Reducing Child Mortality D-tree International

the problem

Infant and child mortality rates are high in Malawi, due in part to widespread poverty, lack of access to sanitation, food insecurity, and preventable diseases.

While the prospects for child survival have improved over the past few years, children are still dying of preventable causes such as neonatal conditions, pneumonia, diarrhoea, malaria, and HIV- related diseases.

In such circumstances, decision support software on mobile devices can play an important role in supporting health workers to examine children systematically so that signs and symptoms of potentially deadly but treatable conditions do not get overlooked or mistreated.

Here we describe some of our work in Malawi aimed squarely at this problem.

the innovation (1) - triaging

Firstly, have a look at this video, from Action Meningitis. It was taken in a busy clinic on the outskirts of Blantyre in Malawi. Clinics can be so busy that babies and infants with severe conditions can die while waiting to see the clinician.

But there is a WHO triage algorithm, ETAT, which is designed to prevent this. If it is applied correctly, then severe cases will be identified and can brought to the front of the queue to see the clinician.

And that is exactly what you see in the video. Software running on a mobile device has the logic of the ETAT algorithm encoded and Community Health Workers (called Health Surveillance Assistants - HSAs) can use it to methodically examine each child.

Every severe case identified and brought to the front of the queue, is potentially a life saved.

D-tree International developed this application for the Meningitis Research Foundation and it has been in operation, with the support of Malawi-Liverpool Wellcome Trust, in some of the busiest clinics in and around Blantyre for a number of years.

the innovation (2) - community case management in village clinics

We also work, at the community level, with various partners, to support HSAs running Village Clinics.

Although 85% of the Malawi population live within a 10 km radius of a health centre, only 46% can access health services within a 5 km radius. In many places therefore, an HSA is vital point of contact for health concerns.

In the Village Clinic , the HSA deals with infant and child health according to guidelines laid down by the government scheme "iCCM" - Integrated Community Case Management.

iCCM is a package of child survival interventions designed to address infant mortality, primarily in hard-to-reach areas, in all 28 districts of Malawi.

It includes the following interventions:

  • For diarrhoea, treatment with zinc and oral rehydration salts
  • For malaria, treatment with artemisinin combination therapy
  • For pneumonia, treatment with antibiotics
  • Treatment of red eye (or conjunctivitis)
  • Diagnosis of neonatal sepsis and referral with an initial antibiotic dose

As part of iCCM, HSAs are trained to use a job aid called the Sick Child Recording Form.

This is a form whose directives embody some of the decision logic required for correct diagnosis and treatment.

In other words, the Sick Child Reporting Form is a care protocol.

In D-tree, when we see such a care protocol, we think of software running on a mobile device rather than a form or a flow chart.

So we set out to transform the Sick Child Reporting Form into something interactive, something easier, and something more supportive. We initially produced and deployed a "CCM App" for this purpose.

It has since developed into a comprehensive integrated Village Clinic App covering child health, maternal health and family planning.

This digital health solution is deployed to over 1,000 of the 11,000 Village Clinics of in Malawi.

One major advantage of an interactive app from a quality of care point of view, is the inexorability of its logic. Simply: it reduces the likelihood of error.

But it helps the HSAs in other ways too, such as ..

  • calculations: of correct medicine doses, relative to the patient's age
  • timing and counting: measuring respiratory rate requires timing and counting, two things software can do accurately, leaving the HSA to focus on observing breaths
  • reminding: support for the steps in the process of applying an mRDT (Rapid Diagnostic Tests for malaria)
  • stock management: support for sending drug stock messages via SMS to the central government drug logistics system (C-Stock)
  • reporting: an HSA using the app does not need to compile a monthly statistical report - it is automatically there in the digital health system and can be viewed by the HSA, supervisors and managers.

Rapid diagnostic tests for malaria are a recent introduction to the iCCM syllabus. The process of applying such a test can be complicated.

The app supports the HSA to execute this process correctly, step-by-step, every time.

But this is not just an app, this is an app which is part of a system, and we use digital technology to support other parts of the system too.

HSAs supervisor are charged with monitoring and supporting HSAs. Regional health managers have even broader responsibilities. For both of these kinds of health system employees, data coming from the integrated Village Clinic App as a by-product of the care provided by an HSA, can be analysed and aggregated to identify strengths and weakness in the functioning of the health system.

The Village Clinic app supports the HSA beyond care of infants - it embodies also care protocols for ante-natal and post-natal care of women, and it supports the provision of family planning advice.

D-tree International


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