Cost–Benefit Analysis of a Mobile Community-Based Electronic Medical Record System for Community Differentiated HIV Service Delivery in Lilongwe, Malawi

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ABSTRACT Background Community-based differentiated service delivery (DSD) models are critical for sustaining high-quality HIV care in resource-limited settings. However, these models often rely on labor-intensive documentation processes that reduce efficiency. The Community-based ART Retention and Suppression (CARES) app, a tablet-based electronic medical record system designed through a human-centered design process, was developed to extend Malawi’s national electronic medical record system into community settings used by Lighthouse Trust’s nurse-led community ART program (NCAP). This study evaluated the cost–benefit of implementing CARES within NCAP. Methods A cost–benefit analysis was conducted from the payer perspective, using data from a time–motion study of NCAP nurses and staff observed before and after CARES implementation. Observations were collected over 28 days between 2022 and 2024. Costs included one-time development, equipment, and training expenses, and annual maintenance costs. Benefits included annual time savings for healthcare workers and reduced documentation errors. All costs were converted to USD, discounted at 5%, and modeled over a 10-year horizon. Outcomes included present value (PV), net present value (NPV), benefit–cost ratio (BCR), and break-even benefit. Results CARES reduced total time spent on observed NCAP tasks from 8 hours and 9 minutes pre-implementation to 4 hours and 23 minutes post-implementation. Annual benefits totaled $7,108, primarily from nurse time savings. The 10-year present value (PV) of benefits was $54,883, compared with PV costs of $46,499, yielding a net present value of $8,384 and a benefit–cost ratio of 1.18. CARES exceeded the annual benefit required for cost-neutrality by approximately $1,086, indicating a positive economic return under routine implementation. Conclusion CARES substantially reduced the time required for healthcare worker documentation within a routine community-based DSD model and surpassed cost-neutrality, generating a net economic benefit over 10 years. These efficiency gains create additional capacity for patient care and reinforce the platform’s operational sustainability. CARES provides a practical foundation for additional, future AI-enabled enhancements. Continued evaluation is needed to quantify clinical and system-wide benefits beyond time savings.

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