Background

Baobab Health is a local Non Governmental Organization (NGO) dedicated to improving the delivery and management of HIV/AIDS care in Malawi through continued development, enhancement and support of information systems used in real-time by clinicians at the point of care. Baobab has been working with the Ministry of Health (MOH) to design and deploy medical informatics to resource poor settings. In Malawi, paper-based registers have traditionally been used to record patient/client data. This data is commonly transcribed and subsequently manually aggregated by staff with little or no training in medicine or clinical terminology.

Baobab's strategy has been to improve data quality and to replace traditional paper-based data collection with point-of-care systems. The core of Baobab's approach is the installation of easy-to-use touch screen clinical workstations at the point of patient care. This system efficiently and accurately guides health care workers through the diagnosis and treatment of patients according to national protocols. The system also captures timely and accurate data that is used by health care workers during patient visits, which

supplements decision making. The data is aggregated and used at a national level for policy-making and analysis.

HIV-AIDS also has a major impact on the paper records in clinics. Some clinics have over 5000 patients and district hospitals often more than 1,500. This increases the workload and the possibility of data errors at clinics. Baobab's Electronic Point-of-Care Data System (EDS) facilitates data processing at patient, clinic and national level. Baobab trains health care workers to use the system and provides support for maintenance. Baobab has done a proof of concept and deployed at 5 HIV sites, it can now be rolled out nationally on demand of the Ministry of Health (MOH) - HIV-AIDS unit. Baobab system will be deployed mainly in the Southern region of Malawi due to the higher HIV incidence. Baobab partners with Luke International Norway in the Northern region, and continues to strengthen activities in the central region.

In the current Baobab system clinics, there is an opportunity to increase the system's breadth by adding software modules: e.g. TB, Malaria, Pharmacy, etc. All Baobab activities are aligned with MOH objectives, and Baobab is working with the HIV unit and Central M&E Department (CMED). Baobab has proposed a framework to prioritize HIV sites for implementation over the next 5 years. Baobab will start scoping the central data repository for Malawi.

Overall Goals & Objectives are in line with the PEPFAR Partnership Framework and the National Action Framework:

1) Improve the quality of treatment and care for Malawians impacted by HIV - PEPFAR funds will support Baobab to roll-out the HIV-EDS system, so that more patients will be able to benefit from the follow-up and care support given through the EDS.

2) Cross Cutting Systems strengthening by improving Health Information Systems - The EDS provides better data for overall M&E for the national ART-program, to support ART drug-procurement, and to support reporting needs of the MOH HIV-AIDS unit. EDS supports the implementation of MOH protocol and contributes to a higher standard of care in each EDS-site. As more sites become active on EDS, Baobab will ensure patient data sharing between sites. The objective is to create a national central repository at the MOH, which would contain all patient data, collected on EDS.

Three primary activities will be supported:

1) To Improve HIV-AIDS Patient Care through EDS development Baobab will continue to:

i) roll-out of EDS installation; ii) collaborate with MOH/CMED; iii) develop an EDS for T&C (MACRO); iv) strengthen its software development team to improve current modules.

2) To build robust monitoring and evaluation capabilities: The EDS supports delivery of cohort reports for the MOH, informing drug forecasting and procurement decisions and providing information to the MOH and District Health Officers.

3) To build indigenous capacity in medical informatics and a mentoring centre Being a leader in the information technology, Baobab will continue building capacity within the MOH and support HIV clinics to move to an electronic data system. Baobab will share its know-how with stakeholders, nationally and internationally.

Overall Project Sustainability: The long term goal of the MOH is to have ART EDS in all high-burden sites over a period of 5 years (2010 - 2014).

The installation of the ART EDS-system (software development and initial deployment at ART-site) and maintenance for year 1 is funded by CDC (and others). When deploying the system at a health-care site, a Memorandum of Understanding (MOU) will be drafted, in which the site commits to carrying part of the maintenance costs for ongoing years. Basic technical expertise will be taken on by MOH over time. However, it is mandatory that hardware and software are maintained at high quality level, to ensure that data are captured for each patient at every visit. When maintenance is handed over, it must be ensured that the MOH can really commit to maintaining the system, so that the initial investment made by donors can further be built on.

