Supporting LIFE in Malawi

In developing countries, most of the 11 million deaths per year of children under the age of five years occur in areas where adequate medical care is not available. With nearly 80% of the population living in rural areas, access to skilled healthcare is one of the major obstacles facing developing countries such as Malawi. 

While first-level facilities (ie. local health centres) are commonly used, they are generally run by community health providers who tend to have limited medical training, but are expected to manage the vast majority of primary care for these populations. Thus, the absence of skilled health providers is a major contributory factor to the high child mortality rate in Malawi, where the under-five mortality rate is 133 per 1,000 live births. 

Management of childhood illness 

To support these frontline workers, the WHO and UNICEF developed the Integrated Management of Childhood Illness (IMCI) guidelines in the mid-1990s as a strategy to reduce morbidity and mortality from common and potentially serious childhood illnesses such as malaria, pneumonia, infantile diarrhoea with dehydration, meningitis and sepsis. The strategy has now been adopted by more than 100 countries. The IMCI strategy involves a stepwise and structured approach to the assessment and management of children presenting with acute illness in developing countries. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities.

Even in facilities where IMCI guidelines are in use, there are issues with the implementation. In many cases, community health workers use IMCI guidelines to assess presenting symptoms but do not implement the guidelines comprehensively. For instance, one study reported that only 12% of observed health workers assessed the general danger signs in every child. Disconcertingly, less than half (47%) of children with severe classifications were correctly identified. 

Misclassification of children with severe infections who either need immediate treatment (eg. with antimicrobial or antimalarial therapy), or who need referral to higher level healthcare facilities (eg. the local hospital) is a major problem for healthcare systems in countries such as Malawi. Also, people may not present when unwell in settings with limited resources and expertise. For example, pneumonia is a leading cause of death of young children but only 20% of children in Malawi presenting with symptoms of acute respiratory infection and/or fever were taken to a clinic, a recent study found. Incorrectly identifying children as having a serious illness when in fact they only have a minor or self-limiting illness results in inappropriate use of scarce medications, and personal and health service costs. 

Single disease approaches pose a challenge in low resource settings. Children may present with multiple problems and it is important that the healthcare worker is provided with the means to detect and manage multiple problems simultaneously. 

The move from a vertical, disease-orientated approach to a horizontal, child-centred approach was initially realised in the development of the IMCI guidelines. However, the complexity of IMCI is, in part, limited by its paper-based approach and the need to refer to relatively complex paper-based algorithms in settings where large numbers of people may be seen every day, with limited support.

Supporting LIFE initiative

The Health Information Systems Research Centre (HISRC) is a multidisciplinary centre in UCC. It was established in 2009 and builds on the growing synergy between information systems, technology and healthcare. Translational research within the HISRC investigates how technology integration, social factors, organisational structures and business processes affect healthcare services.  Recently, the HISRC has secured EU FP7 funding for a project entitled ‘Supporting Low cost Interventions For hEalth (LIFE)’ that will use mobile phone and sensor technology to improve primary healthcare for young children with acute illness in Malawi.

The Supporting LIFE initiative was developed and is being led by researchers in the HISRC. It involves a number of Malawian and European partners who each bring unique skills to the project. The Malawian partners involve Mzuzu University, Ungweru, a local charity dedicated to community work, and Luke International Norway, a charity involved in establishing information technology solutions in Malawi. European partners are Lund University in Sweden and Oxford University. 

Mobile phone-based system

Africa now has more than 650 million mobile phone subscribers – more than either the US or the European Union. Since 2000, the mobile phone market has grown almost 40-fold. Simultaneously, the development of low cost sensors for vital signs (ie. heart rate, breathing rate, temperature, blood oxygen levels) and sustainable power initiatives is on the increase, which allows extension of these technologies to low resource countries to aid healthworkers with limited training to objectively assess ill children. 

The Supporting LIFE project will develop and trial a mobile phone-based system of managing acutely ill children in Malawi, using a decision support system based on the IMCI. This will be combined with low cost sensors for heart rate, respiratory rate, temperature and pulse oximetry.  Using this system, a healthcare provider will assess a child using IMCI criteria while being prompted by the mobile phone application to ensure completeness of assessment in a user-friendly manner (eIMCI). These will be inputted into the mobile phone application and combined with heart rate, respiratory rate, temperature and pulse oximetry values. 

This data will be analysed using current guidelines and advice on management and referral will be immediately provided to the healthcare provider. In addition, data on symptoms and diagnoses can be transmitted to a central database, thus providing accurate real-time disease statistics in an area by monitoring symptom trends (eg. fever/diarrhoea) centrally. This will help circumvent the absence of healthcare infrastructures in Malawi and enable the Ministry of Health to improve public health initiatives. 

Ongoing trials

In order to ensure that the use of this new technology is of benefit, a number of studies will be undertaken as part of the Supporting LIFE project. These will include an assessment of the technical and clinical feasibility of using eIMCI and the feasibility of using vital signs sensors in rural clinics in Malawi. We will examine adherence to eIMCI and its effect on other process measures and patient outcomes. A cluster randomised controlled trial of eIMCI compared to usual care with paper-based IMCI in Malawi will be undertaken to determine the effect of eIMCI on clinical outcomes. Finally, we will examine how the eIMCI solution can become part of a national disease surveillance and management policy.

Developing primary care

Significant challenges remain in providing healthcare in rural and remote areas in developing countries. This leads to persistently high levels of morbidity and mortality. However, the explosion in mobile phone use in these locations provides an opportunity to support local healthworkers and improve the prevention, diagnosis and treatment of illness in a novel manner. 

Developing primary care in these areas is crucial. Initiatives such as Supporting LIFE will develop and test new ways of providing primary care. However, it is equally important to build capacity in Malawi to ensure that projects such as Supporting LIFE are sustainable and are relevant to the needs of people in Malawi. The HISRC, UCC and Mzuzu University are currently developing the Supporting LIFE Institute in Malawi. This is a research and education institute that will develop the use of information systems to improve primary care provision in Malawi and ensure the sustainable development of these important initiatives. Further details on the project, see www.supportinglife.eu

Joe Gallagher is co-director of Health Information Systems Research Centre, UCC