Scaling up a health and nutrition hotline in Malawi: the benefits of multisectoral collaboration

Programme design

Chipatala Cha Pa Foni (CCPF)—Chichewa for “health centre by phone”—is a free health and nutrition hotline. Launched in 2011 as a pilot project in a rural district of Malawi, it is now available nationwide to anyone with access to an Airtel phone. Airtel is one of two major communications providers in Malawi, it is available in all districts and has over four million subscribers.7 A SIM card costs about $0.30 (£0.23; €0.26). CCPF originally focused on pregnancy, antenatal and postnatal advice, and advice for callers to seek facility care when appropriate. CCPF has since expanded to include all standard health topics—including water, sanitation, and hygiene; infectious diseases; and nutrition—in accordance with Malawi’s Ministry of Health (MoH) guidelines. Youth services were introduced, increasing access to sexual and reproductive health information for young people. The service has the flexibility to handle emergent problems, such as cholera outbreaks.

CCPF was developed iteratively by public, private, government, community, donor, and non-governmental stakeholders (fig 1). The non-governmental organisation (NGO) VillageReach is transitioning CCPF operations to the MoH, and the service will be promoted in every district in the country by the end of 2018. CCPF will be one of the first government run nationwide health hotlines in Africa when the handover is completed in 2019.

Fig 1

Timeline map

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The goal of CCPF is to improve health by increasing access to free, timely, quality health information and links to health facility services, thus extending the health system’s reach within communities. CCPF was designed to connect rural communities with the health system, as it is free and can be use by anyone through an Airtel phone (box 1).

Service delivery and impact

Since 2011, almost 58 000 people in Malawi have used CCPF, comprising 0.3% of the population and 1.4% of Airtel’s subscribers (table 1). Around 13 000 people have received tips and reminders, and 17 000 were referred to a health facility by hotline staff. The main purpose of calls diversified substantially between June 2016 and May 2018 (figs 2 and 3). CCPF is increasingly popular with adolescents (aged 15 to 19) and young adults (aged 20 to 24) as information targeted to their needs was added in August 2017 (supplementary file 1). These groups now represent 38% of all calls to the hotline. By mid 2017, the numbers of female and male clients had equalised; the age range of beneficiaries is now 0 to 80+ years.

Fig 2

Diversification of the main purpose of call: June 2016 to May 2018

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Fig 3

Diversification of the main purpose of call: comparison of June 2016 and May 2018

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By May 2018, more than 2000 calls were answered monthly by hotline workers (supplementary file 1), with numbers increasing as the service continued to expand to new districts. Approximately 20% of calls were made by using another person’s Airtel phone, showing that many people without an Airtel phone (or perhaps any phone) are accessing the service.

Users have been very satisfied with CCPF and appear to be recommending the service to friends and family in districts where no advertising has yet taken place (supplementary file 1). In 2016, a user satisfaction survey received feedback from 239 people (of 421 contacted; 57% response rate). Analysis revealed that there were extremely high levels of trust in the information given (98%), satisfaction with CCPF (99% “very satisfied”), and likelihood of recommending CCPF to someone else (95% “very likely”). Almost all users (93%) found the hotline easy to use, 75% learned something new by calling CCPF, 96% thought the hotline answered their questions completely, and 97% were “very comfortable” discussing sensitive health topics. A further evaluation of user satisfaction is under way in 2018.

An independent evaluation of the CCPF pilot phase found that CCPF was linked with improvements in knowledge about maternal and child health, and certain health behaviours.8 The evaluation found that CCPF was positively associated with:

• Increased use of antenatal care within the first trimester

• Increased use of a bed net during pregnancy and for children under five

• Increased rates of early initiation of breastfeeding

• Increased knowledge of healthy behaviours in pregnancy and postnatally.

CCPF connected nearly one fifth of the pilot phase population (women of childbearing age) to hotline workers. Those living further from health centres experienced a greater increase in knowledge of maternal, newborn, and child health practices, compared with those living close to health facilities.8 Qualitative data from focus groups revealed that CCPF was an easy-to-use service that saves time and delivers respectful, helpful advice while also empowering patients with information if they do seek care at a facility.8

Improved knowledge is important for preventive and health seeking behaviours, and although attribution of CCPF’s impact on health outcomes was not possible, the results of the pilot evaluation demonstrated CCPF’s potential to tackle health behaviour on a larger scale.