The protocols followed in the EDS are all provided by the MOH and there is a very close collaboration between Baobab and MOH. Baobab is a permanent member of the Data Standard Working Group and takes the lead to develop a 'concept-dictionary' - and will continue to work on a national unique patient identifier.

In partnership with other donors, Baobab is developing an in-patient diagnosis and outcome module and a diabetes and hypertension treatment and follow-up module. Baobab is working towards cooperating with other donors for peadiatrics and maternity healtcare. Other international donors interested to use the Baobab system are Dignitas in Zomba, MSF France and MSF Belgium. Baobab has further formed a public/private partnership with Pfizer.

Year 1 Budget - $1,000.000

Year 2 Budget - $2,000.000

Budget Code - HVSI

Year 1: $200,000

1. With PFIP Year 1 funding, the Baboab system will be installed in 7 ART sites, 2 general health sites and 3 HTC sites (+ a mobile HTC system). The quantity of data of these high burden sites is very high and an EDS will help facilitate the gathering of data, analysis and aggregation of data at patient level, Clinic level, district level and eventually nationally at the MOH-level.

To build robust monitoring and evaluation capabilities, Baobab will support the delivery of cohort reports, for the MOH, informing drug forecasting and procurement decisions. ? Provide and develop M&E capabilities within BART software tools ? In close cooperation with the MOH - HIV-AIDS unit the EDS will be adapted to the changing needs of the MOH. For example, the master card may require other fields of information, more detail, or other aggregated data. It is Baobab's aim to work closely with them to address the need of change in software. ? Develop a supervision tool to more easily and interactively supervise the EDS sites

? This is a software tool that will be deployed on the touch screens and used at supervision missions, to help understand and analyse the data captured (at traditional sites, supervision happens manually which is time consuming and is prone to errors). ? Start scoping the central repository framework ? The main task will be to canvas the needs of the stakeholders. MOH, CDC, CMED and look at realistic objectives and targets of this central repository. In cooperation with LIN, a first draft on the technical characteristics will be drawn up. ? Reports ? Baobab will continue to work closely together with those people receiving reports, e.g. hospital directors, District Health Officers (DHO's), MOH to ensure that the EDS-reports are addressing their information needs.

With Year 2 funding, Baobab system will be installed in 10 new sites and provide maintenance services in 12 sites supported by Year 1 funding.

Year 2: $400,000 To build robust monitoring and evaluation capabilities, Baobab will support the delivery of cohort reports, supporting the Ministry of Health with drug forecasting and procurement decisions. By using the EDS at burdened ART-clinics, we will help to collect qualitative and reliable data and can aggregate and analyse them in a short space of time. These figures help the clinic and the District Health Officers to deliver results to the MOH in a timely and qualitative way.

Activities include: ? Provide and develop M&E capabilities within the BART software tools ? This will consist of more reporting modules, based on expressed needs from users. At a care level (nurses), clinic level and national level. The aim is to work on a national system that is similar in every site. No individual requests will be adhered to unless; it has the support at national level. ? Specific to the ART cohort reporting - Baobab will continue to improve the cohort-reporting and further improve on presenting relevant data in a better way.

? Strengthen the supervision tool for supervising EDS sites ? As more sites start using the EDS, the system supervision tools will be further developed and improved.

? After initial set-up of framework for the central repository, initiate the installation at MOH - HIV-AIDS unit. ? Malawi will continue to have more and more sites that use a system of electronic data-collection,

although the MOH encourages standardisation between the systems, there are differences but there is also a need to easily aggregate and analyse all this data. Baobab will take the lead, in close coordination with the MOH HIV-Aids unit, to explore the development of the architecture for a central data repository. Other relevant partners will be participating in this process.

