WhatsApp's Real-Time Advice Helps Surgery in Rural Malawi

In remote and rural areas of Malawi, hospitals often face life and death decisions. Women needing an emergency cesarean section, elderly people with hernia and children with appendicitis should be operated on. But should they be rushed to the operating room or transferred to specialists in the city's hospitals?

The answer depends on the condition of the patient, the distance that separates him from the city and the facilities available at the local hospital. Surgical skills, clinical experience and self-confidence are also critical factors.

Until recently, smaller hospitals, generally counting about 200 beds and only two or three qualified general practitioners, usually recent graduates with a few years of experience, have often found it more prudent to transfer patients for surgery. .

A handful of clinicians – a health professional degree with no medical degree – are responsible for transfers and sometimes perform routine surgical procedures in rural clinics. Although these systems are vital to local health systems, their surgical experience and clinical judgment may be limited and many feel professionally isolated from academic hospitals.

"Clinicians are not surgeons as such and they do not have a lot of contact with surgeons, but with supervision, they can do a lot," said Gerald Mwapasa, a researcher at the College of Medicine's University of Malawi.

Mwapasa is the moderator of an invitation-only WhatsApp group, which allows health workers to seek advice from specialists before or sometimes during surgical operations.

"Before the WhatsApp groups, the doctors in the regional hospitals felt that the specialists were difficult to reach, they are now affordable," he said.

The group was born as part of a project called SURG-Africa, of which Mwapasa is the project coordinator in Malawi. The goal is to expand access to safe surgery in sub-Saharan Africa through the training, supervision and increased use of the Surgical Safety Checklist. the World Health Organization.

As part of this project, researchers in Malawi are working to strengthen surgical teams at the district level and strengthen links between rural and urban reference hospitals. They considered developing an application to connect healthcare professionals and allow them to share images and videos, but they understood that WhatsApp was a solution right under their noses.

Vital support

The group has become a vital support for rural hospitals facing clinical dilemmas.

"This gives clinical officers confidence when making decisions," Mwapasa said. "They can get advice on how to proceed with hernia surgery or how best to prepare a patient for the transfer rather than trying a procedure for which the hospital may not have the necessary facilities. . "

In 2018, about 200 cases were discussed by the group, all of which had already been referred to urban hospitals. Thanks to the advice given, less than two-thirds of these patients had to be transferred.

Martin Malunga, a clinical manager at the Mulanje District Hospital in southern Malawi, said the group was a valuable educational tool.

"If a district (hospital) publishes a case and a consultant responds, we all learn," he said. "The WhatsApp group has improved management by providing guidance on how to proceed or before referring a patient to a specialist."

Dr. Tiyamike Kapalamula, a pediatric surgeon at Queen Elizabeth Central Hospital in Blantyre Financial Capital, gives advice via WhatsApp.

"The cases that are recommended for referral come here in better shape because the basic investigation, resuscitation and preparation work is already done at the district level," she said.

Strict guidelines apply to the content that can be posted. To maintain confidentiality, no identifiable patient name, face, or image is shared. About 40 questions a week are shared, usually by clinicians from one of the nine participating district hospitals. At first, informing Mwapasa of the group's rationale was a challenge, but it is now easier to manage.

Since the beginning of March 2018, more than 160 health workers have registered. Another group began to focus on obstetrics and gynecology.

Specialist teams also travel to remote areas for training and mentoring, according to Dr. Jakub Gajewski, Project Manager SURG-Africa, who works at the Royal College of Surgeons in Ireland. In the past, rural clinicians had little contact with specialists between visits, but they now maintain contact with the group.

"It helps to reduce the feeling of isolation of doctors working away from teaching hospitals," he said.

The whole system

Dr. Gajewski said the project was helping to unleash the potential of health workers, and by eliminating unnecessary referrals, specialists can focus on the complex cases of patients for whom they were trained. "The whole system benefits," he said.

With representatives from the Ministry of Health, the Medical Council and the Group's blood transfusion service, members were able to report shortfalls and quickly receive replacement tools such as surgical lamps.

The initiative has sparked interest from Zambia, Tanzania, and Rwanda, where surgeons are keen to explore how a messaging application could narrow the gap between surgeon communities and improve the lives of patients. doctors.

But for health services in sub-Saharan Africa, one of the biggest challenges remains the limited availability of health professionals. Too few are trained and many leave Africa to develop their skills. Most African countries have less than one doctor per 1,000 population – the EU average is above 3.5 per 1,000.

The implications of this can be devastating. Take maternity care, for example. While Africa is the continent with the highest birth rate (Malawi's fertility rate is 5 births per woman, for example), the maternal mortality rate in sub-Saharan Africa is much higher than the maternal mortality rate in sub-Saharan Africa. other parts of the world, with 920 maternal deaths per 100,000 live births.

"Without a sufficient number of health professionals, the quality or accessibility of care suffers tremendously," said Professor Paul Cunningham of the International Information Management Corporation (IIMC), an Irish technology company coordinating mHealth4Afrika, a project focused on improving primary health care in Ethiopia, Kenya, Malawi and South Africa.

Technology is key to strengthening delivery and expanding access to primary health care, he said.

One of the key challenges for local health sector decision-makers is to collect accurate data from clinics so that they can forecast demand and therefore plan for future investments. For patients, better use of resources would reduce the lengthy waiting times to meet the much-needed health needs.

First aid

According to Professor Cunningham, paper records remain the default mode for collecting primary care data.

In collaboration with partners in Africa, Norway and Turkey, IIMC co-designed a patient-centric health informatics system used by ministries of health and district offices, clinic managers and nurses. four African countries. He described this approach as a "cradle-to-grave" approach to patient care, consisting of tracking health information throughout their lives – and building trust in information technologies related to their health. to health care.

This electronic system can capture and integrate personal health records as well as compare medical data over time. The platform saves time during consultations and provides health professionals with up-to-date patient information to guide their decisions.

By automating data counting of key health indicators, such as births, deaths, immunization rates and diseases, staff can focus on clinical tasks, while ministries of health have access to data more specific to inform policy and service planning.

The platform now incorporates key medical programs including maternal health, tuberculosis, HIV / AIDS and cervical cancer screening. Support is being provided to diabetes, malaria and hypertension, all of which are major challenges in the region.

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