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Improving child health in Malawi, one text message at a time


A girl is weighed at the Makhwira Health Centre in southern Malawi, where a growth monitoring clinic is screening children for malnutrition using a new text messaging system. Jennifer Yang/Toronto Star

Last week, I stood beneath the shade of a giant mango tree and met perhaps the most miserable little girl in all of Malawi.

Just moments ago, she had been happily strapped to her mother's back, held snugly in place with a patterned mint-green cloth known as a chitenge. But now, the chitenge is knotted to a weighing scale and hanging from a thick tree branch – and the little girl is still wrapped inside, suspended hammock-style and screaming bloody murder.

As she twists and squirms, her tiny legs scissoring frantically in the air, a man calmly holds her in place and leans in to peer at the scale. After he notes her weight, the little girl is taken down but her ordeal is not quite over yet – next, she is laid on a wooden measuring board and her upper arm is wrapped in measuring tape.

When all of this is over, the little girl's job here is finally done. But her measurements – weight, height, arm circumference – will travel more than 250 kilometres north to the capital city, Lilongwe, where a computer software program will analyze the data, assess the girl for malnutrition, and send back any necessary treatment instructions.

This process used to take months. But nowadays, it only takes minutes, thanks to a cheap, basic and increasingly accessible technology: text messaging.

In Malawi, malnutrition is a massive and widespread issue. An estimated 10.6 per cent of Malawian children die before their fifth birthdays and at least a third of these fatalities are caused by acute malnutrition. Seventeen per cent of all under-five children in Malawi are underweight and a staggering 47 per cent are stunted, meaning they have a low height for their age. 

Stunting is caused by chronic undernutrition and its effects are sometimes fatal. Children who are severely stunted are more vulnerable to disease and four times more likely to die.

But stunting also has long-term consequences. It impairs cognitive development and cripples a child's capacity to learn, thus trapping him or her in a cycle of poverty. According to estimates by the World Bank, countries with high levels of undernutrition suffer GDP losses of between two and three percent every year. The World Bank has also said that in Malawi – currently ranked 170 out of 186 on the Human Development Index – more than $600 million U.S. in GDP is lost every year thanks to vitamin and mineral deficiences. 


A child is measured at the Makhwira Health Centre in southern Malawi, where a growth monitoring clinic is screening children for malnutrition using a new text messaging system. Jennifer Yang/Toronto Star

A major challenge when it comes to stunting, however, is that it is largely irreversible. It also tends to set in before the age of two.

This makes it crucial to identify and treat malnutrition as early as possible – which brings us back to the disgruntled little girl dangling from the mango tree in Chikwawa, a district of more than 500,000 people in Malawi's southern region.

This tree grows just outside the Makhwira Health Centre, which I visited last week as a press fellow with the United Nations Foundation.

It serves as the site of an ongonig growth monitoring clinic and every week, mothers bring their children here from all over Chikwawa, some trekking for hours with their babies strapped to their backs (roughly 80 per cent of Malawians live in rural, often-remote areas). On the Friday that I visited, a line of more than 50 mothers snaked up to this mango tree, the air filled with the screams and cries of babies.

In the past, measurements were recorded on paper and shipped off to Lilongwe, where the information would be manually entered into a database. Needless to say, this was a time-consuming process, with data entry and analysis taking anywhere between two months to a year – precious time lost for the malnourished child in need of treatment.

The paper-based system was also prone to mistakes. According to a UNICEF report, an average of 14.2 per cent of all data collected was unusable in 2007 due to data entry errors or illegible handwriting.

So in 2009, UNICEF teamed up with the Malawian government and graduate students from Columbia University to develop a new system using text messages and an open-source software platform called RapidSMS.

Here is how RapidSMS works: after a child is weighed and measured, a health surveillance assistant – typically a high school graduate who has received two hours of RapidSMS training – texts the information to a central server in the capital Lilongwe, where the software program automatically analyzes the data for signs of malnutrition. A reply is then texted back to the health assistant, along with a diagnosis and any necessary treatment instructions.

Any data entry mistakes are caught by the software program, which can detect them and message the health worker to re-send the info. The data also gets updated in real time on a website, which automatically flags cases of severe malnutrition.

A pilot study of RapidSMS was a resounding success and the award-winning system is now being rolled out across Malawi, including in Chikwawa, which launched the new SMS system in September 2012. (You can read UNICEF's final report of the pilot program here).


A new text messaging system is being used at the Makhwira Health Centre in southern Malawi, where a growth monitoring clinic is screening children for malnutrition. Jennifer Yang/Toronto Star

Last Friday, I watch as a health worker named Stephane January types the following message into his weathered Nokia cellphone:

GM 1177 031211 m 9.6 83.0 n 12.1

January explains that the "GM" stands for "growth monitoring" and the "1177" is a code identifying the child. The next six digits are the date of birth – December 3, 2011 – followed by the sex (male).

The remaining characters paint a picture of how this two-year-old is developing; he is 9.6 pounds, 83 centimetres tall and a mid-upper arm circumference of 12.1 centimetres. The "n" also indicates "no" for oedema, which is a symptom of severe acute malnutrition.

According to UNICEF nutrition officer Benson Kazembe, this child's measurements indicate he is "mild to moderate malnourished" and may even be "moderately acute malnourished" judging from his arm circumference. He is eligible for treatment and has likely now been admitted to a feeding program, where he will receive a corn-soy blend and nutrition counselling. 

The above information is what should have been texted back to January after he hit "send" on his cellphone. But on this particular Friday, there is a problem.

"The network," he says, laughing sheepishly as he stood up and waved his cellphone around, trying to capture a signal. "I'll just try and send it again."

This is a common issue, January admits, and likely the biggest hiccup in Malawi's RapidSMS program so far. Kazembe says the RapidSMS servers are currently being hosted by UNICEF but there are now plans to move to a server hosted by the Malawian Ministry of Health, which should hopefully improve connectivity.

But server issues aside, the program has been a huge success and is only growing in size. Kazembe said 4,619 Malawian children are now registered and in Chikwawa alone, RapidSMS is being used at 21 health facilities.

"Now we are able to track – to monitor – every child," said John Mugawa, the district nutrition coordinator for Chikwawa. "This technology has really helped us."

Jennifer Yang is the Star’s global health reporter. Follow her on Twitter: @jyangstar


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