? Start the process of transfer knowledge from Baobab to MOH, for strengthening internal M&E capabilities. ? For the sustainability of the project, the MOH will identify staff members who will become involved in the day-to-day management of the EDS-sites. The software development is deemed too specific, but overall maintenance and support will over time, become a responsibility of MOH

OHSS - Health Systems Strengthening

Year I: $800.000

To Improve HIV-AIDS patient care, Baobab will continue to roll-out the installation of the EDS (Electronic Data System) to more sites, in line with the vision of the MOH HIV-AIDS unit. The sites are chosen based on a number of criteria in coordination with MOH- HIV AIDS unit. ? Further development of BART software, in line with MOH requirements ? The MOH has institutionalized the mastercard as the main data-sheet on which all basic and necessary patient data are recorded to follow-up the evolution of a patient. Any changes in the mastercard, warrants changes in the EDS software. ? Support of current 5 BART sites (Lighthouse, Martin Preuss, Dedza, Salima District hospitals and Queen Elizabeth Central Hospital) ? Installation of BART in 2 high burden sites of more than 1500 patients, in line with requirements of HIV- AIDS unit. A module to select sites, based on a number of criteria will be deployed to objectively choose the most needing sites. ? Cooperate with LIN in the North (maintenance of 5 EDS-sites in the Northern Region: Mzuzu (2), Karonga, Nkhata Bay and Rumphi) ? Develop and install HIV Testing and Counseling(HTC) software module for clinic use at MACRO in Lilongwe, Blantyre and Mzuzu ? The system will allow for the testing records to be confidential rather than anonymous; ? This includes training of MACRO staff and upgrading the hardware systems.

? Develop a software module for a mobile-device that can be used to record routine patient data while testing in the field. Baobab will deliver a prototype application and hardware for testing by one MACRO field team (maximum 3-4 mobile devices). ? Maintain the outpatient diagnosis module installed at 2 sites (CMED) Ngoni and M'bangombe, which are sites off the electricity grid. Baobab is working with wind and solar energy to keep the EDS running. Baobab will now move into the second year on these sites. ? Initiate the use of electronic mastercard at all BART sites (replacing the current manual mastercard). The overall benefit of this is to reduce the workload of the overburdened nurses and health care workers) ? Work together with LIN to explore using HL7 messaging, to support interoperability between systems, to the benefit of national data-collection/data warehousing.

2) To build indigenous capacity in medical informatics and build a mentoring center Baobab will build capability within the MOH and Baobab to support HIV clinics to move from a paper system to electronic. ? Hire and train 7 new Baobab staff. Baobab hires and trains its local staff to ensure sustainability and capacity of the system on the ground. This includes: data manager, software developer, trainer, network technician and a senior hardware supervisor. ? Train approximately 30 (new) health care staff on EDS and re-train 65 health care staff. The success of the system is completely reliant on the day-to-day use by the nurses/health care workers. Training is therefore a highly important element in the installation of the EDS at a site. ? Train staff at MACRO on static system ? Training in 3 locations, with the objective to hand-over some of the technical knowledge to IT-staff on site. Over time, MACRO will be responsible for its own day-to-day maintenance. Baobab will remain responsible for the development of software. ? Work closely with and train MOH HIV-AIDS unit supervision staff on EDS ? Every quarter a team of MOH-staff visits every ART site, as well as EDS ART sites, to counter-check the accuracy of the data reported. As EDS- reports are gathered on the system, training needs to be given to this team, so they feel comfortable analysing the accuracy of the EDS data ? Share knowledge nationally and internationally ? Attending relevant conferences in which we showcase the Baobab EDS system ? Brown-bag lunches at Baobab office - sharing of knowledge from different partners and stakeholders through informal presentations. Some of these are attended by external partners/ interested people or colleagues from the health-care sector who want to learn more about the EDS.

Year II: $1,600,000 To Improve HIV-AIDS patient care, Baobab will be working with the Ministry of Health HIV-AIDS unit to roll out the Baobab ART (BART) system from 2010 - 2014. Activities include:

