With 9.5% of its population estimated to be HIV-positive in 2019, Malawi has one of the highest rates of HIV prevalence in the world. While untreated HIV can lead to infection and death, antiretroviral therapy (ART)—a combination of medications that suppresses the virus, restores immune function, and reverses the progression of AIDS—is available to Malawian patients at no cost. But success depends on patients adhering to regular treatment, and tracing patients who have lapsed from care is expensive and time-consuming for clinics that are already understaffed.
To address the challenge, the nonprofit Baobab Health Trust and Malawi's Ministry of Health, began migrating clinics from paper-based patient records to electronic medical records (EMRs) in 2005.
In a recent study by Wharton School assistant professor Leandro "Leo" Pongeluppe and colleagues, researchers examined the impact of this change on patient outcomes in 106 HIV treatment clinics between 2007 and 2019. Their findings, published in The Review of Economics and Statistics , show that EMR introduction led to an estimated 28% reduction in deaths after five years, with the greatest reduction among children. Pongeluppe and co-authors, Ragnar Frisch Centre For Economic Research researcher Laura Derksen and University of Toronto professor Anita M. McGahan , estimate that over time, EMR adoption prevented roughly 5,050 AIDS deaths.
"We are using management technology to help support the ones who are most vulnerable among the vulnerable," Pongeluppe says. "We can save lives, especially the lives of the most vulnerable, and in a way that is very cheap. This hopefully will be a way for us to incentivize further implementation."
The authors estimate that the cost of EMR implementation is about $448 per life saved in the first five years. Pongeluppe says that EMR usage is limited in other Sub-Saharan African countries, along with parts of Latin America, meaning there is great opportunity for nongovernmental organizations to expand this system across developing countries.
The EMR system allows staff to track scheduled ART visits, identify patients who are at least two months late for an ART appointment, and prompt for referrals to other services and screenings for tuberculosis—one of the leading causes of sickness and death for people with HIV/AIDS. In clinics without EMR, staff must examine thousands of paper records to identify lapsed patients.
Their findings suggest that these improvements in health care outcomes are the result of gains in efficiency rather than changes in medical care, and the reduction in deaths is driven by an increase in lapsed patients returning for care.
"The broad efficiency gains delivered by the EMR system enable clinics to manage higher patient volumes and retain patients more effectively without exceeding capacity limits," they write. "We contribute to a broader literature on healthcare policy that goes beyond the provision of medicines by showing that managerial interventions such as EMR systems have important health impacts and can be implemented at scale in low-resource settings."
Looking ahead, Pongeluppe is planning to analyze the impact of using shipping containers transformed into clinics on main roads in Sub-Saharan Africa to deliver ART, an intervention designed to reach transient populations—such as truck drivers and sex workers—who often don't continue visiting the same clinic.
Leandro S. Pongeluppe is an assistant professor of management and the Leonard J. Horwitz Faculty Scholar in the Wharton School at the University of Pennsylvania.
The co-authors are Laura Derksen of the Ragnar Frisch Centre for Economic Research and University of Toronto and Anita M. McGahan of the University of Toronto.
This research was supported by a Connaught Global Challenge Award.
