The Story
In Malawi, access to antiretroviral therapy (ART) has improved dramatically, with 79% of people living with HIV receiving treatment. Yet viral load suppression rates have stagnated at 73%. Stable patients were lost to follow-up due to long travel distances, clinic congestion, and hidden costs such as missed work or transport. The Nurse-led Community ART Program (NCAP) was introduced to bring ART care closer to patients. But without digital support, NCAP nurses relied on paper forms that often failed to sync with national EMRs, risking data loss and treatment gaps. Patients were underserved, and nurses struggled with inefficiencies.
The Challenge
The challenge was to design a system that enabled NCAP nurses to deliver high-quality ART care in community settings, while maintaining data integrity and integration with national EMRs. The solution had to be offline-first, nurse-friendly, and scalable for thousands of patients across Malawi.
The Turning Point
The turning point came when the team reframed the question: instead of extending facility EMRs to the field, why not design a community-first EMR? By prioritizing offline functionality, sync-on-demand, and streamlined workflows, the CARES app could empower nurses to deliver facility-grade care in villages without compromising data quality.
The Execution
Fieldwork with Lighthouse Trust and NCAP nurses exposed systemic gaps such as missing viral load tracking, frequent stock-outs, and incomplete registers. Patients shared stories of spending entire days traveling for brief refills.
We defined three personas: the NCAP nurse, the data clerk, and the patient. Their user stories revealed critical needs nurses wanted to identify patients due for viral load testing, and clerks needed synced records to align facility and community care. Mapping workflows inspired ideas like daily EMR syncs, offline-first entry, and modular design for evolving ART guidelines.
The first CARES App prototype captured registration, ART dispensing, and viral load monitoring with simple, intuitive screens. Pilots confirmed offline reliability and smoother service delivery. Feedback prompted new features inventory tracking and real-time viral load alerts. CARES evolved into a connected ecosystem improving accountability, data accuracy, and patient experience in community HIV care.
The Evidence
The CARES app demonstrated that NCAP nurses could manage patients in the community with the same confidence as in facilities. Synchronization with EMRs ensured continuity, while patients reported shorter wait times and reduced travel burdens.
The Result
Human impact: Patients stayed on ART consistently, avoiding costly journeys. One patient noted, “I no longer fear missing my drugs as the nurse brings the care to me.” Nurses gained efficiency and confidence, reducing paperwork and focusing more on patient counseling.
Systemic transformation: CARES proved that offline-first EMRs could extend differentiated care sustainably. It set a model for community-integrated digital health, positioning Malawi for national scale-up and influencing regional HIV care strategies.