3. Case Study: Malawi

Background

While the project in Ghana addresses maternal health, there are also mobile phone initiatives in Africa that address child health. Specifically, the RapidSMS Malawi project has created a mobile platform used to diagnose and combat child malnutrition in Malawi. This initiative, launched in 2009, is headed by UNICEF Malawi, UNICEF’s Division of Communications Innovations Team, and Mobile Development Solutions (MDS). In addition, our very own Columbia University School of International and Public Affairs has successfully expanded the RapidSMS platform into Ethiopia.

Child malnutrition in Malawi

Malawi, a land-locked country in sub-Saharan Africa, is one of the poorest countries in the world. The country has been hit hard by the AIDS epidemic, with around 12% of the population infected with the disease (CIA World Factbook). In fact, the current average life expectancy is only 50 years (CIA World Factbook). Furthermore, Malawi has an extremely high infant mortality rate, ranking a depressing 11th in the world with 83.5 infant deaths for every 1,000 births (CIA World Factbook). In short, Malawi suffers from an extremely precarious health situation. With this in mind, RapidSMS set out to target child malnutrition in the country.

Rapid SMS Predecessor and Lessons Learned

Before the creation of the RapidSMS platform, the main method for monitoring child nutrition in Malawi was the Integrated Nutrition and Food Security Surveillance System (INFSS). However, this platform faced many challenges and impediments to its success, mainly as a result of its clunky nature. The system experienced poor data quality, significant delays in timeliness between data collection and data analysis, and also witnessed high participant dropout. Below is a flow chart showing the hierarchical and clunky nature of the IFSS organization system:

With the development of mobile technology, RapidSMS saw a potential solution to the issues experienced by IFSS. The networked structure of mobile technology might bring quicker and more accurate data collection and a greater ability to stay in touch with participants, which could reduce the drop-out rate.

RapidSMS

What is Rapid SMS?

RapidSMS is "a SMS-based (text message) framework that manages data collection, complex workflows, and group coordination using basic mobile phones — and can present information on the internet as soon as it is received" (see Rapid SMS website). Specifically, the platformed was tailored to the child health situation in Malawi through the following steps:

The Health Service Assistant sends a text message in a pre-determined format to assigned 4-digit numbers with the child’s measurements.
A central server receives the SMS.
The server updates the database with the child’s measurements and compares them to accepted standards.
The server replies with an automated SMS confirming the receipt of initial SMS and advises on whether there has been a data entry error (when a second corrected SMS should be sent back) or whether the child needs further attention, while at the same time providing instructions on how to do that.
Last, the database website is updated in order for the entry to be immediately available to all the stakeholders.

The procedure is illustrated in the image below. Note the difference between the networked nature of the RapidSMS procedure, versus its more hierarchical predecessor:

How Does RapidSMS Work in Malawi?

The RapidSMS program reached this successful stage of implementation through numerous stages (source: the great RapidSMS Malawi wiki and this UNICEF paper):

Project leaders focused first on information gathering, including collecting data on Malawi's mobile technology, analyzing the former INFSS system, and learning more about child malnutrition.
They then customized the new program’s design to the former program’s patterns, keeping the minimum standards and a similar format in data entry.
The final implementation staged was reached after several key partnerships and contracts, especially with local actors such as University of Malawi’s Bunda College of Agriculture in Lilongwe. These local entities helped in selecting the areas to try out RapidSMS, due to difficulties in transportation to more remote areas, especially during the rainy season.
Training, of course, proved to be of vital importance and was facilitated in order to include non-English speaking populations, while at the same time providing laminated instruction cards and phone credit for the first pilot study patients.
Monitoring and evaluation was significant in repeating training sessions in hopes of a possible national rollout. Many improvements also followed the M&E stage.
Moreover, the two major mobile phone companies in Malawi expressed a clear interest in the project, as they proposed some sort of cooperation and/or sponsorship.

Findings

The RapidSMS initiative managed to (all findings and challenges from the UNICEF paper, Mobile Development Solutions (2008) Using Mobile Phones to Improve Child Nutrition Surveillance in Malawi) :

Beat the delays endowed by the INFSS system with instantly available data. It should be noted that transmission times used to range from 1 to 3 months and are now cut down to an average 2 minutes.
Improve the quality of the data, mainly owed to the feedback loops received back, thus lowering the margin of error. At this stage, information sharing should also be underlined, since without it, subtle and mild cases of child malnutrition would have been disregarded, as was often the case with INFSS.
Build an automated system that rendered mundane tasks unnecessary. Bureaucracy would often be a reason for errors since officers at the national level would not only delay in recording the reports, but would also make mistakes.
Encourage participation by both child caregivers and Health Assistants. Better tracking of children that were thought to need more surveillance than others and follow-up visits were now possible, thus assisting both caregivers and parents do a more effective job.

In short, technology managed to surpass traditional setbacks that range from illegibility of handwriting to mundane bureaucracy, ultimately making for a more reliable and pleasant system.

However, the need for better training of Health Practitioners is an existing difficulty. Measurement inaccuracy is frequent; nevertheless it can now be traced through the system’s standard specifications. Dataset outliers can now be traced back more easily than with manual recordings leading to a way of counter the problem of measurement inaccuracy. However, basic training and practice has to be repeated in order to eliminate any such first priority occurrences.

Furthermore, the RapidSMS system faces potential future challenges in Malawi, including: A lack of responsibility and defined roles.
- A continual need to update the system when necessary and include a wider range of settings by facilitating caregivers as well as server operators in succeeding in their tasks.
- Mobile network coverage, as well as SMS cost, should be ameliorated; as should, power outages and electricity issues, since these could severely hurt the process of feedback.
- A better know-how should be applied while taking instructions by counterparts such as the European Union or UNICEF in ways of updating the system.
- Training should be continuous, as should a national level of monitoring.

Implications

Though the RapidSMS Malawi project focused on improving child nutrition, it does have implications for future projects pertaining to mobile phones and maternal health. For example, the networked nature of gathering data - especially in comparison to the hierarchical former program - sped up the delivery of data and improved accuracy. Moreover, using cell phones to stay in communication with participants led to a higher participation rate.

In addition, the challenges the project faced can also teach lessons for future mobile phone and maternal health projects. Though cell phones can greatly speed up data collection and reduce errors, they do not serve the same function as a properly trained health practitioner. Cell phone technology used in this manner cannot provide better education and training of health professionals, a factor that has huge consequences on maternal and child health.

Intro Background Case Study: Ghana Case Study: Malawi Proposal: Brazil Proposal: Peru Conclusion Further Resources

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