Health Surveillance Assistant (HSA) Ethel Kubwalo

Malawi is among the nine low-income countries that reduced their under-five mortality rate by 60% or more between 1990 and 2011. Despite this progress, many children continue to die from conditions that are easily preventable and treatable. A large proportion of children in Malawi are still at increased risk of mortality due to common childhood infections. The leading causes of under-five mortality in Malawi are malaria (13%), AIDS (13%), pneumonia (11%), diarrhea (7%), and neonatal conditions (31%).

The Ministry of Health (MOH) and its partners have been scaling up a package of high-impact interventions to reduce under-five child mortality since 2007 under the Accelerated Child Survival and Development strategy. These efforts have included integrated Community Case Management (iCCM) in hard-to-reach areas to complement fixed or scheduled facility-based services. D-tree International is the partner providing mHealth solutions to support the implementation of iCCM to improve the quality of care provided to children under five.

Nsona2“The introduction of D-tree’s smart phone application has improved how Health Surveillance Assistants (HSAs) assess children under five. They can do more precise diagnosis, and provide the correct dosage for medicine. It also enables them to work more efficiently and report on medicines that need to be restocked. Above all, these smart phones with the iCCM application are a great source of motivation among HSAs and now iCCM HSAs in other districts are requesting them. Based on this program’s success, we hope to scale this up to 4,000 HSAs in all the districts in Malawi.”

Humphrey Nsona
Head, IMCI (Integrated Management of Childhood illness) Unit
Ministry of Health, Malawi

Mobile Application: Enabling Proper Diagnosis & Treatment

In this project, health surveillance assistants (HSAs), a cadre of community health workers, use a mobile application to provide health services to children under five years old (2-59 months) in line with the MOH-approved iCCM protocol. The iCCM mobile application is a Mangologic application which runs on an Android platform.  The components of the mobile application strengthen the ability of HSAs to deliver effective and efficient care. These components are synergistic in providing a comprehensive array of tools and a supportive supervisory framework for the HSA.

“The phone enables me to conduct a comprehensive assessment of the child. It makes my work a lot easier because after I enter in the responses to the questions in the application, it provides a diagnosis and recommended treatment. Before I had to evaluate the symptoms and make the diagnosis on my own.”

Daniel Mandevu
Health Surveillance Assistant
Bembeke Health Centre, Dedza

1. Improving Quality of Care
The first component of the iCCM application captures all the elements of the village register used by the HSA. The application supports HSAs to make the appropriate decisions on treatment. HSAs are also enabled to accurately report on their work in a timely manner. The iCCM mobile application therefore enforces adherence to clinical protocols and iCCM holistically.

2. Tracking Availability of Medicines
The second component links the iCCM application to the logistics management system to improve the availability of needed medicine to the rural clinics where HSAs see patients. This work has been coordinated with the MOH cStock pro-gram to improve its use in tracking drug inventories. D-tree developed a simple user interface within the application for the health workers to use to report stock levels, which is then submitted to cStock via structured SMS.

3. Supervising Healthworkers
The third component of this project is the supervisory tool for those who are managing and supervising HSAs. The tool is based on the new paper-based routine supervision checklist developed by the MOH and Save the Children. It focuses on key performance indicators for the HSAs. The tool facilitates both collection and interpretation of data and also has a dashboard so users can see the status of the work being done by HSAs; it will also provide information for project-related decision-making.

Scaling Up

After initial development and refinement, the iCCM mHealth application was rolled out in Ntchisi District with about 20 HSAs in 2013. By December 2014, 138 HSAs and 15 HSA supervisors in Ntchisi District had been trained. The application was expanded to HSAs in Dedza and Ntcheu districts in 2014 and in Mzimba North District in 2015. By February 2016, 128 HSAs and 33 HSA supervisors in Dedza, 116 HSAs in Mzimba North, and 133 HSAs and 38 supervisors in Ntcheu had been trained to use the iCCM and supervisory applications. The HSAs have dedicated two to three days a week to running the village clinics. However, they see children who come to the village clinic even outside the dedicated days.

On average, 75% of the HSAs are consistently using the mHealth application when assessing and treating children at the village clinics. HSAs are responsible for a number of health services, including family planning; community case management; community-based maternal and neonatal health (CBMNH); nutrition; and water, sanitation, and hygiene (WASH).

Number of children seen
D-tree plans to integrate as many services as possible into one application to support the work of the HSAs. The current iCCM application was integrated with CBMNH protocols to have an integrated CCM/CBMNH application. This application was rolled out to 350 HSAs in Dowa District and 166 HSAs in Machinga District in 2015. In total, the program has trained and equipped 1,031 HSAs and 84 HSA supervisors since 2013. The total number of clients seen as of March 2016 is 307,762. During 2016, D-tree will also add a family planning com-ponent to the application and add coverage to at least one more district.

Measuring Impact

D-tree International carried out an evaluation to determine the clinical effectiveness of the electronic CCM. A mixed approach was used to collect both quantitative and qualitative data. The results showed higher scores in assessment, identification of danger signs referrals (diagnosis), treatment, and counseling. These are the key elements in the management of illnesses in children under-five.

Adherence to assessment using the eCCM app was 100% compared to 91% for those using paper. With the phone application, all questions are asked and recorded before going on to the next phase to encourage the HSA to go through the complete assessment. Paper users correctly identified 60% of the danger signs compared to 100% of the phone users. Treatment of cases with no danger signs was higher in the pa-per users (79%) compared to the phone users (74%). While the phone provides the recommended treatment, the actual treatment given depends on the availability of the drugs and supplies recommended. Sixty percent of cases were referred appropriately in the intervention (phone) group while 48% of the cases were referred correctly in the control (paper) group. Counseling and treatment advice were seen to be higher among the phone users (93%) than the paper users (87%).

From the HSA and caregiver interviews, considerable positive feeling and feedback were recorded. HSAs felt more confident in using the iCCM application. They also felt that there was a reduction in the frequency of visits by the same children as compared to before, which they attributed to the comprehensiveness of the assessment and care given to the child when using the phone. HSAs expressed knowledge gain in using the application from the prompts and advice as well as counseling messages they get from the phone. HSAs also expressed improved follow up rates for cases. However, they were concerned with the double entry of data as they use both the phone and paper registers.


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