We developed this case study in order to understand the drivers of success in the development and growth of CCPF, which was selected from a global call from the Partnership for Maternal, Newborn, and Child Health (PMNCH) for proposals on success factors for multisectoral collaboration.9 A case study methods guide, developed by PMNCH, was used to ensure a standardised approach.10

Specific methods used for this case study included reviewing available data, interviewing key informants, producing a working paper, and holding a multi-stakeholder workshop to review the working paper and gather additional data and inputs (supplementary file 2).

Drivers of success in multisectoral collaboration to deliver CCPF

CCPF’s evolution from a community innovation in 2011 to nationwide reach in 2018 stems from the cooperation of the government, NGO, and private sector stakeholders (box 2), and the leadership and long term vision provided by government champions with VillageReach support (supplementary file 3). We identified four drivers of success underlying how partners worked across sectors to deliver sexual and reproductive health services for Malawians.

A joint vision for government ownership

As one government stakeholder explained during our interviews, “The collaboration has worked smoothly and effectively because every stakeholder felt that the initiative is serving the same purpose.” This joint vision of creating a government run hotline to deliver health information to some of Malawi’s most remote communities unified the diverse group partners from inception, despite different institutional agendas (see supplementary file 3). While most agencies recognise the MoH as the primary provider of public health services, we found through the interviews that CCPF partners expressly prioritised the role of government from the beginning, identifying champions and building trust, and reflecting government priorities.

VillageReach collaborated with the technology organisation Baobab Health Trust to develop the free hotline and the tips and reminders message service, with MoH providing overall stewardship. VillageReach and Balaka’s District Health Management Team implemented the pilot, ensuring optimum integration of CCPF into existing health services and generating local MoH leadership. The close relationship with the District Health Management Team facilitated meaningful engagement with local stakeholders, ensuring that CCPF was designed for, and by, its users at community level. This was acknowledged as essential by interviewees.

More recently, Johnson and Johnson, which supports activities related to the transition to the MoH, funded a branding exercise that served two purposes. Firstly, it positioned the MoH as the most prominent and visible partner in CCPF’s external materials—crucial for expanding the service to new districts and communities. Secondly, it helped ensure that beneficiaries and stakeholders collaborated on a set of CCPF brand principles and design materials that reflect the benefits and valued elements of CCPF. Stakeholders noted this was a common challenge in multi-stakeholder initiatives with competing agendas and demand for partner brand visibility. Johnson and Johnson explained they had experience of undertaking branding exercises and trusted its potential to generate cohesion among different interested groups. Importantly, the government’s commitment to, and engagement with, CCPF has grown over time, and it is now primed to adopt operational responsibility in 2019.

Gradual expansion in scope and scale

During the multi-stakeholder workshop, partners agreed upon the importance of being able to deliver successfully on a smaller scale before expanding services and geographical scope from one to ultimately 28 districts (fig 1). The goals, resources, and expertise of a diverse group of partners helped extend CCPF from its initial maternal and child health focus to a broader range of health topics, making it relevant to a wider audience. The value of multiple partner organisations was reiterated in the stakeholder interviews; one CCPF funder said, for example, “Collaboration is absolutely critical—there is no one organisation that has the complete range of skills required to implement a programme like this on its own.”

Evidence from the CCPF pilot was crucial for cementing the relationship with the MoH at national level and attracted other partners and donors. A funder confirmed that, “Evidence was a standout thing for CCPF; it was one of the reasons CCPF was on our radar. There was a sense that CCPF was supporting the field at large. The evaluation was widely used to make the case.”

The German Society for International Cooperation (GIZ) motivated the addition of nutrition components to the hotline, and the US government saw the opportunity for CCPF to spread geographically and strengthen its adolescent sexual and reproductive health services. Support through the DREAMS initiative brought additional funding and expertise to add training, clinical modules, and community mobilisation for adolescent sexual and reproductive health and HIV/AIDS prevention. The adolescent sexual and reproductive health module was fully launched in August 2017 with corresponding district level community engagement activities (supplementary file 4). Although callers could already consult the hotline about sexual and reproductive health, substantial resources helped develop youth friendly health modules and extensively train hotline workers on these topics.

