Malawi is officially ranked as one of the world’s poorest countries in terms of GDP per capita, but it’s often hard to see what that means when you’re living in the commercial capital of the country. No doubt, there’s a different standard of living, but the people here are thriving and Blantyre’s hilly streets run with the ebb and flow of a healthy city. Yet, when you look at the statistics, 40% of Malawi’s budget comes from donors and foreign aid. Or, rather, it used to. In 2013, the EU, World Bank, and the UK all withdrew aid to Malawi over “cashgate” (1)–a corruption scandal that involved high-ranking members of Joyce Banda’s administration, $10 million of misappropriated aid money, and a botched murder attempt (2). In the past when foreign donors withdrew aid under President Bingu wa Mutharika, Malawi operated on a “zero-deficit budget”, mandating cuts across the board that sent the country reeling with fuel shortages and commodity scarcities. This time, however, President Peter Mutharika (not to be confused with his brother) adopted a “zero-aid budget” that left a 107 billion kwacha ($150 million) deficit (3).

The effects of the aid cuts aren’t readily apparent to the untrained eye. Even after being underfunded and underprepared for the flooding earlier this year, the country seems to have returned fairly quickly to business as usual. However, when talking to people at Queens, it seems that almost every dilemma leads back to the lack of aid. Dr. Edward Kommwa first mentioned this to us when we were studying MgSO4 procedures in the Maternity Ward. He explained that for the past two years, Queens has had to deal with intermittent drug shortages due to the lack of donor aid. Since Malawi still relies on its remaining aid flows from countries such as China, India, and Russia, it gets a lot of its pharmaceutical products from these nations in the form of donations or cheap contracts. The $150 billion deficit has made it hard to acquire a steady supply of drugs even with outside help. Just last year there was an entire month during which the Maternity Ward had no access to MgSO4 for its pre-eclamptic mothers.  “One of the most frustrating experiences was knowing exactly what was wrong with my patient and how to fix it, but being unable to do anything about it,” Edward noted grimly. Clearly, fluctuating and conditional foreign aid has far reaching consequences, creating instability and uncertainty in government-run establishments like QECH.

An unopened donation from “People of India to the People of Malawi”

The other aspect of medical procurement involves hospital machines and equipment. As I mentioned in my previous post, PAM is in charge of maintaining, inspecting, and repairing medical equipment, but budget cuts have relegated PAM’s efforts to the back burner. If PAM is a graveyard for broken machines, then the headstones are the paper labels inscribed with the names of a dozen donor nations. Though Malawi still receives aid in the form of capital, the problem is that the donated equipment is often unnecessary or hard to maintain. Joseph, a PAM engineer who graciously answered our barrage of questions, pointed to a wall of boxes twice my height explaining that they were soft collars that were donated to QECH instead of the hard neck braces that the hospital needed. So the collars were going to be sold for a few hundred kwacha each, which in American currency amounts to pennies on the dollar. Moreover, even the useful donations (oxygen concentrators, suction pumps, autoclaves) usually end up breaking. In a lot of cases, it’s nearly impossible for PAM to get the correct parts to fix the machines because the budget is out of their hands and hospitals usually choose to spend what little money they have on life-saving drugs rather than machine repairs.

Various models and brands of donated suction pumps on the shelves at PAM

The conversations I’ve had with Edward and Joseph have taught me how essential it is to develop sustainable interventions. Currently the Malawian government is trying to win back favor with its donors by rooting out corruption with the help of institutions like the Anti-Corruption Bureau (4). In the meantime, health interventions and technologies need to focus on local sourcing and manufacturing as well as supply chain solutions that don’t rely exclusively on foreign aid. This level of sustainability obviously can’t be achieved overnight, but moving in this direction is beneficial because it encourages the convergence of advances in healthcare and economics, creating a positive feedback loop for innovation and economic growth.

