Improving healthcare in the developing world

By Dr Joe Gallagher*

In developing countries, most of the 11 million deaths per year of children under the age of five years occur in areas where adequate medical care is not available.

While we in the developed world might usually take the provision and availability of healthcare as a given, this is often not the case in the developing world. Significant challenges remain in providing healthcare in remote and rural areas in these countries.

However, the exlposion in mobile phone technology use in the developing world can be harnessed to change things for the better.

With nearly 80% of the population living in rural areas, access to skilled healthcare is one of the major obstacles facing developing countries such as Malawi.

While first-level facilities (i.e. local health centres) are commonly used, they are generally run by community health providers who tend to have limited medical training but are expected to manage the vast majority of primary care for these populations.

Thus, the absence of skilled health providers is a major contributing factor to the high child mortality rate in Malawi, where the under-five mortality rate is 133 per 1,000 live births.

To support these frontline workers, the WHO and UNICEF developed the Integrated Management of Childhood Illness (IMCI) guidelines in the mid 1990s as a strategy to reduce illness and death from common and potentially serious childhood illnesses such as malaria, pneumonia, infantile diarrhoea with dehydration, meningitis and sepsis. The strategy has now been adopted by more than 100 countries.

The IMCI strategy involves a stepwise and structured approach to the assessment and management of children presenting with acute illness in developing countries. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities.

However, even in facilities where IMCI guidelines are in use, there are issues with the implementation. In many cases, community health workers use IMCI guidelines to assess presenting symptoms but do not implement the guidelines comprehensively.

For instance, one study reported that only 12% of observed health workers assessed the general danger signs in every child. Disconcertingly, less than half (47%) of children with severe classifications were correctly identified.

Misclassification of children with severe infections who either need immediate treatment (e.g. with antimicrobial or antimalarial therapy), or who need referral to higher level health care facilities (e.g. the local hospital) is a major problem for health care systems in countries such as Malawi.

Also people may not present when unwell in settings with limited resources and expertise.

For example, pneumonia is a leading cause of death of young children but only 20% of children in Malawi presenting with symptoms of acute respiratory infection and/or fever were taken to a clinic in a recent study.

Incorrectly identifying children as having a serious illness when in fact they only have a minor or self-limiting illness, results in inappropriate use of scarce medications, and personal and health service costs. Single disease approaches pose a challenge in low resource settings.

Children may present with multiple problems and it is important that the health care worker is provided with the means to detect and manage multiple problems simultaneously. The move from a vertical, disease orientated approach to a horizontal, child centred approach was initially realised in the development of the IMCI guidelines.

However, the complexity of IMCI is in part limited by its paper- based approach and need to refer to relatively complex paper based information in settings where large numbers of people may be seen every day with limited support.

The Health Information Systems Research Centre (HISRC) is a multidisciplinary centre in University College Cork which was established in 2009.

Recently the HISRC has secured EU funding for a project entitled Supporting Low Cost Interventions For hEalth (LIFE) that will use mobile phone and sensor technology to improve primary healthcare for young children with acute illness in Malawi.

The Supporting LIFE initiative was developed and is being lead by researchers in the HISRC. It involves a number of Malawian and European partners who each bring unique skills to the project.

The Malawian partners involve Mzuzu University, Ungweru, a local charity dedicated to community work and Luke International Norway, a charity involved in establishing information technology solutions in Malawi. European partners are Lund University in Sweden and Oxford University.

Africa now has more than 650 million mobile phone subscribers - more than either the United States or the European Union.

Since 2000, the mobile phone market has grown almost 40-fold, from 16.5 million Simultaneously, the development of low cost sensors for vital signs (i.e. heart rate, breathing rate, temperature, blood oxygen levels) and sustainable power initiatives are occurring which allows extension of these technologies to low resource countries to aid healthworkers with limited training to objectively assess ill children.

The Supporting LIFE project will develop and trial a mobile phone based system of managing acutely ill children in Malawi using a decision support system based on the IMCI. This will be combined with low cost sensors for heart rate, respiratory rate, temperature and pulse rate.

Using this system a healthcare provider will assess a child using IMCI criteria while being prompted by the mobile phone application to ensure completeness of assessment in a user friendly manner (e-IMCI).

These will be inputted into the mobile phone application and combined with heart rate, respiratory rate, temperature and pulse oximetry values. This data will be analysed using current guidelines and advice on management and referral immediately provided to the healthcare provider.

Also data on symptoms and diagnoses can be transmitted to a central database thus providing accurate real time disease statistics in an area by monitoring symptom trends (e.g. fever/diarrhoea) centrally. This will help circumvent the absence of healthcare infrastructures in Malawi and enable the Ministry of Health to improve public health initiatives.

In order to ensure that the use of this new technology is of benefit a number of studies will be undertaken as part of the Supporting LIFE project to assess its impact.

The explosion in mobile phone use in developing countrties provides an opportunity to support local healthworkers and improve the prevention, diagnosis and treatment of illness in a novel manner.

Developing primary care in these areas is crucial. Initiatives such as Supporting LIFE will develop and test new ways of providing primary care. However, it is equally important to build capacity in Malawi to ensure that projects such as Supporting LIFE are sustainable and are relevant to the needs of people in Malawi.

The HISRC, UCC and Mzuzu University are currently developing the Supporting LIFE Institute in Malawi.

This is a research and education institute that will develop the use of information systems to improve primary care provision in Malawi and ensure the sustainable development of these important initiatives.

* Dr Joe Gallagher is Co-Director of the Health Information Systems Research Centte, UCC and is a GP in Co. Wexford.

(This article also appears in Forum, journal of the Irish College of General Practitioners, published by MedMedia.)



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