0 401525 40 2020 1400 20 4 50 50 202030 60 P 1600 25 30 5546 70 60 e 403035 80 1990 40 6Laboratory Technician r 90 70 35 289 60401990 1995 100 1990

c 50 1980 Malawi Health 80451995 2000 Plan488 Therapist Sector Strategic 7Dental 1995 1982 e 0 60 8Radiography Technician 1984 2000 100 2000 2005 n 10 1986 2011-2016 70 9543 In EHP 1988 20 2005 Pharmacy Technicians t 120 2005 2010 1990 30 Filled Posts 2010 80 1970Posts 1992 2015 Figure2.2: Prevention and treatment of malaria in Malawi 40 OLD 2002 Vacant 19942010 2015 50 90 UP: SENIOR MANAGEMENT COMMITTEE: InAssistant 1980 EHP 2020 Government of Malawi 1996 2004 Committee Medical hip is drawn fromDistrictCommittee/Village MoH, COMMITTEE ON HEALTH District Executive Committee/District Development - GoM ministries and Departments, HDGs and the private sector (bo Area DevelopmentVillageof 19982015 HEALTHCOMMITTEE Health Centre PARLIAMENTARY otherCommittee Health Health ZONAL Committee rural Development all Ministry Management Development Committee stakeholdersCouncil of LocalSUPPORT OFFICES Centre LocalSub-Committee District 2020CABINET Health Health Ministry Teamand Health Government1,262 Management of Government Advisory Committee Ministry namely 60 100 all stakeholders namelyand Heads of Departments in Officer headed by Secretary for Health sector (both profit and non All Directors MoH,2006 GoM SWAP SECRETARIAT other 5 Year of survey MoH ministries and Departments, HDGs and the private 1990 Under 2000 70 Clinical NEW Figure 20022020 2.9: CPR Physician 80 child 1990 2000 2004 Trends in maternal mortality in Malawi 90 2008 - FigureFigure 2.6: 2,726 Partlyin5EHP 2006 sleeping 2.3: Children Out EHP underweight trends and projections under 100 561 2008 all 2010 forms of contraception ofOfficer -1995 2010 Health married women aged 15-49 under an Environmental 2010 2020 Midwife) Figure 2000 Nurse (+ projection ITN 2012 last 2.10:Tuberculosis MDG Indicators - Malawi 2005 T13,357 Fig 2.1:MDG Immunisation coverage Malawi and Africa 1980 -2010 -55% night 7,540 2014 detection rate for all forms of tuberculosis (%) MDG Case Pregnant 2010 FPhysiotherapist MDG target Smear 2016 target Medical Engineer women 2015 - target R 248 14% sleeping155 positive 2.13: Adult Figure tuberculosis treatmentand 2.8: Total fertility rate in Malawi Measles Malawi 65% projection39 2020 Figure child ART coverage DTP3 Malawi ITN - under Ministry of Health 1 projection BCG projection Malawi success rate (%) PoW projection last nightFigure 2.7: Births attended by skilled attendant Measles Africaof435 10 Incidence 12% tuberculosis (per 114% due projection 100 000 population per year) DTP3 Africa 2004 to tuberculosis 5.5% 100 PoW Deaths among projection HIV Source:WHO Global Observatory Data Repository 2011 1000 - - PoW MDG 2004 435 10000 SWAp 1 72% negative people (per 100 000 population) -2004 2011 100000 target Global Observatory 2004 2011 Source:WHO PoW Data Repository MDG 1000 WHO Rx Success 2011 80% target 2004 10000 rate target MDG ITN 100000 - 2011 target 80% 1000000 2011 85% 2011 10000000 WHO Detection 80% projection rate target PoW MDG Burden in 2011 2004 5.5% Rx 70% target DALYs log scale) 50% 2011 projection Fig 3.1: The size of burden and cost effectiveness of EHP interventions
55 19 23 26 29 31 32 36 38 39 40 42 43 44 46 47 48 49 50 52 53 54 3 12 13 8 11 15 17 22 27 33
Maternal mortality per 100,000 live births Percent Percent Rate per million incidence and 100,000 deaths Percent immunization coverage among 1 year olds (%)

% Coverage based on Spectrum model using CD4 count of <250 cells/mm3

Percent

cost effectiveness US$/DALY (log scale)

67% projection 31%

MALAWI
HEALTH SECTOR STRATEGIC PLAN 2011-2016
Moving towards equity and quality

14.7.2011

Malawi Health Sector Strategic Plan 2011-2016 TABLE OF CONTENTS

Malawi Health Sector Strategic Plan 2011-2016 ACKNOWLEDGEMENT

Malawi Health Sector Strategic Plan 2011-2016 ABBREVIATIONS ACT ACSD ADC AJR AIP ANC ARI ART AU BLM BoD CBO CBR CDC CDR CG CH CHAM CHSU CMED CMR CMS CoM CPR CSO DALYs DEC DFID DHO DHRMD DHS DHMT DIP EMS DoDMA DOTS DRF EH EHP EHRP Artemisinin-Combination Therapy Accelerated Child Survival and Development Area Development Committee Annual Joint Review Annual Implementation Plan Antenatal Clinic Acute Respiratory Infections Antiretroviral Therapy African Union Banja La Mtsogolo Burden of Disease Community Based organization Community Based Rehabilitation Centers for Disease Control and Prevention Case Detection Rate Core Group Central Hospital Christian Health Association in Malawi Community Health Sciences Unit Central Monitoring and Evaluation Department Child Mortality Rate Central Medical Stores College of Medicine Contraceptive Prevalence Rate Civil Society Organization Disability Adjusted Life Years District Executive Committee Department for International Development District Health Officer Department of Human Resource Management and Development Demographic and Health Survey District Health Management Team District Implementation Plan Essential Medicines and Supplies Department of Disaster Preparedness Affairs Directly Observed Treatment, Short Course (for Tuberculosis) Drug Revolving Fund Environmental Health Essential Health Package Emergency Human Resource Program 4

Malawi Health Sector Strategic Plan 2011-2016 EmOC EML EmONC FBO FGD FICA FM FMIP FMR FP FSH GBV GCLP GDP GFATM GoM GVH HCAC HCMC HCW HDP HEU HIS HMIS HR HRH HRMIS HSA HSC HSC HSS HSSP HSWG HTC IA IDRC ICT IFMIS IEC IHP+ IMCI IMR IPT Emergency Obstetric Care Essential Medicines List Emergency Obstetric and Neonatal Care Faith Based Organization Focus Group Discussion Flemish International Cooperation Agency Financial Management Financial Management Improvement Plan Financial Management Report Family Planning Food, Safety and Hygiene Gender-based violence Good Clinical Laboratory Practice Gross Domestic Product Global Fund for the Fight against AIDS, Tuberculosis and Malaria Government of Malawi Group Village Headman Health Centre Advisory Committee Health Centre Management Committee Health Care Worker Health Development Partners Health Education Unit Health Information System Health Management Information System Human Resource(s) Human Resource for Health Human Resource Management Information System Health Surveillance Assistant Health Services Commission Health Services Commission Health Systems Strengthening Health Sector Strategic Plan Health Sector Working Group HIV Testing and Counseling Internal Audit International Development Research Centre Information and Communication Technology Integrated Financial Management Information System Information Education and Communication International Health Partnerships and other Initiatives Integrated Management of Childhood Illness Infant Mortality Rate Intermittent Preventive Treatment 5

Malawi Health Sector Strategic Plan 2011-2016 IRS ITN JANS JAR KCN LRI MASEDA MBTS MCH MDG(s) MGDS MICS MMR MoLGRD MoE MoF MoH MoU MP MTEF MTHUO MTR MYR MZUNI NAO NCD(s) NCST NDP NGO NHA NHSRC NLGFC NMR NPHI NSO NTDs ODPP OI ORT OES PAM PBM PETA Indoor Residual Spraying Insecticide Treated Nets Joint Assessment of National Strategic Plans Joint Annual Review Kamuzu College of Nursing Lower Respiratory Infections Malawi Socio-Economic Database Malawi Blood Transfusion Service Maternal and Child Health Millennium Development Goal(s) Malawi Growth and Development Strategy Multiple Indicators Cluster Survey Maternal Mortality Ratio Ministry of Local Government and Rural Development Ministry of Education Ministry of Finance Ministry of Health Memorandum of Understanding Member of Parliament Medium Term Expenditure Framework Malawi Traditional Healers Umbrella Organization Medium Term Review Mid-Year Review Mzuzu University National Audit Office Non-Communicable Disease(s) National Commission on for Science and Technology National Drug Policies Non-Governmental Organization National Health Accounts National Health Sciences Research Committee National Local Government Finance Committee Neonatal Mortality Rate National Public Health Institute National Statistical Office Neglected Tropical Diseases Office of the Public Procurement Opportunistic Infection(s) Oral Rehydration therapy Oral Rehydration Solution Physical Assets Management Performance-Based Management Public Expenditure and Financial Accountability 6

Malawi Health Sector Strategic Plan 2011-2016 PHC PHL PLHIV PMTCT PoW PPP QA/QM RH RTC RUM SBM-R SDP SGBV SHI SLA SMC SOPs SRH STI SWAp TA TA TBA TFR TI ToT TWG UNFPA UNICEF U5MR USAID VDC VH VHC VIA VSO WASH WHO ZHSO Primary Health Care Public Health Laboratory People Living with HIV Prevention of Mother to Child Transmission Program of Work Public Private Partnership Quality Assurance/Quality Management Reproductive Health Road Traffic Accidents Rational Use of Medicines Standard Based Management and Recognition Service Delivery Point Sexual and Gender Based Violence Social Health Insurance Service Level Agreement Senior Management Committee Standard Operating Procedures Sexual and Reproductive Health Sexually Transmitted Infection Sector Wide Approach Traditional Authority Technical Assistance Traditional Birth Attendant Total Fertility Rate Training Institutions Trainer of Trainers Technical Working Group United Nations Population Fund United Nations Childrens Fund Under Five Mortality Rate United States Agency for International Development Village Development Committee Village Headman Village Health Committee Visual Inspection with Acetic Acid Voluntary Services Overseas Water, Sanitation and Hygiene World Health Organization Zonal Health Support Office

Malawi Health Sector Strategic Plan 2011-2016

Forward

Malawi Health Sector Strategic Plan 2011-2016

EXECUTIVE SUMMARY

he Malawi Health Sector Strategic Plan (HSSP) (20112016) is the successor to the Program of Work (PoW) which covered the period 2004-2010 and guided the implementation of interventions aimed at improving the health status of the people of Malawi. The Ministry of Health (MoH), other government ministries and departments, Health Development Partners (HDP), Civil Society Organisations (CSO), the private sector and other stakeholders in the health sector were involved in the development and implementation of the PoW which was extended to June 2011 to allow for the final evaluation. The Midterm Review and the final evaluation of the PoW informed the development of the HSSP whose overall goal is to improve the quality of life of all the people of Malawi by reducing the risk of ill health and occurrence of premature deaths thereby contributing to the social and economic development of the country. Among the achievements during the period of the PoW, according to preliminary results from the 2010 Demographic and Health Survey there has been a reduction in infant and child mortality rates from 76/1000 in 2004 to 66/1000 in 2010 and from 133/1000 to 112 /1000, respectively. Maternal mortality rates have reduced from 984/100,000 in 2004 to 675/100,000 in 2010 with an increase in women delivering at health centres from 57.2% in 9

2004 to 71.5% in 2010. There has also been a reduction of pneumonia case fatality from 18.7% in 2000 to 5.7% in 2008 and an increase in the proportion of children with acute respiratory infections taken to health facilities for treatment from 19.6% in 2004 to 65.7% in 2010. Immunization coverage is high: 81% of the children aged 12-23 months old were fully vaccinated in 2010. This is an increase in coverage of 26% since the 2004 DHS. There has been an increase in HIV infected person accessing ARVs from 3% in 2004 to 65% in 2011. While sustaining the gains made under PoW, the HSSP has taken further measures to address the burden of disease by putting more emphasis on public health interventions including but not limited to health promotion, disease prevention and increasing community participation. The Essential Health Package (EHP) has been expanded after taking cognizance of the increasing burden of disease arising from non-communicable diseases, such as mental health, hypertension, diabetes, cancers and other lifestyle diseases. As the EHP is being implemented, the main focus or priority will be interventions that are cost effective and expansion of services to the under-served. Despite the gains made there are still a number of factors that need to be addressed that negatively impact on the health of Malawians namely availability and quality of health services,

Malawi Health Sector Strategic Plan 2011-2016 access to health services and environmental and behavioural issues. #

10

1. INTRODUCTION 1.1 Geographical Location Administrative System and

alawi is a small, narrow and landlocked country and shares boundaries with Zambia in the West, Mozambique in the East, South and SouthWest and Tanzania in the North. It has an area of 118,484 km2 of which 94,276 km2 is land area. The country is divided into 3 administrative regions namely the northern, central and southern regions. Malawi has 28 districts. Each district is further divided into traditional authorities (TAs) which are ruled by chiefs. The village is the smallest administrative unit and each village is under a TA. A Group Village Headman (GVH) oversees several villages. There is a Village Development Committee (VDC) at GVH level which is responsible for development activities. Development activities at TA level are coordinated by the Area Development Committee (ADC). Politically, each district is further divided into constituencies which are represented by Members of Parliament (MPs) and in some cases these constituencies can combine more than one TA. 1.2 Population

1987 it was at 8 million. At this growth rate it is estimated that by 2016, the population will be at 16.3 million and the health sector will cater for an extra 3 million people1. With this population increase, there will be need for a corresponding increase in funding for the health sector. The proportion of Malawis population residing in urban areas is estimated at 15.3%. Malawi is one of the most densely populated countries in Africa: the population density was estimated at 105 persons per km2 in 1998 and increased to 139 persons per km2 in 2008 with the Southern Region having the highest population density at 184 persons per km2. Malawis population growth rate is estimated at 2.3%. This high population growth is predominantly due to the high total fertility rate (TFR) now estimated at 5.7 and the low contraceptive prevalence rate (CPR) of 42%2. Almost half of the population is under 15 years of age and the dependence ratio has risen from 0.92 in 1966 to 1.04 in 2008. About 7% of the population is comprised of infants aged less than 1 year, 22% are under-fives and about 46% are aged 18 years and above. Malawi is predominantly a Christian country (80%). 1.3 Literacy status

n 2011 Malawis population was estimated at 14.4 million. This means that population has almost doubled over a 20 year period as in

1NSO. (2009). Malawi housing and population census

1

2008. Zomba: NSO

2NSO. (2011). Demographic and health survey 2010

2

preliminary results. Zomba: NSO.

ow literacy levels especially among women and the prevailing cultural diversity have impacts on the health of Malawians. The 2006 Multiple Indicator Cluster Survey (MICS) and 2010 preliminary DHS report show that the prevalence of diseases such as malaria, diarrhea and acute respiratory infections decreases the higher the educational qualifications. Knowledge about diseases such as HIV and AIDS increases the higher the educational level attained and that educated people are more likely to access modern health care services compared to those who have low or no education. Education is therefore an important determinant of health. The Government of Malawi (GoM) introduced free primary education in 1993 and enrolment increased from 1.9 million to about 3 million. Although enrolment increased, studies have found that only 30% of the children who start Standard 1 actually reach Standard 8 in primary school. This implies that 70% of the children drop out of primary school before reaching Standard 8. Literacy rate is estimated at 62% and it is higher among men (69%) than women (59%)3. A significant proportion of Malawians are illiterate and this might affect the implementation of the HSSP. 1.2 Poverty and health Malawis Gross Domestic Product (GDP) per capita has grown from less than $250 in 2004 to $313 in 20084. During the
3NSO. (2009). Malawi housing and population census
3

implementation of PoW there has been remarkable economic growth rate ranging between 6% and 9%, This has contributed to a reduction in the proportion of Malawians living below the poverty line from 52% in 2004 to 39%.5 In 2009, the proportion of people living below the poverty line was higher among rural residents (43%) compared to urban residents (14%)6. The prevalence of diseases such as malaria, ARIs and diarrhoea are higher among poor people compared to those who are rich7. Therefore, the successful implementation of the HSSP will depend to a large extent on the reduction of poverty. Malawi is predominantly an agricultural country and this sector accounts for about 35% of the GDP, 93% of export earnings primarily from tobacco sales, and provides more than 80% of employment. The sources of revenue for funding public services are taxes on personal income and company profits, trade taxes and grants from donors. In the event of insufficient revenue to cover the budgeted expenditure, the financing of the deficit is met either from the domestic bank and non-bank sources, or from foreign financing in a form of loans from donor and overseas banks. In such a scenario, the financing of public services in Malawi is inextricably linked to the aggregate of each of these revenue sources. For instance, in the 2008/09 financial year, the major public
5 NSO. (2009). Welfare monitoring survey 2009. Zomba:
5

NSO.

6NSO. (2009). Welfare monitoring survey 2009. Zomba:

6

NSO.

2008. Zomba: NSO

7 NSO, (2010), Demographic and health survey 2010

7

4 IMF Article IV Consultation Report 10/87 of March

4

preliminary results, Zomba: NSO

2010

sector sources of finance contributed in the following proportions: domestic taxes had a share of 77.9% and trade taxes had a share of 10.1%, while non-tax revenue was 12.0%. These revenues represented 24.5% of GDP. In terms of recurrent expenditures, health was the third at 10.2% after General Administration (33.9%), Agriculture (18.9%) and Education (13.7%)8. 2. SITUATION ANALYSIS

tuberculosis; sexually transmitted infections (STIs) including HIV/AIDS; diarrhoeal diseases; schistosomiasis; malnutrition; ear, nose and skin infections; perinatal conditions; and common injuries. The section below provides progress that has been made so far in the fight against these conditions/diseases including progress in attaining the health-related Millennium Development Goals (MDGs). 2.1 MATERNAL, NEONATAL AND CHILD HEALTH

n 2004 the Ministry of Health (MoH) in conjunction with other government Ministries, the private sector, Civil Society Organizations (CSOs) and HDPs developed the Sector Wide Approach (SWAp) Program of Work for the period 2004-2010 to guide the implementation of interventions in the health sector. The PoW was completed in 2010 but was extended to June 2011 to allow for the final evaluation of the Program. Substantial progress was made during the implementation of the PoW as maternal mortality ratio (MMR), infant mortality rate (IMR), Contraceptive Prevalence Rate (CPR) and other health indicators improved. An Essential Health Package (EHP), comprising of diseases and conditions affecting the majority of the population especially the poor, was agreed upon. This package was delivered free of charge to Malawians and most of the interventions for EHP conditions were cost effective. The conditions in this package were: vaccine preventable diseases; Acute Respiratory Infections (ARIs); malaria;
8 Mwase, T. (2010). Health Financing Profile for
8

2.1.1 Vaccine preventable conditions alawi has a robust and enviable immunization programme over many years (Figure 2.1) and recent high coverage is confirmed in the preliminary 2010 DHS report which shows that 81% of children aged 12-23 months were fully immunized. This is an increase in coverage of 26% since the 2004 DHS. However, in 2010 the country experienced an outbreak of measles with an estimated 43,000 children requiring treatment.

Malawi and Malawi Health Financing Strategic Plan. Lilongwe: MoH

High coverage, particularly of measles is required to maintain herd immunity and additional resources will therefore be required to sustain a vaccine coverage of 90 per cent and above for all antigens. 2.1.2 Acute respiratory infections

2.1.3 Malaria

neumonia is common and can be serious particularly in children. Treatment with antibiotics can be highly effective. Between 2004 and 2010 the proportion of children with ARIs taken to a health facility for treatment increased from 19.6% to 65.7%. There has also been a reduction of pneumonia case fatality from 18.7% in 2000 to 5.7% in 2008. Along with malaria and oral rehydration of diarrhoeal disease, it forms a major part of Integrated Management of Childhood Illnesses (IMCI). Successful implementation of pneumonia interventions in the PoW is likely to be part of the reason for the dramatic fall in infant and under 5 mortality. Continuation will help to achieve the two MDGs 2015 targets dealing with child mortality.

he prevention and treatment interventions for Malaria, which is still endemic in Malawi, are all cost-effective. Insecticide Residual Spraying (IRS), although expensive is new to the EHP, but cost-effective and will be rolled out to 12 of the 28 districts. Improved Insecticide Treated Nets (ITN) coverage and prompt treatment of fever in children under 5 are MDG targets (Figure 2.2). In order to reach the health-related MDG 4, the HSSP has put in measures that will sustain and increase vector control interventions such as larvacides, IRS and ITNs. Poor diagnostic capacity, abuse of ITNs, low coverage of second dose of SP in pregnancy, ACTs not being available in the private sector, poor adherence to treatment guidelines and policies have affected the implementation of malaria interventions. The HSSP will therefore also include additional capacity to diagnose malaria by laboratory means to ensure costeffectiveness of interventions for malaria treatment.

2.1.4 Acute Diarrhoeal Diseases

he BoD assessment calculates that the number of episodes of acute diarrhoea in children under 5 years of age is over 13 million per year yet the health service

treated only 324,000 in 2010, which suggests only 12% of need is being met. The plan is to increase this by 10% a year for the duration of HSSP through better access to health centres. Reorientation to homemade ORS would reduce the dependence of families on the health sector for what is a common and treatable condition and save money and lives.

2.1.5 Malnutrition lthough there has been some reduction, malnutrition remains high. The nutritionrelated MDG target is projected to be reached but underweight children and stunting remain high due to poor coverage of interventions. This is happening against the backdrop of more food in households because of the fertilizer subsidy program being implemented by GoM (Figure 2.3).

The interventions chosen to combat malnutrition will be identical to those of the first EHP and also detailed in the National Nutrition Policy and Strategic Plan (2008-2012) namely growth monitoring and screening for children under 5, Vitamin A supplementation, deworming and the treatment of severe and moderate malnutrition. Investments in child survival interventions such as

vaccines for various diseases, effective treatment of pneumonia even at community level, effective prevention and treatment of malaria and diarrhoeal diseases have contributed significantly to the remarkable decline in infant and under 5 mortality rates as can be seen in Figures 2.4 and 2.5 below:

Figure 2.4

Figure 2.5

160 140 120 100 80 60 20 0 40

Infant mortality rates in-trends M alawi and projection

M DG target 45
R = 0.973

U nder 5 child mortality rates in M alaw i trends and projection

2 50 2 00 1 50 1 00 50 0

M DG target 78

SWAp 1 2004 -2011

1990 1995 2000

projection 34
2020

SW Ap R = 0.971 1 projection 2004 -2011 57

b v i l 0 1 r p s h t a e D

b v i l 0 1 r p s h t a e D

1 985 1 990 1 995 2 000 2 005 20 10 20 15 20 20

1985

Year

2005

2010

2015

Year

These trends in infant and under 5 child mortality rate demonstrate that there is a possibility that Malawi can reach the MDG targets for these two indicators. This will be possible if significant investments are made in child survival interventions. 2.1.6 Maternity and Neonatal Care

aternal mortality rate has decreased from 984/100,000 in 2004 to 675 /100,000 live births in 2010 with an increase in women delivering at health centres from 57.2% in 2004 to 71.5% in 2010. Unlike Child Health

MDGs, Maternity MDG targets are unlikely to be met without significant additional investment to increase Emergency Obstetric Care (EmOC) access to many more pregnant women (Figure 2.6). Using data from the 2010 EmOC survey it is estimated that only half of the births requiring emergency care are receiving such care. Plans are in place to increase this access from 8% to 15% of births by 2016 by staffing and upgrading existing maternity units. The HSSP intends to increase operative deliveries from 4% now to 10% by 2016.

Currently, the neonatal mortality rate (NMR) is estimated at 33 deaths per 1,000 live births and it is higher in rural areas (34/1,000) compared to urban areas (30/1,000). It is also higher among male children (38/1,000) compared to female children (30/1,000). About 88 per cent of pregnant women are protected against tetanus.

The HSSP has included strategies to increase skilled attendant deliveries to reach the MDG target by 2015 and crucial to this is increasing the availability of trained midwives in all maternity units (Figure 2.7).

2.2 Family planning

he population projections using the 2008 census data reinforce the importance of scaling up interventions to meet the family planning MDG targets. The TFR is

expected to remain high and only slowly fall in the next 5 years with substantial investment in additional family planning services (Figure 2.8).

