Written by Ellen and the rest of the MIT Sloan Baobab Team
Our G Lab project revolved around looking at the benefits of implementing an electronic data system in healthcare clinics in Malawi. Our partner organization, Baobab Health Partnership, developed a touchscreen appliance that can be used both for patient registration and as a clinical support tool for healthcare workers. Baobab is based in Lilongwe, Malawi, and at the moment, the software is specifically tailored for anti-retroviral therapy (ART) clinics in the country. One key benefit of the system is improving the quality of the data collected at clinics (there are many others, but they will not be discussed here). Right now, most ART clinics use a paper-based system to collect and store patient information. This raises a host of issues relating to the quality of data kept by the clinics. We heard stories of incomplete or lost records and witnessed first-hand how human error can unintentionally produce inaccurate data when manual systems are used. As clinics expand their patient base, these issues will become increasingly problematic. By having an electronic system at the point-of-care, so the argument goes, you can reduce data errors or incompleteness, and thus improve the quality of the data gathered. Why does this matter?
Each quarter, the Malawi Ministry of Health (MOH) visits every ART clinic to collect the data in order to aggregate it across the entire country. This data is used to identify needs, observe trends, direct resources and set national policy regarding HIV/AIDS. Clinics are asked to compile data themselves in advance of the visit. In the quarterly visits we attended, we joined a team of MOH staff who pour over the registration books and tally up the numbers using a paper and pencil. The staff average roughly 4 hours at a clinic with approximately 1500 patients. If you can imagine a clinic with over 10,000 patients, the task seems quite daunting and much more time intensive. It is easy to see how data irregularities can occur. We were told by an MOH official that one 2006 audit (we were unable to locate a copy of it) showed a 10% difference between the numbers found by the MOH and those reported by the clinics. In other words, there was a 10% difference in the numbers compiled by the clinic staff in preparation for supervision visits, and the numbers compiled by the supervision team. In a country like Malawi that purchases $15M of ARVs per year, 10% amounts to a discrepancy of $1.5M.
After working together as a team in Malawi for three weeks, I left the team and returned to Kenya where I had the privilege to meet staff members from the Partnership for Supply Chain Management, Inc, a team of sixteen private, non-profit and faith-based organizations who implement the PEPFAR-funded USAID Supply Chain Management System (SCMS) program. The staff members I met with were primarily concerned with supplying laboratory equipment and supplies. They faced huge challenges in implementing their program in a cost-effective manner because they lacked quality data from laboratories. None of the laboratory supplies they purchased were available in-country. With long and highly variable lead-times, it is difficult and extremely costly to make last-minute purchases. It is also a challenge to ensure quality supplies are purchased particularly where a cold chain is required. Timely and accurate data is critical to ensuring Kenya’s labs are fully stocked with a high quality product. SCMS staffers really liked the idea of having an electronic system that made it easy to track usage of laboratory supplies without over-burdening already overworked lab techs. They were particularly in one that can be used at the point-of-care rather than for retroactive data entry. Dare I say they could even have more accurate forecasts?
Incidentally, in the logistics realm, the USAID DELIVER project has created ton of training materials, case studies, guidelines and tool kits to set-up and manage a logistics information system. The DELIVER website is packed with things to download. I actually came across quite a few of them posted in healthcare clinics and pharmacies in Malawi and Kenya. Although Baobab is not an inventory management tool, here is another paper-based solution that faces the same problem of data quality.
Returning to the original question, we should ask ourselves is a paper-based system sufficient? For managing inventory? What about managing patients?
While we at the MIT love technology solutions, implementing an electronic data system comes at a price. In the case of Baobab Health, the Malawi MOH is looking to roll out an electronic data system to the largest sites throughout the country over the next five years. The cost of implementation, including maintenance and ongoing training is in the millions. Despite the costs, there are lots of beneficial ways the data collected by the system can be used on an aggregate level as well as on the individual patient level which we wrote about for our project. The challenge our team faced is that while we know clinics may not maintain inventories or deliver healthcare services in the most efficient manner, we have no way of quantifying exactly how much money could be saved or how service levels could improve with better quality data. We do know that as more patients move from first line to second line ARV regimens, procurement and inventory management of ARVs will become increasingly complex and reliant on good data as the number of different drugs needed in substantial quantities proliferates. It is already incredibly complex in laboratory management, as I saw in Kenya. The Baobab system has a lot of potential to help with these issues by improving data quality, and is an exciting piece of technology to look at.
It was great to have an opportunity to take what I learned with the MIT Sloan team in Malawi and look at how healthcare is delivered in Kenya. Maybe some readers out there have experience with data quality in other parts of the world? What would be the impact of good quality data on your program? How much would you be willing to pay for it? Take a look at Baobab’s website, think about your own data needs and tells us what you think!