Executive Summary

There is a high incidence of urinary tract infections (UTIs) among pregnant women in Sierra Leone which often lead to severe kidney damage and spontaneous abortions. Pregnant women are also at risk for a hypertensive condition called preeclampsia. Ukweli Test Strips, with the help of community health workers, enable women in rural communities to be screened for UTIs  and Preeclampsia in the comfort and privacy of their own homes and connect with the healthcare system for treatment. Ukweli test strips are specific, affordable, and accessible. In contrast to nine parameter test strips that cost upwards of 15,000 leones, Ukweli test strips cost 500 leones and are easier to use by community health workers with a primary school education. Ukweli test strips exhibit a clear, instantaneous color change when dipped into an infected urine sample. Over the last three years, UTI (and diabetes) test strips have been field-tested across three provinces of Sierra Leone. With funding from Grand Challenges Canada, Ukweli has studied fourteen different distribution strategies in urban and rural communities based on the season and local livelihoods. Ukweli has demonstrated that (1) people are willing to pay to get tested, (2) with appropriate training, CHWs are able to screen and refer patients, and (3) the healthcare system can integrate this simple but potent innovation to improve maternal health. In addition, with the funding, Ukweli has bona fide on-the-ground operations selling strips to CHWs and is collecting data about distribution and the results of the tests. The goal is to expand into the rest of the country and be designated as a National Essential Medicine. Once adopted as an essential medicine, the venture will be integrated into the government. Leveraging the data and support from the venture in Sierra Leone the adoption of Ukweli test strips will be negotiated in Liberia.

Problem: Maternal Mortality and Healthcare Access

Sierra Leone has the highest incidence of maternal mortality in the world with 1,360 deaths per 100,000 live births. In combination with the high total fertility rate, low use of contraceptives, and exceptionally low physician density (0.02 physicians per 1,000 population) in Sierra Leone, diseases are often untreated and become lethal. A urinary tract infection (UTI) is one such infection that, while easy to diagnose, is often left untreated. In fact, if untreated for an extended period of time, UTIs can lead to a myriad of complications in both daily life and childbirth including maternal mortality, preeclampsia, proteinuria, mother-to-child transmission of syphilis, low birth weights and spontaneous abortion. Access to care is further limited when people need to travel long distances for medical care. Most clinics and major hospitals are located in, and near, urban areas. It is difficult for people in rural areas to reach the primary care facilities, often walking for miles. How can we empower these people with a screening technology and help them make an informed decision to seek out the care they need?

Ukweli Product Line

Ukweli Test Strips for UTIs and preeclampsia screen for three biomarkers in urine: nitrites, leukocyte esterase, and proteinuria. Using a urine dipstick technology, Ukweli delivers a readable and vibrant color change. The choice to reduce nine parameters to three has been integral in keeping costs down without sacrificing accuracy. Ukweli delivers a 92% confidence level for UTI tests as opposed to 98% by the nine-parameter test strips that cost 30 times more, which is acceptable for screening purposes. These strips are manufactured by a partner in China with ISO 9001 and ISO 13485 quality certifications since 2017. Ukweli has successfully imported these test strips into Sierra Leone with local IRB and regulatory approvals.

Distribution Strategy

The test strips arrive in Freetown and are transported to Makeni under the direction of Allieu Bangura, Director of Health Projects for World Hope International, who also handles quality control and regulatory compliance issues. Once in the World Hope Office in Makeni, the distribution employee disseminates the boxes of strips to the peripheral health units (PHUs). These boxes are distributed monthly when all CHWS in their respective divisions attend their monthly meetings at Community Health Centers (CHCs). These boxes contain 50 strips and are sold to CHWs at a price point of 25,000 Sierra Leonean Leones (SLLs) per box so that they can be sold at ~50,000 SLL to turn a small profit for CHWs. The CHWs use their discretion on how much to actually charge community members – their cost price of 500 Leones, for 2,000 leones and earn a small profit, or to give them for free to women who just can’t afford them. The price cannot exceed 3,000 Leones under any circumstances. Depending upon the location, season, income level,  and proximity to the nearest clinic, CHWs use specific last-mile awareness and distribution approaches developed by the Ukweli team. These approaches include going door-to-door, engaging with mother support groups, educating community stakeholders and religious leaders, and marketing via posters at health facilities and community centers. The peer supervisors as well as nurses-in-charge oversee all CHW operations. They provide guidance to the CHWs and support their flexible and autonomous operations while providing oversight.