The 2010 preliminary DHS Report confirms the slow increase in contraceptive use and the projected percentage of women aged 15-49 who use any form of contraceptive and in 2015 it is anticipated to be 55%, while the MDG

target for 2015 is 65% (Figure 2.9). The reproductive health strategy has an ambitious target of 65% of women aged 15-49 using modern methods by 2015.

There is significant unmet need of contraception as indicated in the preliminary 2010 DHS Report which found that 73% of women wanted to delay reach the 65% modern methods target using the MoH, Christian Health

pregnancy or have no more children. Therefore there is need to increase the availability of family planning services to Association in Malawi (CHAM) Banja La Mtsogolo (BLM) services. and

2.3 Major Communicable Diseases

part from malaria, the other major communicable diseases are tuberculosis, HIV/AIDS and STIs.

2.3.1 Tuberculosis

ith regard to tuberculosis, the effort to collaborate and support the HIV/AIDS programme is paying off. More cases of tuberculosis are

being ascertained and treatment failure is diminishing. The tuberculosis MDG targets provide a measure of success (Figure 2.10).

The treatment success rate at 86% is slightly above the World Health Organization (WHO) target of 85%. However, the case detection rate (46%) is still below WHO target (70%). Through the National Tuberculosis Control Programme additional strategies have been developed to include the private sector and also increase the detection rate while maintaining the treatment success rate.

2.3.2 Sexually Transmitted Infections including HIV/AIDS (This section HIV not aligning in columns )

his component of the EHP consumes the greatest resources with direct costs in the order of an estimated 16% of the direct costs for the first year of the programme. This is, however, expected to increase as the country moves towards universal coverage for new ART regime. As part of the HIV prevention strategy, the health sector provides 25 million and 1 million of male and female condoms, respectively, per annum. HIV testing and counselling is an integral part of the HIV prevention strategy. Approximately 1.8 million people were counselled and tested for HIV in 2009/2010, which is 28% of the sexually active population. HIV testing among couples is limited and in the HSSP there are strategies to promote couple testing because of the high level of HIV discordant couples (Figure 2.11). Another key prevention component is Prevention of Mother to Child Transmission (PMTCT). In 2009/10 37% of HIV positive mothers received appropriate drugs and counselling. The HSSP provides strategies for increasing this annually by 10% over the five year period. Testing and treatment of other STIs is an important HIV prevention activity. About half the number of incident cases as estimated in the BoD study was treated in 2010. The strategic plan has put in place strategies to increase this number by improving access by 10% a year

Figure 2.11

Figure2.12

Source Maleta and Bowie BMC Health Services Research 2010, 10:243

Source HIV Unit Q4 2010 Report

ARVs are the mainstay of treatment. The criteria of who benefits from ARVs change as and when advice from WHO is updated. So far the implications are that more people will benefit from them. In 2009/2010 with the criteria for starting ARVs based on a CD4 count of less than 250 cells per mm3 , 228,468 adults were on ARVs which was 71% of eligible cases and 22,519 children were on ARVs, which was 29% of eligible children (Figure 2.13). Strategies have been put in place to increase adult coverage to 80% in 2011/2 and by 20% each year in children to reach the MDG target of 80%. Numbers will have to be revised upwards in the course of the implementation of the HSSP if additional resources are mobilized to fund the additional cases derived from the CD4 count change to 350 and maternity cases.

Alongside ARVs is the treatment of Opportunistic Infections (OIs) and community-based home care for AIDS patients. Currently, the coverage of OI treatment is about 20% of need and there are plans to increase coverage by 10% annually. The coverage of home-based care is about right but the quality of care and the availability of drugs are important and need improvement.

2.4 Disability including Mental Illness

he prevalence of disability in Malawi, as defined by the ICF model, is 4.18%. This is higher than earlier estimates of 2% in

1983 and 2.9% in 1993. Ntchisi District has the highest prevalence of disability at 7.79% and the lowest in Mchinji at 1.20%. The most common types of disabilities are physical disabilities (43%) followed by seeing (23%), hearing (16%) and

intellectual/emotional disabilities (11%), communication disabilities (3%) and old age (1%). Other types of disabilities constituted 3% of the sample population. Nearly half of these disabilities were due to physical illness. The other major causes of disability were natural/from birth (17%) and accidents (10.6%). Nearly 7 in 10 respondents became disabled at less than 20 years of age. In terms of health services, even though respondents mentioned that they needed the services, a significant proportion of respondents did not receive the services. For example while 84% of the respondents were aware of health services and about the same proportion expressed the need for such a service, only 61% received health services9. These results generally demonstrate that even though services may be available and the Constitution and the MGDS call for provision of services to all Malawians, PWDs have problems accessing these services mainly because of their disability.

9 SINTEF, CSR and FEDOMA. (2004). Living conditions of persons with activity limitations in Malawi. Oslo: SINTEF.
9

Mental illness interventions were not part of the EHP under the PoW although the illness at 4% accounts for a significant proportion of the total burden of disease. first year of HSSP implementation, there are plans to optimize the use of the cheapest drugs and expand on community outreach in one pilot district which will be assessed for cost-effectiveness after one year. Rolling out to other districts will be contingent upon the outcome of the assessment. The country has a graduate psychiatric nursing course in Mzuzu graduating 10-12 nurses each year, a number of clinical psychologists and one Malawian psychiatrist. There are plans to develop capacity within the mental illness services programme. 2.5 Non-communicable diseases (NCDs)

Treatment options are not particularly cost-effective based on costs in other SubSaharan African countries. During already been successfully piloted in a number of districts in the country. The STEPS survey published in 2010 identified a high level of high blood pressure and diabetes10. The level of hypertension is higher in Malawi (35% of adults) than United States of America (USA) and United Kingdom (27%). District and central hospitals have been treating such patients for a number of years outside the EHP. At present a strategy is being developed by the MoH on treatment regimes and outcome measures to deal with both conditions. The first phase is a pilot site opportunistic screening and treatment using effective but cheap drugs. 2.6 Determinants of health

alawi is currently faced with a double burden of both communicable and non-communicable diseases. NCDs account for approximately 12% of the Total Disability Adjusted Life Years (DALYs) which is fourth behind HIV/AIDS, other infections, parasitic and respiratory diseases. NCDs are thought to be the second leading cause of deaths in adults after HIV/AIDS. The HSSP has therefore incorporated NCDs in the EHP and interventions include screening for cervical cancer, hypertension and diabetes and providing treatment. Cervical cancer is the most common cancer in women in Malawi and accounts for 9,000 DALYs per year, on the borderline of being too small a burden. However, the chosen intervention of one VIA visit using colposcopy with acetic acid and cryotherapy is the best value for money at $74/DALY and has

A
1

nnex 1 highlights some of the underlying risk factors for the major diseases in Malawi which can be prevented through health promotion. One of the major determinants of health is level of education. National surveys show that health indicators are worse off among people who have no or little education than those who have secondary school+ level of education. For example underweight among under five children, the prevalence of diarrhoea and malaria among under five children all decreased the higher the
10Msyamboza KP, Ngwira B, Dzowela T, Mvula C,
Kathyola D, et al. (2011) The Burden of Selected Chronic Non-Communicable Diseases and Their Risk Factors in Malawi: Nationwide STEPS Survey. PLoS ONE 6(5): e20316. doi:10.1371/journal.pone.0020316

educational level of the mother. These health indicators are also better among the wealthier than among poor people. Improving income and educational levels this slightly increased to 67.3% in 2008. In 2004 16.1% of the households did not have a toilet facility and this was especially in the rural areas and by 2008 the proportion with no toilet facility decreased slightly to 13.5%. The proportion of households with soap to use at critical times is quite low at 45%. Only 2% of the population were using electricity for cooking. The majority of the households therefore use solid fuels (approximately 98%) which put children at higher risk of respiratory infection if the rooms are not well ventilated. Nearly a third of the women aged 15-49 have experienced domestic violence since the age of 1511 with women with little education and poor more likely to experience this. It was mostly the husbands who perpetrated violence against married women. The percentage of ever married women who ever went to a doctor or health centre after experiencing physical violence was low at 1.6%. GBV could be a hindrance or could be caused by the womans choice to seek health services such as contraception. In some cases fear of GBV leads women to seek health care rather late leading to poor health outcomes. During community consultations as part of the development of the HSSP, community members mentioned a number of diseases common in their areas and these were cholera, malaria, HIV/AIDS, tuberculosis, pneumonia and malnutrition. All these conditions are in the EHP. Even
11 NSO. (2005). Demographic and health surveys
1

would therefore lead to improvement in health status. In terms of access to safe water, in 2004 64% of Malawian households had access to clean water and though there were some misperceptions about the causes of these diseases, in most cases community members were aware of the causes and they did mention that they sought treatment from health facilities during illness episodes. Community members also consult traditional healers on issues relating to witchcraft. Prevailing cultural beliefs influence health for example the way people seek health care and prevent illness. Beliefs in witchcraft, ancestors and taboos as causes of ill health still prevail. Some cultural norms and practices have also been shown to contribute to unsafe sexual and reproductive health risk behaviours as well as access to timely health services and key commodities. Health promotion will help address the social determinants of health. 2.7 Health Systems Challenges 2.7.1 Drugs and Medical Supplies

2004. Zomba: NSO.

hile the overall availability of tracer drugs has improved over the PoW period, the shortage of drugs and other medical supplies continues to be a major challenge in health facilities. Factors such as lengthy procurement processes, poor specifications, weak logistical information systems, inadequate and unpredictable funding for medicines and inadequate infrastructure contribute to shortage of drugs. A significant proportion of districts overspend on drugs as they buy at higher prices from the private sector. In some cases the health sector is subjected to

inappropriate donations of medicines and other medical supplies. There is also a shortage of pharmaceutical staff and this is exacerbated by low output from health training institutions. In order to effectively deliver the EHP, the HSSP has included 2.7.2 Human Resources for Health (HRH)

strategies that aim at addressing these challenges and ensure that drugs and other medical supplies are available at health facilities.

fter the implementation of a 6-year Emergency Human Resource Plan (EHRP) under the PoW, the human resource situation within the health sector has improved significantly. The total number of professional Health Care Workers (HCWs) increased by 53% from 5,453 in 2004 to 8,369 in 2010; the capacity of health training institutions increased across a range of programs; and staff retention improved, among other things. However, only four of the 11 priority cadres (namely clinical officer, environmental health officers, radiology and laboratory technicians) met or exceeded their targets as set in the original EHRP design. Despite an investment of $53 million during the EHRP on pre-service training capacity, annual output of nurses only increased by 22%. The EHRP experience demonstrates that, with significant investments in human resources, it is possible to achieve a fullystaffed health system. With expanded staff establishment which has led to significant vacancies (see Annex 2) among priority HCW cadres, particularly nurses, physicians, clinical officers, environmental health officers, laboratory and pharmacy technicians, human resource challenges however remain both acute and complex. Increasing outputs from health training

institutions and developing effective recruitment, deployment and retention strategies will help to address the human resource challenges in the health sector. 2.7.3 Laboratory Services and Radiology

he delivery of laboratory and medical imaging services to support delivery of the EHP services has been affected by the shortage of human resources mainly due to low outputs from health training institutions and high attrition of personnel (especially from the public sector), inadequate funding, inadequate and inappropriate equipment, lack of capacity of the National Reference Laboratory to provide reference laboratory services and the low number of voluntary nonremunerated blood donors for blood safety programs. In radiology, challenges also include shortage of human resource, the lack of supervision and appropriate infrastructure with minimum space requirements as stipulated in RSOG. Other challenges include the donation of equipment without following procedure, disposal of radiological waste which poses serious threat to the environment and peoples health. Currently, there are no laws governing the disposal of radiological

waste, protective materials are inadequate, no place has been designated for disposal of radiological waste and equipment for HSSP the challenges affecting the provision of effective laboratory and radiological services will be addressed in order to effectively support the delivery EHP services. 2.7.4 Quality Assurance

monitoring radiation is not available. During the implementation period the of a sustainable QA/QM system with significant impact on outcomes during the HSSP period12. 2.7.5 Medical Equipment

espite being stated in the PoW and the National Quality Assurance Policy, a number of interventions were not implemented. These include the filling of the posts of the National QA Manager and managers, operationalisation of Action Teams at ZHSO, the establishment of QA committees. To date Standard Based Management and Recognition (SBM-R) initiative in Infection Prevention (IP) has been rolled out to all district and central hospitals and some CHAM hospitals have also achieved recognition. Evaluations show that the perception of risks of hospital acquired infections has reduced among both hospital staff and guardians. While knowledge on IP has improved, compliance of IP practice with recommended norms and standards still needs to be strengthened. Another SBM-R program covering Reproductive Health (RH) has since been rolled out to all district and central hospitals and the MoH is in the process of developing standards for IP and RH for health centres. Many stakeholders, however, are already involved in QA measures and are ready to integrate/harmonise their approaches following national guidelines and standards, aiming at continuous quality improvement at systems level. This constitutes a potential for the development

s at the development of the HSSP, the status of medical equipment in health facilities is unknown as the last such exercise was carried out in 2007. The only study that is available that looked at equipment in health facilities is the 2010 EmONC Assessment Study conducted in 309 health facilities. This study generally showed that all instrument kits were incomplete; there were no resuscitation equipment for babies; and that in general other vital pieces of equipment needed for newborn care were in short supply in both hospitals and health centres. The study also found that some basic diagnostic equipment and supplies were in short supply for example only 29% of the hospitals and 7% of health centres had blood sugar testing sticks; uristix for measuring protein was found in 52% of hospitals and 13% of health centres13. There has been a desk study looking at the status of equipment based on the EmONC study and the 2002 survey data. During annual and semiannual reviews the Zonal Offices report on status of equipment but these are incomplete as not all districts
12 EPOS Health Management. (2010). Quality improvement of health care services in Malawi: mission report. Lilongwe: MoH and GTZ.
1

13Ministry
1

of Health. (2010). Malawi 2010 EmONC needs assessment draft report. Lilongwe: Ministry of Health. .

report. In the course of implementing the HSSP, a comprehensive survey to determine the status of medical equipment in the country will be conducted. 2.7.6 Health Financing

ignificant amounts of resources have been invested in the health sector and by the end of the PoW, a total of almost $US900 million was spent with GoM dramatically increasing its level of spending from an estimated $US46.3 million in 2004/05 to $US134 million in 2009/10. Equally, support from HDPs increased from $US21.3 million in 2004/05 to $US63.4 million in 2009/10. However, there was a significant decline from the $US103.2 million of DP pooled funds provided in 2008/09 to $US 56.2 million disbursed in 2009/10. Untimely disbursement of donor funds forced GoM to borrow from the domestic market. A significant amount of donor funds remain off budget because some donors fund NGOs on interventions that are not a priority for the sector. The number of projects funded by donors has increased over the PoW which is unlikely to have been informed by the PoW (meaning outside the PoW). Over the period of PoW, total health spending rose from $US5.3 per capita in 2004/5, peaked at $S16.3 per capita in 2008/09 and declined slightly to an estimated $US14.5 per capita in 2009/10. The GoM budget allocated to the health sector increased from 11.1% in 2005 to 13.6% in 2008/9 before falling back to 12.4% in 2009/10. Progress is being made by GoM towards achieving the Abuja Declaration target of 15%. A resource allocation formula, which is subject to review after 3 years, has since been

developed jointly by the MoH and Ministry of Local Government and Rural Development (MoLGRD). Despite public services being offered free of charge, household out-of-pocket payments increased rapidly during the PoW. The capacity to regularly track health financing sources and their uses using internationally recognized tools such as National Health Accounts remains weak. Over the PoW the health sector experienced inequitable and inefficient allocation of health sector resources but this is being addressed. 2.7.7 Financial Management

inancial management has strengthened over the period of the PoW. The external audits commissioned each year have continually generated unqualified audit reports that is to say they have certified that the financial statements have fairly recorded the income and expenditures of the health sector without any qualifying remarks. Areas requiring improvements and financial management strengthening have also been highlighted and the HSSP has included strategies to address those areas. One challenge is that in real terms (after adjusting for inflation) funds managed in the health sector have more than doubled to reach 229.6% of their 2004 levels resulting in a corresponding increase in transactions but staffing levels have not changed. The ratio of staff to manage funds is especially poor at MoH headquarters compared to other levels. A

review of finance staff establishment will be undertaken in the course of implementing the HSSP to accommodate increased workload. Financial management at district level is now the responsibility of MoLGRD14. At this level, harmonisation is underway so that the district accounting common service staff will be brought together as one unified team in order to increase efficiency. The capacity of health finance staff at district level is being strengthened through the Financial Management Coaching of Cost Centres Programme which was active from March 2009 to March 2011. Building financial management capacity in the districts and central hospitals has also been strengthened through deployment of Financial Analysts in all districts under the auspices of National Local Government Finance Committee (NLGFC) of the MOLGRD. While financial management skills have been steadily improving, a significant proportion of common service personnel in MoH lack relevant accounting qualifications and training of such staff has been infrequent. The Financial Management Implementation Plan (FMIP) has included training for non-financial managers and such training is yet to be done. Finance staff in MoH, central and district hospitals require better access to computers and internet services. Lack of office space for finance staff is evident throughout MoH and in many District Health Offices (DHOs). While the health sector recognizes the value of oversight and audit, and welcomes both, capacity of the Finance Section is continually
14 More detailed discussion on decentralisation is in Chapter 6 .
1

challenged by poor alignment of HDPs with financial systems and the associated ad hoc collection of oversight arrangement and audits which are unharmonised, time wasting and often duplicative. A major effort during the implementation of the HSSP will be to minimize the oversight burden without compromising the quest for continuous system strengthening. Other challenges in financial management include: the flow of funds from central level to districts in some cases do not match cash flow forecasts; the flow of funds within districts is unreliable especially to rural health facilities; the absorption of funds at MoH headquarters, especially in infrastructure, is low due to procurement bottlenecks; financial reporting; donors requiring individual financial reports thereby increasing workload for finance staff; low uptake of internal audit findings; and the existence of numerous external audits. Strategies will therefore be put in place to explore the possibility of direct transfers of funds to rural facilities and strengthen collaborative efforts between the finance and procurement units at the central level. Notwithstanding challenges highlighted above, the Finance Section, supported by the Department of Accountant General, has continued to make steady gains in key areas including audit completion, financial reporting and upgrading of skills. 2.7.8 Procurement

ike any government entity, the public health sector has continued to follow procedures for procuring goods, works and services as laid down in the Public Procurement Act (2002) and elaborated in

the Public Procurement Regulations of 2004. During implementation of PoW, major challenges in procurement have included lack of capacity, especially at the unclear role of the central level in procurements undertaken at the district level, and unabated emergency procurements. Procurement capacity challenges in the public health sector have also been exacerbated by the commissioning of multiple audits by different partners and operation of parallel system of oversight to provide reassurance to HDPs. This arrangement has posed challenges as DPs have failed to align to country systems in accordance with the 2005 Paris Declaration on Aid Effectiveness and the 2008 Accra Agenda for Action. During the implementation of the HSSP, a number of interventions aimed at ensuring adequate capacity at all levels of the public health sector will be undertaken. These will include implementation of strategies that support continuous improvement and best procurement practices while achieving value for money in all procured goods, works and services; engagement on shortterm basis, the services of a Technical Assistance to build capacity in procurement; and encouragement of DPs to align to the countrys systems and simultaneously provide support to strengthen weak areas which they think amenable to suspicion. 2.7.9 Monitoring, Research Evaluation and

he MoH has been implementing a comprehensive HMIS countrywide since 2002. The HIS Strategic Plan explains how data is managed at all levels.

central level; poor coordination between Procurement Unit and other departments including districts; lack of well documented procurement procedures; Routine data on age and sex is collected but it is not disaggregated. The other sources of data include the DHS, MICS and other national surveys. While systems for monitoring and evaluation are in place, challenges exist which impact on the effective functioning of the HMIS. These challenges include inadequate staffing, lack of adequately disaggregated data; inadequate funding, the occasional stock outs of HMIS forms, pencils and other supplies, inadequate support for ICT at district and lower levels, untimely submission of data to CMED by districts and low data quality due to infrequent data validation exercises among other factors. Because of lack of trust in the data generated by the HMIS, with support from donors, parallel data collection systems have since been created. The existence of parallel data collection systems for vertical programs such as HIV/AIDS and malaria puts a strain on already scarce HRH. While civil statistics are vital, Malawi still lacks a coherent system for registering births and deaths even though there is a potential of effectively collecting such data through the HSAs. The MoH has employed Statistical Data Clerks and 65% have already reported for duties. These will be trained by the Zone Trainer of Trainers. Reporting forms will be reviewed and supervision will be carried out by CMED and the District Health Management Team (DHMT). The employment of Statistical Data Entry Clerks will help to address some of the problems that the MoH experiences.

The National Commission on Science and Technology (NCST) regulates the conduct of research in Malawi. While various institutions are involved in the conduct of health research challenges exist which include the absence of legal and policy frameworks to regulate research; weak coordination and monitoring of research being carried out in Malawi; limited multidisciplinary research largely due to lack of highly qualified and experienced indigenous researchers; and poor utilization of research findings for practice and policy formulation due to limited interactions between researchers and potential users of the information. As a way of addressing some of the problems being faced in the area of research, the NCST is implementing a 5 year Health Research Capacity Strengthening Initiative (HRCSI) with support from the Wellcome Trust, Department for International Development (DfID) and the International Development Research Centre (IDRC). The HRCS initiative offers an opportunity for Malawi to improve the capacity of Malawian researchers to conduct highquality research. 2.7.10 Universal access

Evidence shows that the removal of user fees in CHAM facilities has resulted into an increase in the number of patients seeking care in these facilities. Universal coverage also looks at geographical coverage. The proportion of Malawis population living within an 8km radius from a health facility (Annex 3) shows that there are certain districts that are well served compared to others. At Likoma Island, where there is no government facility, 100% of the population is not served by any government facility and this is followed by Chitipa (51%), Kasungu (38%), Balaka (32%), Chikwawa and Mangochi (27%). In Chiradzulu, Blantyre, Mulanje, and Zomba Districts less than 5% of the population reside more than 8km from a health facility. For districts that are not well served it is important to either construct new facilities or SLAs be signed with CHAM facilities. In some rural places, the health infrastructure is absent or dysfunctional. In others, the challenge is to provide health support to widely dispersed populations. In urban areas, health services can be physically within reach of the poor and other vulnerable populations, but provided by unregulated private providers who do not deliver EHP services. Annex 4 shows the number of health facilities in Malawi between 2003 and 2011: about half of the facilities in both 2003 and 2009 belonged to the MoH. Between 2003 and 2010 the number of health facilities in Malawi increased from 575 to 606. This increase was largely due to an increase in the number of health centres from 219 to 258. The number of health centres under MoH increased significantly because some public facilities mainly maternities and health posts were upgraded to health

urther refinement to the approach to improve equity will be updated when the full DHS 2010 report and data are available for further analysis. However, the MoH ensure that Services in the EHP are supposed to be available and accessed to by all Malawians. The signing of the SLAs with CHAM facilities for the delivery of Maternal and Neonatal Health (MNH) services is one way of ensuring that the services are accessed by everyone regardless of their socio-economic status.

centres in line with the aim of the Program of Work for the Health Sector (PoW) 2004-2006. While new health facilities have been constructed and some existing health facilities have been renovated or upgraded, challenges still exist: the construction of Umoyo Houses has not been completed and staff accommodation remains a challenge especially in hard to reach areas; in some rural areas health facilities are not available or dysfunctional while in others the challenge is provision of health care to a widely dispersed population. Rehabilitation of infrastructure is rarely done; hence the need for refurbishment. In urban areas, health services can be physically within reach of the poor and other vulnerable population, but provided by unregulated private providers who do not deliver to the population the health services they need. Other challenges relating to infrastructure include lack of ICT in most health facilities, inadequate staff in the Infrastructure Unit at MoH headquarters and inadequate funding for construction and maintenance of infrastructure and equipment. 2.8 Policy Context 2.8.1 National Policy Context

T
1

he Constitution of the Republic of Malawi states that the State is obliged to provide adequate health care, commensurate with the health needs of Malawian society and international standards of health care15. The Constitution therefore guarantees all Malawians that they will be
15Section 13 (c) of the Constitution of the Republic of
Malawi.

provided with health care and other social services of the highest quality within the limited resources available. It also guarantees equality to all people in access to health services. The Malawi Growth and Development Strategy (MGDS) is an overall development plan for Malawi and aims at creating wealth through sustainable economic growth and infrastructure development as a means of achieving poverty reduction. The MGDS recognizes that a healthy and educated population is necessary if the country is to achieve sustainable economic growth, achieve and sustain MDGs. The long-term goal of the MGDS with regard to health is to improve the health of the people of Malawi regardless of their socio-economic status and at all levels in a sustainable manner. Currently, the health sector has developed the National Health Policy and is reviewing the National Public Health Act. The HIV Bill is in draft form and expected to be passed during the period of the HSSP. The development of this Plan also took into consideration other existing pieces of legislation including the draft HIV Bill and Prevention of Domestic Violence Act, the Wills and Inheritance Act and the Child (Care, Protection and Justice) Act etceteras. Other pieces of legislation such as the Divorce, Marriage and Family Relations bill and the Diseased Estates Bill (to replace the Wills and Inheritance Act) are being reviewed. In 1999 the GoM defined the MoHs strategic vision for health care in Malawi into the 21st century and this document titled To the year 2020: A vision for the Health Sector in Malawi outlines the broad policy direction for the health sector at all levels. The document acknowledged that financial resources for health in

Malawi are inadequate to address the increasing population, disease burden and awareness of rights among Malawians. It was in this document that GoM first defined the EHP for Malawi which would be made available to every Malawian at his or her first contact with the formal health care system16. This EHP was revisited in 2004 during the development of the PoW and then in 2010 during the development of the HSSP. It is the policy of GoM that EHP should be provided free of charge to all Malawians and hence contribute to reducing poverty as it addresses the conditions that most poor people suffer from. The HSSP has also been informed by the draft National Health Policy (NHP)) whose overall goal is to improve the health status of all the people of Malawi by reducing the risk of ill health and occurrence of premature deaths. This overall goal will be achieved by implementing strategies and interventions that address critical areas in health services delivery such as management, hospital reforms, quality assurance, Public and Private Partnerships (PPPs), HRH, Essential Medicines and Supplies (EMS), blood safety, infrastructure and health financing. The NHP also redefines the EHP based on the burden of disease study and the STEPS survey and it further puts emphasis on the need for an effective monitoring, evaluation and research system that will address the data needs of the sector. The HSSP takes on board all these issues. The National Health Policy also acknowledges the inadequate resources available for the health sector;
16MoH. (1999). To the year 2020: a vision for the health
1

hence it also defines the EHP which will be available to all Malawians free of charge. The provision of health services has been decentralised and the MoH headquarters is not responsible for services delivery as this has become a responsibility of the MoLGRD in accordance with the Decentralisation Policy and Decentralisation Act. Policies and laws are therefore available that guide the development and implementation of interventions in the health sector. Districts have since been given greater responsibility of managing health services at district and lower levels.

