Germany is supporting Malawi’s Ministry of Health in piloting an electronic patient register in a rural health centre, which replaces paper records and gives health workers a reliable, cost-effective tool for improving diagnoses and treatment at the same time as automatically contributing valuable data to the national health information system.

The wooden benches are lined with heavily pregnant women at Bilira health centre’s busy ante-natal clinic. With an average 80 babies a month delivered at the centre, the four maternity nurses have their work cut out. As she calls her next patient, Nurse Chimwemwe Mapanji pulls out a tablet – not the sort that comes in boxes of pills, but one that she swipes. With a few taps on the hand-held device she has access to simple electronic medical records for the mother, or can create a new record for first-time patients. Then, with a couple more taps she can access a step-by-step treatment ‘check list’ to follow, based on WHO guidelines.

It is perhaps surprising to see high-tech digital solutions in use in one of the poorest countries in the world, but the maternity unit now has four hand- held tablets and there are another 19 in use at the health centre. These are the tools of a new electronic health record system, openSRP, an open source smart register platformsoftware system designed to help transition from paper to digital health records, and to empower health providers to provide better care through decision-support and data monitoring in-line with WHO recommendations. And the world is watching: WHO’s recently published second annual report of GAP (Global Action Plan for Healthy Lives and Wellbeing for All) cited Malawi as an example of progress on digital health. 

Building partnerships for the pilot

The Malawi-German health programme, implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of BMZ, is supporting the Ministry of Health and Population (MoHP) to introduce the e-register pilot in partnership with Jembi (a South African NGO working on health strengthening projects); Ona (an IT company working on open-source source solutions that has helped to develop and customise the system in accordance with Malawi’s digital blueprint), and HISP Malawi (the health informatics programme responsible for implementing the national health information system, DHIS2).  The pilot is co-funded by the Gates Foundation and the German government, and Jembi and Ona were contracted to prepare and install the system and train health workers to use it, in partnership with HISP Malawi. GIZ oversees the Bilira pilot as part of the policy support Germany provides to Malawi’s MoHP in its on-going efforts to formulate a digital health information architecture and a comprehensive policy Blueprint, as well as to improve the quality of care to patients.

 ‘We were chosen for the pilot because Bilira is a neglected rural area, with no electricity,’ says Emmanuel Gawanika, Bilira’s medical assistant. ‘GIZ wants to make Bilira a centre of excellence for improving data collection and delivery of services, and show that  even in these difficult conditions, digitalisation can make all the difference for health workers and patients.’ 

Why openSRP?

Malawi, like many other countries, is trying to establish a coherent digital blueprint for the future – preferably one that provides a single system for collecting data, rather than multiple, fragmented initiatives. However, many of the applications currently in use have been  developed in a fragmented way and operate in ‘silos’, so data cannot easily be exchanged or used elsewhere. A task force has been established to look at harmonising the number of digital platforms in use. However there’s also a growing realisation that a single platform does not yet exist that is able to combine all the complex tasks of health service delivery, including, for example, human resources and logistics management, gathering health service data on treatment and annual work plans, financing and budgeting and managing information needed for health insurance schemes.  Given the existing limitations of DHIS2, it will need to be supplemented by other applications that work with the existing systems. 

 ‘The government is looking at what will be the best system for the future,’ says GIZ’s Programme Manager Kai Straehler-Pohl, ‘We believe openSRP can be a good candidate because it can have interoperability to others systems and works well in the conditions found in Malawi’s health system.’

Crucially, apart from having fewer requirements in terms of connectivity and hardware, OpenSRP has been designed to be interoperable with existing health information tools that are widely used (e.g. OpenMRS and DHIS2). It also operates in real time, so enables health workers to make data-driven decision-making at all levels of the health system, from patient care to planning at both local and national levels. It is designed to bring about systematic improvements AND better service delivery. 

Since the e-register is run on an open-source smart register platform, there are no expensive licence updates and it can be customised to Malawi’s needs. But finding out what works is a learning process, and will require collaboration and an honest exchange between health systems and development partners at both national and global level. Help and guidance is also available from the global openSRP community, and in return, Malawi’s experiences and the lessons learned from the pilot in Bilira will be fed back into the community, thus contributing to an open-source ‘global good’ that can be applied worldwide.

An integrated user-friendly modular system that improves quality of care

The pilot project in Bilira has so far focused on developing modules for reproductive, maternal, new born and child health and a module for the outpatient clinic is currently in development.  These modules are linked so that an electronic patient file is registered when a pregnant woman first presents at the ante-natal clinic, and her records can automatically be accessed by the post-natal clinic after the baby is born. The baby’s records will also shift to the child health module which covers immunisations, vitamin-A, deworming and bed net distribution workflows. Stephen Macheso, Director of Health and Social Services, Ntcheu District says the e-register has simplified everything and improved patient care.’ It avoids duplication of bureaucracy or incomplete record-keeping, and saves time for overstretched staff in resource-poor settings, so that they can concentrate on better patient care using the step-by-step diagnostic and treatment tool following WHO guidelines. Also, openSRP makes sure that busy health workers do not take shortcuts during physical exams, such as, for example, skipping the measurement of pregnant women’s blood pressure. It simply refuses to move to the next step before the required value has been entered.

