In Southeast Africa lies Malawi, where a nation affectionately known as “the warm heart of Africa” grapples with the formidable challenge of delivering quality primary health care (PHC) to a largely rural population. Despite strides in recent years, only 50% of Malawians can access health facilities within a 5-kilometer radius. The median travel time from home to a health center is an hour and 2.5 hours to a central hospital.
This limited access, coupled with a shortage of health care workers, casts a long shadow over the health outcomes of many Malawians. Maternal and child mortality rates remain stubbornly high, while infectious diseases like malaria and HIV/AIDS continue to pose significant threats. VillageReach’s Community Insights to Action (CITA) Framework illuminates a path forward. Here are key opportunities to apply CITA in Malawi.
Government Leadership and the Power of Innovation in Digital Solutions
Given the geographical and institutional barriers that hinder access to PHC in Malawi, digital solutions can be a game changer. VillageReach has been at the forefront of leveraging digital tools to enhance health care delivery in Malawi, spearheading the Health Center by Phone initiative, known as Chipatala cha pa Foni (CCPF) in Chichewa, in partnership with the Ministry of Health (MoH).
CCPF is a free national health hotline that provides health information across the country over the phone and via text or voice messages with tips and reminders tailored to the individual.
Following this success, the Malawi Government, in partnership with VillageReach, developed a social listening approach within CCPF by analyzing caller needs and concerns regarding COVID-19 vaccination and identifying opportunities to channel the data to relevant MoH directorates for informed decision-making. This is one example of the government’s commitment to health care innovation that centers on prioritizing community feedback and preferences.
Government Commitment to Community Health Outcomes
The release of the Malawi Health Sector Strategic Plan III in 2023 further reinforced this commitment to health care innovation. The plan emphasizes the importance of community empowerment in health care provision, calling for “communities to be enabled to have greater control of their health outcomes including decision-making for service delivery and the health systems that affect access, as well as quality and efficiency of the services.”
Through the Quality Management Directorate (QMD), the MoH also has established Hospital ombudsmen at each health facility who play a pivotal role in receiving health service user complaints, feedback and suggestions. However, they are often operating with insufficient resources to enable them to complete the analysis and application of the feedback they receive from health service users. As one government officer told our research partner ThinkPlace, “We are good at collecting data, but the problem is how to use it.” That is where the CITA Framework comes in.
Incentivizing Action Based on Community Feedback
The CITA Framework provides a comprehensive framework for systematically incorporating community insights into policy decisions. By routinely and actively listening to feedback from community members, we can provide PHC that responds to clients’ changing needs and preferences, even in times of crisis. But there are often gaps in identifying what actions need to be taken after gathering insights and then incentivizing the right actors to take these steps.
CCPF social listening is a notable example of the application of the CITA process. In 2022, VillageReach and the MoH partnered to systematically collect and disaggregate incoming calls on COVID-19 vaccination to categorize call-in data by topic discussed, location, gender and age of the caller to understand what issues were concerning for the population regarding COVID-19 vaccines. Bi-weekly analysis of this social listening data helped us co-develop low-cost strategies to improve public health messaging through the MoH Health Education Services with great success.2 This shows how digital innovation can assist in completing feedback loops and influence decision-making in the health system when data is utilized at appropriate policy levels.
Our next step must be to move from targeted social listening to a broader exercise of community listening at scale, building in sources external to CCPF, analyzing and visualizing this data so that insights are verified and actionable, and supporting key decision makers with the platforms and tools to prioritize these needs and incentivize action and improvements to the health system based on these data.
Leveraging Health System Actors to Help Close the Feedback Loop and Build Trust
Routinely incorporating insight from communities into health program decision-making can lead to powerful results. But closing the loop entails not only action but also awareness, including informing people of changes and the reasons behind them. Furthermore, communities should not merely be involved in identifying problems but can also play a pivotal role in identifying solutions and tracking progress. In developing the CITA Framework, we found that the feedback loop is often left open, despite closing the loop being vital for building and maintaining trust with the communities that provide feedback.
Empowering health system actors like community health workers (CHWs) to actively participate in this feedback loop is paramount to improving the quality of care. CHWs often serve as the first point of contact for communities, providing invaluable insights into local health needs and concerns. Malawi is also one of the few countries that relies on CHWs to administer routine immunizations and many other community based health services. These CHWs, known as Health Surveillance Assistants in Malawi, are also trained and trusted members of their local communities.
By equipping CHWs and other community members with the resources to collect, analyze and utilize data to identify and address health challenges effectively, we can build strong two-way feedback and data review systems, fostering a culture of continuous improvement.
Harnessing the Power of the People
The ultimate goal of embedding CITA into responsive primary health care systems is to build health care for and shaped by communities. By equipping communities with the tools and information they need, we aim to pave the way for a more responsive and equitable health care system in Malawi, a system that focuses on the needs of the most marginalized and gives everyone an opportunity to thrive
Digital solutions offer one powerful avenue to operationalize the CITA Framework at scale. By utilizing digital tools to collect and analyze data, we can help health system actors – from local communities to the upper echelons of government – uncover trends and patterns that would otherwise remain hidden. This invaluable information can then inform decision-making and elevate the quality of PHC services.
A Vision for the Future
The CITA Framework can be a catalyst for change, holding the potential to transform Malawi’s health care landscape. Fully realizing this vision of the future will require continued government stewardship and a coalition of the willing to amplify the voices of Malawian communities, increase investment in solutions that strengthen feedback loops and foster a culture of collaboration, learning and informed decision-making.