? Further development of BART software, in line with MOH requirements, this entails upgrading the system to reflect changes in master-card, changes in what data to capture. ? Support of current 7 BART sites (and work with BART sites installed with other donor-monies) ? Installation of BART in 7 new high burden sites >1500 patients (sites indicated by MOH - HIV-AIDS unit) ? When installing a system, much time is dedicated to ensure that the ownership of the system lies with the sites and MOH. So, the selection of a site and the initial communication prior to the installation is crucial to the success of the EDS. ? Cooperate with LIN in the North (maintenance and upgrade of 5 EDS-sites in the North) ? Roll-out the Counseling and testing module to 3 more MACRO sites and maintain 3 current sites (Zomba, Kasungu and Karonga) train MACRO staff ? roll-out mobile device (50 sets) with technical and practical support from MACRO ? Macro has a large field team, which does testing and counseling. They are in need of a mobile system, in which they can collect the data at point-of-care, and can submit the data to the 'server' for aggregation of data. ? This includes training of MACRO staff + hand over of technical knowledge on the mobile devices. ? Maintain the outpatient diagnosis module installed at 2 sites (CMED) ? Upon agreement of needs - further develop features. ? continue and reinforce the use of electronic master card at all BART sites ? through refresher training courses, regular checks and quarterly cooperation on cohort reporting ? Continue to collaborate with other partners of MOH to roll-out BART (e.g. MSF, CHAM, MACRO) ? Develop a pharmacy management software module, which can better register not only ART-drugs, but also general drugs available at ART-clinics. ? Work together with CMED and the national data standards workgroup to develop a national unique patient identifier ? Integrate the current Baobab ARTsystem (BART) with Open Medical Records System MRS, to increase the interoperability between different systems.

2) To build indigenous capacity in medical informatics and build a center of excellence: Baobab will build capability to support HIV clinics to move from a paper system to electronic. Activities include: ? Hire and train 10 Baobab staff, in software development, software support, training, project coordination, technical networking, connectivity, data management, stock management, support staff and others. ? At times consultants are brought in to train on new areas of expertise. It is envisaged that there will always be a transfer of knowledge with each consultant. ? Train approximately 100 (new) health care staff on EDS and further train 100 current health care staff.

? Train MACRO staff on usage of static and mobile system ? Work closely with and train MOH HIV-AIDS unit supervision staff on EDS supervision tools ? Share knowledge nationally and internationally ? see above ? Attend national and international conferences on Information Technology. ? Baobab is planning to hold a high level workshop to showcase the baobab system to all relevant stakeholders, to increase the interest in the system. ? Promote the simple, robust and user-friendly EDS Baobab developed in cooperation with MOH and CDC, so that other countries might benefit from learnings gathered in Malawi. ? Work with CMED and co-chair the national standards Task Force (leading the policy making on patient identifiers, central repository and collaboration with HMIS-stakeholders) ? Continue to liaise with international organizations such as WHO, Partners in Health, who are interested in use-cases of information technology world-wide. As it leads to overall better data-quality, and in Malawi, support of better patient care.

PMTCT Budget Code Narrative $325,000

Activity 1: Provide and develop M& E capabilities for PMTCT within the current EDS software modules

In close cooperation with MOH and key partners including Lighthouse, the current BART module will be adapted to suit PMTCT-specific needs. This will include capturing medical data of pregnant women (HIV- positive) throughout pregnancy, delivery and post-natal period. Ensure that the PMTCT module can deliver reports in line with MOH requirements for those sites where EDS is available including tracking defaulters, loss to follow-up, linkages between child and mother, and linking patients to other services

Activity 2: Mobile solution for follow-up of pregnant women to reduce loss to follow-up

Develop an application for a mobile handset to be used by healthcare workers to help remind women about their next ART clinic visit. This service will also help identify PMTCT candidates and will support follow-up throughout the treatment by sending messages prior to expected visits. Women who were not registered would receive follow-up via mobile phone, and the mobile system will be developed to support EDS-sites (test-period) and at a later stage non-EDS sites as well.

Activity 3: Test and roll-out the PMTCT Electronic Data System module

The Martin Preuse Clinic (MPC) and the Bwaila maternity ward sites have longstanding experience with EDS and staff has a great deal of oversight and input in the system. There is already an existing working relationship with MPC and Bwaila in following-up PMTCT candidates. Deploying the EDS PMTCT module in this setting will be the best strategic testing ground, enabling Baobab to further strengthen and finalize it the system before deploying it to other sites.

After testing, the PMTCT module will be deployed to other sites rural health centers (Ngoni or Mbangombe), or where PMTCT is already being delivered in EDS-sites. After successful testing and optimization, the PMTCT module will also be tested in non-EDS sites in-line with the pilot for the unique national patient ID.

Thirty healthcare staff as well as Baobab staff will be trained to support the implementation and management of the EDS PMTCT project which will increase the pool of people trained in medical informatics in the country.