the universe of private sector providers in Kenya and beyond, working in partnership with governments and other stakeholders with a vested interest. This will go beyond COVID-19 related support, catering to all the capacity building needs of providers to strengthen Primary Health Care delivery. We will continue to strengthen the platform based on user insights, furthermore, to undertake further analysis on cost effectiveness to ground the approach. If successful, health providers will have more control of their personal development, as they will be a ‘click’ away from the support they require.
To learn more about PS Kenya’s Digital Health Strategy, click here.
To learn more about PSI’s Vision for Digital Health, click here.
