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Background To effectively deliver on proposed objectives, it is vital that practitioners, policymakers, and other stakeholders are able to clearly understand how strongly their large-scale program is being implemented. This study sought to test the feasibility, cost-effectiveness, and validity of a phone-based method as an innovative and cost-efficient approach to assessing program implementation strength (through an Implementation Strength Assessment - ISA), alternative to the traditional in-person field methods. Methods We conducted 701 mobile phone and 356 in-person interviews with facility in-Charges and two types of community health workers who provide family planning services in the Dowa and Ntcheu districts in Malawi. Responses received via the phone interview were validated through in-person review of records and inspections. Sensitivity and specificity were calculated to determine validity. Results Most indicators at the health facility and community health worker levels were above a 70% threshold for sensitivity. However, there were fewer indicators that met this threshold for specificity. The primary reason for lower specificity was due to poor recordkeeping. Collecting data via mobile phone was found to be feasible and twice as cost-efficient as collecting the same data via in-person inspections. Conclusions The rapid increase in mobile phone ownership and network availability in lower income countries could offer an alternative, cost-effective avenue to collect data for a better understanding of program implementation. Through rigorous assessment, this study found that using mobile phones could be a low-cost alternative to collect data on health system delivery of services, especially in places where routine data quality is poor and traditional, in-person methods are costly.

Background: Routine health data can guide health systems improvements, but poor quality of these data hinders use. To address concerns about data quality in Malawi, the Ministry of Health and National Statistical Office conducted a data quality assessment (DQA) in July 2016 to identify systems-level factors that could be improved. Methods: We used 2-stage stratified random sampling methods to select health centers and hospitals under Ministry of Health auspices, included those managed by faith-based entities, for this DQA. Dispensaries, village clinics, police and military facilities, tertiary-level hospitals, and private facilities were excluded. We reviewed client registers and monthly reports to verify availability, completeness, and accuracy of data in 4 service areas: antenatal care (ANC), family planning, HIV testing and counseling, and acute respiratory infection (ARI). We also conducted interviews with facility and district personnel to assess health management information system (HMIS) functioning and systems-level factors that may be associated with data quality. We compared systems and quality factors by facility characteristics using 2-sample t tests with Welch9s approximation, and calculated verification ratios comparing total entries in registers to totals from summarized reports. Results: We selected 16 hospitals (of 113 total in Malawi), 90 health centers (of 466), and 16 district health offices (of 28) in 16 of Malawi9s 28 districts. Nearly all registers were available and complete in health centers and district hospitals, but data quality varied across service areas; median verification ratios comparing register and report totals at health centers ranged from 0.78 (interquartile range [IQR]: 0.25, 1.07) for ARI and 0.99 (IQR: 0.82, 1.36) for family planning to 1.00 (IQR: 0.96, 1.00) for HIV testing and counseling and 1.00 (IQR: 0.80, 1.23) for ANC. More than half (60%) of facilities reported receiving a documented supervisory visit for HMIS in the prior 6 months. A recent supervision visit was associated with better availability of data ( P =.05), but regular district- or central-level supervision was not. Use of data by the facility to track performance toward targets was associated with both improved availability ( P =.04) and completeness of data ( P =.02). Half of facilities had a full-time statistical clerk, but their presence did not improve the availability or completeness of data ( P =.39 and P =.69, respectively). Conclusion: Findings indicate both strengths and weaknesses in Malawi9s HMIS performance, with key weaknesses including infrequent data quality checks and unreliable supervision. Efforts to strengthen HMIS in low- and middle-income countries should be informed by similar assessments.