The past two weeks have been all about designing and developing a low cost digital phototherapy dosing meter. A Phototherapy dosing meter is used to measure the intensity of blue light that is administered to babies that are suffering from jaundice.

At Queen Elizabeth central hospital, the biggest government hospital in Blantyre, there is a shortage of phototherapy dosing meters. The meter they are currently using was designed by Greg Nusz and Advait Kotecha in cooperation with engineering world health. Since this meter uses an analogue meter to show the reading, it suffers from calibration drift problem. This renders the meter unreliable.

Objectives:

 Our main objective was to design and develop a low cost digital   phototherapy dosing meter which is portable, accurate and has no calibration drift problem.

 We had two prototypes that were already developed, one from rice,  another from fifth year students from poly. We chose the prototype from Poly which uses an LCD to show the readings instead of an  analogue meter.

Design:

We made some modifications to the Poly prototype:

1. Changed the sensor.
2. Modified the circuit.
3. Changed the meter casing.

Progress:

Right now we are almost done with the dosing meter, the only thing which is remaining is, calibration. We are waiting for a commercial dosing meter to use as a standard meter.

I was so thrilled (and a little nervous), when I heard that I had been selected to be among the few students that would be doing the Rice and Poly internship this summer. The chance of working on different biomedical projects together with fellow students from Rice University, was indeed an honor.

The first week was fun, meeting our cool friends from Rice; Emily, Sarah and Catherine; teaching them a few Chichewa phrases and Shopping for the materials that we would use.

We choose this project to solve the problem at queen’s hospital. They have few analog dosing meters at hand right now. Besides this, they usually have calibration drifting which sometimes can be hard to read and give false readings.

We had two prototypes of phototherapy dosing meters, one from Rice university team and another which had been developed by senior polytechnic students. So we had to choose one and improve on it because they all had drawbacks. We choose the poly device after having a thorough analysis of the two devices.

Problems with the Poly design

1. The first drawback with the poly design was that it was not using a blue light filter, hence giving false readings as it was prone to ambient light.
2. The relationship which was used in the arduino program was not correct

Objective

So basically our main focus was to develop a low cost phototherapy dosing meter that suffers no calibration drifting, more accurate and portable. This partly involved changing the circuitry because we used a solar cell instead of an LDR that was used by the poly students. We used the Arduino Uno as a microprocessor and we coded it in C language.

Operation: The sensor will be covered by a blue light filter thereby measuring only the blue light from the Bili lights. Then it will pass a current through the circuit dropping a voltage across a resistor. This voltage then fed to a low pass filter, allowing less than 4 kHz to pass through. From there on, the output is fed into the arduino for processing. The arduino outputs the result on then LCD.

I had some personal expectations about the program just everyone would. First expectation was the program would be all work at all time, bearing in mind that the period was too short. Besides that, I was looking forward to doing projects which probably Rice had already selected for us to do. It was mind blowing to see none of these come true. I really like the approach we had because it was an open discussion.

So basically, the first week involved setting plans, choosing the projects we wanted to do and most importantly getting to know each other. Rice University sent three students Emily, Sarah and Catherine. These guys are really nice and friendly. Sometimes work can get too routine because of the environment, but I must say with these guys work is so much fan. They so eager to learning Chichewa and my personal secondary plan is making them half Malawians before they return home. The first weeks will always be memorable.

These past few weeks have definitely given me a greater appreciation for the importance of project implementation and management, especially in the context of the CPAP Study. This week in particular, we had three different CPAP trainings going on. We had one for graduate students at the Kamuzu College of Nursing, one for district hospital coordinators hosted here at Queens, and one for nurses during a CPAP installation visit at Thyolo District Hospital.

