Ministry of Health and Population

mHealth in Malawi
Landscape Analysis
May 2018
Table of Contents
1 Key Acronyms 17 Modes of Interaction

Overview of the Servers and Data

2 mHealth 360 Analysis 18 Storage

The state of mHealth in

3 Malawi
19 Types of Users

4 Timeline of mHealth in 20 Number of End Users

Malawi

Project Costing Across

5 Geographic Distribution 21 All Projects
Project Maturity by
6 Users 22 The Average Project
Costs
National Community
7 Health Strategy 23 Average Device Costs

8 HSAs Using mHealth

24 Applications vs. SMS in
mHealth
Health Informatics
9 System Architecture 25 Application vs. SMS
Projects
Achieving Integrated
10 Service Delivery at Scale Cost of Application Projects
25.1 vs. SMS Projets
Current mHealth Focus
11 Areas
25.2 Applications vs. SMS Users
Potential Areas for
12 mHealth Expansion
26 Key Takeaways

13 Service Domain Areas

Appendix 1: Registered
27 Projects
14 Functional Roles

Malawi Essential Health

15 Package (EHP)

16 Types of Hardware

Page 1 of 17
 1. Key Acronyms
CHS  Community Health Services Section 
CHT Community Health Team
CHW    Community Health Worker
CMED Central Monitoring & Evaluation Division
EHP      Essential Health Package
EPI       Expanded Program on Immunizations 
GPS      Global Positioning System
HIS      Health Information System
HSA      Health Surveillance Assistant
HIV       Human Immunodeficiency Virus
IMCI     Integrated Management of Childhood Illnesses

M&E Monitoring & Evaluation

MoHP    Ministry of Health & Population
 
NTDs     Neglected Tropical Diseases
PDAs   Personal Digital Assistants
SMS       Short Messaging Service (Texting)
TB       Tuberculosis
USSD     Unstructured Supplementary Service Data 

Page 2 of 17
 2. Overview of The
mHealth 360 Analysis
As mobile technology has become ubiquitous, Malawi has seen several robust service delivery mobile
applications for healthcare deployed with different levels of success. SMS and phone hotline projects
have reached national scale and have been widely regarded as having both high impact and ease of use.
Unfortunately, to date, no smartphone applications have been able to scale to a national audience and
systems remain in silos both geographically, topically, and technically. 
With limited resources, how do we determine which solutions should expand, where pilots can provide
new insights into existing gaps, and how to create a national policy that allows for both innovation and
scale?  To aid the Kuunika: Data for Action project in developing and implementing mobile technology in
Malawi, and to a larger extent, to aid the Ministry of Health and Population in the governance of mobile
technology, we conducted an independent evaluation of mobile health technology systems currently
being implemented in Malawi.  This assessment provides a concrete way that Malawi can adapt high-
level frameworks and tools into assessments that provide evidence for policies, standards, and
strategies in mobile health.

As part of the Kuunika Project, the Central for Monitoring and Evaluation Division (CMED) and the
Community Health Services Section (CHS) in the Ministry of Health and Population worked with
Cooper/Smith to conduct a mobile health landscape analysis and technical feasibility study. This activity
aligns with the project work plan and complements the current efforts of other Malawi programs. To
date, few countries have conducted such an assessment.  We hope this assessment will serve as a
template for routine evaluations in Malawi and other countries interested in improving the alignment of
mobile health investments and streamlining mobile health systems.
The mHealth 360 analysis consists of a 4-step approach:

Survey of all mobile End user experience

1 health projects in
Malawi
3 feedback with a select
group of platforms

Provide

2
In-depth analysis of
a select group of 4 recommendations
for policy and
platforms standards

This report includes the results from mHealth 360 Analysis Step 1: survey of all mobile health
projects in Malawi. This survey was undertaken as part of a national registration of all mHealth
projects with results were synthesized by Cooper/Smith.

