It is 6:30 am in summer and Makhuwira Health Centre’s Outpatient Department (OPD) is already full of people waiting to be attended to.
The majority are women accompanying their under-five children.
At exactly 7:15 am, a health surveillance assistant (HSA) appears and enquires from guardians about symptoms the children have shown.
“My child has high temperature, is vomiting and has a cough. He hardly slept last night,” says Christina Saulo of Maraba Village, Traditional Authority Makhuwira in Chikwawa.
She looks exhausted. She has walked a nearly two-hour distance with her child weighing about 15 kilogrammes on her back.
Saulo only has K300 which she thinks of using to get a bicycle taxi on her way back home.
By the time she arrives at the health facility, the OPD waiting area is already pregnant of people; she has no idea that her child will be seen to in a little while.
But when she presents the child symptoms to the HSA, he gives her a yellow ruler (which means her child is a priority patient) and advises her to go in front of the queue.
Looking surprised and having the fear that the other guardians would confront her, she edgily proceeds to the front of the queue.
Surprisingly, no one says anything until she gets into the consultation room.
“The HSA says my child has been through Chipatala Robot system which sorts which patient needs medical help urgently. Everything has happened so fast and I’m now going home for my child to rest,” she says.
Chipatala Robot is Emergency Triage, Assessment and Treatment (Etat) approach towards improving emergency paediatric care developed by the World Health Organisation (WHO) which Malawi’s Ministry of Health has adopted.
Malawi Liverpool Welcome Trust (MLW) is conducting a study using the approach in primary healthcare facilities of Blantyre and Chikwawa. The system is also in use at Chikwawa District Hospital and Queen Elizabeth Central Hospital (Qech).
Makhuwira Health Centre HSA Asharf Kananji says Etat involves sorting sick children according to the severity of their illness using traffic robot colours.
“Red (E) means emergency, the child is extremely sick and needs to be seen immediately, yellow (P) means priority, child is very sick and must be given priority in the queue and green (Q) means a child has minor illness and they can wait in the queue,” Kananji explains.
Triaging or sorting patients is part of his routine tasks once he arrives at the health facility.
“This sorting is mostly done for newborn children to 14-year-olds. Those that are less than two months are automatically a priority,” he says.
Kananji says the sorting is mostly done through a mobile phone App whereby he ticks on the signs and symptoms which are stated on the App then it automatically indicates where a child belongs on the robot.
This is also effectively done manually; through ticking on the signs and symptoms and determining when a child should be treated.
Makhuwira Health Centre is located 40 kilometres away from Chikwawa Boma and the place regularly has mobile telecommunications network problem.
This usually distracts the use of the mobile App to triage patients. The App requires consistent use of Internet from data bundles. But this is almost impossible to use because residents of the area have to climb a nearby hill or anything higher to make calls.
But this health facility has operated some weeks without the use of the modern App and Saulo’s child has been triaged manually.
Makhuwira Health Centre In-charge Moses Zalira says since the Etat approach was introduced at the facility in 2013, there has been an improvement in terms of child deaths.
“We no longer have cases of children dying while waiting to receive treatment. We are able to call for an ambulance early enough for a child to receive further treatment at the district hospital,” he says, adding that at least three children died per week before.
Zalira says the facility is already full by 6:30 am although it opens at 7:30 am but “in most cases by 11:30 am, there are very few patients”.
The facility treats over 300 patients per day and 70 of these are children taken through the Chipatala robot system before they get treatment.
“Today, I have attended to one emergency, 25 priorities, 47 in a queue and two referral patients,” Zalira says.
He says the facility has a catchment area population of 77,000 people and common illnesses in children include malaria, severe pneumonia and diarrhoea.
The situation is more like the same at Mfera Health Centre, also located in Chikwawa’s rural area. It has a population catchment area of 17,400 people.
In-charge of the health facility Matthews Makoka says even though Chipatala Robot has helped reduce child deaths, it has some challenges.
“Most of the times we do it manually because of either the persistent electricity blackouts or poor network. This makes us go weeks without using the modern App which also makes it difficult for Malawi Liverpool Welcome Trust to monitor its progress,” he says.
The health centre treats about 150 patients a day and around 40 of them are children.
The Daily Times investigations have established that much as the system helps to detect cases that need to be referred to the district hospital for further diagnosis and treatment, health workers get frustrated by ambulance delays.
An ambulance takes a minimum of three hours to reach the facility to pick up emergency cases and this is mostly due to some logistical challenges at the district health office (DHO) and shortage of ambulances.
Chikwawa DHO Etat Coordinator Grace Zakeyu says Etat prevents deaths within 24 hours of reaching health facility or admission.
“This has assisted us in reaching zero deaths of children in the first 24 hours at all the three health facilities that Etat or Chipatala Robot is being practised. Deaths, of course, are there but not because of delays in the first 24 hours,” she explains.
Research nurse at MLW Harriet Khofi says MLW intensified the approach after noting that there was a gap in managing emergency illnesses in children.
She says a survey that was done at Qech exposed that most children spent almost the whole day at a health facility awaiting treatment.
The programme initially targeted meningitis and cerebral malaria but is now being used to manage any serious illness in children aged zero to 14 years.
“In worse situations, children could die waiting or could not respond to treatment because the disease has advanced,” Khofi recalls.
She acknowledges that the project is facing hitches to use the modern App due to electricity blackouts and network problems.
“We are monitoring the approach closely, so if the phones are not used, it affects our data collection and the results may not be as effective,” she says.
According to MLW records, the approach has helped to assist 230,000 children from 2013 to November 2016. It is operational at eight health centres in Blantyre, namely Chilomoni, Ndirande, Bangwe, Mpemba, South Lunzu, Limbe, Chileka and Zingwangwa. In Chikwawa, it is piloted at Chikwawa District Hospital and Mfera and Makhuwira health centres.
Unicef says despite that Malawi achieved goal four of the United Nations (UN) Millennium Development Goals, which targeted to reduce child mortality by two thirds by 2015, one in eight children are still dying of preventable diseases.
Pneumonia, diarrhoea, malaria, HIV-related diseases and malnutrition are some of the major diseases contributing to child deaths in the country.
Goal three of the UN Sustainable Development Goals (SDGs), which countries adopted in September 2015, aims at ensuring healthy lives and promote wellbeing for all at all ages by 2030.
One of the targets indicates that by 2030, there is need to end preventable deaths of newborns and children under five years of age among others.
Ministry of Health Chief of Health Services Charles Mwansambo says Etat has been in the ministry’s policy since 2003.
“It’s the ministry’s wish to sort patients according to level of their illness so that we should save more lives, that’s why we have this policy,” he says.
Mwansambo says the use of mobile App in triaging patients may be adopted later depending on what the results will say on its effectiveness.
Perhaps Malawi would have done better in reducing under-five deaths if the system was widespread. Many mothers would be satisfied with local health service provision just like Saulo.