GAIA Mobile Health Clinics

Across Sub-Saharan Africa, the majority of people live in rural areas and often endure a day-long walk to the nearest health facility. In Malawi this is the case for 84% of the country’s 19 million residents. Lack of access to healthcare puts millions of lives at risk, especially those living in poverty who suffer from high-prevalence of preventable and treatable diseases like HIV, malaria and tuberculosis.

GAIA’s Mobile Health Clinics provide access to critical community-based healthcare in the most remote, rural regions of Malawi while building the capacity of the national healthcare system. Working closely with the government and the communities we serve, Malawian clinical officers, nurses, and nurse aides operate MHCs out of Land Cruisers stocked with medical supplies. They are an adaptable, cost-effective approach to filling gaps in the healthcare grid and to preventing and treating, and could ultimately improve health outcomes for millions around the world.  

As one of the poorest countries in the world, 68% of Malawians live in extreme poverty, and this rate is even higher in rural areas. Poverty contributes to extremely poor health outcomes, low-life expectancy, early marriage and high pregnancy rates. Across Africa, the majority of people live in rural areas and often endure a day-long walk to the nearest health facility. In Malawi this is the case for 84% of the country’s 19M residents. While the Malawi Ministry of Health’s strategic plan establishes a goal of ensuring access to community-based healthcare within 5 kilometers of their homes, most of Malawi’s rural population live at least twice that far from healthcare -- a distance they must walk as transportation costs are unaffordable. Lack of access to healthcare puts millions of lives at risk, especially those living in poverty and who suffer from high-prevalence of preventable and treatable diseases like HIV, malaria and tuberculosis. In addition, Malawi faces a chronic shortage of healthcare workers, with 65% of nursing positions in public facilities vacant. This gravely impacts accessibility and quality of care in a country with an already fragile health system.

We have a proven solution that brings healthcare within an hour’s walk

Our cost-effective, adaptable solution is a community-based approach to rural healthcare that combines mobile clinics and community health workers (which we refer to as follow-up coordinators and certified HIV Diagnostic Assistants), bringing basic healthcare services to where they are urgently needed.

Collaborating with the MOH, GAIA’s mobile programs efficiently and effectively fill gaps in the healthcare grid, reducing disease among hard-to-reach, rural populations, and providing proactive, preventative education and services.

Through our network of mobile clinics – utility vehicles stocked with medicines, supplies and a team of 5 healthcare workers -- we bring healthcare to 45 rural sites/week delivering care within a one-hour walk for all of the 1.1 Million residents in the districts we work.

Clinics set up in schools or community buildings, and communities commit to cleaning sites and constructing structures as needed. Chiefs and village health committees rally support and GAIA trains volunteers in infection prevention and compassionate care. These volunteers help us keep a pulse on what is working well, and what we can adapt to meet community needs. 

Follow-up coordinators, fully licensed nurses, serve as frontline health workers using motorbikes and bicycles to visit households, ensuring clients are responding and adhering to treatment.

GAIA serves those living in poverty in rural Africa who have extremely limited access to healthcare. The vast majority are subsistence farmers living well below $1 (PPP) per day. Over 90% of our clients are women and children, however the clinics are open to men and community members of all ages, and some are specifically dedicated to men. 

On average, each clinic treats 150-250 patients daily, with numbers especially high in the rainy season, when malaria incidence increases. Malaria symptoms account for 40% of clinic visits (more than half are under-5), followed by respiratory infections 22% (including pneumonia, 60% of which are in under-5s), diarrheal diseases account for 8% of visits, while HIV/STIs account for 4%. We also provide access to reproductive health services. 

An estimated 1-in-5 adults is living with HIV, 1/4 of whom are not on ART. In this high-prevalence area, persistent stigma, limited access to HIV services and inadequate knowledge of HIV/AIDS are barriers to diagnosing people living with HIV and sustaining them on treatment. GAIA clinics provide an opportunity for diagnosis and rapid linkage-to-care for HIV positive individuals who might not otherwise be tested, thus reducing onward transmission and bringing Malawi closer to ending the epidemic.

Founded 20 year ago in response to a raging HIV epidemic and a glaring injustice – lack of access to healthcare for the most vulnerable – GAIA has made great strides toward reaching the UNAIDS 90-90-90 goal, amongst other health achievements, through providing access to primary healthcare in rural Africa while building the capacity of local healthcare systems.  With a track record of adapting services to a variety of diseases, our MCHs are uniquely positioned to battle COVID-19 while tackling the threat COVID-19 poses to especially fragile system, which could reverse gains made a multitude of health and social outcomes. 

Our innovation is a bridge between fixed healthcare facilities and a community health worker approach.