2.8.2 International and Regional Policies

sector in Malawi. Lilongwe: MoH and Population.

here are a number of international conventions that Malawi is a signatory to but the most important is the 2000 Millennium Declaration which has 8 goals, 4 of which are on health and these are to: reduce extreme poverty and hunger (malnutrition) (Goal No.1), reduce child mortality (Goal No. 4), improve maternal health (Goal No. 5) and combat AIDS, malaria and other diseases (Goal No. 6).The country is on course to achieving Goal No. 4 which is reducing child mortality. However, Goal No. 5 may be difficult to achieve within the MDG lifespan due to a number of factors. Because of the desire to achieve MDG targets related to health, the HSSP has therefore included strategies and interventions that are aimed at accelerating progress towards achieving the MDG targets by 2015.

As a member state of the WHO, Malawi is also a signatory to the Ouagadougou Declaration on Primary Health Care (PHC) and Health Systems in Africa: Achieving better Health for Africa in the New Millennium in which African Countries reaffirmed their commitment to PHC as a strategy for delivering health services and an approach to accelerate the achievement of the MDGs as advocated by the World Health Report (WHR) of 2008. In addition, other important international declarations to which Malawi is a signatory are: The Abuja Declaration which called African Governments to increase their budgetary allocation to health to at least 15%. The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action which call for harmonization and alignment of aid in the sector. The Africa Health Strategy 20072015. The 1986 Ottawa Charter on Health Promotion. Libreville Declaration on Environment and Health. AU Maputo Plan of Action on Sexual and Reproductive Health and Rights Malawi is committed to these declarations and strategies but challenges still remain. For example, the country is as yet to achieve the target of 15% budgetary allocation for the health sector as detailed in the Abuja Declaration. This long term goal is expected to be achieved but within the context of overall budgetary balance, recognizing other developmental priorities including education, water and sanitation,

agricultural development, and infrastructure. Such areas of spending have their own developmental merits, but also contribute to health outcomes. 2.9 Summary of the analysis

he PoW (2004-2010) has overall registered progress in many spheres of the health sector as discussed in this section. For example, there has been decline in MMR, improvement on staffing levels (although this has been offset by expanded staff establishment, therefore creating more vacancies), generally improved availability of drugs and other medical supplies, among many other successes. Annex 5 details the strengths, weaknesses, opportunities and threats that may affect the implementation of the HSSP. Some key risks might hinder the implementation of the HSSP by the MoH and its stakeholders and Annex 6 provides a risk analysis that outlines key risks and how they will be mitigated.

3. INTRODUCING THE HEALTH SECTOR STRATEGIC PLAN

3.1 Development of the HSSP: Rationale and Process

coincides with the development of the MGDS, an overall development agenda of the Government of Malawi. In mid-2010 the MoH formed a core group (CG) to coordinate the development of the HSSP. In order to ensure that the process was participatory the CG drew membership from all departments in the MoH, health workers training institutions, the private sector, Civil Society Organizations (CSOs) and HDPs. The CG was chaired by the Director of the SWAp Secretariat in the MoH and members met regularly to discuss the progress made in the drafting of the HSSP as well as other emerging issues. Technical Working Groups (TWGs) were given the responsibility of contributing towards the development of the situation analysis for their thematic area, identifying objectives, strategies and key interventions and key indicators and also looking at implementation arrangements. The following TWGs participated in the development of the HSSP: Finance and Procurement, Hospital Reform, Human Resource (HR), Health Promotion, Public Private Partnerships (PPP), Health Infrastructure, Essential Medicines and

he HSSP (2011-2016) has been developed following the expiry of Sector Wide Approach (SWAp) Program of Work, a forerunner strategic document for the health sector in Malawi which covered the period 2004-2010 and guided the implementation of interventions aimed at improving the health status of the people of Malawi. The MoH, HDPs and other stakeholders in the health sector were involved in the development and implementation of the PoW. In addition to program monitoring and evaluation (M & E) data routinely collected using the Health Management Information System (HMIS), the PoW also provided for Joint Annual Reviews (JARs) for the health sector, with the MTR and the final evaluation as ways of measuring progress towards achieving the targets set in 2004. Although the PoW expired in June 2010, it was extended for one year partly to allow for the final evaluation. The results from both the MTR and the final evaluation therefore informed the development of the HSSP. The development of the HSSP also

Supplies (EMS, Laboratories, Essential Health Package, Quality Assurance and Monitoring, Evaluation and Research. Consultations were also made with individual departments and disease programs. The development of the HSSP also benefited from technical assistance provided by both local and international experts and supported by HDPs namely DFID, WHO, GTZ, FICA, USAID and UNFPA. A number of agreements were made during the 2010/2011 JAR meeting in October 2010 including: o Revision of the Essential Health Package (EHP) based on the burden of disease (BoD) study conducted by the College of Medicine (CoM) and the STEPS study on NCDs conducted by the MoH and WHO. o Discussion of some critical issues that should be addressed in the HSSP for example alternatives for sustainably financing the non-EHP conditions. Traditional authorities, religious leaders and MPs, among other interest groups, participated in this JAR workshop. As part of the development of the HSSP, literature was also reviewed including the Malawi MDG reports, the MGDS and specific disease strategic plans. The development of the HSSP also benefited from existing or draft strategic plans namely Malaria; Pharmaceuticals; Tuberculosis; Environmental Health; Nutrition and Food Security Policy and Strategic Plan; the Extended National AIDS Action Framework; Health Information Systems (HIS); the comprehensive Multi-year EPI

Plan; and the Sexual and Reproductive Health and Rights Strategic Plan. The HSSP was also informed by the draft National Health Policy and the draft Health Bill. Focus Group Discussions (FGDs) were conducted with community members in 6 districts, 2 from each region, to get their inputs into the HSSP. The major outcome of this consultation was that community members also identified as important the diseases that have currently been included in the EHP. Thereafter, a national consultative workshop with participants from the Zonal Health Support Offices (ZHSOs), MoH headquarters, DHOs, chiefs, CSOs, HDPs and other government Ministries and Departments was held at Crossroads Hotel in Lilongwe on 2nd December 2010 to review the first draft of the HSSP. This workshop was also attended by Traditional Authorities, religious leaders and MPs. Comments were then incorporated into the document and a consultant was hired to cost the HSSP. As part of developing the HSSP two internal JANS assessments were done by the CG and stakeholders. The comments from these assessments were incorporated into the HSSP. In April-May with support from the HDPs an external team was invited to conduct the JANS. The comments from the external JANS were used to finalize the HSSP document. Annex 7 shows the roadmap for development of the HSSP and stakeholders who were involved.

3.2 Priorities for the HSSP 3.2.1 Major Recommendations from Evaluation of the POW 1

he following are some of the major recommendations from the evaluation of PoW:

also be gradual expansion of the EHP (e.g. by including costeffective interventions for noncommunicable diseases such as cardiovascular diseases, Diabetes, mental health interventions, and a package of highly cost-effective surgical procedures provided in rural and district hospitals) o The drug supply system needs to be strengthened and dependence on emergency tenders has to be reduced. The logistics Management Information Systems needs to be improved to generate accurate data at facility level and that departments have to provide accurate and complete specifications. There is also a need to recapitalise the CMS. o The HSSP should address issues of equity including gender and geographical location. Preventive and curative health care should target hard to reach and vulnerable groups, e.g. adolescents seeking sexual and reproductive health care and antiretroviral treatment, orphans and vulnerable children, women and girls seeking postabortion care, the disabled, rural and traditional communities, and border and migrant populations. o Quality assurance approaches need to be strengthened and become systematic as over the years QA has been implemented on a piecemeal basis. The implementation of interventions at

o Both MoH and HDPs are experiencing high staff turnover with great loss of institutional memory. Over the HSSP mechanisms need to be put in place in order to retain staff as well as addressing the critical staff shortages at all levels. o In terms of M and E, there is a need for the health sector to focus on measurement of impact and outcomes, ensuring that hospital statistics is added to the routine HMIS and made available, extending the M and E system to monitor quality of care and that data should be disaggregated by gender, age and place of residence and recommended the use of a broad baseline survey linked to impact evaluation, to complement DHS. The baseline survey should be done before the beginning of the 2011/12 financial year. The role of research should be made clear. o The EHP was defined in 2004 and since then the disease patterns have changed. The evaluation recommended that the EHP should be revised take into consideration introduction of new technologies, changing disease patterns and available resources. There should

district level should be based on need and health priorities. o The HSSP should address issues of HRH management, coordination and oversight at all levels of implementation o Revision of DIP guidelines to allow better alignment of POW

planning and budgeting formats with MoLGRD/MoF. These recommendations from the final evaluation of the PoW have been taken into consideration during the development of this plan.

3.2.2 Burden of Disease (Bod) for Malawi

n 2006 the College of Medicine (CoM) conducted a BoD study looking at incidence and prevalence of all major diseases and disease specific death rates and ranked the top 10 conditions according to these rates. Based on this study, the top 10 risk factors and diseases causing deaths in Malawi are as shown in Annex 9. This study showed that HIV/AIDS is the major cause of mortality followed by LRI, malaria, diarrhoeal

diseases and conditions arising from perinatal conditions. The ranking of the top diseases and conditions was useful as it enabled an assessment of priority diseases which could be included in EHP. For most of these diseases and conditions cost effective interventions are available. As has been mentioned earlier on, the STEPS survey also clearly demonstrates that NCDs and their risk factors are a significant public health problem as can be seen in Table 4.1 below and this has led the MoH to establish an NCD Unit at headquarters.

Table 3.1: Prevalence of NCDs in Malawi Disease/condition Prevalence Hypertension 32.9% Cardiovascular diseases (using 8.9% cholesterol as a marker) Injuries other than RTA 8.5% Diabetes Asthma RTA 5.6% 5.1% 3.5%

Data sources NCD STEPS survey 2009 NCD STEPS survey 2009 age 25-64 years) WHS Malawi Report 2004 age >=18years) NCD STEPS survey 2009 WHS Malawi Report 2004 age >=18years) WHS Malawi Report 2004 age >=18years)

(N=3910, (N=5297,

(N=5297, (N=5297,

These diseases as identified by the BoD study and the STEPS survey contribute to high levels of morbidity and mortality in Malawi. From these studies the national Technical Working Group on EHP identified 13 EHP conditions that should be prioritized during the EHP. Based on this evidence and after wide consultations, the original EHP as contained in the PoW 2004-2010 was modified to include interventions not previously included in the EHP. The original set of interventions is continued. The full list of interventions (with new ones marked with an asterisk) deal with the following conditions:1. HIV/AIDS 2. ARI 3. Malaria 4. Diarrhoeal diseases 5. Perinatal conditions 6. * Non communicable diseases (NCDs) including trauma 7. Tuberculosis 8. Malnutrition 9. * Cancers 10. Vaccine preventable diseases 11. * Mental illness and epilepsy 12. * Neglected Tropical Diseases (NTDs) 13. Eye, ear and skin infections During the FGD with community members, participants also mentioned that the most common diseases in their communities were HIV/AIDS, ARIs, tuberculosis, malaria, diarrhoea among others. The evidence used to assess each intervention is derived from core datasets comprising a revised Burden of Disease assessment for 201117, an assessment of
17 Burden of disease estimates for 2011, College of
1

the cost-effectiveness of past and potential interventions, the preliminary report of the Demographic Health Survey of 2010 (DHS2010), ad hoc epidemiological surveys (such as the Malaria and EMOC surveys of 2010), projections of Millennium Development goals (MDGs) and published research evidence. The EHP TWG used the following criteria for prioritising interventions for inclusion and setting targets of activity in the EHP. The criteria chosen were: Burden of disease Cost effectiveness Access to poor MDG condition Proven successful intervention Discrete Earmarked funding through bilateral agreements

Table 3.2 shows an overview of the key interventions for EHP conditions:

Medicine 2011, at http://www.malawimph.co.uk/data/bod%202011/Burden%20of%20BOD %20and%20EHP1.doc

Table 3.2: Cost effective interventions in the EHP EHP condition Interventions HIV/AIDS/STIs o Multi level BCC across all sectors o Health promotion18 o Screening (HIV testing and counseling through all entry points) o Provision of home based care o Procurement and provision of male and female condoms o Provision of ART o Provision of PMTCT services o CPT o Blood and needle safety o STIs - Screening and treatment and promotion o Treatment of opportunistic infections o Peer and education Programs for high risk groups o Condom promotion and distribution ARIs o Health promotion on recognition of danger signs for ARIs o Early treatment of ARIs using standard protocols o Treatment of pneumonia Malaria o Health promotion o Early treatment of malaria at household, community and health centre level o Promotion and use of LLITNs o Promotion and use of IRS ( o Vector control - Larvaciding and control of breeding sites o IPTp Diarrhoea diseases o Health promotion o Early care seeking use of ORT o Provision of zinc o Construction of low cost excreta disposal o Provision of home solutions o Promotion of exclusive breastfeeding o Surveillance of water and food quality 19 Adverse maternal and neonatal outcomes o Promotion and provision of family planning methods o Promotion of institutional deliveries o Provision of services for
18 Health promotion includes BCC/IEC, behavioural change, social mobilisation, screening etc
1

19 Other stakeholders such as Ministry of Water and Irrigation are involved.

1

o Surveillance of water and food quality o NCDs and trauma o o o o o o Tuberculosis o o o o o o o o o o o Vaccine preventable diseases o o o o o o o o o o NTDs o o o o o complications of delivery (BEmONC and EmoNC) Screening for cervical cancer using VIA Repair of obstetric fistula Health promotion on awareness about health risks such as smoking and drinking of alcohol, safe driving Screening for risk factors and conditions (cardiovascular, diabetes) Promote physical activity Promote healthy diets Community and facility based rehabilitation, first aid Community DOTS Health promotion Treatment of TB including MDR Promotion of exclusive breastfeeding Growth monitoring De-worming Micronutrient supplementation Treatment of severe acute malnutrition Health promotion Early screening (cervical ,breast and karposis) Treatment with cryotherapy and surgery (scaling up ) Health promotion Pentavalent Polio Tuberculosis Measles Tetanus Health promotion interventions to create awareness about mental health Mental health promotion in schools and workplaces Treatment of epilepsy Treatment of acute neuropsychiatric conditions inpatient Rehabilitation Case finding and treatment of trypanosomiasis LF mass drug administration Mass drug administration for onchocerciasis STH mass drug administration in

Malnutrition

Cancers

Mental illness including epilepsy

o Surveillance of water and food quality Eye, ear and skin infections school children o Mass drug administration o Health promotion on prevention of eye, ear and skin infections o Treatment of conjunctivitis, acute otitis media, scabies and trachoma

As has been the case in the PoW, the EHP will also be provided free of charge over the period of implementing the HSSP The level of burden of disease and the cost effectiveness of each intervention are found in the BOD 2011 for each disease for which the intervention is targeted and the cost-effectiveness estimate from the Disease Priorities in Developing Countries publication. The findings are summarised in Figure 3.1, which shows the conditions with disease burdens above and below

10,000 DALYs per year and interventions above and below $150/DALY (the threshold below which interventions are particularly good value for money in developing countries) and $1050/DALY (the threshold above which interventions are considered too expensive for the economy of the country (three times the GNP).

Legend - 1-ARV;2-HIV prevention; 3-IMCI; 4-Maternal care; 5-ARI in under-5s; 6-Malaria bednets; 7-Malaria - under 5 using ACT; 8-IPT child; 9-HCT; 10-Dehydration Thanzi; 11Home made ORS; 12-Water supply; 13-Improved sanitation; 14-Family planning; 15-School health; 16-Wounds, fractures; 17-first aid training of volunteers; 18-Emergency ambulance service; 19-IRS; 20-Management of OIs; 21-Penta vaccine; 22-DPT Polio; 23-NTD mass treatment; 24-Measles vaccine; 25-Supplementary Feeding ; 26-Rotavirus vaccine; 27Prevention of RTAs; 28-Treatment -smear + TB; 29-BP - polypill; 30-Growth Monitoring; 31-Cataract extraction; 32-Depression; 33-Cancer; 34-STIs; 35-PMTCT; 36-Aspirin for stroke; 37-Malaria - 5 + ACT; 38-Anxiety disorders; 39-IHD - drugs; 40-Trachoma surgery; 41-Treatment smear- TB; 42-Drug misuse; 43-Bipolar disorders; 44-Schizophrenia; 45CBHBC; 46-Diabetes - screening; 47-Diabetes - lifestyle change; 48-Diabetes - drugs; 49Epilepsy; 50-CCF drugs; 51-IPT Preg; 52-Alcohol misuse - PC advice; 53-Cervical screening cryotherapy; 54-HPV; 55-TB relapsed; 56-Rheumatic h d20. The key decisions over priorities based on an assessment of past and potential interventions are:1. All the interventions from the previous EHP are appropriate with good reasons for the three outliers.
2

ORS with Thanzi is much more expensive than homemade ORS with health education input but is largely funded by USAID and UNICEF; ARVs are expensive but funded by Global Fund; and relapsing cases of TB are

20 BoD 2011 College of Medicine; Cost-effectiveness ratios from BDDC 2nd Edition 2006.

uncommon but an integral part of TB control. 2. The interventions marked partly EHP include IMCI, water and sanitation and school health. These are good value interventions which 4. The items marked Out EHP are good value interventions not included in the EHP. Intermittent prophylaxis in children is an intervention being considered by the Malaria Unit but not yet included in their strategy. First Aid for volunteers as part of trauma services could but is not yet a component which can be run by the Red Cross on a national scale. The prevention of Road traffic accidents is the responsibility of the Ministry of Roads. Homemade ORS and DTP vaccine are being covered by alternative interventions. Otherwise there are no value for money interventions which could be included in the programme. 5. Most of the new items in this EHP are cost effective and cover a significant burden of disease. Those that are expensive with costeffectiveness ratios over $150/DALY but dealing with high burden conditions mental illness and interventions for noncommunicable diseases are being piloted in year1 to set up services which are cheaper than such services elsewhere and which will thereby reduce their costeffectiveness ratios to affordable levels. 3.2.3 What is New in the HSSP?

are partly implemented in the EHP and partly in other development programmes, water and sanitation being the responsibility of the Ministry of Water and Irrigation.

3. his Plan is different from the PoW2004-2010 because it: Places emphasis on health promotion and disease prevention as the majority of the diseases affecting Malawians are preventable. In line with the Ouagadougou Declaration, focuses on community participation. Promotes integration of EHP services delivery at all levels. Redefines the EHP based on the Burden of Disease and the STEPS survey and mental health and NCDs will constitute part of the new EHP. Promotes the expansion of SLAs. Leveling of EHP delivery. Encourages exploring and implementation of alternative sources of financing. Places emphasis on reform of central hospitals. Promotes implementation of quality assurance interventions. Promotes increased coordination and alignment and reduction of transaction costs.

4. VISION, MISSION, GUIDING PRINCIPLES, GOAL AND BROAD OBJECTIVES OF THE PLAN (review style of chapter 3 ? to put in boxes ) 4.1 Vision and mission

The vision, goal, mission and guiding principles of the HSSP:

Vision:

he Vision of the Health Sector is to Achieve a State of Health for All the People of Malawi that Would Enable them to Lead a Quality and Productive Life.

Mission:

4.2 Guiding Principles

he Vision of The Health Sector is to Provide Strategic Leadership by The MoH for the Delivery of A Comprehensive Range of Quality, Equitable and Efficient Health Services To All People In Malawi by Creating an Enabling Environment for Health Promoting Activities.

he guiding principles for HSSP are inspired by the primary health care approach. The principles are:

National ownership and government leadership: in the interest of national development and self-reliance, all partners in the health sector will respect national ownership of this HSSP, the extent to which this principle is reinforced will be measured. Human Rights Based Approach and Equity: All the people of Malawi shall have access to health services without distinction of ethnicity, gender, disability, religion, political belief, economic and social condition or geographical location. The rights of health care users and their families, providers, and support staff shall be respected and protected. Gender Sensitivity: Gender issues shall be mainstreamed in the planning and implementation of all health Programs and tracked for impact. Ethical Considerations: The ethical requirement of confidentiality, safety and efficacy in both the provision of health care and health care research shall be adhered to. Efficiency: All stakeholders shall use available health care resources efficiently to maximize health gains. Opportunities shall be identified to facilitate integration of health service delivery where appropriate to address client needs efficiently and effectively. Accountability: All stakeholders shall discharge their respective mandates in a manner that takes full responsibility for the decisions made in the course of providing health care. All health workers at all levels and all DPs shall be accountable to the people of Malawi.

 Inter-sectoral collaboration: In addition to the MoH there are also other Government Ministries and Departments and CSOs that play an important role especially in addressing social determinants of health; hence inter-sectoral collaboration shall be promoted. Community Participation: Community participation shall be encouraged in the planning, management and delivery of health services. Evidence-based decision making: Interventions shall be based on proven and costeffective national and international best practices. Partnership: Public-Private Partnership (PPP) shall be encouraged and strengthened to address the determinants of health, improve service provision, and create resources (e.g. training of human resource) and sharing of technologies among others. . Decentralization: Health services management and provision shall be in line with the Local Government Act of 1998 which entails devolving health service delivery to Local Assemblies. Appropriate Technology: All health care providers shall use health care technologies that are appropriate, relevant and cost effective. 4.3 Goal

he goal is to improve the quality of life of all the people of Malawi by reducing the risk of ill health and occurrence of premature deaths thereby contributing to the social and economic development of the country.