Background Malawi has made progress in increasing its overall modern contraceptive prevalence rate since 2000, resulting in a dramatic reduction in its total fertility rate. However, youth, 15–24 years, have not had the same successes. Teenage pregnancies are on the rise and little progress has been made in reducing unmet need for family planning among youth. With two-thirds of the population under the age of 25 and with Malawi’s rapid population growth, reducing unmet need for family planning among youth remains a priority for the government’s reproductive health agenda. To further explore this situation, we conducted a qualitative study to explore the perspectives of youth and adults about the drivers and barriers to youth accessing family planning in Malawi and their ideas to improve services. Methods We conducted 34 focus group discussions with youth aged 15–24 and parents or legal guardians of female youth in 3 districts in Malawi. Focus groups were translated and transcribed. Data was input into Dedoose and analyzed using a thematic framework to identify broader patterns and themes. Results Youth participants felt motivated to use family planning to protect themselves from sexually transmitted diseases and to prevent unwanted pregnancies. Females focused on the consequences of unplanned pregnancies and believed family planning services were targeted primarily at them, while males thought family planning services targeted males and females equally. Barriers to youth accessing family planning included contraception misconceptions, the costs of family planning services, and negative attitudes. Parents had mixed views on family planning. While many parents acknowledged they could play a role in supporting youth, most said they are reluctant to support youth using family planning. Participants said improving counseling services, integrating family planning services and education within school curricula, and utilizing youth clubs could improve family planning services for youth. Conclusions Policy makers and program implementers should consider the diverse preferences among youth and parents and continue seeking their input when designing policies and programs. Youth clubs and school-based services were among the most common suggestions. However, the effectiveness of youth clubs and school-based initiatives to increase contraceptive use among youth in Malawi is not clear. Electronic supplementary material The online version of this article (10.1186/s12978-018-0549-9) contains supplementary material, which is available to authorized users.

In 2010, 7.6 million children under five died globally – largely due to preventable diseases including pneumonia (14%), diarrhea (10%), and malaria (7%) [1]. Ninety–nine percent of these deaths occurred in low–resource settings and nearly half (47%) in Sub–Saharan Africa in communities where people have limited or no access to life saving interventions and medical supplies. Integrated Community Case Management (iCCM) is a strategy designed to bring care and treatment for childhood pneumonia, diarrhea, and malaria closer home by training community health workers (CHW) in the identification and treatment of common childhood illnesses [2,3]. iCCM involves training CHWs on essential health packages and ensuring that they have the medicines needed to manage and treat illnesses among children under five years of age. Continuous access to these medicines by CHWs requires a well–functioning supply chain across all levels of the health care system. However, the supply chain systems of many resource–constrained countries function poorly and face a myriad of challenges [4], including but not limited to shortage of human resources, weak inventory management, low supply chain skills among health workers, and a lack of data visibility and utilization for sound decision making. In 2008, the Government of Malawi (GoM) initiated iCCM as a strategy to reduce child mortality. The program entailed training an existing cadre of CHWs, known as Health Surveillance Assistants (HSAs) to treat children in the community. HSAs are posted nationwide to serve communities at a ratio of 1:1000 population. By September 2011, 3296 HSAs had been trained in integrated management of childhood illness (IMCI) [5]. With the implementation of the iCCM strategy in Malawi, mortality among children under five years decreased from 225 deaths per 1000 live births in 1990 to 71 per 1000 live births in 2012 [6], and the country is considered on track to achieve Millennium Development Goal (MDG) 4, to reduce child–mortality by two–thirds, by 2015. Despite the gains made towards MDG 4, the health care infrastructure in Malawi still faces challenges, among them weak supply chain systems. This affects continuous health product availability at the community level, consequently undermining the full effectiveness of the iCCM strategy. In order to identify the constraints associated with maintaining regular product availability, Supply Chains for Community Case Management (SC4CCM) in collaboration with the Ministry of Health (MOH), conducted a formative assessment across 10 districts in Malawi (Nkhatabay, Nkhotakota, Mulanje, Kasungu, Nsanje, Machinga, Mzimba North, Zomba, Nchitsi, and Salima) in 2010 [7]. The assessment identified poor availability and limited use of logistics data (ie, low data visibility) across all levels of the health system, low motivation among HSAs and transport challenges such as