We have adopted best practices from well-equipped stationary health facilities and combined those with a CHW program-like accessibility, that can still operate while many homevisits have been shut down due to COVID-19. Traditionally permanent facilities cannot equally reach all rural villages, while CHWs are typically not equipped to diagnose or treat acute conditions. With an average patient visit costing $3USD (inclusive of all operational costs), our model is extremely affordable. We estimate to reach the entire rural population of Malawi through mobile clinic services would cost approximately $5.7M/year.

Our approach is also comprehensive in that that we provide both preventative and treatment services. Our prevention programming brings down the cost of treatment and use proven social and behavior change approaches. The model is adaptable as health workers can be trained on new approaches to care as needed.  

Our locally-led team in Malawi has extensive technical expertise in community healthcare, but also deeply understands the local context. Hailing from remote, rural environments, each staff member has had first-hand experience with many of the situations our clients face.

It is evidence-based, data-driven, and expert-backed. To provide the services with the most impact we partner with two of the top global research institutions, UCSF and Johns Hopkins. Our interventions have been shaped by formative research we have conducted and we've published 24 peer-reviewed journal articles and 20 scientific presentations informing discourse among the global health community.  

Core technology: The wheel /(h)wēl/ -- a circular object that revolves on an axle and is fixed below a vehicle or other object to enable it to move easily over the ground.

In all seriousness, this reliable and age-old technology helps us reach those who lack access to critical primary healthcare in remote, underserved settings...bringing a whole lot of other important technologies! 

We also use: 

• Mobile data collection (in some circumstances)
• Human-centered design and behavior change approaches
• Rapid HIV and Malaria diagnostic tests
• Medical tech like pulse oximeters
• Proven medications 

Since its inception, GAIA’s programs have contributed to significant reductions in disease burden, extending and improving quality of life and productivity. Life expectancy in Malawi has risen from 46-64 years, driven by a 55% reduction in annual AIDS deaths from 81,000-36,000 cases, and a decrease in annual AIDS-related deaths of 67%, from 73,000-24,000 (2003-2017). In GAIA’s service area, comprehensive knowledge of HIV and prevention has increased, with 20% more women able to properly identify how to prevent and treat the disease and 26% more women reporting having ever been tested for HIV. 

Since 2008, MHCs have conducted more >2M client visits, including treating 400,000 cases of malaria, with close to half among children <5, and testing more than 80,000 individuals for HIV and connecting more than 6,000 clients (8%) to treatment. Clinic staff gave health talks resulting in 213,091 client contacts on topics including nutrition, malaria and HIV/TB prevention, medication adherence and many more.

We are proud to be part of a coalition to achieve the 90-90-90 UNAIDS HIV targets by 2020, which is on track. Our interventions have been shaped by formative research we have conducted and subsequently published in peer-reviewed public health journals. GAIA’s impact has been presented at international AIDS conferences including AIDS 2010 (Vienna), AIDS 2014 (Melbourne), and AIDS 2016 (Durban).  

MHCs have been recognized by the international global health community, notably UNAIDS, as an effective way to reach remote populations with basic healthcare including HIV testing and treatment, a key to ending the epidemic.

GAIA's community-based healthcare programs directly address the needs of the vast majority of the population living in rural areas without access to services, with the overall aim of improving health and productivity in the rural communities where we work. Our theory of change along with program logic models (see section below) provide the basis for how GAIA will achieve its ambitious goals.

Activities: GAIA delivers community-based healthcare through mobile clinics and healthcare workers, and supports the training and deployment of nurses to where they are needed most.

Outputs: If we expand healthcare into underserved communities, we can help rural communities overcome barriers to accessing care 

Outcomes: If rural communities are able to easily access health services, then morbidity and mortality from preventable causes will decrease.

Goal: If access to, appropriate use of, and quality of healthcare services improves, we can end preventable/treatable diseases like AIDS, Malaria, etc. and mitigate other healthcare crises, allowing for rural communities to live healthier, more productive lives. 

We currently serve 1.1 million residents in the two districts which we work: Mulanje and Phalombe. Within the next year we plan to expand to Blantyre district, which is home to 800,000 individuals. 

GAIA proposes to expand its Mobile Health Clinic program so that each of Malawi’s 28 districts has at least one MHC, equipping each DHO with a flexible health care option to reach remote and rural villages or to target specific demographics or health challenges, as determined by district needs. We would begin by replicating Mobile Health Clinics in the 5-10 most underserved districts, adding 3-5 more per year. This aims to cover the vast majority of the rural population of Malawi, which is approximately 68% of 19M people, or roughly 13M people within 5-7 years. 

We are also interested in exploring the opportunity to provide technical assistance to other NGOs and governments in neighboring countries that also seek to fill gaps in their existing healthcare systems with an adaptable, cost-effective solution.  

As mentioned above, GAIA proposes to replicate the successful Mobile Health Clinic innovation so that each of Malawi’s 28 districts has at least one MHC, equipping each DHO with a flexible health care option to reach remote and rural villages or to target specific demographics or health challenges, as determined by district needs. We would begin by replicating Mobile Health Clinics in the 5-10 most underserved districts, adding 3-5 more per year.