4.4 Broad Objectives of the HSSP The broad objectives of the HSSP are:

Increase coverage of the high impact, quality Essential Health Package interventions. Strengthen the performance of the health system to support delivery of EHP services. Reduce risk factors to health. Improve equity and efficiency in the delivery of quality EHP services.

5. STRATEGIES, INTERVENTIONS AND IMPLEMENTATION ARRANGEMENTS FOR THE HSSP

5.1 The Essential Health Package Objective

community, health centre, district and central hospitals. Annex 9 shows a comprehensive list of services that will be offered at each level of health care. The criteria for choosing the services that will be offered at each level of health care takes into account issues of cost effectiveness: For example there are a number of interventions that have been put in Annex 9 which have been taken from the ACSD strategic Plan for Malawi which have been proven effective in the control of childhood diseases. Implementation Arrangements

T
S

o ensure universal access to quality EHP services consisting of promotive, preventive, curative and rehabilitative services to all people in Malawi. Strategies and key interventions trengthening the delivery of community health services and ensuring community participation. Improving the treatment of EHP conditions using regimes or protocols that are cost effective. Improving access of the population to quality EHP services Strengthening the prevention, management and control of EHP conditions. Improving diagnostic services at all levels. Strengthening health promotion activities at all levels. Delivering EHP services in an integrated manner.

s has been the case in the previous PoW, the EHP will also be provided free of charge over the period of implementing the HSSP. The problem, however, is that during the implementation of EHP in PoW it was difficult to translate it into service delivery realities. Health workers tended to pay attention even to non-EHP conditions21. District hospitals and health centres spent significant resources on treating non-EHPs during PoW.

The Range and level of EHP delivery

he key interventions/services that will be provided are in Annex 9. A decision was made that while diseases and conditions as described above are components of the EHP, it is important to also define the EHP in terms of services that will be offered at each level of Malawis health care system namely

21MoH. (2010). Final evaluation of the PoW 2004-2010.

2

Lilongwe: MoH.

In the HSSP, as discussed later, alternative sources of funding will be explored in order to fund non-EHP conditions. Proper referral mechanisms will be respected and where this is not done, a bypass fee will be charged to patients. The EHP will be implemented in an integrated manner. Integration across clinics and integration across technical areas will help delivery of the EHP to be as efficient as possible. Currently, some services are run in a vertical manner, which not only fragments service delivery, uses more staff time, but it also could contribute to loss to follow up, especially among HIV-positive women detected in ANC. By creating a singular service of integrated ANC, a woman will be able to be tested by the same nurse who is implementing the rest of her ANC visit. Similarly, a woman delivering in a facility should have access to not only skilled birth attendants but also attendants who have been appropriately trained in PMTCT protocols, post-partum family planning, breastfeeding, etc. By orienting clinical staff to respond comprehensively to a clients needs, it is probable that the health status of women will increase and human resources will be more efficiently utilized. Making Access equitable to EHP services

he following population groups are considered vulnerable: poor people, women, children, orphans, people with disabilities and the elderly, persons living in hard to reach areas and displaced persons (including refugees and persons displaced due to natural disasters). The Ministry of Health and stakeholders will ensure that the special health needs of these vulnerable groups are addressed in line with the Constitution of the Republic of Malawi which calls for the provision of adequate health care, commensurate with the health needs of Malawian society and international standards of health care. In order to address the needs of vulnerable groups, Government and stakeholders will (i) continue conducting outreach/mobile clinics in order to reach hard to reach populations; (ii) will sign strategic SLAs with CHAM to enable populations in their catchment areas to access free services; and (iii) will consider the construction of new health facilities in underserved area which will take into consideration issues of access by people with disabilities. The MoH and stakeholders will also conduct sensitisation meetings in communities in order to create awareness about available services and the need for these special groups to access them.

5.2 HSSP Objectives

5.2.1 Objective 1: Increase coverage of Essential Health Package interventions.

n order to improve access to and coverage of EHP services, the MoH and stakeholders will construct health facilities This will help to ensure that the majority of Malawians live within an 8 kilometre radius of a health facility. Strategies and key interventions 5.2.1.1 Infrastructure To improve access and coverage to EHP services through the development of infrastructure Interventions Install and maintain utility systems in existing facilities. Rehabilitate existing buildings. Upgrade existing health facilities. Construct new health facilities. Construct Umoyo houses. 5.2.1.2 Service Level agreements Develop service level agreements with CHAM/Private

Interventions Review coverage Identify gaps and priority areas by district Sign service level agreements 5.2.1.3 Transport Improve Health Transport System Review current transport management system Regular inventory of emergency transport especially in hard to reach areas and trauma centres Implementation arrangements ased on mapping of health facility exercise conducted as part of the HSSP design process, locations for constructing new facilities need have been identified and also facilities that need to be rehabilitated and upgraded to a higher level . The MoH will ensure that proper procedures are followed in identifying contractors for carrying out these works. Public Private partnerships will be reviewed during the 1st year (ref section on partnerships and financing . )

5.2.2. Objective 2 Strengthen the Performance of the Health System to Support Delivery of EHP Services

Objective o To provide human resource that is adequate, properly trained, remunerated, well motivated and capable of effectively delivering the EHP to the Malawi population. Strategies and key interventions Strengthen human resource management for effective EHP delivery at all levels o Recruit new and returning staff according to staffing norms for all cadres. o Create and clarify job descriptions and career paths for appropriate health cadres. o Review and standardize policy on Locums to ensure equity and costeffectiveness. o Review and standardize policy on scope of work for HSAs. o Sustain top-ups for existing priority cadres and support a phase-in strategy to integrate top-ups into salaries. o Institutionalize PBM as management tool (leveraging an effective appraisal system, meritbased processes and supportive supervision) o Improve supervision structures and mechanisms at all levels of the health system

n order to implement the EHP as defined above there is a need for adequate Health Systems support in place to support service delivery. This section summarizes the objectives and strategies and key interventions for these support systems. 5.2.2.1 Human Resources for Health

hile the EHRP helped in addressing the human resource crisis that Malawi had, the country continues to experience critical shortages of HR that can adequately respond to Malawis disease burden. The Plan acknowledges that there is critical shortage of HR, low motivation for health workers, weak HR planning and management, inequalities in the distribution of HCWs and that training institutions are not producing adequate numbers of graduates to meet Malawis needs among other challenges. Over the next 5 years of implementing this plan, interventions will be implemented that will aim at addressing HR management, development and planning issues including use of technical assistance. A functional review of the MoH establishment shall be conducted during the five year period. Human Resource Planning, Development and Management

Improve the capacity of HRH planning in the health sector o Recommend new establishment figures to Department of Public Services Management based on results of workload analysis. o Expand, maintain and integrate HRMIS with existing management databases, enable greater coverage of other cadres and facilitate its use with other relevant organizations such as CHAM and the private sector. o Scale up the training of key health workers in the use of HRMIS at all levels. o Orient Directors and Managers at all levels in human resource policy, planning, data management and dissemination. o Make use of data management capacity to provide accurate and timely information on numbers, cadres, qualifications, deployment, transfer and attrition of health staff in order to make effective HR decisions Improve retention of healthcare workers o Implement appropriate retention22 and incentive measures for health workers at central, district and health centre levels especially in hard to reach areas comprising: o Maintenance of 52% salary top-ups. o Institutionalization of performance management incentive scheme.
22This has been derived from existing evidence/studies.
2

o Continuation of professional development. o Extension of housing scheme to health cadres according to needs. Strengthen HRH training and development o Increase the numbers of health workers being trained to subsequently address the HR needs for Malawi. o Ensure high quality training at all TIs, with sufficient clinical facility and hands-on training, and reducing the number of students per tutor o Create a tracking mechanism on the bonding of students. o Pilot (and revisit existing pilot studies) for cost-effective further qualification training such as eLearning, distance learning, applied and part-time learning o Scale up the training of specialists (i.e. in nursing, physicians, etc). o Develop and roll-out training in applied epidemiology and public health management as core components of district and zonal health managers skills sets. o Review existing in-service training schemes, pilot new in-service training methods including mentoring and coaching and target in-service training for particular needs (e.g. for newly appointed HRH at rural HCs and inclusion of support staff) o Strengthen linkages and coordination with HCW regulatory bodies to track in service trainings

o Implement leadership and management programs for health workers at all levels. o Orient health managers at all levels with current responsibility for human resources on effective HRM practices o Support the rolling out of continuing professional development programs for nurses and clinicians. o Review the in-service training plans and mechanisms and develop a revised fair and transparent system. o Lobby for internship program for all health workers in training. o Lobby for establishment of a loan scheme to support student fee and mechanisms for bonding. Build capacity of health training institutions o Establish a working forum involving Ministry of Education, regulatory bodies and other stakeholders with a mandate and finances to work together to accomplish the following: o Produce an appropriate number of tutors with required qualifications in conjunction with larger student intakes and facilitate their continuing professional development. o Implement training program on leadership, management and professional development for training institution staff. o Orient and assign existing cadres for clinical instruction activities and increase number of clinical instructors as necessary.

o Optimize existing infrastructure and staffing according to training needs, utilize flexible accommodation arrangements (e.g. non-residential students) and undertake innovative planning techniques to enable costeffective increases in student intake. o Continue equitable incentive packages for tutors taking into consideration placement (e.g. urban vs. rural). o Provide adequate infrastructure and equipment where necessary to accommodate increased numbers of students. o Delineate training responsibilities of priority health cadres between College of Medicine, Mzuzu University, Kamuzu College of Nursing, Malawi College of Health Sciences and CHAM Training Institutions. o Revise curricula for training health workers to ensure that training Programs address the health needs of modern Malawi in line with WHO recommendations on transformative education for health professionals. Strengthen capacities for HRH stewardship in policy, partnerships and monitoring and evaluation at national level o Review existing regulatory acts. o Champion capacity building of key HR functions at all levels o Engage the management and coordination of technical assistants (regional and international) at all levels. o Promote multi-stakeholder c

o ooperation through the HRH Observatory and other platforms o Enhance collaboration between Health Services Commission and Ministry of Health (e.g. review the Health Services Commission Act) o Strengthen partnership agreements with other health service providers (e.g. CHAM, private sector) o Review and implement the HRH Strategic Plan, the National Health Sector Deployment Policy and the HRH Deployment Policy o Enhance interdivisional collaboration on HRH for EHP delivery o Advocate for strong presence of Ministry of Health and MOH HR department in decisions relating to health training institutions and student fees o Promote the sustainability and growth of gains made in EHRP (pre-service training, recruitment and retention) o Advocate for decentralization of HR management at district level o Develop strategy to control migration of health workers o Provide adequate resources and skills in the MoH for health planning, management and development while addressing the organizational context and the institutional environment through a comprehensive capacity development approach Technical Assistance for Health This strategic plan identifies the lack of capacities within the MoH and its subordinated structures and institutions to

effectively the EHP. Over the years the MoH has engaged technical assistance (TA) to help to build capacities in various priority areas of the health sector. Over the HSSP period the MoH and stakeholders have identified some critical areas where there will be a need for TA. This HSSP has identified financial management as a critical area where technical assistance is required and currently there is already a TA in place who is working with the MoH and stakeholders in order to ensure that credible financial systems (including financial reporting) are in place and adhered to. This technical assistance will be required throughout the period of the HSSP. At a global level there is a general decrease in funding and Malawi should not expect a substantial increase in funding from the donor community over the period of the HSSP. This HSSP is ambitious and there is a need for financial resources to be mobilised for it to be implemented successfully. One of the interventions in the health financing section of this HSSP is that in the first year of this plan there will be a need for the health sector to develop a health financing strategy, supported by Technical Assistance. The College of Medicine trains general doctors and within the Directorate of Clinical Services there is a feeling that Malawi has an adequate number of general doctors but will need specialists in the areas of clinical psychology, internal medicine, paediatrics, obstetrics and gynaecologists and pathologists. Other areas that will require TAs include procurement, health promotion, monitoring and evaluation, epidemiology, human resources planning and

management, laboratories, the ZHSO and the Central Medical Stores. It is expected that the sourcing and financing of the TAs will be done by the individual HDPs but the MoH will provide the ToR, approve the candidates and manage the TAs. The TA strategy will outline the short and long term needs for technical assistance. Implementation arrangements The Department of Human Resource in the MoH, in consultation with other Departments in the Ministry, has the overall responsibility of managing human resource in the Ministry. The HRH TWG provides technical guidance on human resource issues in the health sector. The MoH in conjunction with the stakeholders have conducted the work load analysis upon which the new staffing norms to adequately provide EH services will be based. The Health Services Commission will continue being responsible for the recruitment of health workers into the MoH. Before the start of implementing the HSSP the MoH and stakeholders will also work collaboratively with the Ministry of Education to plan and implement a human resource training program that will be aimed at addressing the HR needs for Malawis health sector. 5.2.2.2 Essential Medicines and Supplies Over the period of PoW significant progress has been made to ensure that EMS are made available in health facilities. However, challenges still remain for example inadequate space for storage of EMS, procurement processes are lengthy, pilferage is still a major problem, a weak supply chain management and that

some health facilities still report shortage of drugs among other challenges. Over the period of the HSSP, the MoH will ensure the availability of adequate quantities of high quality safe and affordable EMS for effective delivery of the EHP to Malawians. 1. Objective o To ensure availability, equitable access and rational use of good quality, safe, efficacious medicines and supplies at affordable costs. 2. Strategies and interventions Improve the HR capacity in the pharmaceutical sector Develop and implement a pharmaceutical HR development plan for all pharmacy personnel e.g. Pharmacy Assistants, Pharmacy Technician and Pharmacists. Expand physical infrastructure of training institutions. Support the training of lecturers. Increase intake of pharmacy students at training institutions. Support training of Pharmaceutical Department at post graduate level. Develop focused pre-service training modules in drug management for non-pharmacist health professions educational Programs, particularly for nurses, who often take on the role of drug management at the local SDP level. Strengthen collaboration with stakeholders in the pharmaceutical sector including the private sector.

 Develop guidelines on rational use of traditional and complimentary medicines. Enforce utilization of guidelines for donated medicines at all levels. Advocate and promote local production of medicines Strengthen security system within the supply chain of commodities Form a high-level committee, (Ministry of Justice, Ministry of Local Government, and Ministry of Labour) including members from outside of the MoH, and assisted by a logistics security expert, to review the recommendations of the Leakage Study and set priorities for cost-effective interventions. Revive and build capacity of the drug committees at all levels (Central hospital, District Hospitals and Health centres) Improve transport security of EMS through piloting the use of roll cages for packing at EMS, transport, and delivery to SDPs. Account in writing of medicines that have been dispensed to the patient Strengthen warehousing and distribution of pharmaceuticals through PPP arrangements Outsourcing Warehousing Outsourcing Distribution

Review and/ fast-track the Construction a modern, warehouse for CMS and refurbish the RMS and thereafter install an appropriate warehouse management software Recapitalize the CMS. Build and maintain capacity for procurement of medicines and medical supplies Review (by high level committee ) the latest (2009/10) external auditors reports of procurements carried out under the SWAp 1 POW, in order to determine how the CMS can better leverage its procurements for improved savings for the Government of Malawi. Consider hiring and retaining an internationally-known and reputable procurement agent. Develop capacity and reinforce compliance in the utilization of the LMIS to collect and report dispensed to user data in order to provide for more accurate quantification. Build capacity for forecasting and quantification using the bottom up approach. Review forecasting and quantification system continuously. Develop and maintain a rolling, three-year quantification, particularly of high value/volume commodities. Write commodity contracts for multiple deliveries in a year to avoid overburdening storage and ensure fresh product. Consider multi-year framework contract, particularly for high value procurements.

 Develop capacity of the CMS Trust to carry out its mandate Build the capacity of health workers and general public on rational use of medicines (RUM) Review of formulary and guidelines, NDP policies and other reference material related to RUM. Sensitize training institutions and health workers on formulary and guidelines, policies and other reference material related to RUM. Review pre-service curricula to incorporate RUM. Develop a communication strategy on RUM. Build capacity (health workers and laboratory infrastructure ) for quality control of medicines at Pharmacy, medicines and Poisons Board. Implementation arrangements The MoH in particular the Pharmaceutical Division will coordinate and provide guidance on procurement and distribution of medicines within the health system. The Central Medical Stores will be responsible for procurement and distribution of medicines at all levels including ensuring rational use. The DHO shall be responsible for the purchase of drugs from the CMS. The Pharmacy Board will be responsible for monitoring the quality of medicines and health supplies. 5.2.2.3 Essential Equipment To ensure availability of high quality and functional medical and laboratory

equipment at all levels of health care delivery. To standardise equipment for each level of health care delivery i.e branding of equipment To build capacity of medical equipment and infrastructure maintenance services To review PAM policy and disseminate revised policy Strengthen capacity of maintenance services. Upgrading of Engineers, Physicists and Technicians Improve spare parts procurement and management systems Carry out quality assured regular and comprehensive planned preventive maintenance and corrective maintenance Construction and equipping of standard workshops for district and central hospital Strengthen physical assets management information systems. Train maintenance staff on Planning and Management of Assets in the Health Sector(PLAMAHS) software Train other stakeholders on PLAMAHS software Strengthen the organisation and management of equipment o Review responsibility for technical and administrative management of infrastructure and equipment (during functional review)

5.2.2.4 Diagnostics and support for patient management

Build the HR capacity for the laboratory sector o Update and standardize laboratory biomedical pre-service training curricula and incorporate new content areas such as statistics, biomedical surveillance, research, supply-chain management and molecular biology o Strengthen capacity of lab training institutions to include expansion and renovation of classrooms and training laboratories to graduate at least 150 lab personnel per annum. o Increase the number of laboratory assistants at health centers through continued support to laboratory assistants training program o Establish a structured career ladder, incentives and in-service training in order to improve retention of lab staff. o Create an adequate number of posts for lab personnel at all levels. Improve Blood transfusion Safety o Provide budgetary support for MBTS for blood safety activities (recruitment and retention of blood voluntary non-remunerated blood donors, blood testing, blood cold chain; quality assurance and appropriate use of blood and blood products). o Publish and disseminate the Blood Policy and the Guidelines on Recommended Practice of Blood Transfusion in Malawi o Devise and implement strategies which increase the proportion of

n order to ensure availability of diagnostics services for EHP services delivery the focus of the Plan will be building capacity in diagnostics; training staff, improving staffing levels, having adequate and standardized equipment and mobilizing resources for the sector. 5.2.2.4.1 Laboratories Objective o To provide high quality laboratory services to support the effective delivery of EHP services at all levels of health care. Strategies and key interventions Strengthen the organization management of laboratory services and

o Introduce the accreditation and licensure of laboratories in accordance with international standards. o Review responsibility for administrative and technical management of the medical diagnostics and public health laboratory services (functional review) o Train laboratory managers/supervisors at the zonal level in management. o Promote collaboration between private medical laboratories and MoH.

voluntary non-remunerated blood donation. o Improve quality assurance programs and blood safety training to ensure quality blood transfusion services o Build capacity for blood safety and quality transfusion services. Strengthen supply chain management
1.

o Strengthen capacity of Public Health Reference Laboratory at CHSU to include renovations, equipment, personnel and training in order to be the focal point for all QA activities
2 . Finalize,

disseminate and train laboratory personnel on SOPs, QA & Safety guidelines, and Good Clinical Lab Practice (GCLP).

o Disseminate guidelines on standardization of equipment to stakeholders and CMS in order to incorporate recommendations and strengthen the procurement process. o Develop a laboratory information system, and revise the current logistics management to ensure the integration health and laboratory commodities. o Design System Laboratory Logistics

Improve service delivery o Rapidly scale up laboratory services at each level of health care system for screening, diagnosis, confirmation, and monitoring patients on treatments. o Strengthen capacity and functions of national public health laboratory. o Strengthen national sample transportation/referral and result reporting system. o Standardize test menus across tiers of laboratories. o Improve the physical laboratory infrastructure through building and refurbishment according to agreed national standards. o Improve availability of appropriate rapid diagnostic tests, especially at peripheral levels.

o Update the laboratory pre-service training curriculum on laboratory logistics and supply chain management and conduct TOT on logistics management for tutors. o Designate a laboratory officer to assist with management of lab commodities at CMS. Improve quality management systems o Implement National Laboratory QA Framework including the identification of a National QA officer, a system for national certification of medical laboratories.

Strengthen the Laboratory Information Management System, Research and Surveillance o Develop a system for effective collection and analysis of lab data.

o Monitor laboratory performance and implementation of strategic plan. o Strengthen capacity and functions of national public health laboratory. o Strengthen laboratory capacity to contribute to research. o Strengthen and sustain lab services to ensure evidence based disease surveillance and response. 5.2.2.4.2 Radiology Objective o To ensure availability of high quality medical imaging services to support EHP services at all levels of health care. Strategies and interventions Build capacity for medical imaging personnel to ensure adequate provision of routine and specialized services o Expand training to increase the number of medical imaging personnel. o Introduce degree course in medical imaging in Malawi Create adequate space which conforms to international standards and enables medical imaging personnel maneuver equipment and provide requisite quality services. o Construct and/or refurbish medical imaging infrastructure according to set standards.

Improve capacity to medical imaging services o Maintain medical imaging equipment. o Purchase medical imaging equipment. o Explore technological advances in medical imaging and their adaptation to Malawis situation. Institute and continuously monitor radiological standard operating guidelines, to ensure adequate and proper use of medical imaging equipment o Develop a mechanism for monitoring medical imaging equipment. o Institute radiation protection and proper disposal of radiological waste materials to protect staff, patients, the public and environment. o Initiate and maintain a functional system for effective radiation protection. o Provide and maintain appropriate infrastructure for disposal of radiological waste materials.

5.2.2.5 Hospital Reform

ver the period of the HSSP a number of hospital reforms have been suggested as detailed below in order to ensure that CHs are run efficiently and effectively. The reforms that have been suggested will also help to ensure that CHs provide tertiary level services as defined in Annex 9 in an efficient and equitable

manner. While some of the interventions are directed at lower level facilities (hospitals, community hospitals and health centres), ultimately they aim at ensuring that CHs deliver services efficiently. For example in urban area, urban health centres will be strengthened in order to decongest central hospitals. Objective:

o To ensure that Central hospitals provide equitable access to tertiary quality health care to all Malawians. Strategies and key interventions Strengthen quality of care for the referral level patients of Malawi

o Establish gateway clinics at CHs to be managed by DHO. o Capacitate urban health centres to provide comprehensive ambulatory care. o Advocate for creation of district hospital in urban settings. o Capacitate CHs to provide quality tertiary care. o Develop clinical guidelines, protocols, and procedure manuals. o Compile inventory of hospital equipment by area and status and improve infrastructure and equipment maintenance. o Provide effective emergency ambulance system. o Develop and implement service level agreements and performance management systems. Improve use of public resources in an efficient, effective, accountable and transparent way o Improve Central Hospital Information Systems including development of key performance indicators. o Orient cost centre managers on accountability and responsibility.

o Computerize accounting and financial systems. o Standardize medical equipment. o Improve personnel management systems. o Improve security, storage and dispensing environment for EMS. o Design and develop a computerized pharmaceutical management system. o Promote increased autonomy of CHs. Mobilise additional resources for tertiary level facilities o Develop a new revenue management system for tertiary facilities. o Revise patient fees based on recosting of services and ability to pay o Establish guidelines for collection and for use of user fees and submit for approval by Treasury o Refurbish private wards. o Develop and implement an incentive system to improve revenue generation o Inform public and hospital users about private wards

o Initiate dialogue with private health insurance companies. o Sign agreements with private health insurance companies. Create an enabling environment for improving Quality of Care and Management in Central Hospitals o Use lessons learnt from the field to be used for evidence based decision making with regard to hospital reform o Conduct operational research to improve service delivery o Develop networking with partner institutions within and outside Malawi to learn from each other. o Develop a hospital reform policy. o Advocate for implementation / communicate on need for hospital

o o

reform with decision makers, the public, staff etc. Improve capital investment planning (offices, accommodation for staff etc) for central hospitals. Advocate for sufficient funding and adequate HR for CH Improve relationships between CHs, Training Institutions and Research Centers. Develop and implement clinical and nursing care standards.

