In the global fight against HIV/Aids, one of the most exciting innovations is not a new drug, but a better filing system.
This is what we’re seeing in Malawi, one of the most HIV-affected countries in the world. About 7% of the population there live with the virus.
The country is one of the few meeting the United Nations 95-95-95 targets (95% of people living with HIV are diagnosed, 95% of those diagnosed are treated, and 95% of those on treatment have a viral load below 200 copies per millilitre). Sustaining this progress is a massive challenge in large clinics, and requires not only medical staff and supplies but efficient management of patient data.
Effective HIV treatment requires lifelong consistency. Patients must visit clinics every few months to refill prescriptions for antiretroviral therapy, a combination of drugs that prolongs life and prevents HIV transmission. In high-volume, under-resourced clinics, tracking who has missed an appointment is difficult.
As a team of management and global health economists, we wanted to know whether better data management could help explain Malawi’s success. Our recent research used an event study to analyse a gradual rollout of an electronic medical record system, to replace paper-based records, in 106 Malawian HIV clinics between 2007 and 2019. Event study analysis, which involves comparing outcomes before and after a policy change while accounting for clinic and year fixed effects, is a method for causal inference widely used by health economists.
At the time of electronic records adoption, roughly half of patients had stopped coming for treatment. The switch to electronic medical records allowed clinics to track patients more efficiently and support return to care among lapsed patients. Five years after the system was adopted, the annual number of patients who died was estimated to have fallen by 28%.
As with any study, there are important caveats to keep in mind. The findings are based on 106 clinics in Malawi, and while HIV clinics face common challenges across sub-Saharan Africa, results may not translate directly. The study also relies on administrative data, which means patient deaths could be slightly under-counted, and some patients who lapsed from care and returned under new identifiers may not have been accurately identified. Finally, it is not possible to directly observe whether clinic staff used the system to trace lapsed patients; instead, we infer this mechanism from the increase in the total number of patients actively returning to care after electronic records were introduced.
Paper records in a digital age
HIV care in Malawi is managed by the Ministry of Health, in collaboration with local and international organisations. HIV patient clinics are typically situated within larger hospitals or health centres. The 106 clinics in the study were responsible for treating 358,843 active patients as of 2018.
Under the traditional paper-based system, identifying a patient who missed a crucial appointment meant that staff had to manually sift through thousands of physical files. In an understaffed clinic, this often simply did not happen.
To address this, the Ministry of Health collaborated with Baobab Health Trust, a local NGO, to develop and implement a new electronic medical record system. The system involves touchscreen workstations designed for durability and ease of use. Because the system was designed to be user-friendly, it did not require hiring new, specialised personnel. Existing clinic staff were trained to operate the system in sessions as short as half a day.
How the system saves lives
The electronic system did not change the medication patients received, nor did it increase the number of doctors. Instead, it improved managerial efficiency. The system automatically generates a list of patients who have missed their appointments by a specific margin. This allows clinic staff to quickly identify who needs help and use their limited time to trace these patients. They could then call them or visit their homes to encourage them to return to care. According to the clinic staff we interviewed, patients often view this outreach as a form of social support and a sign that the clinic cares about their well-being.
The effects were immediate. In clinics equipped with electronic medical records, the probability of a patient being lapsed from care dropped significantly. In the year following its adoption, clinics saw a 17% increase in the number of patients actively in care.
The benefits were most profound for the most vulnerable patients: children. Children under the age of 10 are uniquely dependent on caregivers and are at the highest risk of dropping out of treatment. Before the electronic medical records were introduced, 57% of children had lapsed from care.
These lapses result in many child deaths, as HIV/Aids is fatal without treatment. Within five years of the adoption of electronic medical records, the number of children in this age group dying fell by 44%. The electronic system acts as a safety net, ensuring that when a child misses a visit, the clinic notices and acts before it is too late.
A cost-effective solution
The electronic medical system played an important role in Malawi’s success in the fight against HIV/Aids. By 2019, the rollout of this system across the 106 clinics in our study had prevented an estimated 5,050 deaths. The system helped clinics identify patients who had stopped receiving lifesaving care and encourage them to return.
The total cost for an average clinic to adopt the system, including hardware, installation and training, was approximately US$34,050. This was funded by the government with support from international donors.
Based on the number of deaths prevented within the first five years, we estimate the cost to be US$448 per life saved.
To put this in perspective, some of the world’s most highly rated charitable life-saving programmes are estimated to cost around US$4,500 per life saved. In the US, implementing electronic medical records to monitor the health of newborn babies costs roughly $531,000 per life saved.
The future of digital health in Africa
While the study focused on the transition from paper to electronic records up to 2019, the system has continued to evolve and scale. The 106 study facilities represent only a fraction of the more than 700 HIV clinics in Malawi. Scaling and sustaining this system across the remaining facilities represents a challenge and opportunity.
Our findings prove that digital health tools are not a luxury, and should not be reserved for rich countries. In low-resource settings, where staff are overburdened and patient volumes are high, managerial technologies like electronic medical records are a frontline, life-saving intervention. They allow health workers to shift their focus away from managing thousands of paper files and towards addressing patient needs.
As international aid dwindles, these kinds of efficiency gains will be key to delivering lifesaving care and maintaining progress in the fight against HIV/Aids.
Laura Derksen received funding from the Connaught Global Challenge Award.
Anita McGahan receives funding from Canada's Social Sciences and Humanities Research Council, the University of Toronto, a Connaught Global Challenge Award, and the Burnes Center for Social Change at Northeastern University.
Leandro Pongeluppe receives funding from the Wharton Impact, and the Wharton AI & Analytics Initiative.
This article was originally published on The Conversation. Read the original article.
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