Here’s a brief overview of what a training looks like:

• Introduction to CPAP as a treatment option
• Explanation of conditions appropriate for CPAP treatment
• Description and outcomes of the pilot study at Queens
• An explanation of assembly and cleaning of the machine
• Instruction on how to place a baby on CPAP
• Instructions on monitoring care, tracking progress, and weaning babies from CPAP when treatment is complete
• Explanation of the current study procedures and data that should be obtained during treatment
• Suggestions for talking to mothers about the benefits of CPAP treatment

The training itself is a mix of classroom instruction and observational periods on the wards, and the classroom portion combines presentations and videos with practical, hands-on experience with the CPAP machine.

Tanya and I helped prepare the training for district hospital coordinators here at Queens, and we had seven participants from five different hospitals attending. The hospitals included Machinga District Hospital, Thyolo District Hospital, Chiradzulu District Hospital, and Mulange District Hospital, marked on the map below:

District hospital coordinators are critical to effective CPAP implementation. District hospitals are much smaller than central hospitals like Queens, so oftentimes these hospitals are even more short-staffed and pressed for resources. By training coordinators, each hospital then has its own CPAP expert to be able to conduct further staff and clinician training when they return home to their district. All of the coordinators were engaged in the material, and it was neat to see how the simplicity of the bCPAP design makes it an approachable and exciting machine to learn about and train with.

Hospital coordinators during the instructional and practical training sessions.

However, no matter how simple or intuitive a design, this training also showed me that no machine can be successful without a full-force effort from a wide range of community members, nurses, clinicians, and policymakers. The amount of resources that go into planning, executing, and evaluating training shows that the quality of these trainings have been fundamental to the CPAP’s success thus far. The enthusiasm and effectiveness of the facilitator, pediatrician, and nurse running the program today were a powerful reminder that improving outcomes for patients comes from the dedicated professionals who commit to constant development and educational opportunities as much as it comes from the technology innovation itself.

Nurse Florence and Dr. Mzikamanda look on as trainers demonstrate how to select the appropriately sized tubing for infants on CPAP.

The past two weeks we were designing and developing the dosing meter. We went to Queen Elizabeth Central Hospital, Gogo Chatinkha Ward to check how the blue lights are used. We then proceeded with the design and its almost done now. We tried to design the meter at low cost as possible so that it should be affordable to purchase by different hospitals. 

Oh. I forgot. We went to Kabula lodge to have dinner. I taught Catherine, Emily and Sarah how to cook Malawian dishes. We cooked nsima, dry fish and some vegetables. I also learnt how to prepare banana pancakes. They were so delicious.

the food that we prepared.

We went to Physical Assets Management( PAM) in QECH so that we can have an enlightenment on other projects that we can work on. We came with many ideas. One of them was about the Suction Pump. It sucks body fluids from the patient into a bottle. When the bottle is full, the fluid goes into the machine which then gets broken. we came up with an idea of having something like a buzzer which will alert the nurse that the bottle is full so that they can empty it.

I was really excited after having heard that I was selected to be a part of the Malawians-Rice interns this summer, mostly because the projects would involve designing and developing electronic devices in the biomedical engineering sector. I am Telecommunications engineering major but I like learning new things and I saw this as an opportunity to greatness.

Much Thanks to global health for bringing such a great opportunity in my life. I bet this summer is going to be the best ever, and I am really looking forward to the designs.

My name is Christina Samuel. I am a fourth year student studying Electrical and Telecommunications Engineering. I am so excited that I have the opportunity to be part of the Beyond Tradition Borders summer internship program. I haven’t written a blog before, so bear with me..hahaha. I have made friends with Emily, Catherine and Sarah. They are so cool.

The first week was all about getting to know each other and brainstorming about the projects that we want to design and develop. The first project that we all agreed to do was a Phototherapy Dosing Meter. Some students at Rice University designed and developed an analog dosing meter but it was not working. Final year students from the Polytechnic also designed and developed a digital dosing meter but it had no filter and it was not sensitive to light. We brainstormed about how we could come up with a working dosing meter. We all agreed that it should be a digital one which is well calibrated and more sensitive to light.