Implementation arrangements

T
Objectives
o

Development, the Department of Human Resource and other relevant departments will work with the DHOs in order to strengthen the urban health centres so that CHs are not congested. In addition to this, gateway clinics will be established at the CHs which will be run by the DHOs. 5.2.2.6 Quality assurance

he Directors of the CHs will be responsible for implementing the hospital reform agenda in conjunction with the Department of Planning and Policy Development, Directorate of Clinical Services and Department of Nursing. The Department of Planning and Policy interventions have been designed in order to improve quality in delivery of EHP services.

uality assurance is cross cutting issues and it applies to all the components of the HSSP. Factors that hinder quality improvement in the health sector in Malawi include poor facilities, lack of equipment, lack of qualified human resources, and weak management. The health sector has already started addressing these issues and during the implementation of this plan strategies and key

To develop and implement a comprehensive approach to Quality Improvement at all levels facilitating effective service delivery.

Strategies and key interventions Improve the implementing interventions. policy environment for quality assurance

o Review the Assurance Policy.

National

Quality

o Development a 5 year comprehensive strategic plan for quality assurance. Improve quality accreditation in standards and

o Institutionalize the concept of service charter in all facilities, units and departments Improve Client and Provider Satisfaction o Conduct systematically client satisfaction surveys focusing on (the clients perception of): waiting time and staff attitude, availability of drugs and consumables, appropriateness of user fees, and quality of care in general); o Ensure follow up on quality deficiencies identified through surveys; o Train staff on client/provider interpersonal relationships, professional ethics o Provide appropriate working conditions ((staff facilities, accommodation, uniforms, incentive packages) for Health Workers in remote areas among others). o Establish and support health centre committees o Set up a customer complaints desk to answer and address concerns. o Carry out periodic external reviews. Implementation arrangements

o Develop/revise and systematically introduce clinical guidelines/pathways for the EHP conditions. o Define minimum norms for infrastructure, staffing, drugs and consumables, equipment, budgets o Establish a continuous Monitoring & Evaluation and reporting system on service quality indicators (processes, outputs and outcomes). o Develop and implement a licensing/accreditation system for health facilities. Improve performance management o Strengthen (internal) performance M&E at all levels through standardized / harmonized tools o Support efficient resource management (through M&E and reporting) o Establish QI Teams at all health facilities and zones. o Conduct training on Service Performance M&E and specific audits / research e.g. on maternal mortality. o Introduce staff appraisal and incentive system (Performance Related Pay) o Introduce Output Based Financing for public and private providers through SLAs.

he health sector has a Quality Assurance TWG which will continue coordinating and providing guidance on quality assurance issues within the health sector. In the interim the Department of Planning and Policy Development, the Department of Clinical Services, the Department of Nursing Services and Health Technical Support Services) will take the lead in the development of policies, standards and

guidelines on quality assurance and ensuring that all stakeholders at different levels adhere to set guidelines and standards. Each department at headquarters and service delivery points will have a focal person for QA. The ultimate aim will be to create a Secretariat within the MoH Headquarters and attached to the PS that will coordinate quality assurance within the health sector. The ZSHO will provide technical support to districts to ensure that quality standards are adhered while DHOs will ensure that this is done at district and lower levels. CHAM and professional associations namely the Medical, Nursing and Midwifery and the Pharmacy councils will be involved in implementing quality assurance interventions at various levels including accreditation system for all facilities. 5.2.2.7 Financial Management

Challenges therefore remain and Section 2.7.7 has highlighted some of them. MoH recognizes the value of oversight and audit, and welcomes both. However, capacity of the Finance Section is continually challenged by the poor alignment of HDPs with financial systems and the associated ad hoc collection of oversight arrangement and audits which are unharmonised, time wasting and often duplicative. A major effort over the next five years will be to minimize the oversight burden without compromising the quest for continuous system strengthening. In its reform process MoH will seek to observe the first PFM reform principle as set out in the recent Public Expenditure and Financial Accountability (PEFA) report: that it is better to devote time, effort and resources to getting existing systems, processes and practices working better, since often there is a sound system in place but for various reasons, it is not working properly. The MoH will continue improving financial management by adhering to financial management rules and regulations of the GoM and at the same time ensuring transparency and accountability. During the course of HSSP the Financial Management Improvement Plan (FMIP) will be regularly revised and monitored through the Technical Working Group. A revised FMIP is expected at the beginning of the 2011/12 Financial Year. The FMIP will detail interventions in financial management and indicate the responsible officers or units. It will provide indicators to support the monitoring process. The following interventions, to be implemented over the

ignificant progress has been made in financial management, over the period of POW 1. This is evidenced by the fact that the health sector has embraced the advent of external audit by local firms of Chartered Accountants, and has met the challenge. Audit reports for all years have been issued without any qualification, that is to say auditors have certified that the financial statements have fairly recorded the income and expenditures of the health sector without any qualifying remarks. That said, in the normal way of audits, health sector auditors have continually noted areas in which improvements can be made and financial management strengthening strategies indicated in this document focus upon those areas.

next 5 years, will help to address the challenges MoH is experiencing. Objective o To design and implement transparent and user-focused financial management systems to serve the needs of all SWAp stakeholders. . Improve budget execution: o Review of causes of under execution (poor availability of funds; delays in procurement; over ambitious plans; etc.) and take appropriate action. Strengthen the capacity of staff: o Create a position of Director and Deputy Director for the Finance Section and improve staffing, especially at supervisory levels. o In collaboration with AGD, developing and maintaining taskfocussed Financial Management Manuals for HQ, Districts and other CCs, which are consistent with the GoM financial management framework, legislation and regulations o In collaboration with AGD, developing a five-pronged training strategy which:

o Emphasises task-focussed training for financial and nonfinancial staff both in-house and at STI, guided by an annual training plan o Supports training through doing under a systematic process of supervision o Supports staff to acquire practical further education e.g. polytechnic certificates or diplomas, or in exceptional cases, Masters Degrees o Monitors the transfer of skills from TAs o Supports staff to gain professional qualifications such as AAT or ACCA and retain such staff within MoH. o Includes refresher training courses on practical issues affecting accounting and financial reporting

o Monitoring the effectiveness of different training approaches and prioritising those which produce best results o Ensuring that staff are properly equipped with IT hardware and software, including anti-virus software regularly updated, reliable internet in all locations, and a continuous power supply Strengthen financial reporting

o Continuing to improve the format of the FMR so that it is increasingly informative and user friendly; ensuring that it can be produced in its entirety within MoH (without consultant input) o Adopting all IFMIS improvements as soon as they are available and maximising their use, including the new Chart of Accounts with multi part code (which is to be revisited) o Exploring ways to generate useful management information from IFMIS including activity costing related to the EHP; and financial data to be used in analysis of key expense areas such as transport costs and allowances. o Introducing effective output accounting to assess the impact of the POW o Disseminating financial information more widely to users including through the MoH Intranet (to be established) o Supporting AGD to develop a set of standard reports in IFMIS suitable for sector management o Engaging fully with the IPSAS pilot to secure early benefits for MoH. Improve the flow of funds at all levels o Monitoring the flow of funds in a systematic manner, especially to rural health centres, community hospitals and CHAM.

o With MoF and NLGFC, exploring the possibility of transferring funds directly to rural health service delivery points at sub-district level, to ensure adequate within- district availability of funds. o Engaging with MoF and NLGFC to secure a smoother flow of funds throughout the year in accordance with cash flows submitted. Strengthen grant management and DP liaison o Creating a financial management environment that encourages DPs to pool funds o Minimizing separate/parallel financial reporting and audits, through a series of measures including: o Development of an audit protocol and guidelines for carrying out audits in the health sector o Continued sensitisation of Development Partners to the burden created in the health sector by uncoordinated, duplicative and unplanned audits o Ensuring that the provisions of the MOU set out a sufficient but appropriate audit regime o Including indicators for audit rationalisation in the FMIP o

o Communicating regularly with DPs through regular FMP TWG meetings (minimum every other month). Strengthen financial management districts and central hospitals in

o Liaison with NLGFC and DCs to ensure a coordinated approach in the districts. o Institutionalizing the coaching program and in the short term arranging for key MoH staff take part in Coaching visits, so that such staff can carry on coaching visits. o Identifying HQ staff to work as district/central hospital support. o Ensuring continued use of the FM Guidelines and related Training Programs.

adhered to. There will be periodic external audits in the MoH by independent auditors. The District Commissioner shall account for district expenditures at the district level while the Secretary for Health will be responsible for expenditures at national level (including the ZHSOs) and central hospitals. The HSSP audits shall fully be endorsed by the NAO. Expenditure tracking: this HSSP acknowledges the critical importance of tracking disbursed funds and distributed resources (medicines and medical supplies) to ensure that they reach service providers at district and sub-district HF levels in a timely and predictable fashion, and support specific programs at district level. With this in mind, the forthcoming FMIP will include proposals for institutionalized internal tracking of funding based upon regular reporting and periodic visits. Proposals for the tracking medicines and medical supplies appear in section 5.5.2 of this HSSP. Additionally, tracking of funds and resources will be specifically addressed in the forthcoming study of Results Based Financing. 5.2.2.8 Oversight and fiduciary Risk

Implementation arrangements

he health sector will follow the financial management systems and financial reporting procedures of the GoM as detailed in the laws of Malawi. Where necessary financial management procedures will also follow guidelines provided by HDPs. In order to effectively implement the rules and regulations guiding financial management and reporting the MoH shall train or orient health workers and finance staff in financial management and reporting. The Internal Audit Departments in the MoH shall provide objective audit services to the MoH and mechanisms will be put in place in order to ensure that these are

he health sector will continue its efforts to mitigate fiduciary risks and to strengthen financial management, and fiduciary oversight at all Cost Centres. The primary controls in this will come from close adherence to procedures in financial management as well as procurement; and from stronger supervision in both units to ensure compliance with laid down procedures for the proper management of budgets, the scrutiny of transactions, and timely financial reporting. Ministry of

Health, working together with officers of National Local Government Finance Committee, will devise routines for internal scrutiny and reporting at Cost Centres, and a schedule of regular monitoring visits to document shortcomings and improvements. These procedures, together with measures to raise the skill levels and understanding of finance staff, will be specified in the forthcoming FMIP and its successor plans. These efforts will be supported by coordinated, risk-based examinations of activity from both Internal and External Audit, and the strategies for strengthening these functions are outlined below. 5.2.2.9 Internal Audit

o Provision of urgent training in Excel and IFMIS, as well as the development of internal taskfocussed training. o Engaging with MoLGRD, IA, NLGFC, DHRMD and DCs to ensure and agree an effective Internal Audit approach for health that recognizes the new dispensation under devolution, and includes full collaboration with District-based IA. o Regular reviews of vehicle needs for HQIA. o Closer monitoring of the development and implementation of IA plans on a quarterly basis through a revived Audit Committee. Review of plans to ensure that they are justified on a sound analysis of risk. o Activities of Internal Audit to be extended further in non-financial areas such as supply chain management, transport management and plan implementation. 5.2.2.10 Procurement

nternal Audit is a central part of the fiduciary oversight process. The health sector is audited by Central Internal Audit (MoF), Ministry of Health Internal Audit; and District Internal Audit (for DHOs). The proposals indicated below are intended to strengthen MoH Internal Audit and to ensure that its efforts are better coordinated with District Internal Audit: Strategies to Strengthen Internal Audit in MoH o Ensuring a full complement of Internal Audit staff, including 50% graduates by 2016. o Provision of computers with full virus protection and MS Office for all professional staff. o Exploration of the usefulness of dedicated audit Programs, and if acquired, provision of training

he procurement capacity in the MoH is quite limited as has been highlighted earlier. This is exacerbated by the commissioning of multiple audits by different partners. The proposed interventions are aimed at ensuring that there is capacity within the MoH for procurement and also ensuring that the recommendations made in the 2009/2010 external procurement audit are

implemented. There will also be a need to practice the current single source procurement on reputable and durable equipment to simplify process. Improve the internal procurement standard operating processes (SOPs) and procedures for health sector procurement o Review and adapt the guidelines to suit the current ODPP guidelines for Health Sector guidelines o Dissemination of reviewed guidelines to cost centres o Review and redesign policies of emergency procurement of EMS by CMS, Central and District hospitals o Streamline the procedures for the procurement and reporting for different SWAp pool partners. o Advocate for a single procurement audit report that will address the needs of all donors. o Revisit and revise VFM bidding and evaluation criteria Enhance professional procurement capacity of MoH headquarters (including CMS) central and district levels will have been enhanced o Lobby and recommend for Department procurement officers. o Develop a plan of work to implement recommendations made by the 2009/2010 external procurement audit. o Finalise the work plan for capacity building for the Procurement Unit. o Strengthen capacity of procurement unit through provision of technical assistance.

Implementation arrangements

rocurement in the health sector will be governed by the Public Procurement Act and the subsequent Public Procurement Regulations (2004) which operationalise the Act. Where necessary the sector shall also ensure that procurement guidelines provided by donors are adhered to. The health sector shall ensure that procurement of goods and services are done in a transparent and accountable manner. A procurement plan will be developed on a yearly basis approved by senior management and parliament as part of the budget during the budget process. This will be endorsed by the Health Sector Working Group and progress reviewed by senior management and the Budget and Review Committee (which takes place on a 6 month basis) and reported on during the mid year and annual reviews. 5.2.2.11 Monitoring, Evaluation, Surveillance

O
Objective

ver the period of the HSSP the MoH and stakeholders will ensure that monitoring, evaluation and epidemiology including surveillance is strengthened, including making the HMIS functional.

o To provide reliable, complete, accessible, timely and consistent health and related information and ensure that it is used for evidencebased decision making at all levels of the health system.

Strategies and key interventions Strengthen the HIS policy and legislative environment o Review, print and disseminate the Malawi HIS policy. o Develop and disseminate the ICT policy for the health sector. o Implement a comprehensive M and E strategic plan for the health sector. Build the capacity of the health sector to effectively generate, manage, disseminate and utilise health information at all levels of the sector for programme management and development o Undertake a functional review of CMED. o Fill the vacancies (including HIS personnel) at CMED, district and health facility levels to ensure availability of adequate staff. o Set up a National Public Health Institute (NPHI) at CHSU with leadership for epidemiology and surveillance in Malawis health sector as one of its core functions. o Strengthen Malawis approach to vital registration and mortality surveillance. o Provide the necessary tools (computers and software, data collection forms etc) for data collection, analysis and reporting. o Train health workers at all levels in computer skills, data collection, entry, analysis and report writing. o Conduct in-service training for health workers on monitoring and evaluation.

o Work with training institutions to introduce HMIS into training curricula for health workers. o Mobilise adequate resources for M and E activities. o Conduct routine validation of data and audits. o Promote utilisation of data for evidence based decision making at points where data is generated. o Develop and provide guidelines for data utilisation. Strengthen the monitoring and evaluation along with epidemiology and surveillance systems for Malawis health sector. o Support population based surveys such as the DHS and ensure they are conducted timely to ensure availability of appropriate data for planning and management. o Strengthen epidemiology and surveillance programs including Integrated Disease Surveillance and Response (IDSR) within CHSU or within a newly established National Public Health Institute (NPHI) at CHSU. o Develop HMIS sub-systems. o Develop a hub for health information system data in MoH/CMED o Supply MASEDA (http://www.maseda.mw/) with timely and accurate health, population and demography data o Develop and maintain a national health observatory o Conduct and improve of quality of annual health sector reviews o Establish electronic connectivity to and from health facilities.

o Extend the HMIS to the private sector and ensure that HMIS reporting is one of the conditions of compliance. o Establish and operationalise the linkage between the community based health information system and the HMIS. o Promote the collection of vital information by the HSAs. o Develop and implement an incentive mechanism for achievers to be recognised. Implementation arrangements

D
Objectives

uring the HSSP research will be an important component as it will generate evidence that will be used in the health sector in order to inform the development of policies and interventions. The MoH will play an important role in terms of developing and implementing the national health research agenda. Under the leadership of the NCST and with support from DFID and the Welcome Trust, the health sector will continue implementing the activities under the HCSI.

he Department of Planning and Policy Development will have the overall responsibility of coordinating monitoring and evaluation of the progress made in the implementation of the HSSP. Within the Department of Planning and Policy Development, the CMED will be responsible for production of quarterly, biennial and annual reports using data from HMIS. The Department of Planning will have the responsibility of producing the annual health sector performance report which shall be deliberated during the Annual Joint Review meeting held in October of each year. In addition to HMIS data, other data will be sourced from surveys conducted by stakeholders such as NSO and the University of Malawi. Appendix 13 shows the list of indicators that has been agreed upon by the stakeholders to monitor performance of the sector. 5.2.2.12 Research

o To coordinate and regulate health research in such a way that it generates information that will inform evidence-based decision making in policy and programme implementation. Strategies and key interventions Build capacity for high-quality health research at all levels o Train DHMTs and Programs in Health Systems and Public Health Research Methodologies. Strengthen governance and stewardship role of the Ministry over conduct of health research o Implement the National Health Research Agenda. o Develop and implement a National Health Research Policy. o Support the National Health Sciences Research Committee

(NHSRC) in the review and approval of research proposals. o Set up a National Public Health Institute (NPHI) at CHSU with leadership for public health research as one of its core functions. o Ensure that all health research institutions sign MOUs with the Ministry of Health. o Support the conduct of regular inspections and monitoring visits of all health research institutions Mobilize resources for the health research o Advocate with the MoH to allocate 2% of the national health budget on research in line with the recommendations of the Commission on Health Research for Development (COHRED) and as endorsed by Ministers of Health in Abuja (March, 2006), Accra (June,2006), Algiers(June,2008) and Bamako(November, 2008).

Promote the utilization of research findings for policy and programme formulation o Create a website for the Research Unit and NHSRC o Establish a health policy analysis unit which will produce policy briefs and newsletters for the MoH. o Develop leadership for the integration of public health research into policy formulation and program planning within a new Malawi NPHI. o Organize annual health research dissemination conferences for the health sector. o Promote evidence-based policy debates.
Coordinate the research activities being undertaken by various departments within the ministry

5.2.3 Objective 3 Reduce Risks to Health

ublic health carries out its mission through organized, multi- and inter-disciplinary efforts that address the multiple determinants of health (biological;

behavioral; environmental; socio-cultural; and living and working conditions among others) in communities and populations at risk for disease and injury. Its mission is achieved through the application of health promotion and disease prevention technologies and interventions designed to improve and enhance quality of life. Health promotion and disease prevention technologies encompass a broad array of functions and expertise, including the three core public health functions: (i) assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities; (ii) Formulating public policies, in collaboration with community and government leaders, designed to prioritize and solve identified local and national health problems; and (iii) Ensuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care. 5.2.3.1 Health promotion

addressing risk factors and mediating between different interests in society. Objective o To promote behavioural change for healthier life styles. Strategies and interventions Create supportive environments through influencing healthy public policies and other initiatives. o Advocate for the review, development and implementation of specific healthy public policies based on EHP priorities (including legal instruments and regulations that affect gender equity and health of marginalised populations). o Work with relevant multi-sectoral committees to promote health diets and physical exercise. o Advocate for systematic assessments of the health impact of rapidly changing environments including areas of technology, work, energy, production and urbanisation. o Advocate for proper strategies to ensure that the environment is contributing towards good health. o Develop and implement national standards and guidelines on the development of health promotion strategies and interventions for EHP priorities based on geographical targeting and segmentation of key populations to reach. o Develop national communications strategies that guide integrated approaches to addressing EHP priorities at all levels.

he majority of Malawis EHP conditions are preventable as they are, among other factors, caused by poor hygiene and sanitation and this is exacerbated by the high prevalence of poverty. Other diseases such as malaria, ARIs, diarrhoea, AIDS and vaccine preventable diseases can all be prevented as effective preventive measures exist. The strategies and key interventions identified will address barriers to uptake of health behaviors and encourage timely access to health services/products as well as addressing other determinates of health through advocacy, participation of communities and all stakeholders in

Promote community participation

action

and

o Support the implementation of community action interventions to address prioritised EHP health priorities using the health promotion in multi-sectoral settings at all levels23. o Strengthen and sustain health facility and community structures in health promotion. o Integrate resources from Programs for sustaining community based workers and volunteers. o Train community based workers in health promotion. o Advocate for special focus towards understanding and advising on the gender roles and issues that may require attention in the delivery of the health care services and impact on health. o Advocate for the development of bye-laws at district and community level that would empower communities to do certain actions on their own health and demand services that they believe are important. o Support community structures to plan, implement and monitor health. o Promote community participation in DIP development. Promote Personal skills o Promote healthy life styles based on the global and national evidence to prevent communicable and non23 These settings shall be empowered to set priorities,
2

communicable diseases24, advocate for personal strategies to enable people to learn throughout life, to prepare themselves for all the stages of life and to cope with chronic illnesses and injuries. Reorientation of health services o Ensure health promotion permeates through all health delivery entry points i.e. training of health workers, review of curricula, screening in health facilities and communities. o Strengthen community engagement within health care delivery to ensure that health services are responsive to community needs both in facility and community settings. . Enabling structures for health promotion delivery o Strengthen and position HEU to effectively manage the significant roles identified in the HSSP o Establish and sustain an intersectoral National Health Promotion Committee that will give guidance to the HEU. o Establish multi-sectoral structures for coordinating health promotion planning and implementation at all levels. o Advocate for inclusion of health in all policies of public, private and CSO sectors. o Strengthen capacity for health promotion among all cadres for
24 The healthy life style promotion shall be based on
2

make decision, plan strategies and implement them to achieve better health for themselves using the existing human and material resources.

harmful use of alcohol, drinking and driving, safe sex, physical exercise, tobacco health hazards, healthy diets and food security, road safety among others.

strategic planning, design, and monitoring and evaluation. o Identify research priorities that impact health promotion planning and effective delivery. Implementation arrangements Health Promotion will be implemented at a number of levels. Recognizing that health promotion is multi-sectoral, the Health Education Unit at MoH headquarters shall work with programs and other stakeholders to develop standards and guidelines and communication strategies and ensure their implementation by Programs, districts and partner implementing agencies including public, not for profit and profit organizations and private sector. This will include establishment of multi-sectoral coordination bodies at national, district and community levels to define key strategies based on situational analysis, formative research, and ensure interventions and relevant communications products developed are reviewed by the appropriate committees based on the development of guidelines for the implementation of healthy settings and monitored for impact. District health teams (especially Environmental Health and Health Education officers) will be responsible for ensuring that health promotion is an integral part of the district health and development plans based on priority areas and local epidemiology of diseases and particular target groups for lifestyle interventions. This will include advocating for healthy public policies (through development and enforcement of local bye-laws) at district and community level.

All health workers at district, health centre and community level will ensure that screening for priority diseases/conditions shall be implemented at service delivery levels as appropriate. At community level, HSAs, VHCs, DRFs, volunteers and other community based workers across sectors shall work through all settings and committees at village, health centre, households and individuals to promote healthy lifestyles and healthy environments. HSAs will be oriented to promote health promotion and they will be responsible for training VHC and ensure they are functional at all times. 5.2.3.2 Environmental health

E
Objective

nvironmental factors contribute significantly to the burden of disease. During HSSP implementation period attempts will be made to provide adequate resources, both human resource and financial, for the implementation of environmental health interventions specified below. In the HSSP special attention will be made to improve water and sanitation issues (including improving drinking water quality) and ensuring food safety and hygiene.

o To reduce morbidity and mortality related to environmental and related factors Strategies and key interventions: To reduce incidence of food borne diseases

o Conduct food inspection and food premise auditing. o Conduct routine medical examinations for food handlers. o Establish mechanisms for food testing. o Conduct investigation and reporting of food borne diseases and food poisoning incidents. o Train food premise owners in FSH standards. o Conduct monitoring of salt iodisation. o Conduct monitoring of compliance with the code on marketing of breast milk substitutes. To reduce the incidence of water and sanitation related diseases. o Conduct water chlorination at household level. o Conduct testing of water quality. o Detection and reporting of WASH related diseases. o Conduct promotional activities for water hygiene, sanitation and hand washing. o Advocate and work with other relevant stakeholders (e.g. Ministry of Water and Irrigation) to improve access to safe water and proper sanitation. Strengthen the response to disasters and emergencies o Monitor health status and proactively identify community health problems o Diagnose and investigate health problems and health hazards in the community

o Strengthen epidemiology and surveillance capacity at national level o Strengthen public health assessment and response capacity at district and zonal level o Develop guidelines for emergency assessment and response for both community district and national level. o Train (or retrain) existing committees on guidelines. o Establish national health coordinating committee for disaster assessment and response. o Strengthen cross-sectoral planning and coordination for emergency response To improve the management of health care wastes in health facilities o Conduct management of health care waste according to set standards. Promote sustainable vector control methods o Establishment of healthy settings. o Conduct larvaciding. o Advocate for clearing of mosquito breeding sites. To reduce trans-boundary transmission of diseases o Conduct health checks at all border posts. o Vaccinate unvaccinated immigrants. Implementation arrangements

he responsibility of environmental health issues does not lie with the Ministry of Health alone. There are many CSOs and other government Ministries and Departments that play an important role in addressing environmental health problems in Malawi. The MoH will spearhead the development of strategic alliances with the Ministry of Natural Resources and the Environment and other stakeholders to ensure implementation of interventions addressing environmental factors affecting health. The MoH will ensure that a multi-sectoral approach is used in addressing environmental health issues and that relevant line Ministries (such as Ministry of Water and Irrigation, Ministry of Labour, Ministry of Natural Resources), development partners and CSOs shall participate in implementing the proposed interventions.