difficult terrain and long travel time for HSAs to collect products as key barriers to continuous product availability. This assessment identified additional opportunities of using mobile phones to promote data visibility as 89% of the HSAs surveyed had mobile phones, 80% of HSAs and health facility (HF) staff had continuous network coverage at their place of work and all districts surveyed had computers and access to the Internet. The survey also found high levels (80%) of bicycle ownership among the HSAs [7]. To address the identified constraints related to data visibility, motivation and transport, SC4CCM designed and piloted cStock, a mHealth tool for community–level reporting of stock on hand data and resupply of 19 health products managed by HSAs. cStock was nested within two broader interventions, namely, Enhanced Management (EM) and Efficient Product Transport (EPT), to address challenges in motivation of HSAs and transport to the health facilities, respectively. The primary objective of this paper is to assess the feasibility, acceptability, and effectiveness of cStock as a mHealth strategy for improving data visibility and reducing stockouts of health products used at the community level. Additionally, the study will explore the added effects of the team approach deployed through EM in improving supply chain performance. Program description cStock is an SMS and web–based reporting and resupply system that is used by HSAs to report stock data via SMS through their personal mobile phones. cStock calculates HSA resupply quantities and sends this information to HF staff to use to pick and pack products for HSAs and notify them about a collection time. cStock was designed using a consultative, user–centered and iterative process. Potential users at all levels of the health system provided inputs based on their experience with the existing manual reporting and resupply system. Information on the existing flow of data across levels of the health system was combined with inputs from supply chain specialists to ensure the system was based on supply chain best practices. In designing the workflows and dashboard for cStock, an important criterion was to ensure the health care workers and managers at each level would have access to data most relevant to them, at the right time and in a format that could be easily accessed, interpreted and used for decision making. HSAs and HF staff would interact with cStock using SMS messages on their own phones, while district and central level staff would receive alert messages from cStock on their own phones. District and central level staff would use computers to access the web–based dashboard for reports. The dashboard was redesigned six months after implementation so that district and central level users could incorporate their experience interacting with the system into the redesign and prioritize metrics and visuals most useful for their day–to–day operations. cStock is a key component of both the EM and EPT intervention packages. The EM intervention addresses challenges related to data availability and visibility, as well as low motivation among HSAs while the EPT intervention addresses challenges of transport in addition to data visibility. The additional component of the EM intervention was District Product Availability Teams (DPATs). These are multilevel quality improvement teams that use data supplied by cStock to monitor performance of the supply chain and make informed supply chain decisions. In contrast, the additional component of the EPT intervention consisted of training all HSAs on bicycle maintenance, provision of a basic tool kit, and the use of a continuous review inventory control system. HSAs and HF staff in six districts where the project was piloted were trained on the use of cStock for reporting and resupply and used their own phones to register with cStock. Training was conducted using a cascade approach. The project trained a group of trainers consisting of central and district level staff from pilot districts as TOTs and they in turn trained the HSAs, HF and district staff. Both intervention groups were trained over a 2–day period, with one day dedicated to training users on how to register and use cStock. HSAs in the EM group were trained to send reports to cStock using a fixed monthly reporting schedule between the last day of the month and second day of the next month, while those in the EPT group were trained to send reports to cStock at any time during the month when they planned to travel to the HF giving them the flexibility to report and receive product. Once trained, HSAs were provided with job aids to carry back to their facilities and expected to start using cStock immediately. Implementation support for cStock was provided through group messages sent by the system administrator to users to correct common errors, automated messages sent directly by the system to users in response to formatting errors, and field visits made by Ministry and project staff to monitor and reinforce good practices. In designing the interventions, the project identified feasibility and acceptability of cStock as critical components to enhancing uptake and laying the foundation for country ownership and scalability. See Figure 1 for a visual representation of the intervention design. Figure 1 Components of the two intervention groups (EM – Enhanced Management and EPT – Efficient Product Transport). DPAT – district product availability teams.