Right to Care Malawi
Right to Care Malawi is a non-profit company incorporated under the Malawian Companies Act and established in 2016.
As part of the USAID/PEPFAR-funded EQUIP project, which closed out in 2019, our implementing partners in Malawi were:
- Baylor,
- Partners in Hope and
- Dignitas.
Our work began with grant management, technical assistance, coordination of programme implementation, joint monitoring, evaluation and reporting
Since inception, Right to Care Malawi’s priority goal has been geared towards achieving ‘UNAIDS’ 90-90-90 target. To achieve this, a strong partnership with the Malawian Ministry of Health was established.
Right to Care Malawi supported 257 sites across 15 districts. This is 56% of the PEPFAR-funded sites in Malawi. Four of our areas have formed part of an aggressive acceleration programme given the high prevalence of HIV in these areas:
- Chikwawa,
- Machinga,
- Mangochi and
- Zomba
Our goals in Malawi
There are five primary focus areas to Right to Care Malawi’s work:
01. Rapid HIV Test and Start roll-out
02. Differentiated models of antiretroviral therapy (ART) delivery with a focus on multi-month scripting and dispensing (MMSD) in healthcare facilities and communities
03. Strategies to boost:
- HIV testing
- initiation onto ART
- retention on ART and
- viral suppression
04. Treatment approaches geared to key populations
05. Innovative approaches to rapidly scale-up viral load monitoring.
These five focus areas allowed us to:
impact positively on adherence to treatment
increase the number of new patients initiated on treatment
implement an efficient data management system
Towards ‘UNAIDS’ 90-90-90 targets in Malawi
The first 90 – 90% of all people living with HIV will know their status
Right to Care Malawi’s approach to meeting the first 90 has encompassed:
- providing support to a designated cadre of HIV testers,
- using innovative approaches to increase testing amongst men and key populations,
- reaching communities through effective testing initiatives,
- ramping up provider-initiated counselling and testing (PICT) through:
- early morning testing
- weekend testing
- community testing
- door to door testing
- moonlight testing
- hot spot
- self-testing and
- training HIV diagnostic assistants, nurses and clinical officers.
The second 90 – 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART)
To increase access to sustained ART, we focused on three main interventions:
- promoting effective linkage to care,
- implementing a dedicated campaign to reach adolescents and men and
- identifying and effectively treating co-morbidities.
We have also provided training on the new breakthrough antiretroviral (ARV), Dolutegravir.
Right to Care Malawi has worked hard to trace defaulters and people who miss appointments – efforts which help people stay on their treatment.
Constructed 15 prefabricated facilities across the Zomba district which supported our efforts to test people and keep people on their medicine.
The use of TB screening questionnaires in clinics helped remind healthcare workers to screen patients for TB, a move which improved TB diagnosis and treatment among HIV positive clients.
The third 90 – 90% of all people receiving antiretroviral therapy will achieve viral suppression
In our efforts to reach the third 90:
- viral load specimen transport was optimised,
- a focus was placed on improving intra-lab service quality,
- viral load scale up mentors were trained and
- patients received adherence counselling.
Other interventions to boost viral suppression have included:
- improving viral load monitoring,
- finding better ways to reach men and adolescents,
- motivating healthcare workers to send their patients for viral load testing and
- providing additional laboratory support and diagnostic services.
Right to Care Malawi Board
Dr. Ann Phoya
Ms Lynn Hiwa
Mr Wilson Moleni
Dr Eula Mothibi
Collaboration Improves Use of National HIV EMRs by PEPFAR IPs in Malawi
In 2019, USAID/Malawi engaged Data.FI to work closely with Partners in Hope (PIH) and Baylor, two USAID- and PEPFAR-supported implementing partners (IPs), to improve their use of the national HIV electronic medical record system (EMRS) and the data it generates. Data.FI has focused its efforts to strengthen EMRS use on hands-on capacity building, using a highly collaborative approach ― providing fit-to-purpose training materials, training of trainers sessions, and facility-based hands-on mentorship sessions.