Page 3 of 17
 3. The State of
mHealth in Malawi
3.1 National mHealth Registration
In 2017, the Secretary for Health and Population required that
all Malawian mHealth projects complete a formal registration
process. 31 mHealth projects officially registered. Information
about the projects was extracted during
registration. Additionally, a list of known mHealth projects was
cross-referenced using existing databases. 

31
mHealth is a component of electronic
health (eHealth). It is the medical and
public health practice supported by
mobile devices, such as mobile
phones, patient monitoring devices,
mHealth Projects in Malawi personal digital assistants (PDAs), and
surveyed  through the national mHealth  other wireless devices.
registration

-Wo r l d He a l t h O rg a n i za t i o n ( W H O)

Page 4 of 17
4. Timeline of mHealth in Malawi
mHealth projects in Malawi have existed since at least 2007, with an average of 2 new projects coming
online each year.  The average lifespan of a mHealth project is 5 years.  2016 was the most active year for
new projects with 7 new projects coming online. As of March of 2018, there were 22 live mHealth projects.

mHealth Projects in Malawi Over Time

25

Malawi continues to have an

20
upward trend of mHealth
projects
Number of Projects

15

10

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Years

New Projects Total Projects

2007 2 5
projects years

First mHealth Average number of

project in Malawi new projects per Average project
year lifespan 

Page 5 of 17
5. Geographic Distribution
At least 5 mHealth projects have been implemented in each district in Malawi. There is an average of 8 projects
per district. In addition, national/regional projects tend to span an average of 8 districts (out of a total of 28).
Most mHealth projects are concentrated in the Southern region. Blantyre & Zomba districts have 13 projects

5
each (the greatest number).

MINIMUM PROJECTS
mHealth is PER DISTRICT

geographically
widespread,
8
AVERAGE NUMBER OF
PROJECTS PER DISTRICT
reaching every
district in Malawi.
13
MOST PROJECTS PER
DISTRICT (BLANTYRE &
ZOMBA)

6. Project Maturity by Users

When broken down into scale categories, the majority of mHealth projects in Malawi have less than 100 users
or have 100-500 users, meaning they are either in the pilot phase or are scaling. Of those projects at a large
scale, the majority are using voice or SMS services. No smartphone applications have been able to reach a
large scale of users to date. 

Number of Projects by Number of Users

10
10
Pilot
9 8
8
7
Scaling
6
5 National Scale
4 3
3 2
2 1
1
0
<100 100-500 500-1,000 2,000 5,000

Page 6 of 17
7. National Community Health Strategy
The Malawi National Community Health Strategy 2017-2022 states that

50%
Community Health Teams (CHTs) should increase the use of mHealth and has
set the target that by 2022, 50% of CHTs will be using mHealth for integrated
service delivery, data collection, and supervision.
Based on the registration survey results, we estimate that 1,823 Health
Surveillance Assistants (HSAs) are currently using mHealth for community
health service delivery.  This number was calculated by including all
registered projects that address the Malawi Essential Health Package for
"Community Health" and have HSAs as the target end users. Excluded in the By 2022,  50% of Community Health
calculation are projects such as cStock - which is solely focused on nutrition, Teams (CHTs) will be using mHealth for
CCPF which does not specifically target HSAs, and ONSE which had not integrated service delivery, data
started implementation at the time of the registration.
collection, and supervision.
Using the  Community Health Strategy target of 15,000 HSAs employed by
2022 to fulfill the proper ratios, 12.15% of HSAs, or a quarter of the target
goal, has been achieved. To achieve the target in full, we will need to see a 3
fold increase in mHealth uptake among HSAs.