At national level, the Directorate of Preventive Health Services in conjunction with stakeholders shall be responsible for coordinating environmental health interventions especially the development of policies, standards and guidelines; providing technical support to districts and lower levels; and building capacity of people involved in the implementation of environmental health interventions and diagnosing and investigating outbreaks through the epidemiology section and the Public Health laboratories. At district level, the DHO especially the District Environmental Health Office shall coordinate these interventions with other stakeholders. At community level, the HSAs and

VHCs shall be responsible for creating awareness about environmental health issues such as the need for households to have toilets, to properly dispose of their household among other issues.

5.2.4 Objective 4 Improved equity and efficiency of the Health System

5.2.4.1 Health financing

he major health financing focus over the next 5 years will be increasing the total amount of health funds, improving efficiency, equity and effectiveness in resource allocation, introducing/strengthening of innovating

purchasing mechanisms; and strengthening national health financing capacities at in the health system at all levels. Objective o To increase overall financial resources and allocate them efficiently and equitably. Strategies and key interventions Increase overall financial resources in the Malawian health sector
o

o o

Develop and implement a health care financing policy and strategy for Malawi. Lobby with Ministry of Finance to increase actual budget allocation to the health sector as a share of total government expenditure in order to meet key international commitments in health care financing, especially the Abuja target of allocating at least 15% of the budget to health, Identify ways of broadening the tax base and non-tax revenues. Lobby with Ministry of Finance to introduce (sin) taxes on tobacco, alcohol and environmental pollutants to finance the health sector. Lobby with Ministry of Finance to introduce or replace some fuel levies with a health levy. Lobby appropriate parliamentary committees for increased domestic appropriation Annually conduct modelling of expected resource needs versus

o o

expected resource availability, the resource gap that needs to be filled, and the service priorities for available resources and the present the findings to the Ministry of Finance, donors and all other stakeholders. Lobby with donors to increase their budgetary support for the health sector. Undertake donor mapping exercise to establish the amount, activities and funding modalities by donors, donor commitments and produce a Technical Cooperation document for Round Table Resource Mobilization Conduct comprehensive studies on modalities of introducing social health insurance. Pilot and implement social health insurance. Institutionalise data collection and analysis in support of health financing policy.

Strengthen Public Private Partnership to health financing and management Investigate the potential and feasibility of using Public Private Partnership to mobilize additional revenues in particular for infrastructure development o Introduce/strengthen a Public Private Partnership Unit within the Department of Health Planning Policy and Development at MOH o Promote private sector investment in health systems such as corporate social responsibility initiatives, employer financed health care, increasing access to local
o

international capital for private investors in health. o Review service level agreements and ensure that they are performance based and ensure equitable access to quality health services. o Strengthen User fees collection systems in private wings of district and central hospitals and retain fees at the collecting district and central hospitals o Review current fee collection systems at district and central hospitals private wings o Review Guidelines for collection and utilization of user fees at district and central hospitals private wings o Renovate/refurbish private wings in district and central hospitals to attract more paying patients. o Introduce computer-based financial management system for billing and payment of user fees in all private wings at district and central hospitals o Train staff in fee collection, banking and utilization of proceeds from user fees in private wings of district and central hospitals. Improve efficiency and equity in financial resource allocation; and utilization Re-design the resource allocation formula which should incorporate internationally known proxy indicators of health needs and use it in resource allocation. o Pilot and implement performance based health financing.
o

Undertake detailed studies on unit costs of providing health services in different health services and make comparisons so as to identify efficient and inefficient health facilities Review and expand by-pass fees from lower level health facilitieshealth centres, rural hospitals etc. to higher level health facilities-district and central hospitals. Investigate the feasibility of direct funds transfer to health centres and rural hospitals and/or splitting the DHO budget into two-district hospital budget and peripheral health facilities including prevention and public health Programs Design a financing mechanism for paying for non-EHP services and referrals to private health facilities and abroad Lobby with donors to pool funds in a basket-move away from project funding approach-islands of excellence towards broader support for integrated budgetary process Lobby with donors to allocate their funds in line with the SWAP II priorities that reflect the sprit of 2005 Paris Declaration on Aid Effectiveness and 2008 Accra Agenda for Action

Strengthen national health financing capacities all levels Train staff at all levels in tools/frameworks used to generate health financing evidence such as National Health Accounts, District Health Accounts, Economic
o

EvaluationCost Effectiveness Analysis, Cost Utility Analysis, Cost Benefit Analysis, Burden of Disease, Essential Health Packages, health financing mechanisms, provider payment mechanisms etc. o Train health workers from both the public and private sectors to strengthen health financing structures, processes and management systems-strategic planning, sectoral investment plans, financial management, information management etc. for revenue collection, pooling, and strategic purchasing Implementation arrangements

significant proportion of Malawians is poor and cannot afford to pay for health services. The MoH shall

therefore continue providing the EHP services free of charge but will charge user fees in paying wings of central and district hospitals. Over the period of the HSSP patients will have to follow strict referral procedures and where this is not followed a bypass fee will be charged to patients. The GoM will continue to provide subsidies to CHAM and its institutions. SLAs with CHAM and other private providers will continue in order to ensure that poor people are able to access EHP services. While donors will still constitute a major source of financing the health sector over the period of the HSSP, GoM will also explore other alternative sustainable sources of financing. This is especially important because funding for the sector is already inadequate to effectively implement the EHP services.

5.2.4.2 Partnerships While acknowledging that the MoH is the major provider of health services, there are also other partners that are playing an important role in the provision of services, especially the private sector. Currently, the partnership with CHAM is quite strong while with the private for profit sector it is weak. In order to effectively implement the HSSP, there will be a need to create and strengthen partnerships with the private sector especially CHAM, the private for profit sector, CSOs and other government agencies. Currently, there are no structures and no policy and guidelines to provide a framework under which the private sector can work with the public sector. Over the next 5 years of the HSSP, the GoM will strengthen partnerships with all stakeholders in order to effectively provide the EHP services and achieve the objectives as set in this plan. Objective o To improve the participation of the private sector in the implementation of the HSSP with a specific focus on the delivery of EHP services. Strategies and interventions

Strengthen the policy environment for effective public private partnership o Develop and implement a National Policy on public private partnership. o Disseminate the national policy on PPP at all levels. Operationalise the partnership in health. public private

o Establish structures at national and district levels to coordinate PPP activities. o Conduct a partner mapping exercise in all the districts in order to determine districts and areas which are underserved. o Review and sign a new MoU with CHAM regarding delivery of EHP services. o Revisit SLAs signed with the private sector in order to get value for money. o Explore signing of SLAs with the private for profit sector. o Develop innovative mechanisms that would attract private for profit practitioners to under-served and difficult to reach areas. o Develop and train private for profit providers to provide HMIS data to CMED.

o Work with CSOs to strengthen community HMIS. o Advocate for CSOs involvement on issues of health rights and awareness raising on prevention of disease and disability. o Develop, implement and regulate standards for health promotion activities being implemented by CSOs. o Promote, through provision of incentives, the delivery of EHP services by the private sector. Strengthen partnerships with government ministries o Work with other GoM ministries and departments on health issues.

o Advocate for inclusion of health in all policies. Implementation arrangements The Department of Planning and Policy Development in the MoH shall be responsible for coordinating the creation and strengthening of partnerships with other Government agencies, the private sector and CSOs. It will also lead the process of developing policies on public private partnerships for EHP services delivery. .

6. GOVERNANCE OF THE HEALTH SECTOR

he implementation of the HSSP will be the responsibility of all the partners in the health sector. The SWAp MoU lays down the coordination mechanisms for the health sector. The GoM has put in place sector technical working groups in all Ministries in recognition that better coordination of aid and alignment to government systems enhances efficiency and effectiveness, reduces duplication and ultimately improves health outcomes. This Chapter discusses the governance structures for the health sector during the period of implementing the HSSP. Annexes 10 and 11 detail the governance structures for the health sector at both national and district levels.

6.1 Governance Structure at National Level

he MoH, composed of different departments, is a government agency that sets the agenda for health in Malawi in collaboration with stakeholders. It is responsible for the development, review and enforcement of health and related policies for the health sector; spearheading sector reforms; regulating the health sector including the private sector; developing and reviewing standards, norms and management protocols for service delivery and ensuring that these are communicated to lower level institutions; planning and mobilizing health resources for the health sector including allocation and management; advising other ministries,

departments and agencies on health related issues; providing technical support supervision; coordinating research; and monitoring and evaluation. The MoH established five zonal offices. The role of the Zonal Offices is to provide technical support to District Health Management Teams (DHMTs) in planning, delivery and monitoring of health service delivery at the district level and facilitation of central hospitals suppervision to districts. o Cabinet Committee: The health sector will work very closely with the Cabinet Committee on Health. This committee will be responsible for providing overall political and policy direction for the health sector in Malawi. It will ensure that the health sector develops and implements health and related interventions to achieve objectives as set out in the Malawi Growth and Development Strategy 20112016, the National Health Policy and the Health Sector Strategic Plan. o Parliamentary Committee on Health: The Parliamentary Committee on Health will interact closely with the Senior Management Committee and it will be responsible for lobbying for the health sector in Parliament. In order to effectively do this Members of Parliament will be oriented about the health sector. o Health Sector Working Group (HSWG): The HSWG is mandated by GoM as a Sector Working Group and is the overall

coordinating body for the sector. Its membership will comprise of MoH and other GoM ministries and Departments, training institutions, local government, regulatory bodies, CSOs, the private sector (including CHAM) and HDPs. Committee members will be responsible to their constituents and will be obliged to ensure that all members of their constituents are consulted and informed of any proceedings of the quarterly meetings. The HSWG will be responsible for endorsing the budget and the AIP, overseeing the implementation of the AIP and the HSSP and recommending policy directions that will be discussed by SMC if there are any policy bottlenecks in the implementation of the HSSP. o Senior Management Committee: This committee will comprise of all the Directors and Heads of Departments in the MoH and will be chaired by the Secretary for Health. It will be responsible for final approval of policies and plans. It will meet weekly and provide technical advice to the HSWG. o Technical Working Groups: There will be 10 TWGs in the health sector namely: Finance and Procurement, Hospital Reform, Human Resource (HR), Health Promotion, Public Private Partnerships (PPP), Health Infrastructure, EMS (EMS), QA; Laboratories, Essential Health Package (EHP) and Monitoring,

Evaluation and Research. Other TWGs will be established as need arises. These TWGs will be guided by guidelines produced by OPC. The TWGs will provide guidance to the SMC and will be responsible for following up of milestones agreed during the MYR and the JAR. o Zonal Health Support Offices: There will be five ZHSO namely North, Central West, Central East, South East and South. These offices will be technical extension offices of the central MoH and will provide supportive supervision to District Health Management Teams in the implementation of the AIP.

The implementation of the interventions within this Plan shall adhere to the SWAp approach which promotes effective partnerships and coordination in all health sector intervention including financing, planning and monitoring. The SWAp process will be coordinated through a Secretariat headed by a Director within the MoHs Department of Planning and Policy Development. The MoH as a line ministry dealing with health and related issues shall take the responsibility of coordinating the SWAp process with support from all stakeholders. The MoH shall put in place mechanisms that will ensure transparency in the way finances are managed as advocated in this plan.

6.2 Decentralisation for the health sector: governance at district level

he Cabinet approved the National Decentralization Policy in 1998 and, subsequently, the Local Government Act was endorsed and local governments were established. Guidelines were developed to further define the roles of District Assemblies in the decentralisation process. The health sector was one of the earliest to start the process of decentralisation. In 2004 health devolution guidelines were formulated taking into consideration prevailing legislation, the policy framework and available local capacities for implementation of the decentralisation process. The guidelines further identified the functions and activities to be devolved to district assemblies and the role of the

central MoH in monitoring and evaluating, how devolved functions are being executed in line with the Ministrys overall goals, overarching sectoral plans and policies. In 2005, the MoH developed Guidelines for the Management of Devolved Health Service Delivery which envisioned that the managerial autonomy of District Assemblies will help in achieving improved health outcomes. The key challenges with regard to decentralisation include weak coordination of decentralisation at national level and the MoLGRD does not really follow up on what is happening on the ground, underfunding of DIPs and that within the health sector staff movements tend to affect health services delivery at district level. The MoH is committed to the

GoMs process of decentralisation and will continue supporting efforts by District Assemblies to be wholly responsible for health services delivery at that level. While the Ministry of Local Government is represented in TWGs and attend the MYR and AJR25, there will still be a need over the period of the HSSP to strengthen this collaboration through joint planning of interventions as well as monitoring of the implementation of DIPs. There will also be a need to harmonise the planning documents for MoH and MoLGRD. 6.2.1 Health services planning at district level

his process is effectively done by all local stakeholders at district level namely DHO, CHAM, NGOs, communities, civil society groups and the private sectors within the decentralised environment. Under full devolution, the planning process is anticipated to be coordinated by the Health Services Directorate in conjunction with the Director of Planning and the Health and Environmental Committee of the District Council based on planning guidelines issued by Central MoH departments. In addition, Zonal Health Support Offices and the District Health Management Team (DHMT) provide technical support to the District Assemblies during planning taking into account review of the DIP implementation especially outstanding issues. While this is well elaborated in the planning guidelines there are a number of challenges with regard to planning at district level and these include the lack of capacity to
25 For example District Commissioners attend these
2

effectively plan for health services delivery and frequent changes in planning formats without accompanying capacity building interventions to make staff to understand the formats. The district plans are not widely shared with the MoH thereby raising doubt as to whether districts are planning and implementing activities in line with national health sector plans. During the HSSP there will be a need to strengthen the capacity of Zonal Offices through training, provision of an adequate budget and improving staffing levels so that they are able to provide technical support to the districts and report to MoH headquarters. A core team is therefore envisaged at the zonal level that will be provided with a proper supervision checklist to monitor all the services at district level. The DHMTs will also need to be properly oriented in planning frameworks in order to enhance efficient delivery of EHP services. The Ministry of Local Government and Rural Development shall be requested to share DIPs with the MoH. 6.2.2 Budgeting and resource allocation

meetings.

he rules and guidelines stipulate that planning must necessarily be undertaken within the boundaries of available resources. Financial ceilings are normally communicated to the various DHMTs to enable them to develop realistic plans. The cost of service delivery is supposed to be based on the cost and quantity of EHP interventions as detailed in the costing documents for the EHP and the proposed coverage of the district population. The core strategy for health service delivery and development is anchored in the health SWAp. However, at

district level, SWAp is reported to be managed outside district structures but with direct link between DHO and central MoH hence it is difficult to determine how activities and services under SWAp are done including how funds are utilized. Devolution of budgeting and resource allocation has resulted in more than half of the national health budget going directly to the districts. The funds are managed by district management teams under the responsibility of the local authorities, thus enabling local solutions to health problems to be developed and implemented, using funds more efficiently. While this is in the spirit of decentralisation, for example there is double reporting as District Assemblies have to report to the MoLGRD and MoH. It also seems that control and accountability for SWAp activities and resources remain under strict custody of the central line ministries. In order to address budgeting and resource allocation there is a need to build capacity at the district and zonal levels in budgeting and reporting. The building of capacity at the zonal level will be useful in terms of scrutinizing certain key areas in budgeting and resource allocation that constitute core functions of DHOs and are in the national plans. There will also be a need to harmonise reporting: while DHOs are answerable to District Assemblies, the MoLGRD should share program and financial reports with the MoH. 6.2.3 District Implementation Plans (DIP)

but they do not use the DIP as a guiding force for their internal budgeting purposes to manage most of the routine needs of the districts.Consequently, with the emergence of DIPs, activities have been increasingly pushed to the districts but unfortunately budgets have not changed to correspond with the volume of activities in the districts. In addition, a lot of activities are coming to the districts outside the DIPs which still draw from the DIP funding resulting in resources being distorted from addressing pertinent issues on the ground. These include emergencies such as: measles and H1N1 as well as national events days which force DHOs to divert funds to address these emergencies. This is all done within the context of DIPs being underfunded by Treasury. In order to address these problems there is a need for central level Ministries including health to let go of the devolved functions to district assemblies, emergency budget lines should be incorporated in the budget and that DHOs should only go into SLAs in geographical locations where MoH facilities are not available. 6.2.4 Monitoring and Evaluation of Devolved functions

IPs are formed on the basis of national priorities. However, the DHMTs find the DIP process mostly helpful to identify the longer term development goals

t is envisaged that the DHMT would be responsible for ensuring that data collected at the district, health centre and community levels are used at the point of collection for decision making, and that it is submitted in a timely manner and is of acceptable quality. The DHMT is required to analyze the data, compile it, use it for decision making and provide feedback to the lower levels and submit the required information to the Zones and National level. This process entailed that supervision, annual performance reviews,

annual joint review of HSSP, scheduled meetings, regular HMIS returns, and special surveys would form the basis for the M& E function in health delivery services at the districts. With regard to M & E there seems to be limited understanding and appreciation of M & E roles by the district staff cadres within health sector. While the system is in place to facilitate that M+E feeds into management for decision-making, quality of staff is not in tandem with requirements to fulfill this role. For example, even after review of DIPs, there is no accompanying action to inform subsequent planning. In most cases reviews are merely undertaken as fulfillment of activity plans more than as in input onto systematic planning process. There is also limited utilization of data at point of source to inform programming and the quality of data seems to be of low quality. In order to address these challenges there is a need for training health workers in data collection, analysis and reporting and the need for them to understand that they should use the data for programming. DHMTs should also be trained in operations research so that they are able to design relevant studies that will be used to design interventions. Adequate resources, both human and financial, should be provided to DCs. 6.2.5 Human Resources

Government Service Commission. The District Assemblies were envisaged to appoint, promote and discipline staff in accordance with the provisions of the above stated bodies plus Civil Service Commission regulations and the Malawi Public Service Regulations, as appropriate. However, up to now human resource is still the responsibility of the central MoH. There is limited capacity at the District Council level to handle HR effectively. Currently there are unstructured staff grading and conflicting grades for example while DHOs report to the District Commissioners, some District Commissioners are below the level of DHOs, staff retention is low in hard to reach areas and that within the health sector medical graduates are given administrative responsibilities. The MoH should strengthen the zones so that they are able to manage HR responsibilities at district level and that structures and positions should devolve from central levels to district assemblies which must be harmonized to ensure minimal operational conflicts: for example DHOs should be below DCs in terms of ranks and salaries. 6.2.6 Structures for governance at district level

nder decentralisation, human resources (HR) management and development was anticipated to be guided by the appropriate circulars and policies of the Department of Human Resources Management and Development, the Health Service Commission (HSC) and the Local

here are different structures that will be responsible for implementing the HSSP. Currently, these structures function variably and strategies will be put in place to ensure that these structures are functional. There will also be a need to establish TWGs (but fewer than at national level) at district level o District Executive Committee: The DEC, in line with decentralization, is

responsible for development of overall policy, including for the health sector, for the district, prioritization of interventions that will be implemented and the approval of all expenditures. It is chaired by the District Commissioner and the DHO is a member of this committee. There is a Health Sub-Committee of the DEC which interacts with the DEC members and provides health needs for the district. Other structures at district level include the Area Development Committee (ADC) and the Village Development Committees (VDC) which are responsible for identifying development issues, including in the health sector, at area and village levels, respectively and take them to the DEC. The membership of ADCs and VDCs comprises of community members. o Health Centre Management Committee: Each health centre has a HCMC whose responsibility is to oversee planning and implementation of health services in line with the HSSP. o Health Centre Advisory Committee: At each health centre there is also a Health Centre Advisory Committee and its composition includes the health workers from the health centre and members of the community. o Village Health Committees: These committees are established and supervised by HSAs at village level. VHCs promote PHC activities through community participation and they work with HSAs to promote preventive

and promotive health services such as hygiene and sanitation. At village level, village action plans are developed and these feed into the district development plan of which health is included. The MoH works with the MoLGRD to strengthen the process of inclusion of the public in planning and monitoring of health services at all levels though the VHCs and VDCs. Tools such as the village health register will be reviewed to ensure inclusion of relevant health information including profiles of all areas affecting health. The process of feeding back to communities will be strengthened during the HSSP period ensuring that public rights and responsibilities are clearly disseminated through the patients charter and other appropriate channels. 6.3 Roles of different partners

s has been mentioned earlier, the MoH headquarters is now more involved in development of policies and standards and monitoring of the implementation of the progress being made in the implementation of the plan. The Ministry of Local Government and Rural Development has the overall responsibility of delivering health services at district and lower levels in line with the Decentralization Act (1997). Over the period of implementing the HSSP, MoH will strengthen its relationships with other GoM ministries and departments, the private sector and HDPs with the aim of effectively delivering quality EHP services. The roles and responsibilities of other stakeholders in the delivery of EHP services will be as follows: .

o Ministry of Finance: The Ministry of Finance is responsible for mobilization of financial resources for the GoM and allocating these resources to Government Ministries and Departments in accordance with priorities. The MoH, together with other stakeholders in the sector, will lobby for increased allocation of financial resources to the sector for effective delivery of EHP services. The MoF chairs the Finance TWG within the health sector. o Ministry of Economic Planning and Development: This Ministry coordinates the development and implementation of the Malawi Growth and Development Strategy, an overall development agenda for Malawi. The Ministry of Health will work with the MoEPD in monitoring the health sectors contribution to the national development agenda. The implementation of the HSSP contributes to the achievement of the overall goal of the Malawi Growth and Development Strategy.

o Ministry of Local Government and Rural Development: The MoLGRD is responsible for the delivery of health services at district and community levels and mobilization of additional resources for delivery of EHP services at that level. Community members shall participate actively in the management and delivery of health services through HCACs, ADCs, VDCs and VHCs. The MoH provides technical support to the MoLGRD through the ZHSOs. The MoLGRD is also a member of the Finance and PPP TWGs of the MoH. o Local Government Finance Committee: It examines submissions from local authorities in respect to expenditure and requests for special disbursements. It has the power to supervise and audit accounts of local authorities. o Ministry of Education: The health training institutions belong to the Ministry of Education and this Ministry will therefore be responsible for the training of all health workers in Malawi. It will work collaboratively with the MoH in terms of developing training curricula so that the health workers being trained meet the health needs of the people of Malawi. The Ministry of Education will work collaboratively with the MoH to effectively implement school health programs. o Ministry of Water and Irrigation: The Ministry is responsible for the provision of safe drinking water to the people of Malawi. The MoH will work with this Ministry (i) to increase access

to safe water for the people of Malawi in order to reduce water borne and related diseases; and (ii) to ensure that portable water is provided in all health facilities including staff houses. o Ministry of Agriculture and Food Security: The Ministry will be responsible for development and implementation of policies and plans to ensure that the people of Malawi have adequate and nutritious food. o Ministry of Labour and Vocational Training: The Ministry of Labour and Vocational Training is responsible for implementing the Occupational Safety and Health Act which is aimed at prevention of diseases and conditions arising from exposure to workplace health hazards. The MoH will work with this Ministry in order to ensure effective implementation of the Occupational Safety and Health Act and this is especially the case as the HSSP focuses on health promotion and disease prevention. o Ministry of Women, Children and Community Development: This Ministry will be responsible for gender awareness and mainstreaming including in the health sector. Knowledge about gender can contribute to prevention of SGBV which is a major component of this PoW. o Health Services Commission: It will be responsible for the recruitment of health workers and reviewing their conditions of service.

