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Improving access to HIV testing and other basic health services in rural areas of Malawi through mobile clinics

Improvement Report
E.S. Schell, A. Bvumbwe, W. Rankin, S. Youmans, J. Laviwa, T. Lindgren

Topics: HIV counseling and testing, HIV/AIDS

Region and Country: Africa, Sub Saharan, Malawi

Organization: Vienna 2010; Journal of Rural and Remote Health XVIII International AIDS Conference
The Report

Malawi struggles to provide health care to citizens living in remote rural areas where villages may be 15 km or more from health centers that provide HIV testing and other basic services. The goal of this project was to provide basic services (including HIV testing, antenatal care, family planning, growth monitoring, and diagnosis and treatment of acute illness, especially malaria) in such areas.


In October of 2008 Global AIDS Interfaith Alliance (GAIA) launched two mobile clinics funded by the Elizabeth Taylor HIV/AIDS Foundation in high HIV prevalence rural areas of Mulanje District. Working closely with the District Health Office, GAIA had identified two remote areas and conducted a needs assessment which revealed high rates of illiteracy and poor infrastructure. Two 4-wheel drive vehicles were purchased and outfitted. Each is staffed with a Clinical Officer, a Registered Nurse, nurse aide, and driver and returns to the same village each day of the week to allow for predictability. The clinic is set up in a community building such as a church or school. Each vehicle has a bench and can provide emergency transportation to the district hospital. Services are similar to those provided by government health centers and include prenatal care and prevention of mother-to-child transmission, family planning, acute illness diagnosis and treatment (malaria and pneumonia), and VDRL and HIV counseling and testing. Services are provided free of charge.


In 2009, the two mobile clinics had a total of 38,647 client contacts. The contacts include new and returning patients. Of the 38,647 contacts, 1,160 patients were referred to a higher level of care. The most common illnesses seen by the clinics were: Under-five clinical malaria (n=11,924), upper-respiratory infections among patients of all ages (n=6528), over age-five clinical malaria (n=3264), under-five clinical pneumonia (n=3141), and diarrhea among patients of all ages (n=2610). These disease patterns are consistent with the most common causes of morbidity and mortality in sub-Saharan Africa.

2583 people were tested for HIV and 555 (21%) were found HIV+. Mobile clinic protocols require that all patients testing positive for HIV be referred to the health centers for treatment and follow-up.
Patients waiting to see a provider often participate in “health talks,” which are educational sessions on a variety of topics including malaria, sanitation, family planning, HIV and sexually transmitted infections presented at the beginning of the day by the clinical officer or the nurse, while the rest of the staff sets up the clinic. There were 30,887 client contacts made via the “health talks” in 2009.

We encountered the following implementation challenges in this project:

         Medication and supply chain, infrastructure issues, and government/nongovernmental requirements can all affect the implementation process and schedule. Timelines should be flexible to accommodate unexpected delays.
         The scheduling of different services should be adapted to local circumstances. Although the primary purpose of these clinics was HIV testing with referral for treatment, beginning services during the rainy season demanded focusing on malaria first and on HIV second. Priorities should reflect the exigent needs of the communities.
         Assessing the impact of health delivery in Malawi, including that done by mobile clinics, remains challenging. Although mobile clinic data points were matched with HMIS variables, gaps in data from all sites (HMIS and mobile clinics) and inconsistent variables between sites made direct comparisons very difficult. As each patient visit is recorded separately, it is not possible to determine the true number of patients served; therefore, drawing conclusions about disease prevalence and co-morbid disease states is constrained.
         Data collection is further hampered by existing infrastructure: shortages of personnel, pencil and paper data recording methods, and competing demands of high patient volume and acuity.
Integrated basic health services provided by mobile clinics can fill an important gap and provide an excellent platform for HIV testing. Using an integrated primary health care model helps diminish HIV stigma and provide services across the lifespan. GAIA deployed a third clinic in August 2010 to another under-resourced area and is collecting data to show how the clinics provide additive value to a stressed rural health system.