Human Capacity Building Model

Ukweli educates and empowers CHWs, nurses, and other stakeholders through validated training regimens that were developed in collaboration with community partners. These training materials include not just the appropriate use of the test strips but also topics related to informed consent and ethics to ensure that they offer tests without any coercion or conflicts of interest. These training sessions are led by Ukweli staff in collaboration with local governmental health authorities.

Ukweli Business Model

Ukweli makes a profit of 30,000 Leones for every box of 100 test strips. While the Cost of Goods Sold (COGS) and local distribution expenses can be covered through operations, Ukweli cannot recover operating overheads without making the test strips prohibitively expensive. Training CHWs and other stakeholders, measurement and evaluation expenses, and quality control and regulatory compliance are expensive functions that need donor support. While Ukweli will need donor funds for the first three years of operation, it provides a compelling and proven method to improve maternal health by screening women in their own homes and communities.

Project Progress

Since Ukweli received approval from the Pharmacy Board of Sierra Leone in December 2019, the venture has been operational and selling test strips and collecting data it is possible to quantify the project’s progress. To date, 49 health units have been onboarded with 66 health workers certified and 70 boxes of test strips have been sold. Of 1,227 tests administered to pregnant females approximately 90% have tested positive for leukocytes indicating a high prevalence of UTIs and approximately 38% tested positive for proteins indicating a high prevalence of preeclampsia as well. This information indicates that: 1) there is a high proportion of females who are tested which have UTIs and/or preeclampsia 2) Ukweli test strips distributed to CHWs is an effective system in identifying and testing at-risk individuals. In addition to normal on-the-ground operations, a WhatsApp group to connect CHWs at different PHU locations to each other as well as to the distribution manager, and the Lehigh team has been established. This group provides the team with a better sense of the effectiveness of the venture, and allows the CHWs to share information and insights with one another.

 

Next Steps

By July 2021, Ukweli’s goal is to make the test strips available in clinics, hospitals, and PHUs in five of the most populous districts in Sierra Leone, with a catchment population of 3 million people. Upon successful implementation in the Sierra Leonean Healthcare System, Ukweli plans to expand operations into Liberia. The Family Health Division of the Liberian Ministry of Health and United Nations Population Fund (UNFPA) have expressed interest in supporting a pilot program introducing Ukweli Test Strips Liberia. 

Resources

So far, Ukweli has received $25K from VentureWell to develop the test strip and run quality control tests, $100K from Grand Challenges Canada to conduct a 9-month fieldwork study to determine the best Last Mile Distribution strategy, and $12K through fundraising, with World Hope International matching those funds, that were used to start operations in two Sierra Leone districts.  On-the-ground operations take up a major portion of funds which consists of paying the monthly salary for the distribution manager, monthly transportation and printing costs for training sessions, and the manufacturing/shipping costs for getting the test strips to Sierra Leone. 

 

Ukweli needs 75,000 USD to establish operations across three provinces. 50,000 USD of the funding will be allocated for ground operations in collaboration with World Hope International offices in Makeni and Freetown. 25,000 USD are needed for research purposes to study how the test strips are working and further develop and deploy data collection mechanisms across all the community health facilities. These insights will help us refine operations and iterate towards a training, distribution, and tracking strategy that enables the test strips fulfill their destiny and drastically reduce maternal morbidity and mortality rates in Sierra Leone. Lehigh students in the Inquiry to Impact ecosystem will continue to serve as the intellectual base for this project while World Hope International will serve as the operation base in Sierra Leone.