An Overview of the Available Health System for Monitoring Non-Communicable Diseases in Malawi

  

    
Indicators
    
Name of responsible agency
    
Period
    
Remarks
  
  

    
Cancer incidence (by type of cancer)
    
National cancer registry, MoH
    
-
    
Underreporting and delays in reporting
  
  

    
Premature mortality due to NCDs
    
NRB
    
-
    
Lack of comprehensive death registration
  
  

    
NRB: National Registration Bureau. 
  

Table 3: Monitoring of outcome indicators.

Results

Implementation of the NCD monitoring in Malawi

Implementation of NCD monitoring in Malawi is described in this study based on the three major themes of the WHO Global Monitoring Framework for the 25 indicators: monitoring of risk factors; health systems capacity and monitoring of outcomes.

Monitoring of risk factors

Malawi national STEPS non-communicable diseases risk factor survey, which is based on the WHO STEPs survey [11], is a population based cross-sectional survey of chronic diseases and their risk factors. It is designed to help countries build and strengthen their capacity to conduct surveillance. This survey monitored lifestyle risk factors (physical activity, tobacco and alcohol use) and anthropometric measurements (body mass index and central obesity) as monitored in the Global NCD Framework with exception of fat and salt intake. Both fat and salt intake are not routinely monitored at the population level and consequently there is no consistent data available [10].The Government of Malawi uses a standard methodology for a household survey for adults. A three-step multistage sampling method is used to produce a national representative data both at urban and rural areas of Malawi. The data is collected by face-to-face interviews using structured questionnaires as well as collection of clinical and biochemistry tests.

Health systems capacity

The Ministry of Health occasionally conducts health facility survey to enable reporting of drugs and essential technologies and medicine indicators. This is normally a paper-based stock management which can be erroneous and time consuming. There is a shortage of equipments and essential technologies as well as essential drugs in most of the health facilities in Malawi. Furthermore, the government has a subsidy of drugs in all health facilities however, patients are often asked to purchase drugs via private avenues. Malawi uses the District Health Information System (DHIS2) to collect data and transmit them electronically from the district to the national level. However, from the health facility level to the district level, data reporting is still paper-based. This is because most health facilities do not have internet connectivity and or a computer as well as electricity. Data at the health facility level are collected through paper-based system using registers, aggregated on monthly basis and then sent to the district level. This process makes data collection slow and time consuming. The Ministry of health with assistance from non-governmental organizations have developed a suite of touchscreen-based Electronic Medical Record (EMR) system used by health facilities across Malawi. The EMR system includes applications for patient registration, in-and-out patient diagnosis, maternal care, and ARV [12]. This EMR suite is used in more than 60 health facilities across Malawi but there are plans to introduce it to more health facilities.

Monitoring of outcomes

The national Statistics office in Malawi is the main government body responsible for collecting and disseminating all data on premature mortality due to NCDs. However, due to insufficient data on deaths that occur outside the health facility, majority of deaths are non-medically certified. In 2007, the Malawi Government through the National Registration Bureau (NRB) initiated a paper-based village registration system for births and deaths, and this reached full country-wide coverage by 2011. These registers were a potential source of vital statistics data at the community/grass-roots level, but the manual collection, collation and analysis of data from villages up to traditional authorities and then up to the district commissioner were almost impossible due to lack of intermediary human resources, inadequate transport and poor infrastructure [13]. A potential solution was to develop an Electronic Village Register (EVR) to transmit data through wireless networks from village headmen to the TA Chief to the District Commissioner (DC) and then to the National Registration Bureau (NRB), with this data also shared with the appropriate health facilities [13]. In response to high burden of cervical cancer, in 2004, the Sexual and Reproductive Health Directorate of the Ministry of health Malawi, implemented Human Papillomavirus (HPV) vaccination pilot project and screen-andtreat programme using Visual Inspection with Acetic Acid (VIA) and cryotherapy. The programme is integrated with family planning services and targets women aged 30-45 years and women on HIV ART. By 2011 the programme was scaled up to all central and district hospitals, most mission hospitals and some health centers and private hospitals [8]. They receive Malawi Cancer Registry monitors all cancer incidences in Malawi. The receive notifications from all data sources providers in government and private health facilities using a national standardized tool. Comprehensive cancer registration is achieved through data obtained from a combination of sources such as hospital-based cancer registry, hospital death notification forms, pathology records, notification by medical professions and health facility discharges records. All cancer cases obtained outside health facilities and organizations physician or doctor notification are crosschecked against known registry for verification [14].