8. HSAs Using mHealth

Community Health Strategy
Progress to Date

1,823
13,177

1823

Estimated number of Health Surveillance

Assistants (HSAs) or Community Health Workers
(CHWs) currently using mHealth for integrated
HSAs not using mHealth (87.85%)
service delivery, data collection, and supervision.
HSAs using mHealth (12.15%)

9. Health Informatics System Architecture

To reduce  data collection burden on
HSAs and CHWs, government
programmes (e.g. civil registration and Global
vital statistics, National ID, and others)
and partners need to standardize and District Health Information
System (DHIS2) National
harmonize data collection methods.
Integrated electronic data management District
solutions should be harmonized with the
National eHealth Strategy and consider National Electronic Medical Facility
leveraging existing mHealth/digital Record Platform
tools. Patient

-National Community Health

Strategy 2017-2022 mHealth Community & Household
Applications 

Page 7 of 17
10. Achieving Integrated Service Delivery at Scale
To achieve integrated service delivery at scale, expansion of mHealth will be necessary in 3 areas:

Scaling users both by increasing the number of Community Health Team members using mHealth
tools and expanding geographically.

Linking mHealth users with other levels of the health system to include supervisors and facilities.
Linking mHealth tools to other platforms that are part of the National Health Information System.

Expanding content to include coverage of service delivery areas that are not currently being
covered and fully implement all services provided by Community Health Teams.

11. Current mHealth Focus Areas

The majority of Malawi's mHealth projects are working in maternal and reproductive health, infant and child
health, and community health.

Maternal and Infant and Child Community

Reproductive Health Health
Health
12. Potential Areas for mHealth Expansion
Based on the burden of disease and national priorities, key areas for expansion include HIV and Tuberculosis
(TB); chronic diseases; and vaccines, Expanded Program on Immunizations (EPI) or vaccine-preventable
diseases.

HIV and Chronic Diseases Vaccines and

Expanded Program
Tuberculosis (TB) on Immunizations
(EPI)

Page 8 of 17
13. Service Domain Areas
As part of national policies and guidelines, 5 service domain areas have been outlined. In the registration we
asked partners which service domains they aligned with. While promotive, preventive, surveillance, and curative
service domains were all covered by 22%-30% of projects, only 1 project reported aligning with rehabilitative
services. 
Rehabilitative (1.69%)
Curative (30.51%)
Surveillance (20.34%)
Preventative (27.12%)
Promotive (20.34%)

14. Functional Roles

50% of projects registered aligned themselves
with clinical services (16 projects). Most projects
are in Reproductive Health, Integrated
Management of Childhood Illness (IMCI), and
Nutrition, with HIV, Neglected Tropical Diseases
(NTDs) and Expanded Program on Immunization
(EPI) lagging behind. 

50%
OF PROJECTS
ARE LINKED TO CLINICAL SERVICES

15. Malawi Essential Health Package (EHP)

Projects were allowed to choose multiple areas for the Malawi Essential Health Package (EHP) with which
their project aligned. Community Health, Reproductive Maternal Neonatal and Child Health (RMNCH), and
Integrated Management of Childhood Illness (IMCI) accounted for the majority of the projects. 

Page 9 of 17
16. Types of Hardware
Across all projects surveyed, the hardware used is moving away from basic phones and towards smart devices.
Many projects used multiple types of devices.  However, no projects recorded using Personal Digital Assistants
(PDAs), and only one project recorded using wearable devices.

Basic Phones Tablets

Smart Phones
8
14
24

23
17
7

7 Projects use basic 17 Projects use tablets 23 Projects use smart

phones (23%) (55%) phones (74%)
17. Modes of Interaction
Projects mostly interact with users via mobile applications or SMS as demonstrated below by the number of
projects using each mode.

22 12 12 11 5
Web based Projects GPS Projects
Touch Screen Projects

Application Projects SMS Projects

3 2 2
Voice Projects Email Projects USSD Projects

18. Servers and Data Storage

Across all projects surveyed (31), most host their data on cloud servers (23 projects) and 8 host data
locally. This is despite a GoM regulation that states all data must be stored locally.
22

Most projects are using

cloud servers 7

Fewer projects are

using local servers.
1
1

Cloud Server (70.97%) Local Server (22.58%) Both (3.23%) Unknown (3.23%)

Page 10 of 17
19. Type of Users
Health Surveillance Assistants (HSAs)/ Community Health Workers (CHWs) are the largest group of mHealth
users in Malawi. 23 out of 31 projects citing HSAs and CHWs as users. The second highest group, "other", included
supervisors, district staff, and project-specific staff.
25 23

20 Health Surveillance Assistants

(HSAs) are the main users in 23
15 out of 31 projects
9
10
6
4 4
5 3 3
1

0
Public Patients Caregivers Physicians Nurses HSAs Field Work.. Other

20. Number of End Users

Across all projects since 2007, there have been

87%
15,231 users. 13,275 of those users are still active.