We are also open and willing to provide technical assistance to other organizations and governments to achieve exponential impact.   

In order to do so, our goals include:

• Revise strategic plans adjusting for COVID-19
• Streamlining MCH processes & supply chains
• Improve mobile data collection
• Increase funding to achieve growth goals
• solidify government and other partnerships

Ultimately extending the healthcare grid in rural Africa and achieving universal healthcare coverage where we work. 

At the moment, our main concern is COVID-19: Malawi currently has 572 confirmed cases of Coronavirus. While these numbers currently seem manageable, an analysis commissioned by USAID in March paints a very sobering picture of the potential spread of COVID-19, projecting that 16 million Malawians (85% of the population) could become infected over the next year, 483,000 people hospitalized, and up to 50,000 people could die directly from the virus. With only 25 ICU beds and 17 ventilators in the country, Malawi’s fragile healthcare system would be swamped by an epidemic of this magnitude. 

Generally, and especially today given the circumstances, establishing new partnerships, particularly funding partnerships, with DHOs in new districts can present delays due to bureaucracy and constrained resources. GAIA has learned that if we can launch the clinic with our own funding, buy-in from DHOs brings down the operating costs in subsequent years as districts incorporate MHCs into their plans.

Through the following steps, our team is working hard to prevent community spread of COVID-19

(1)   Protect MHC operations, adding staff to manage patient flow and oversee hygiene and sanitation at clinic sites; supporting the government’s contact notification and tracing efforts; and procuring vital PPE. 

(2)   Equip rural communities with the knowledge and skills to prevent the spread of COVID-19. This includes education on hygiene, social distancing and other pandemic prevention messages via COVID-19 Response Teams at our Mobile Health Clinics; training Village Health Workers to deliver COVID-19 health talks at the household level; and delivering Public Service Announcements over vehicle-mounted loudspeakers circulating throughout the districts. 

 (3)   Deliver essential COVID-19 prevention supplies, including 25,000 locally-tailored masks, and 10,000 water stations and soap for high risk households.

More than ever, MHCs are critical to ensuring that rural Malawians have access to quality basic healthcare and to tackling the threat that COVID-19 poses to Malawi’s fragile health system. It is our fervent hope that this foundational work and our vigorous COVID-19 prevention campaign will prevent the worst projections from becoming a reality, while we also continue to prevent and treat other serious health problems.

Regarding partnerships, our team continuously works to build relationships with officials at all levels. We currently have strong partnerships with the District Health Offices where we work, and have MOUs with each. We ensure strong communication, information sharing, and mutual support. To build new relationships, we point to the success of our programs and strength of existing partnerships.

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Headquartered in Limbe with satellite offices in Mulanje and Phalombe, GAIA Malawi has 65 permanent employees and 30 contracted staff – 100% of whom are Malawian. GAIA’s local board (89% Malawian) has expertise in the medical field, nursing, pharmacy, and legal professions.

In the US we have 6 employees.

https://www.thegaia.org/wp-content/uploads/2019/03/2019-GAIA-Staffing-Poster.pdf

GAIA has invested significantly in hiring outstanding, qualified staff, providing professional development and in utilizing the best project management systems possible. GAIA’s activities in Malawi are supported and guided by a top-tier management team with expertise and credentials in public health, nursing, administration and finance. The executive management team, comprised of the Executive Director, Financial and Administrative Manager, and Programs Managers serves as lead liaisons to donors/funders, ensures grants and MoH compliance, including timely deliverables, monitoring, evaluation and learning support to ensure greatest impact. The executive management team also ensures that project procurement, hiring, payroll and logistics meet top professional standards. GAIA places a high premium on the quality of its services and activities and so invests significantly in hiring top qualified staff and providing professional development opportunities to staff.

Alongside the adaptability of the model, GAIA’s partnership approach to program implementation allows for both sustainability as well as the ability for our community-based healthcare model to be adopted and adapted to fit the needs in other areas. GAIA’s Mobile Health Services operate with Malawi government support, with test kits, treatment and supplies provided by the Ministry of Health. This partnership reduces GAIA’s cost of operation and allows our clinics to reach ever farther. This year, the partnership will expand, with Ministry-funded nurses joining GAIA’s clinic team, reducing staff costs and allowing GAIA to expand its impact even more. 

GAIA’s many funding partners include Sentebale and Grassroot Soccer with whom we work to provide education, health information and health care, specifically sexual and reproductive health, and life skills for youth. Other GAIA funding/program partners include the Clara Lionel Foundation, the Elizabeth Taylor Foundation for mobile health clinics, and USAID/One Community for male-friendly outreach programming. GAIA also works with local Malawian organizations such as YONECO, to whom we refer gender-based violence cases.

In addition, we partner with leading research institutions including UCSF and Johns Hopkins.

Please see program overview.

Cost sharing with government partners, in addition to donations and grants.