Developing the PALM Plus diagnostic tool for Malawi

April 30, 2013
Esme Lanktree
Like other countries in sub-Saharan Africa, Malawi’s health system suffers from an acute shortage of healthcare workers.
Existing staff are overburdened, which reduces access to quality health services. In this environment, inefficient time management is often a system-wide problem that staff are not equipped to address on their own.
“The major weakness is not that the roof leaks, it’s the fact that there are just not enough staff. So the question is, how do you actually support the staff who are there?” says project co-investigator Michael Schull.
Some efforts have focused on increasing the number of health workers, but another strategy has sought to provide healthcare workers with the training and tools to use their time more effectively.

A diagnostic tool originally developed for use in South Africa  is now being tested in rural communities in Mali. PALM Plus may improve staff efficiency and as a result, patient outcomes.

The project was funded by the Global Health Research Initiative, a Canadian partnership of IDRC, the Canadian International Development Agency, and the Canadian Institutes of Health Research.

Tools that help health care workers to work more effectively offer a practical solution that has the potential to reduce the burden on health care staff, increase the quality of patient services, and contribute to sustainable improvements in the health system.
New treatments, new problems
In sub-Saharan Africa, existing pressures on health services are compounded by the HIV epidemic. Initially, the international community focused on reducing the cost of treatment, which was too expensive for the vast majority of people living with HIV/AIDS in Africa. With the arrival of lower-cost antiretroviral treatment for HIV/AIDS, the focus has shifted to getting treatment to those in need.
While the arrival of generic antiretrovirals significantly reduced the cost of treatment, the limiting factor is still the health system’s ability to provide timely and accessible treatment to people where they live. There have been advances in this area across Africa, but it remains a problem due to a lack of infrastructure and staff, especially in rural areas.
Rural health system is strained
In the past several years, Malawi’s Ministry of Health has expanded HIV treatment to 16 rural centres in Zomba District, making treatment more accessible to rural residents. However, decentralizing services has the potential to strain an already overburdened rural health system. REACH Trust (Research on Equity and Community Health), an independent Malawian research organization, and Dignitas International, a Canadian NGO, have been working with the ministry to find ways to address the problem.
With antiretroviral treatment, people with HIV/AIDS are living longer. This means an increased likelihood of resistance and co-infections — such as other sexually transmitted infections, tuberculosis or malaria — which can complicate treatment.
In a district like Zomba, this translates into more patients experiencing more complex health problems. Not only do health care workers have less time to devote to individual patients, but they are faced with HIV cases that are increasingly difficult to treat and require more specific training.
From South Africa to Malawi
In this context, there is a growing need for a simplified decision-making tool to assist health care workers in making diagnostic and treatment decisions.
Developed for use in South Africa, the PALSA-PLUS diagnostic tool has been suc­cessful in improving care, treatment, referral, and tuberculosis case detection. The Malawi-based team  partnered with the developers of PALSA-PLUS to adapt the tool for use in Malawi. The partnership led to the creation of the PALM Plus, Simplified Tools and Training.
“The evidence from South Africa shows that this kind of tool can improve clinical care and have a dramatic impact on staff satisfaction,” says Schull.
The team is now piloting the PALM Plus tool in health centres in Zomba. The centres were randomly assigned to two groups, one of which will use the PALM Plus tool. The study will compare the two groups to determine whether there are differences in staff retention and satisfaction, as well as patient outcomes in HIV/AIDS, tuberculosis, malaria, and other primary care conditions.

This article was written by GHRI Program Management Officer, Esmé Lanktree, with files from Gyde Shepherd and Marie-Danielle Smith.

Learn more about the Global Health Research Initiative

Read more about this project: Strengthening human resources for health through simplified clinical tools and educational outreach

Read more about research supported by the Africa Health Systems Initiative — Support to African Research Partnerships:

Photo (right): Dignitas International
Clement Khondiwa leading a PALM Plus training session at the Police Hospital in Zomba District.