o The Private sector: Through signing SLAs with DHOs, the private sector will contribute to the delivery of effective and high quality EHP services to the people of Malawi especially for the poor and hard to reach population groups. o Department of HIV/AIDS and Nutrition: The Department of Nutrition, HIV and AIDS was established in August 2004 with the mandate to provide policy direction, guidance, oversight, coordination, monitoring and evaluation and facilitate the creation of implementation structures and capacity building on issues of nutrition, HIV and AIDS in Malawi. The MoH will work collaboratively with the Department in the areas of HIV/AIDS and nutrition. o National AIDS Commission: This is under the Office of the President and Cabinet and coordinates the national response to the HIV/AIDS epidemic. o Health development partners: In addition to funding priority interventions in the HSSP through budget support, the HDPs will also play an important role in monitoring the implementation of the Plan and actively participating in the health sector review meetings such as the Joint Annual Reviews. o Department of Human Resource Management and Development: This Department is responsible for human resource planning, management and development within the civil service

including the MoH and has been empowered by the Public Service Act of 1994 to be responsible for Public Service administration and management. It is a member of the HRH TWG in the health sector. o Department of Disaster Management Affairs: The Department of Disaster Management Affairs (DoDMA) is responsible for coordinating and directing disaster risk management programmes in the country in order to improve and safeguard the quality of life of Malawians, especially those vulnerable to and affected by disasters. As an overall coordinating agency it will work with the MoH whose role is to advocate for healthy public policies, timely emergency responses to address priority risks to health and ensuring access to health services; establishing trauma centre along the major roads and ensuring that there are functional emergency committees in collaboration with the DoDMA. o Ministry of Commerce and Industry: As has been the case, the Ministry of Commerce and Industry, in conjunction with Malawi Bureau of Standards, will be responsible for screening and monitoring of fortified foods in the country. o The Health Regulatory Mechanism: The health regulatory mechanism bodies, which include the Medical Council of Malawi, Nurses and Midwives Council of Malawi and the Pharmacy and Poisons Board, have a responsibility to register professional

health workers. These bodies were established through the Acts of Parliament. All practicing health workers are required to register with relevant Professional Councils. The regulatory bodies get some form of subventions from the MoH. The regulatory bodies will continue to be important for the health sector over the next 5 years of the HSSP as they play a major role in monitoring the quality of services, focussing on the health care workers, training institutions and health facilities. They also ensure that the health services are provided following the highest possible ethical standards. (a) he Medical Council of Malawi: The Medical Council of Malawi was established by the Medical Practitioners and Dentists Act No. 17 of 1987. The overall objective of the Council is to set and maintain standards of health care in relation to premises, equipment and supplies as well as the qualifications and credentials of personnel employed at health establishments including their behaviour and conduct towards patients and clients. The functions of the Medical Council include to assist in the promotion and improvement of the health of the population of Malawi; to control and exercise authority affecting the training of persons in, and the performance of the practices pursued in connection with the diagnosis, treatment or prevention of physical or mental defects,

illness or deficiencies in human beings; to exercise disciplinary control over the professional conduct of all persons registered under the Medical Practitioners and Dentists Act and practicing in Malawi; to promote liaison in the field of medical training both in Malawi and elsewhere, and to promote the standards of such training in Malawi; and to advise the Minister of Health and information acquired by the Council relating to matters of public health. In general, the Medical Council of Malawi is responsible for registration and maintenance of a database of registered medical and dental practitioners as well as licensing of medical and dental practitioners. Its responsibilities also include coordination and regulation of registration of clinical services in the country. (b) urses and Midwives Council of Malawi: The Nurses and Midwives Council of Malawi was established by The Act of Parliament Cap 36:2 (1995) to regulate training, education and practice of all nursing and midwifery services. The Nurses and Midwives Council has an important role in the development of human resource. The Council carries out the following functions to fulfill its role in HRD: gives approval of nursing/midwifery colleges to train nurses and midwives; sets standards for

nursing/midwifery education and practice; sets Monitoring and evaluation criteria of the training institutions and checks if the set standards are being followed to ensure compliance; sets and conducts licensure examinations for the nurses and midwives that have undergone training; gives certificates to those nurses/midwives who pass the licensure examinations; keeps the registers for all nurses/midwives that are licensed and practicing; and conducts monitoring and evaluation of health facilities to ensure that standards of care are adequately complied with. (c) he Pharmacy, Medicines and Poisons Board: The Pharmacy, Medicines and Poisons Act, 1978 and the Pharmacy, Medicines and Poisons (Fees and Forms) Regulations 1990 provides for the establishment of the Pharmacy, Medicines and Poisons Board by the MoH to regulate, register and control the quality of drugs in Malawi. The Board is also responsible for the registration, ethical control and training of pharmacy professionals; regulates the quality and distribution of drugs in the country; and inspects the inflow of these drugs to ensure they are of quality and valid.

6.4 Developing and implementing annual implementation plans

s part of implementing the HSSP, each year the MoH headquarters will develop annual implementation plans and set targets that will be reached by the end of the year which will be in line with the targets set in the HSSP. The basis for the development of AIPs and DIPs will be the HSSP. The ZHSOs, CHs and other central level institutions will also prepare their own annual work plans. At district level, annual district implementation plans will be prepared and these will include the plans by the DHMTs based on needs and priorities of the districts emanating from health facilities, ADCs and VDCs. The District Commissioners in the Ministry of Local Government and rural Development shall coordinate the development of District Implementation Plans. During the HSSP there will be a need to strengthen the capacity of Zonal Offices through training, provision of an adequate budget and improving staffing levels so that they are able to provide technical support to the districts and report to MoH headquarters. The DHMTs will also need to be properly

oriented in planning frameworks in order to enhance efficient delivery of EHP services. The Ministry of Local Government and Rural Development shall be requested to share DIPs with the MoH.The annual health sector plan shall consist of all the plans at different levels and this shall be ready by February each year in order to inform the budget for the following financial year which begins on 1st July. 6.5 managing finances at district level

n line with decentralization, the District Assemblies will be responsible for budgeting for their activities in line with the district implementation plans and these budgets will be submitted to the MoLGRD with copies to the MoH. The management of funds and other resources at the district level shall be managed by the District Commissioners. Auditing shall be the responsibility of the MoLGRD and financial reports prepared by the District Assemblies shall be sent to the Ministry of Local Government with copies to Ministry of Health.

7. DELIVERING THE EHP SERVICES

n Malawi health care services are delivered by both the public and the private sectors. The public sector includes all facilities under the

MoH, MoLGRD, the Ministry of Forestry, the Police, the Prisons and the Army. The private sector consists of private for profit and private not for profit providers (mainly CHAM). The public sector provides services free of charge while the private

sector charges user fees for its services. In accordance with the Decentralisation Act (1997) the MoLGRD is responsible for the delivery of health services at district and lower levels with technical guidance from the MoH. As has been mentioned earlier, the MoH headquarters is mainly responsible for development of policies, standards and protocols and providing technical support supervision. It also manages central hospitals. As was the case during the PoW 2004-2010, during the HSSP the health services will be delivered at different levels: namely: primary, secondary and tertiary. These different levels are linked to each other through an elaborate referral system that has been established within the health system. 7.1 Levels of care 7.1.1 Primary level

provide health services through outreach programs. VHCs promote PHC activities through community participation and they work with HSAs to promote preventive and promotive health services such as hygiene and sanitation. At primary level health centres support HSAs. Each health centre has a Health Centre Advisory Committee which ensures that communities receive the services that they expect in terms of quantity and quality through monitoring of performance of health centres in collaboration with VHCs. Health centres are responsible for providing both curative and preventive EHP services26. At a higher level there are also community hospitals (also known as rural hospitals). These facilities provide both primary and secondary care. They have admission facilities with a capacity of 200 to 250 beds. 7.1.2 Secondary level

his level consists of community initiatives, health posts, dispensaries, maternities, health centres and community and rural hospitals. At community level, health services are provided by community-based cadres such as HSAs, community-based distributing agents (CBDAs), VHCs and other volunteers from NGOs mostly. HSAs provide promotive and preventive health services including HIV testing and counseling (HTC) and provision of immunization services. Some HSAs have been trained and are involved in community case management of acute respiratory infections (ARIs), diarrhoea and pneumonia among under 5 children. Services at this level are conducted through door-to-door visitations, village clinics and mobile clinics. Community health nurses and other health cadres also

D
2

istrict hospitals constitute secondary level of health care and each district is supposed to have a District Hospital. They are referral facilities for both health centres and rural hospitals and have an admission capacity of 200 to 300 beds. They also service the local town population offering both in-patient and out-patient services. CHAM hospitals also provide secondary level health care. The provision and management of health services has since been devolved to Local governments following the Decentralization Act (1997). The district or CHAM hospitals provide general services, PHC services and technical
26MoH. (2004). Handbook and guide for health
providers on the Essential Health package in Malawi. Lilongwe: MoH.

supervision to lower units. District hospitals also provide in service training for health personnel and other support to community-based health programs in the provision of EHP. Health services are managed by the DHMT. The DHMT receives direct technical support and supervision from Zonal Health Support Services (ZHSOs). 7.1.3 Tertiary level

facilities and only visit central hospitals if referred. 7.2 The role of the private sector

he tertiary level comprises of central hospitals: these provide specialist referral health services for their respective regions. Specialist hospitals offer very specific services such as obstetrics and gynaecology. There are currently 4 central hospitals namely: Queen Elizabeth in Blantyre, Kamuzu in Lilongwe, Mzuzu in Mzimba and Zomba in Zomba with admission capacities of 1250, 1200, 300 and 450 beds, respectively. Queen Elizabeth and Kamuzu Central Hospitals are also teaching hospitals because of their proximity to College of Medicine and Kamuzu College of Nursing. Currently, CHs, however, also provide EHP services which should essentially be delivered by district health services. The plan, as has been mentioned earlier, is that over the HSSP period. The CHs are also responsible for professional training, conducting research and providing support to districts. Tertiary care is also provided by Zomba Mental Hospital. The Plan makes a recommendation that gateway clinics will be established at all central hospitals in order to decongest central hospitals. These clinics will be run by the DHOs. Urban clinics will be strengthened so that patients can first go to these

he private sector plays an important role in the delivery of health services. At community level, numerous NGOs, FBOs and CBOs deliver promotive health services but the majority of the providers and the services they offer are unknown to MoH and stakeholders. The MoH and stakeholders in the health sector have mainly involved TBAs which were introduced to expand maternal and child health (MCH) services to the community. The relationship between the MoH and traditional healers has, however, been weak. The Malawi Traditional Medicine Policy has since been put together and it guides the practice of traditional medicine in Malawi. The health sector will continue to work with traditional healers through the Malawi Traditional Healers Umbrella Organization (MTHUO). CHAM is a non-profit health services provider and is the biggest partner for the MoH. It provides services and trains health workers through its health training institutions (TIs). It owns 11 out of the 16 TIs in Malawi and most of these are located in rural areas. CHAM facilities charge user fees to cover operational costs and are mostly located in rural areas. The charging of user fees constitutes a major barrier to accessing services for most poor rural people; hence gross inequality to those living in catchment areas of CHAM facilities. This is especially the case as catchment areas of CHAM and GoM health facilities rarely overlap. The GoM heavily subsidizes CHAM by financing

some drugs and all local staffing costs in CHAM facilities. In order to increase access to EHP services, the MoH has encouraged DHOs to sign service level agreements (SLAs) with CHAM and BLM facilities to remove user fees for most vulnerable populations. To date the MoH has signed SLAs with 72 of the approximately 172 facilities mainly for the delivery of maternal and newborn health (MNH) services. A few facilities have SLAs for an entire EHP. SLAs involve the transfer of a fee from the DHO to a CHAM facility in exchange for the removal of user fees. Many CHAM SLAs are dormant and contractual conflicts are yet to be resolved. Discussions about the potential inclusion of other sections of the private sector especially for profit health care providers have not started yet27. Currently, SLA guidelines with the private sector exist for AIDS and Tuberculosis. 8. MONITORING IMPLEMENTATION HSSP THE THE

OF

I
2

n order to effectively monitor the performance of the health sector during the HSSP implementation period, the Health Systems Strengthening Framework for monitoring and evaluation will be utilized. This framework is based on the Principles of the Paris Declaration on Aid Effectiveness and the International Health partnerships (IHP+). The principles in these declarations include DPs alignment with government systems; harmonization; ownership and mutual accountability. The utilization of this framework ensures the
27MoH. (2010). Final evaluation of the Health Sector
Programme of Work I. Lilongwe: MoH.

existence of one platform for monitoring and evaluation that is relevant for Malawi and its global partners. Figure 8.1 below shows the HSS framework28:The HSS framework in Figure 8.1 is results based: the capacity of the health system is demonstrated by system inputs, processes and outputs while outcomes and impacts are the results of the health system investments and reflect health systems performance29. The HSS framework is designed in such a way that each block (inputs and processes, outputs, outcomes and impact) has a list of indicators which are supposed to be monitored during the implementation of the HSSP. The performance of the health sector will be measured using an agreed set of indicators which were selected based on the implementation framework of the Ouagadougou Declaration on PHC, the MDGs and the MGDS. Annex 12 shows a comprehensive list of indicators that will be used to monitor performance of the health system. The HSSP recognises the various problems in Malawis M and E system and a number of ways have been suggested earlier on how these

28See WHO, World Bank, GAVI and Global Fund.

2

(2009). Monitoring and evaluation of health systems strengthening: an operational framework. Geneva: WHO, World Bank, GAVI and Global Fund.

29See WHO, World Bank, GAVI and Global Fund.

2

(2009). Monitoring and evaluation of health systems strengthening: an operational framework. Geneva: WHO, World Bank, GAVI and Global Fund.

problems will be addressed to ensure availability of quality data for monitoring health sector performance.
Obj100

In

During the data collection process particular attention will be paid to the effect of gender on health and health seeking behaviour. This data will be used to develop appropriate policies and at the same time ensuring that resources are allocated appropriately to address gender imbalances in the provision of the EHP services. 8.1 Routine HMIS data

Development which shall form the basis for the Joint Annual Review meeting. The JAR shall attract participants from the MoH, other GoM ministries and departments, health training institutions, the private sector and the HDPs. 8.2 Demographic health surveys and other national surveys

he main source of data for monitoring progress in the implementation of the PoW will be the HMIS. The HMIS is an important source of data on outputs of the health sector, diagnosis of EHP conditions and diseases and other health systems information. This data is available on a monthly, quarterly and annual basis. While disease Programs have their own parallel systems for collection of data, this shall be discouraged during the implementation of the HSSP. The HMIS will be strengthened to provide timely and reliable data for monitoring the performance of the health sector as has been described earlier on. The private sector shall be encouraged to provide data to CMED. At the end of each year an HMIS Bulletin shall be produced detailing progress made in the health sector. In addition to the HMIS bulletin, an annual health sector report shall be produced by the Department of Planning and Policy

ince 1992 the National Statistical Office in conjunction with MACRO Inc., has been conducting the DHS once every four years. This population is important as it provides very useful information on impact indicators such as MMR, IMR, U5MR and CPR, the prevalence of diseases (e.g. malaria, ARIs and diarrhoea) and the way people seek treatment among other issues. In addition to the DHS there are also other national surveys (such as the malaria indicator survey, the welfare monitoring survey, and the integrated household survey) that are important sources of data for measuring the performance of the health sector. Over the period of the HSSP the National Health Accounts will be institutionalised and carried out regularly in order to effectively monitor the financing of the health sector. 8.3 Baseline, mid-Term Review and EndReview

uring the implementation of HSSP there will be three reviews namely the baseline, mid-term and end-term reviews. Before the start of the HSSP on 1st July 2011, a baseline survey will be required in order to provide baseline figures upon which future evaluations will be based. The 2010 DHS will provide the bulk of the baseline data but special national level surveys will be required as the DHS may not provide data for some new indicators. At the end of 2013 a midterm evaluation will be commissioned by the MoH to evaluate progress made to achieving the targets set in this Plan and make recommendations on how the health sector can fast track the implementation of interventions in order to achieve targets for 2015/2016. In 2016 an end of term evaluation will be done in order to assess whether targets have been achieved or not and provide recommendations for a new health sector PoW to success this plan. 8.4 Mid-term and annual joint review meetings

achieve the targets and how these can best be addressed. Participants in these review meetings will be from MoH, Ministry of Local Government and Rural Development, other Government Ministries and Departments with interest in health (such as MoE, Ministry of Water and Irrigation, Ministry of Agriculture and Food Security, Office of the President and Cabinet, National AIDS Commission among others), the private for profit and private not for profit service providers, HDPs, civil society, training institutions, communities (represented by Traditional Authorities). 9. FINANCING THE HSSP 9.1 Costing the plan

very year there will be a MidYear Review and an Annual Joint Review Meetings. The MoH in conjunction with other stakeholders shall set the ToRs for these reviews. To allow for wider participation and analysis of implementation bottlenecks, the AJR will start at Zonal level, Participation at National level will include representatives of HSWG constituencies will discuss policy recommendation from the Zonal as well as made in achieving milestones as set in the HSSP as well as in the AIPs financing and expenditure status. Specifically emphasis will be on challenges being experienced to

he original costing model was developed in 2002 in conjunction with the Department of Planning and Policy Development and an EHP technical working team with support from UNICEF. The costs were revised downwards from $22 per capita to US$17.5 per capita to take into account the resource envelop and capacity. This did not, however, include tertiary facilities and support to other conditions including ARVs. The implications of this reduction were not properly correlated with the targeted outcomes. The EHP was revised in 2007 and included those elements that were excluded from the 2002 costing such as HIV program costs, increased costs associated with the Road Map to Reduction of Maternal and Neonate Mortality, the strategic plan for accelerated child survival, costs at the MoH Headquarters (HQ), Zonal Health

Support Office (ZHSO) and District Health Office (DHO) levels. This did not include salaries or any activities for central hospitals and mental hospital. The total cost was estimated in 2007 at almost $396 million dollars per year ($27 per capita). The costing model for the PoW (2002) was based on direct costs which included drugs and supplies including laboratory supplies, bed and board, emergency transport and indirect costs comprising of human resources, infrastructure, maintenance , equipment, consumables, IEC, social marketing and supervision. The HSSP costing model has incorporated environmental health, health promotion, training based on outputs of training institutions, estimates for the implementation of the new ART regime, transport based on actual gaps and needs for ambulances, IEC materials, operational costs for tertiary hospitals including mental hospital, cost of IRS and mosquito nets, an expanded NTDs, NCDs, mental illness and scaling up early treatment for cervical cancer. The new HSSP has also estimates for personnel emoluments. .

The initial estimates based on ideal situation was MK 387.9 billion ($2.6 billion ). However the estimate was revised downwards to MK 276.8 billion (USD 1,821 billion ) in order to reflect the projected resource envelop based on government resources and contribution from cooperating partners. Table 9.2 shows the estimates on ideal and resource based scenarios over the five years. A summary of the detailed costs is in the logical framework (Annex X) along with the performance framework. Arguably there are considerable resources in the sector over and above the current estimate which have not been captured due to data unavailability. The resource envelop will be reviewed during the first year of the HSSP implementation plan as more information becomes available. During the first year of implementation, there will be a partner mapping survey to ascertain resources that are currently in the sector and to improve coordination mechanism for efficient utilization of the existing resources. This will enable the MoH to reallocate resources to other priority areas.

Table 9.1: Estimated resource envelop Sources 2011/12 Wages Ceiling based on existing staff Recruitment Total Salaries ORT Ceiling Development Part II Ceiling Transfers to MoH from NAC - TO BE CONFIRMED Total allocation to Ministry of Health Local Councils Total allocation to MoH and LCs 9,992 42,071 10,842 47,138 10,798 50,059 10,800 52,847 10,800 55,953 53,232 248,067 32,079 36,296 39,261 42,047 45,153 194,835 500 12,399 9,517 5,351 4,812 600 13,684 8,441 7,000 7,171 700 15,629 9,461 7,000 7,171 700 17,271 10,605 7,000 7,171 700 19,094 11,888 7,000 7,171 3,200 78,076 49,912 33,351 33,496 11,899 2012/13 13,084 In MWK (000'000s) 2013/14 2014/15 14,929 16,571

2015/16 Total 5 year Allocation 18,394 74,876

Of which financed by domestic resources Of which financed by pooled donor SWAP funds Project Support from Donors off Budget, but with Government Total Resources for Government Activities in Health Sector Direct Project Support from Donors off budget and managed by NGOs Total resources inclusive of donor support for NGOs

27,195

29,902

32,824

35,612

38,718

164,252

10,064

10,064

10,064

10,064

10,064

50,318

5,740

5,740

5,740

5,740

5,740

28,699

47,811

52,878

55,799

58,587

61,693

276,767

16,745

16,745

16,745

16,745

16,745

83,726

59,744

62,451

65,373

68,161

71,266

326,995

Table 9.2: Summary estimated costs by outcome and output for HSSP 2011-20016 Broad Activities /actions Ideal cost Outcome 1 : Increased coverage of essential EHP services EHP infrastructur e constructed according to standards 69,301 5,351 11,978 10,912 7,474 6,058 41,773 2011-12 ESTIMAT ED COSTS MK (000,000) 2012-13 MK USD (000)

2013-14

2014-15

2015-16

Total

274.8

1.1

Broad Activities /actions Ideal cost Implement Service level agreements in underserved areas (both urban and rural Adequate transport provided 75,261 2011-12 -

ESTIMAT ED COSTS MK (000,000) 2012-13 5,351

MK

USD (000)

2013-14 11,978

2014-15 10,912

2015-16 7,474

Total 6,058 41,773

1.2

1.3

3,908

270

289

284

330

331

1,504

Total 5,928 12,596 11,519 8,181 6,765 outcome 1 Access and coverage Outcome 2 Strengthen the performance of the health system to support delivery of EHP services. 2.1 Improve availability of Human resources for health Sector

44,988

Broad Activities /actions Ideal cost 2.1.1 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14 1,768

2014-15 1,706

2015-16 1,949

Total 1,914 9,044

2.1.2 2.1.3 2.1.4.

staff trained 20,455 1,706 with appropriate competencie s pre-service Post 2,002 graduate Recruit and pay staff at all levels 1 Implement human resource management for 2 effective EHP delivery at all levels Total HR Equipment provided in new and upgraded and rehabilitated Health facilities Contracting out maintenance Subtotal 122,573 15,411 15,647 1,843

2,616 15,095 235 19,714 1,973

2,572

2,995 17,237 231 22,305 269

2,997 23,927 269 29,107 2,260

13,182 90,283 1,223 113,733 10,274 594 8

2..2.1

21,747 1,940

27,518 2,258

2.2..2

4,956

593

634

624

726

727

3,304

20,551

2,458

2,630

2,587

3,011

3,014

13,700

Broad Activities /actions Ideal cost new equipment and maintenanc e IT services improved Total equipment and IT Improve availability and quality of essential medicines and supplies 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14

2014-15

2015-16

Total

2.2.3

184 20,734

22 2,480

24 2,654

23 2,610

27 3,038

27 3,041

123 13,823

2.3

91,200

17,088

10,779

10,044

11,681

11,690

61,281

2.4 Appropriat e standards , guidelines , Standard

Broad Activities /actions Ideal cost operating procedures developed 2.4.1 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14

2014-15

2015-16

Total

2.4.2

2.4.3

2.4.4

EHP standard and legislation developed and disseminate d Procuremen t systems improved Financial management and internal audit improved Standards and operating procedures developed

18,929

2,264

2,423

2,382

2,774

2,776

12,619

1,690

202

216

213

248

248

1,127

718

86

92

90

105

105

479

1,617

193

207

203

237

237

1,078

Broad Activities /actions Ideal cost for clinical practice Stakeholder Coordinatio n improved Planning and policy Improved quality of diagnostics services M&E and research Implement the national health research agenda Develop /review standards guidelines etc for 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14

2014-15

2015-16

Total

2.4.5

376

45

48

47

55

55

251

2.4.6 2.4.7

2,853 1,244

341 17

365 18

359 18

418 20

418 20

1,902 93

2..5 2..5.1

737 197

88 24

94 25

93 25

108 29

108 29

492 132

2.6

381

46

49

48

56

56

254

Broad Activities /actions Ideal cost 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14

2014-15

2015-16

Total

essential drugs 2.7 HSS running costs General 21,806 2,609 2,791 administrati on costs Grand total 285,057 41,130 39,475 40,623 outcome 2 Strengthen Performanc e Outcome 3 Reduced Personal Health and Environmental Risks 3.1 Improve living and working Environme nts and decreasing risky behaviors -

2,745

3,196

3,198

14,538

49,484

51,089

221,801

1,

Broad Activities /actions Ideal cost 3.1.1 Health Promotion Policy and advocacy Establish health settings programs Implement integrated vector control management (ITN, Larvaciding, IRS, drainage etc) Carry out water testing and chlorination , advocate 2011-12 119

ESTIMAT ED COSTS MK (000,000) 2012-13 14

MK

USD (000)

2013-14 15

2014-15 15

2015-16 17

Total 17 79

3.1.2

1,723

206

221

217

252

253

1,149

3.1.3

20,887

412

441

3,297

504

3,420

8,074

3.1.4

1,014

121

130

128

149

149

676

Broad Activities /actions Ideal cost for clean and safe water , food safety inspections Emergency preparednes s and response Communica tion for social and individual behaviour change Outcome 3 Total risk behaviour and factors Grand Total Projected Resource 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14

2014-15

2015-16

Total

3.1.5

20

3.1.6

3,792

27,535

753

806

3,657

923

3,839

9,978

387,853

47,811 47,811

52,877 52,877

55,799 55,799

58,587 58,587

61,693 61,693

276,767 276,767

1,

Broad Activities /actions Ideal cost Envelop 2011-12

ESTIMAT ED COSTS MK (000,000) 2012-13

MK

USD (000)

2013-14

2014-15

2015-16

Total

9.2 Health Sector Strategic Plan (HSSP) Costing Rationale Outcome 1: Increased coverage of EHP services Output 1 Health infrastructure developed and maintained This is based on the draft capital investment plan; priorities for the entire period of HSSP based on gaps in coverage of health services denoted by geographical mapping of health facilities (living within 8 kms of Health centre services). Output 2 : Improved availability and maintenance of emergency transport One ambulance per 50,000 population: estimates for 1st Year new ambulance for each district for the year 2011/12. The MoH will make provisions to engage DHOs to re allocate resources to purchase of ambulances and maintenance costs due to aging fleet30. Output 3: Signing of Service Level Agreements (SLAs) with Private not for profit and private for profit Based on the gaps for health service coverage; the number of SLAs available, and the current expenditure trends by DHOs31.