Collective resourcing and adaptability

Despite a number of partners throughout the life of CCPF, in the immediate post-pilot period VillageReach underwent several years (2011 to 2015) with few partners and invested its own resources to maintain the service. Since that period there has been considerable flexibility with roughly half of CCPF’s funding (fig 4), allowing resources to be strategically aligned with programme priorities. We found that the support and flexibility of partner funding had let CCPF adapt to patient demand. Increasing call volume regarding skin infections stimulated the development of clinical reference materials and training of hotline workers on this topic. Similarly, a rise in calls about non-communicable diseases motivated an in depth clinical training module. Key informants confirmed that despite having many partners and funders—which can introduce complexity—CCPF was able to strengthen and expand its services. As one MoH interviewee explained, “The involvement of many stakeholders did not cause any difficulty in collaboration; instead this offered an opportunity for collective improvement of CCPF.”

Fig 4

CCPF budget and funding

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Since the memorandum of understanding between VillageReach and Airtel was signed in 2015, the telecoms provider has covered all incoming call and promotional text costs. VillageReach, through donor support, pays the cost of outgoing follow-up calls to track patient referrals, as well as the airtime cost of the tips and reminders service—around 13% of the total budget (fig 4). With Airtel support, the investment needed for nationwide coverage in 2018 is approximately $365 000; this covers 27 hotline staff; training; supervision; monitoring and evaluation; quality assurance (supplementary file 5); data management and equipment purchases; outreach; and programme management.

The partnership with Airtel enabled government ownership to become a realistic prospect, given the constraints of Malawi’s national health budget. As one MoH interviewee said, “If the collaboration with private sector partners like Airtel did not exist, I doubt CCPF would still be there today.” Importantly, donors, the MoH, and partners have cooperatively funded CCPF, filling in funding gaps as they arise to sustain the hotline and improve its function and scope, without claiming ownership of, or credit for, its success.

Robust collaboration focused on sustainability

We found that CCPF’s partners had deliberately employed mechanisms to strengthen CCPF and build a sustainable programme (supplementary file 6). VillageReach leaders strove to foster strong MoH leadership and help place learning and adaptation at the centre of programme development and partner management. During CCPF’s inception period, VillageReach held co-creation workshops with the Balaka District Health Management Team to develop the pilot hotline content. Nurses from the district hospital supervised the hotline workers. CCPF’s developers created structures to share information, receive feedback, build trust, and generate informed ownership of the programme. The team consulted Malawi’s medical and nursing councils before and after the pilot to ensure ongoing conformity with national legislation, and both bodies are represented on the steering committee established for the transition. The partners prioritised community engagement throughout the design and implementation phases.

The MoH is stewarding CCPF through the transition period with strong engagement by ministry leadership. The MoH organises collective agreement and progress reviews through the steering committee (active since 2016), which was acknowledged by most stakeholders as a vital function for collaboration. One government employee said, “The establishment of the steering committee has helped, as most people regard themselves as part of this new initiative rather than just be spectators.” Several MoH departments and the Ministry of Finance have been involved in positioning CCPF as a national programme. A joint effort was needed to integrate CCPF into the Health Sector Strategic Plan II, for which negotiations are ongoing. Several stakeholders agreed that the CCPF technical adviser has been a key architect of these negotiations and the overall process of transition—which includes a thorough capacity checklist and the development of a transition toolkit to ensure that the correct skills and resources are in place before transfer of operations to the MoH. The adviser negotiates many competing priorities and represents the government while recognising the needs of multisector partners.

Reflecting on the integration of new partners, stakeholders recognised that partnerships took time to build and that third party brokers were helpful, especially in chartering new territories, such as collaborating with the private sector.

Several key informants explicitly valued VillageReach’s non-partisan role; one CCPF funder said, “VillageReach play as an honest broker between the government and private sector,” and a CCPF funder said, “VillageReach have been instrumental in being the bridge between us and the government and other stakeholders, playing that pivotal role in making sure that all relevant stakeholders are on the same page and aligned on objectives.”

Stakeholders expressly valued the fact that transparency was a key feature of the collaboration—for example, through an inclusive steering committee membership, monthly monitoring and evaluation reporting, regular stakeholder meetings, and open communication from VillageReach as the main implementers. A CCPF partner said, “Monthly stakeholder meetings have really helped, we’ve had the opportunity to recap, regroup, and be on same page.” A MoH interviewee said, “One of the reasons the process has worked so well is because of regular updates in the form of reports.”

Limitations and challenges

Several challenges face CCPF as it continues to grow and anticipates transition to the MoH.