15,231 OF EVER USERS STILL

ACTIVE

mHealth Users Ever

across 31 registered
projects in Malawi 

13,275 428
AVERAGE ACTIVE USERS
PER PROJECT
Active mHealth Users
across 31 registered projects
in Malawi

Page 11 of 17
 21. Project Costing Across All Projects
Budget data was not a required as part of registration. However, 12 out of the 31 projects provided detailed costing
data across specific categories. This offers a glimpse into the general cost of mHealth implementation in Malawi.

$9,535,880 12
REGISTERED PROJECTS
SUBMITTED COSTING INFORMATION
All time cost for the 12 projects that submitted costing data

We used the average number of active users

(n=459) and the average cost per project year

$794,657
taken from the 12 registered projects that
submitted costing data ($158,931) to calculate the
average cost per active user per year to be
$346.26.
Average cost per project across
project lifetime (average 5 years) 

$346.26
$158,931
Average cost per active user per year

Average cost per project year 

22. The Average Project Costs

The average cost per category across the 12 projects shows that Software Development accounts for the largest portion of
budgets ($115,076) at 15% of the average mHealth project total budget ($794,657).

Software Development
accounts for an average of
15% of total project
budgets

Page 12 of 17
23. Average Device Costs
The average cost per device per user is $96 with an average of 6% of hardware being replaced each year due to
hardware being lost, stolen, or damaged. This contradicts common misconceptions around the loss of mobile
phones that are often cited as a reason not to undertake mHealth projects. 

$96
average per device
6%
replaced devices
average across all projects

24. Applications vs. SMS in mHealth

Malawi has a mix of both mobile applications and SMS projects. There are challenges and benefits to using each
system. As part of the analysis of registration responses we separated mobile applications and SMS because
these are the largest categories for projects, and there are large differences between the two types of projects.

APPLICATIONS SMS
Expanded functionality such as Typically does not require
collecting surveys, GPS hardware purchases since all
location, and images phones can send an SMS

Uses data which is generally Cost effective for mass

cheaper than SMS communications

Requires a smartphone which is Limited data collection abilities

more expensive than a basic and functionality
phone.

More training is necessary due As smartphones become more

to complexity of applications common, the trend is moving
away from SMS and towards
messaging platforms such as
WhatsApp 
Page 13 of 17
 25. Application vs. SMS Projects
The average cost per SMS project is less than half the average cost of a mobile application project. The average
cost of an application project across the 8 projects that submitted costing information is $1,159,959, whereas
the average cost per SMS project across the 6 projects that submitted costing information is $507,247.
If we split mHealth users by applications and SMS, there are 3.5 times more SMS users (7,772) than application
users (2,244). Application projects average 187 users per project, whereas SMS projects average 1,554 users
per project.

Applications and SMS each have specific use cases for which they are appropriate, and the appropriateness of
the technology, as well as the cost of the tool, should be taken into account with each mHealth project.

25.1 Cost of Application 25.2 Applications vs.

Projects vs. SMS Projects SMS Users
Application vs. SMS Projects Application users vs. SMS users
7,772

$1,159,959
Average Cost per Project

Number of Users

$507,247
2,244

Applications SMS Applications SMS

3.5
On average, SMS
projects cost half
as much as
application TIMES MORE SMS
projects. USERS
than mobile application users

Page 14 of 17
 26. Key Takeaways
Malawi has a mature, geographically
widespread, robust mHealth
ecosystem with a variety of projects
at different levels of maturity.