Discussions

Gaps and challenges in NCD monitoring including COVID-19 in Malawi

There is currently a vigorous monitoring system for NCD surveillance in Malawi for indicators covered by the WHONCD Global Framework. However, Malawi still lacks data for the monitoring the health system indicators of the framework. For monitoring mortalities, despite the challenges reported such as human resources, inadequate transport and poor infrastructure, all deaths that occur outside a health facility can be verbally reported by the chief or local heads. Additionally, these deaths will require an autopsy in case of suspicious foul play which will sometimes change the information of the registration of death. With regards to cancer incidences and mortalities, there are possibilities of under-reporting of cancer cases in Malawi because most cancer patients tend to seek for palliative care at their homes. Other patients often seek alternative treatment options that are not medically proven. There are several studies in Africa that have shown delay in presentation and diagnosis of cancer patients due to these factors [15,16]. Though there are already developed technology-based practices in place to collect data for cancer screening, there still requires paper-based data entry by the healthcare provider especially at the district level. Technology is still limited and this is well-known and documented obstacle in other studies. Some well-known challenges are lack of electricity, computer and little telecommunication coverage. Regarding COVID-19, data collection and monitoring for NCD-related consequences are two major challenges caused by the movement restriction. Current reviews have shown that SARS-CoV-2 infection may affect the progression and health outcome of pre-existing chronic disorder. Evidence from other respiratory disease show that the infection can acerbate chronic NCD conditions include and are associated with functional decline in older persons [17]. The movement restrictions have caused disruption to the screening, treatment, monitoring and follow-up of NCD patients [18]. Additionally, majority of health care workers have been re-assigned to support COVID-19 response. The transfer of healthcare workers has definitely caused disruption in data collection and data entry at primary and district health facilities. There is need to look beyond the NCD-WHO Global Monitoring Framework as the current NCD monitoring tool system in many LMICs including Malawi will not be able to monitor the NCD-related consequences due to COVID-19 in a well-timed manner. There is also urgency to focus more on the marginalized population especially in rural areas and strengthening of surveillance of mental health issues. COVID-19 has shown a great need to address mental health problems especially among women who experience gender-based violence. Psychological, counselling and social support services through helplines have been made available during COVID-19 pandemic. However, the utility and coverage of the data is limited as most of the services are provided by non-governmental organizations. There is great need to incorporate all paper-based data to electronic format to allow ease of decision making for policy makers.

Way forward

The roll-out of Electronic Medical Record (EMR) system in all regions in Malawi could improve the availability and accuracy of data from lower health facilities up to the national levels. Healthcare facility data on morbidity, mortality and risk factors should allow patterns to be detected in real time. The data becomes a reliable repository for NCD surveillance if it can be cross-checked across all health care facilities (public and private) and provide a platform for significant local action. Data capture procedure especially in the lower-level facilities is still paper-based and missing information are usually followed retrospectively in case of missing information. This approach can be time consuming and costly. Research has shown that electronic medical records have potential to assist enhance the privacy and confidentiality, and effectiveness of healthcare services [19]. However, challenges such as lack of training, privacy issues and high cost of installation have also been cited as potential set-backs [20]. Therefore, one option moving forward could be an expanded surveillance at the primary care level can provide important information on the progress of the different aspects of NCD services and utilization on a routine basis [21]. Utilization and modification of existing technologies to closely monitor behavioral NCD risk factors can be adopted and strengthened. This will enable us to monitor the immediate impact of any intervention related to NCD being implemented. Additionally, wearable technologies such as noninvasive self-monitoring technologies hold potential to encourage optimal self-management. Furthermore, these technologies identify new NCD risk factors, intuitions into lifestyle behaviors and tracking patient engagement in self-care [22]. There is great need to incorporate and expand NCD monitoring with the use of artificial intelligence and big data solutions. However, these options remain practically not possible given the many challenges such as financial ability, lack of health care workers and limited technological use and knowledge [23]. Some of the documents that were meant to be analyzed were not readily available from government ministries responsible for policies. As such, this limited our analysis of multisectoral action in the formulation of the policies. The data we received from the various sources on the indicator of each theme might not be exhaustive because some of the data was either not available online or up-to-date.

Conclusion

NCD monitoring is a vital and important component in response to the increasing burden of NCDs affecting the quality of life of the population and health outcomes. The existing NCD monitoring tools for Malawi is able to provide most data for the indicators in the WHO-NCD Global Monitoring Framework, however, there is great need to strengthen the NCD surveillance in planning, monitoring and evaluation of interventions and use on all alternative sources of data. The current COVID-19 pandemic and movement restrictions have shown gaps in the health care system in Malawi and hence there is great need to strengthen the NCD monitoring system in Malawi and other countries.

Declaration

Acknowledgement: The authors also acknowledge the support of the community nurses at the Lighthouse Trust, Malawi for their time and valuable contribution during this study. The authors also thank the various research working groups and teams at the Heidelberg Institute of Global Health for their critical appraisals of this study.

Author contributions: ES and CM conceived, designed the framework and prepared the initial draft. ES refined the draft paper then both authors reviewed and approved the final manuscript.

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