Today, through Data.FI’s collaboration, mentorship, and by other initiatives implemented by Baylor and PIH, the two IPs have been able to achieve the following:
Improved trust and ownership of EMRS data
Due to previous data quality issues, IPs had some doubts about the capacity of the EMRS to produce quality data. But according to Kasungu District Hospital Data Clerk Mentor for PIH Joshua Mtambalika, Data.FI’s training and guidance has strengthened his capacity to produce reliable data, which are vital for informed clinical decision making. Mtambalika commended the training, noting that, “The superlative trainings conducted really increased the personal knowledge and skills of our staff, facilitating their ability to deliver on goals over time. Further, the site-based mentorship sessions supported and encouraged facility staff to own and manage our data so that we can maximize our potential, develop our skills, improve our performance, and enrich our organizational success.” Data.FI has built greater competence among Baylor and PIH data handlers and users to understand and trust EMRS data and the interpretations that can be drawn from data.
Improved system usage
Data.FI’s inputs augmented the IPs’ own efforts to improved system use by strengthening the capacity of the IP teams to use the electronic medical records (EMRs) at both point of care and retrospectively for the eMastercard system, one of the country’s two EMRS for HIV data. This has resulted in an increased volume of data entered into the system by facility-based Baylor and PIH staff. Kabudula Health Centre Data Clerk Mentor for PIH Stephano Nthondo said, “We were not very comfortable using the EMRS when managing clients; now our knowledgeable use of the point-of-care EMRS has improved the quality of data being stored and the reports generated.”
Reliable cleaning of data
Identifying errors in data requires a more in-depth understanding than mere input of data or its acceptance at face value. The IP facility-based teams are now able to periodically review their data, identify and rectify errors and inconsistencies in their own data, and generate high-frequency reports, reducing inconsistencies in higher-level reporting and thus supporting more accurate decision making. “The facility-based teams learned a standard way of cleaning data with very minimal support from the health information system partner (EGPAF/Malawi) and are able to resolve identified errors by using the data cleaning tools in the system,” the PIH e-health manager said. “This process has improved the quality of data and the reports.”
Report generation
IPs are now able to produce a range of tailored reports to meet different requirements for the Ministry of Health, the clinical team, and PEPFAR. Examples of such reports include those for PEPFAR monitoring, evaluation, and reporting (MER) indicators, such as multi-month dispensing (MMD), TX_ML (the number of ART patients on ART at the beginning of the quarterly reporting period and then had no clinical contact since their last expected contact), and TX_RTT (the number of ART patients with no clinical contact or ARV drug pick-up for greater than 28 days since their last expected contact who restarted ARVs within the reporting period); age and sex disaggregation; cohort reports; and reports on appointment and missed appointments. Such reports are used at the facility level and at higher levels of management.
According to one district M&E officer, “During the training we were taught when to run which report and the uses of the reports; we are now motivated and able to generate the report in the EMRS with ease.” He further stated that, “All sites are able to generate reports and use them properly at the facility. The reports helped them to improve in some areas they could not do using manual data. They are now able to see what is happening in their clinic through the data and make programmatic changes.”Informed decision making
Through Data.FI’s efforts, the IP teams that support facilities in 14 USAID-supported districts understand and can now leverage the range of applications for EMRS data and reports. IPs use the data for purposes such as identifying potential stock issues for medicines and bringing clients with interruption in treatment back into care. There has been a cultural shift from the input of data for the sake of it to the input of data for improved healthcare practices. Real-life application of these improved data reports includes their use to check the number of people booked for the next clinic dates, and then to check that against the stock of medicine that is available for those clients. Likewise, IPs use the reports to track clients who miss appointments or do not pick up their antiretroviral therapy (ART) on time and to activate tracing to return them to care.
“We are now able to understand, for example, how many people are currently on ART and then, in the last quarter, how many may have dropped out of care,” says Mtambalika. “We can then look at ways we can improve, whether this be in addressing issues in the clinic or better follow-up of these clients immediately after they default.”
The Data.FI team continues its work ‘on the ground’ to support the IPs in their efforts to institutionalize use of EMRs at the facility level.
In the past 24 months, despite limited resources, PIH and Baylor have strengthened their eHealth human resources and made available resources to build the capacity of the teams. Collaborative engagement, consistent communication, a commitment to capacity building, and tailored training can make a verifiable difference to strengthen the quality and use of HIV data―and thereby improve the health of people living with HIV in Malawi.