There is a clear trend toward Projects are concentrated in 3

smartphone applications and away main healthcare domains:
from the use of basic phones.
Reproductive and Maternal
Health
 

Infant and Child Health 

Smartphone applications have

not been able to reach a scale Community Health
beyond a few hundred users,
whereas SMS and voice-based
projects are reaching regional
and national scale.

An annual registration process for mHealth tools provides

valuable trend information. The registration should be
continued to provide valuable information regarding future
policies and standards. The registration should be expanded
to include other digital health tools and continue to be
conducted by the Ministry of Health.

Page 15 of 17
 27. Appendix 1: Registered Projects
PROJECT NAME ORGANIZATION CONTACT PERSON CONTACT EMAIL

Argus Pilot for IDSR Luke International Norway Joseph Wu [email protected]

Weekly Reporting (LIN)

Malawi Liverpool Wellcome [email protected].

ASPIRE Trust, Clinical Research Dr. Nicola Desmond uk, [email protected]
Programme (MLW)

Barr Foundation iCCM D-tree International Christopher Kulanga [email protected]

mHealth Project

Chipatala Cha Pa Foni villagereachmalawi@village

(CCPF) Health Center by VillageReach reach.org
Phone
CMAM Stock Monitoring World Vision International
Dr. Kovalan [email protected]
System (WVI)

Community Health University of Malawi - [email protected]

Chancellor College Dr. Manda
Tracker

Digital Village Clinic in D-tree International Christopher Kulanga [email protected]

ECHS project
DVC Implementation in [email protected]
SSDI project - Facility D-tree International Christopher Kulanga
IMCI Pilot

e-Health for Community The National TB Francis Muwalo [email protected]

Intervention Programme

ECHS Project - Digital D-tree International Christopher Kulanga [email protected]

Village Clinic (DVC)
EID ART Initiation Clinton Health Access Jonathan Mtaula jmtaula@clintonhealthacces
Tracking Initiative s.org

eIDSR Case Based

Baobab Health Trust (BHT) Soyapi Mumba [email protected]
Surveillance App

Emergency Triage,
Assessment and D-tree International Christopher Kulanga [email protected]
Treatment (ETAT)
mHealth Application

One Community Project Johns Hopkins University Glory Mkandawire [email protected]

Medic Mobile Do-it- Medic Mobile Mercy Simiyu [email protected]

yourself (DIY)

Page 16 of 17
PROJECT NAME ORGANIZATION CONTACT PERSON CONTACT EMAIL
Mentorship and
Enhanced Support at Partners in Health (PIH) Emily Wroe [email protected]
Health Facilities
mHealth4Afrika University of Malawi [email protected]

Millennium Promise Millennium Promise Inc. Abigail Simkoko abigail.simkoko@millenniu

Inc. mpromise.org

University of Oslo and

NeoCare Chancellor College
Dr. Manda [email protected]

Organized Network
Services for
Everyone's Health Management Sciences for
Rudi Thetard [email protected]
(ONSE) Integrated Health (MSH)
Supportive Supervision
Toolkit

Organized Network
Services for Management Sciences for
Everyone's Health Health (MSH) Rudi Thetard [email protected]
(ONSE) - ISS Toolkit

PMTCT Tracing Medic Mobile Mercy Simiyu [email protected]

Program for Social Partners in Health (PIH) Dr. Emily Wroe [email protected]
and Economic Rights

Program Mwana -
RemindMI and UNICEF Marie-Claude Villacorta [email protected]
Results160

RAce iCCM mHealth D-Tree International Christopher Kulanga [email protected]

Application

Screening for Health [email protected]

and Referral at the Partners in Health (PIH) Dr. Emily Wroe
Community
Medic Mobile and AMREF [email protected]
Staying Alive Malawi
Madalitso Tolani

Luke International Norway [email protected]

Supporting LIFE (LIN) Joseph Wu

Towards reaching World Vision International [email protected]

(WVI) Alexander Chikonga
Universal Coverage

UBALE (MIRA Study) Catholic Relief Services [email protected]

Dane Fredenburg
(CRS)

Page 17 of 17
Prepared by Cooper/Smith. For more information email:
[email protected]