Linking to the national health information management system

openSRP is designed to be interoperable with the national health information management system, DHIS2. Data is automatically uploaded electronically from the health centre at Bilira to the national system at regular intervals (daily or weekly), enabling timelier and more accurate aggregation of data nationally.  ‘Unlike other health centres in the area, we don’t have to look for transport to deliver paper reports to the District Health Office,’ says health assistant Emmanuel Gawanika. The data is also immediately available for health practitioners to use to assess and improve health delivery at local level.

The e-register works well with Malawi’s standards-based approach to interoperability so that different data streams can work together through development of a unified language of coding and terminology based on the Open Health Information Exchange (OpenHIE) framework (as shown in the diagram below).  A Master Facility Registry has already been developed and work is ongoing on refining and standardising codes and terminology.

The e-register works well with Malawi’s standards-based approach to interoperability so that different data streams can work together through development of a unified language of coding and terminology based on the Open Health Information Exchange (OpenHIE) framework (as shown in the diagram below).  A Master Facility Registry has already been developed and work is ongoing on refining and standardising codes and terminology.

A ‘unique bottom-up’ design

What differentiates the e-register pilot in Bilira from other electronic records systems currently in use both in Malawi and elsewhere – which often tend to be grafted onto local conditions from a central template – is that it was very much designed with the users in mind. Ona designed the modules and HISP took them to the health centre for extensive user-testing. This is an on-going process to create as joined-up and agile a system as possible.   

‘Although openSRP was already used in some other countries, apart from the child health module, we really started from scratch with the other health modules,’ says GIZ’s Paul Dielemans. ‘They were not copied and pasted from somewhere else. So in that sense openSRP is a unique bottom-up approach designing it with the health workers at the health centre level, which makes it much more likely that in the end it will be accepted and will be sustained. ‘ 

Improved coverage and less waste in immunisations 

The e-register pilot in Bilira has proved particularly effective for improving child vaccination records.  Previously immunisation outreach clinics largely had to guestimate the number of children to be vaccinated and the types of vaccinations needed, and many unused vaccines spoiled in the high temperatures of the lake shore area.  Now the emmunize planning tool, which is part of the e-register, uses data collected from the child health clinics at Bilira as well as that built up over successive outreach clinics to plan exactly how many vaccinations and needed and where. The system can also send out reminders to patients – this is not currently being used in Bilira, but it is potentially an additional function that could be added later. More about use of the e-register for child vaccination will be reported in the next edition of GIZ’s Akzente magazine.

Solar solutions and improving connectivity

‘At first we had issues of internet instability and power blackouts, so it was hard to use the new system,’ admits Emmanuel Gawanika.  Part of the solution to these challenges has been to install solar panels and back-up batteries at the clinic.

GIZ has for some time been supporting the Ministry of Health’s Government Wide Area Network (GWAN) scheme to strengthen connectivity for the ‘last mile’ to health centres in Dedza and Ntcheu Districts. However, stability issues in Bilira meant looking for another solution until the GWAN system can be strengthened.  GIZ has now contracted a mobile phone company to provide data bundles for use by Bilira health centre and the next phase of the pilot will focus on further strengthening internet connectivity.  

Changing mindsets

Another challenge was changing mindsets, especially because the technology was new and some of the health staff had no experience of using tablets so found it hard to grasp the new technology, according to Nurse Mapanji:  ‘To begin with they had to do a parallel process of paper and electronic reporting so some grumbled it that it made more work for them.’ Some patients were also wary of the new technology at first, she says.    

This initial resistance didn’t last long, according to Stephen Macheso, Ntcheu’s Director of Health and Social Services: ‘Now everyone is very happy and the e-register is much quicker for them.’ Training is an ongoing process and there has been an agreement that management shouldn’t move staff around until the system has settled. 

Scaling up from the pilot

The next phase of the pilot will be to roll out the e-register in the outpatient department.  The module, which is still in development, is due to go live by August, and will increase the number of patients covered by the e-register from around 10,000 currently to 30-40,000. 

This small health centre at Bilira is now regarded as an example of what could be done elsewhere, says Ntcheu DHO Stephen Macheso: ‘All the neighbouring health facilities keep asking when they can have the e-register too.’  

The next step will be to look at scaling up to other facilities, with a view to eventually rolling out the e-register nationwide, says GIZ’s Kai Straeler-Pohl, adding: ‘We would love to attract the funding to make it happen.’  The work that we are doing in Bilira will help to ‘fine tune the system, smooth out any bugs and strengthen the interoperability interface with DHIS2,’ he says. ‘We are making a contribution to that, whether the system is here to stay in Malawi or whether other countries are going to use it.’ 

‘A very welcome idea’ 

 As she works her way through the waiting patients in the maternity clinic, Nurse Mapanje says that the e-register pilot in Bilira proves that digital solutions can help to improve the quality of care in resource-poor settings. Overstretched health workers like her now have more time to focus on better patient care rather than paperwork, she says, and she’s more confident about making diagnostic and treatment decisions following the check list.  

‘This was a very welcome idea, ‘says Stephen Macheso, Ntcheu’s DHO. ‘It should have been done years back, given the challenges we faced with paper-based systems and reporting delays. We really needed to move in this direction. This is the way to go for the whole country.’ And GIZ’s Hastings Mtawali who sits on the Government’s digital future taskforce, says based on the lessons learned from the Bilira pilot, ‘we are crossing our fingers’ that openSRP will be one of the applications selected for use nationwide.  

Ruth Evans, July 2021