Outcome 3: Strengthened performance of the health system to support health service delivery. Output 2.1 Recruit and retain human resources for health 2011/12 Personnel emoluments and adjusted 5% increase for recruitment ( recruitment plan to be reviewed and finalized after functional review during 1st year HSSP.; Absorption/recruitment of all yearly output from health training institutions. Output 2.2: Develop human resources for health Current intake of health training institutions and projected outputs over the next 5 years. Inclusion of outputs from KCN, MZUNI and CoM (funded through MOE)

Output 2.3: Improve availability and quality of essential medicines and supplies 2011/12 budget plus MK1 billion drug arrears; 2011/12 budget adjusted by 7% inflation rate, plus MK1.5 billion for 2012/13 and 2013/14; 2013/14 budget adjusted by 7% inflation rate for the subsequent years; 30% increase from other expected sources of funding Output 2.4: Purchase of adequate essential medical equipment and maintenance Current resources within MOH ORT and Development budget, plus MK 800,000, 000 additional resources, adjusted by 7% yearly

30
3

Maintenance costs will be reviewed during the 1styr of the HSSP

31 SLAs will be reviewed during the

3

1st year of the HSSP

inflation rate for the subsequent years Output 2.5 Support and strengthen health systems for EHP delivery Based on the approved budget and adjusted by 7% inflation for the subsequent years Outcome 3: Reduced personal and environmental risks to health Output 1: Improve living and working Environment and decreased risky behaviours Based on the approved budget , adjusted by 7% inflation for the subsequent years Including ITN needs every two years based on one ITN per two people.

9.3 Implications of costing scenarios Given the complex nature of the causes of ill health it is difficult to ascertain direct impact of the Ministry of Health on health status. The social determinants of health are varied and include living conditions, socio cultural, economic (income and social status), education, social support networks, culture, gender, food security, individual lifestyle and behaviours, employment and working conditions and availability and uptake of health services. The costing of this plan is based on inputs into the system linked to health service outputs and outcomes. The implications therefore of reducing the resources on the various outcomes may be: Outcome 1: Increased coverage of quality services.

The reduction in infrastructure development implies that coverage of health interventions will be reduced. This is not withstanding voluntary use of private facilities and traditional medicine. This will likely impact on maternal health and access especially on EmOC. Depending on the epidemiology such as malaria prevalence and the poverty indicators, knowledge and practices and health seeking behaviours, access for children to health care will not be optimal. Similarly a reduction in finances for service level agreements will have an impact on access and coverage. A reduction in the number of ambulances and their response time can have a big impact on health outcomes (along with skilled paramedics) in particular obstetric emergencies and road traffic accidents. Outcome 2. Increased performance of health systems Human resources: Insufficient and poor quality health and support staff will impact on the quality of care and can have serious implications for health. The priority areas are nursing staff, clinicians, tutors and other cadres that will have long term impacts. Essential medicines and supplies including vaccines: Stock outs of essential drugs can have life threatening consequences. The priority essential medicines and supplies would be according to

EHP conditions: i.e. vaccines, general antibiotics for acute lower respiratory infections, TB drugs, STI drugs, ARVs, Anti-epileptic (anti-convulsants), antipsychotics (for violent mentally ill patients); essential medicines to stop post partum hemorrhage, IV fluids (plus ORS at least homemade); pain killers etc. The public health impact of not supplying some of these essential drugs, such as TB, ART, STI drugs is enormous and have a negative impact on incidence and prevalence of these critically important diseases which will cost much more in terms of lives and economic development in Malawi. Essential equipment: Lack of basic standard equipment list at health centre and district hospital level, the lack of aspirators and oxygen concentrators, life support machines, x-rays and basic laboratory equipment and basic sterilizing equipment among others will have a negative impact on delivery of EHP services as all these are all lifesaving equipment. Outcome 3: Reduction of risk factors and behaviors: Lack of investment in addressing risk factors has long term implications not only for health status but for quality of life. Hand washing has one of the biggest impacts of infant and child mortality. Hand washing before breast feeding has been shown to reduce by 60% mortality rates for infants; similarly after going to the toilet, before food

preparations and proper sanitation reduces mortality rates. Estimating the resource envelope is based on figures from Debt and Aid in the Ministry of Finance and does not take into account all available resource. Further detailed studies will be carried out during the 1st year of the HSSP and aim to encourage further coordination amongst all health partners. The costing model itself assumes coverage inclusive of CHAM that estimated to deliver between 30-40% of services. The cost model will be further reviewed during the MHSSP implementation period.

Annex 1: Health risk analysis table

Health Problem Malaria Prevalence : 43% nationally

Risk factors Environment: Too many mosquitoes, Exposure to mosquito bites, too many breeding sites (latrines, stagnant water from washrooms lack of drainage, IRS expensive and tobacco issue lack of drainage, Deforestation, Poor refuse management. No cutting down of over grown grasses Health care : Lack of access to treatment (economic geographical ), poor compliance to treatment, Lack of correct information on treatment , poor diagnosis Behavioural Not sleeping under nets. (55.4% sleeping under nets )

Diarrhoea (151 /1000 incidence rates) 3.1 reported inpatient death rate In the last cholera season, there were about 1,495 cases, and 24 deaths with a Case Fatality Rate (CFR) of 1.6%. Environment Sanitation In 2008 the proportion of households with no toilet facility decreased slightly to 13.5%, 2004 64% of Malawian households had access to clean water, 20% from piped water and 44% from protected wells32.The proportion of people with safe drinking water slightly increased to 67.3% in 2008 Health care poor access to health services, Lack of knowledge of ORS and on the danger of dehydrations. Behavioural No hand washing (Economic?) The proportion of households with soap to use it at critical times is quite low at 45%33. No fuel to boil water to drink, No Proper preparation of food / preservation and lack of good hygiene.

32 DHS 2004
3

33 SCT 2007
3

TB case detection rate currently at 46%34 )

HIV

Economic insufficient food Poverty Health Care poor case detection / Lack of access to treatment , Poor health status (HIV, Malnutrition, mental illness ) Environment, Housing overcrowding , Behavioural Lifestyle( alcohol drugs , hygiene , Behavioural : Multiple partners, Unprotected sex Condom use females 40% while among males it was at 58%, Lack of access to condoms, mental illness , some neuropsychiatric disorders , Substance abuse (drugs and alcohol) Lack of knowledge : ?? % of women are aware that condoms prevent against HIV and STIS, embarrassment, stigma etc Health Care poor access to screening and treatment, lack of confidentiality Unaware of status? %. of those 15-49 years went for an HIV test , Insufficient access to HTC , Mother to child transmission , Environment , Economic : Poverty Cultural practices that enhance the transmission of HIV such as kulowa kufa and fisi Environment: The majority of the households use solid fuels (approximately 98%). This can put children at higher risk of respiratory infection especially asthma and bronchitis if the rooms are not well ventilated: cold during rainy season Behavior poor hygiene and hand washing practices, Health seeking behavior only 1 in 5 caregivers know the two key symptoms of pneumonia (fast and difficult breathing); only 1 in 5 caregivers seek treatment for children from health care providers; Biomedical Health care , asthmatics , Malnutrition, health status (other

ARIs incidence. 14% admissions and 20% of deaths for under fives Asthma

34 WHO. (2005)
3

TB case detection rate currently at 46% )

Economic insufficient food Poverty Health Care poor case detection / Lack of access to treatment , Poor health status (HIV, Malnutrition, mental illness ) Environment, Housing overcrowding , Behavioural Lifestyle( alcohol drugs , hygiene , infections i.e. HIV ) only 1 in 5 areas hard to reach areas are equipped with antibiotics for treating pneumonia; Vaccine preventable diseases Measles (latest to be inserted)Other Behavior : Beliefs and practices amongst some communities individuals Health care delivery Lack of vaccinations , cold chain , logistics Adverse maternal and neonatal outcomes Maternal mortality 807 deaths per 100,000 live births. ? Environment : Access and availability of Health care : 62 % delivered at a health facility (Poor Access to health facilities % of women said that clinics were too far away (no transport or transport too expensive )use of family or TBAs A recent study showed that only 19% of the women with obstetric complications were treated in a facility providing emergency obstetric care (EmOC)35. 8% received 2 doses of malaria prophylaxis Quality of care ( access to Emergency obstetric care) high TFR , HIV , Young age ( ? % teenage pregnancies ) Major causes of MMR = illegal or incomplete abortion, sepsis , hemorrhage Behavioural : Decision making at household level (need to add more) teenage pregnancy, lack of knowledge of danger signs Economic : Poverty no access to transport Neonatal mortality NMR estimated at 33 deaths per 1,000 live births Environment : Unclean environment slightly higher in the rural areas 34 deaths per 1000 and 30 in urban Health care low rates of skilled attendants at delivery, Only 33% of areas; (what are major causes) mothers received postnatal care within the 6 weeks of delivery whilst 18% received postnatal care within 48 hours of delivery. Need to confirm stats the lack of emphasis on community and family care and lack of adequate treatment for neonatal infections., preterm Behavioural : Lack of information on danger signs , poor hygiene Nutrition underweight 25%need to disaggregate ht/wt /wt/age etc Environment prevalence of worms hookworm helminthes , poor Micronutrient deficiency especially Anaemia ? % school kids with hygiene (resulting in diarrhea ) anaemia Economic Poverty , food insecurity at community and household level,
35 MoH. (2005).
3

Behavioural : Decision making at household level (need to add more) teenage pregnancy, lack of knowledge of danger signs Economic : Poverty no access to transport Poor diet , Low intake of iron rich foods ? access to health services , lack of knowledge , equity and gender issues Health care Lack of access to health care Schistosomiasis -0-43% Environment poor hygiene and sanitation , swimming in infected Soil transmitted helminthes water ; transmission cycle continued ; (Tryps , oncho ,) poor vector control , Health care : lack of access Eye ear and skin eye is only focusing on trachoma and not other such To insert next draft as injury and cataracts Leprosy ( % where is skin ???? ) Mental health 28.8% of the patients attending primary care have Environmental (social and physical) unemployment, stress at work common mental health problems of depression or anxiety while 19% and resulting from environmental factors have depression alone. Under reporting /diagnosis Social stress and trauma such as deaths, divorce, poverty Biomedical /health care : Lack of access to treatment and recognition /diagnosis of diseases family history of mental health problems, and substance abuse. Chronic physical illnesses such as HIV/AIDS and/or cancer also lead to mental health problems, Other physical illnesses such as neurosyphilis, thyroid disease and diabetes also contribute to mental health problems. Behavioural Family violence, High consumption of alcohol , Drug abuse, upbringing Trauma 8.5 other than RTA ( need breakdown) 3.5 RTA Environment : Accidents in the workplace , Accidents in the community including domestic violence Behavioural Road accidents due to careless driving and alcohol , Biomedical health care : lack of access to rapid treatment Domestic violence (part of trauma, mental health , Reproductive Psychiatric disorders , Child hood /family Abuse , Trauma triggered health ) by stress family , poverty, alcohol, drugs 13.4% of the women aged 15-49 reported ever having experienced Cultural /social norm, Status of women , Status of men, Poverty, sexual violence 12.7% reported having ever experienced emotional Overcrowdings, Lack of recognition of signs on presentation to health

Behavioural : Decision making at household level (need to add more) teenage pregnancy, lack of knowledge of danger signs Economic : Poverty no access to transport violence. 7% of the ever married women reported having ever had services Barrier to communicate, Lack of referral system lack of bruises and aches resulting from what their husband did to them while knowledge on Legal 1.6% had injury or broken bone Cardio vascular/ diabetes Cardio vascular 32.9% hypertensive (STEPS survey 2010) Behavioural : Diet The overall prevalence of overweight 21.9% . Overall, 8.9% high cholesterol , 16.1%Among men, 28.1% amongst women 5.6% ? what is incidence of diabetes Obesity : 4.6% overall with 2% men and 7.3 % women Lack of exercise : 9.5% with 6.3 % amongst men and 12.6 amongst women ; Smoking Prevalence 14. Overall with 25.9 amongst men and 2.9 % amongst women ; Heavy drinking 19% amongst men and 2.3 % amongst women Environment : Stress in the workplace , office based work Cancer ? incidence Cervical and breast Biomedical health care Genetic , lack of screening , treatment Prostate Lung and Liver other Behavioral (unprotected sex for girls )Unprotected and early sex (cervical cancer)Smoking: alcohol : Environment Exposure to chemicals/ hazards Lack of access or availability of treatment centres Disasters Lack of preparedness for disasters Water and sanitation Injuries safety Mitigate the impact

Annex 2: Workforce size by health cadre

Annex 3: Proportion of the population living within an 8 km radius of a health facility Year 2011 % Not Serviced 32% 3% 27% 2% 51% 8% 15% 8% 38% 100% 12% 22% 27% 23% 4% 6% 24% 8% 23% 15% 21% 5% 9% 11% 20% 13% 5% 4% 19% Year 1999 % Not Serviced 2% 22% 1% 48% 8% 11% 17% 49% 14% 33% 24% 25% 8% 18% 29% 8% 17% 25% 7% 14% 22% 20% 4% 3% 18%

District Balaka Blantyre Chikhwawa Chiradzulu Chitipa Dedza Dowa Karonga Kasungu Likoma Lilongwe Machinga Mangochi Mchinji Mulanje Mwanza Mzimba Ncheu Neno Nkhata Bay Nkhotakota Nsanje Ntchisi Phalombe Rumphi Salima Thyolo Zomba Average

% Serviced 68% 97% 73% 98% 49% 92% 85% 92% 62% 0% 88% 78% 73% 77% 96% 94% 76% 92% 77% 85% 79% 95% 91% 89% 80% 87% 95% 96% 81%

% Serviced 98% 78% 99% 52% 92% 89% 83% 51% 86% 67% 76% 75% 92% 82% 71% 92% 84% 75% 93% 86% 78% 80% 96% 97% 82%

Annex 4: The number of health facilities in Malawi 2003-2010 OWNERSHIP Number of facilities in 200336 Number of facilities in 201137 C o m m u ni ty / R ur al H os pi ta l Hea lth Cen tre R eh ab ili ta ti on C en tr e 1 0 C Hos o pital m m u ni ty / R ur al H os pi ta l 20 18 0 0 Hea lth Cen tre

C en tr al H os pi ta l

Di st ri ct H os pi ta l

M en ta l H os pi ta l

CH 0 0 1 4 113 2 0 Loca 0 0 0 0 13 13 0 AM l 3 36MoH.(2010). Final evaluation of the Health Sector Programme of Work (2004-2010).Lilongwe: MoH.
37MoH. (2010). Annual report on the work of the health sector. Lilongwe: MoH
3

Di sp en sa ry 18 7

M at er ni ty

T O T A L 160 33

C en tr al H os pi ta l

Di st ri ct H os pi ta l 0 0

m en ta l ho sp it al 1 0

109 10

Di sp en sa ry 12 7

M at er ni ty 4 13

R eh ab ili ta ti on U ni t 1 1

T O T A L 162 31

Number of facilities in 2011 MO 4 21 1 15 219 54 2 0 319 MO 0 0 0 0 0 0 0 0 0 H MO 0 0 0 0 39 2 0 0 42 H/ Tota 4 21 2 20* 393* 93** 17 1 575 H/L l * * Note: *1 is other and the ownership is not indicated. ** Includes 8 other health facilities whose ownership is not indicated. ***Includes 12 other facilities whose ownership is not indicated. 4 0 0 4 23 0 0 23 1 0 0 2 18 0 1 37 1 0 0 21 258 1 45 423 54 0 4 77 2 0 0 17 0 0 0 2 361 1 51 606

Annex 5: SWOT analysis Table o o o o STRENGTHS The development of the EHP in the context of limited resources. The development of draft health bill. The availability of the National Health Policy, other health policies and standards and guidelines for delivery of the EHP. Existence of mechanisms for conducting formal health sector reviews and monitoring of the performance of the health sector. Increasing alignment of partners within the sector. Functioning governance structures within the health sector. Strong partnerships with HDPs and other stakeholders including the community. Alignment of HSSP targets with the MGDS and MDGs. Decentralization of the health system to District assemblies (partially). Establishment of CMS trust. Availability of standards for the different levels of health facilities. Commitment to increasing Human resources. Strong commitment to mobilization of financial resources. o WEAKNESSES Limited implementation and enforcement of policies, guidelines, standards and protocols; and delayed revision of PIM. Shortage of human resource and inequitable distribution. Increasing number of donor funded projects. Non-alignment with some donors which results into inequitable distribution of resources and inappropriate management and utilization of resources i.e., human, financial and logistic Procurement systems require further strengthening Inadequate health service coverage and utilization. Financial management and accountability system requires continual strengthening. Weak referral system and overreliance on central hospitals for EHP delivery. Poor coordination of public-private activities in the health sector. Non-adherence to capital investment plan at district level Poor performance of contractors in infrastructure Lack of utilities in some facilities. Poor transport management system Lack of adequate attention to social determinants of health. Weak monitoring and evaluation system and lack of utilization of data for decision making. Slow implementation of decentralization. THREATS

o o o

o o o o o o o o o

o o o o o o o o o o o o

OPPORTUNITIES

o Governments commitment to improve the health service delivery and quality of care through priority and cost effective interventions. o Government commitment to public-private partnerships in health service delivery. o Decentralization of services for effective community participation in health services delivery. o Commitment by donors to support the health sector.

o Compromised national ownership through parallel processes and uncoordinated oversight o Shortage of human resources. o Lack of control over determinants of health. o Climate change. o Illiteracy, poverty and high levels of population growth. o Lack of capacity to implement the decentralized health system. o Rising cost of medical equipment, drugs, supplies and construction materials. o Irrational drug use. o Donor dependency. o Lack of capacity of training institutions to fulfill human resource needs of MOH. o Costs of service level agreement to ensure universal coverage and difficulties in implementation of SLAs o Migration of experienced professionals from the public sector. o Limited capacity of the existing means of communication to reach all segments of the population impacting on IEC/BCC activities. o Resistance from some HDPs to adhere to the agreed requirements and harmonization of budget cycle, fund disbursement and reporting. o Approval of the draft health Bill may take time. o Inadequate resource mobilization to meet resources needed to finance the HSSP.

Annex 6: Risk analysis table RISK RATING L RISK DESCRIPTION Political stability PROPOSED MITIGATION MEASURES o The MoH will work with other Government Ministries and Departments, Civil Society Organisations, the private sector and the HDPs and ensure continued provision of health services to the people of Malawi, o The MoH and other stakeholders in the health sector including the Parliamentary Committee on Health shall advocate for the increased allocation of resources to the health sector by GoM in order to achieve the Abuja Target of 15%. o The MoH is strengthening its financial management systems to ensure efficient utilisation of financial and other resources while at the same time promoting transparency and accountability in the way resources are used. o The MoH with support from HDP will develop a comprehensive health financing strategy which will be used for mobilisation of resources for the health sector. o Some wards at District and Central Hospitals shall continue charging user fees in order to generate additional revenue. o The HSSP contains strategies that will address shortage of Essential Medicines and Supplies in health facilities. o The HSSP has recognised this risk and measures have been proposed in this document to address it.

Inadequate funding for the health sector

H H

Shortage of Essential Medicines and Supplies Financial management systems improvements may

not be sufficient or timely Procurement systems improvements may not be sufficient or timely Outdated legal environment

Critical shortage of human resource

M L M

Slow implementation of decentralisation Non-alignment with some donors Lack of adequate attention to social determinants of health Weak monitoring and evaluation system and lack of utilisation of data for decision making Weak referral system and overreliance on central hospitals for delivery of EHP services Poor coordination between the public and private sectors

o o The HSSP has recognised this risk and measures have been proposed in this document to address it. o o A health bill has been drafted and will be passed by parliament during the period of implementing the HSSP. o The EHRP made great progress in addressing the shortage of human resources in Malawi. Further massive investment in human resource is a major priority in the HSSP. o The MoH will work closely with the MoLGRD in order to ensure effective decentralisation of health services. o The MoH will encourage donors to work within the SWAp environment. o Addressing social determinants of health is a major priority in the HSSP and the MoH will work with other stakeholders in order to address this. o A comprehensive HIS strategic plan has been developed to address this. o A TA will be hired to help improve the HMIS. o The MoH will strengthen urban facilities in order to decongest central hospitals. o The MoH in conjunction with other stakeholders will strengthen its referral system o A TWG has since been created and there is a desk officer within the Department of Planning responsible for public private partnership. Plans are underway to

develop a public private partnership policy.

Annex 7: Roadmap for developing the HSSP and stakeholders involved Eve
nt Mee All stakeholders tings with part ners /stak ehol ders and MOH on desi gn of HSS P End Consultations with all of stakeholders term revi ew stakeholders Mar 201 0 A p Ma y Jl Sept Nov De c Jan Fe b Ma r Ap May J Jly 2011 outp uts Agr eein g on the proc ess of deve lopin g the HSS P

Brief ing on findi ng of end of term revi ew by

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts cons ulta nts core tea m chos en , repo rts from TWG 's Burd en of dise ase pres enta tion distr ict expe ndit ure surv ey pres enta tion sho

Upd ate mee ting on desi gn of POW 11 9th July

MOH, Civil society , DPs'

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts wed high cost s on Non EHP cond ition s agre eme nt to revie w EHP and EHP TWG task ed with comi ng up with key inter vent ions pre sent atio

Cons MOH, DEV partners , UN , ultat civil society , training ive institutions , CHAM , Local

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts ns on: end of ter m revi ew find ing Distr ict Expe ndit ure Surv ey Mala ria Indic ator Surv ey Anal ysis of Burd en of dise ase studi

mee government (DC"s) , ting districts, local chiefs , on regulatory bodies , POW 11 @ capit al hote l, 200 parti cipa nts all stak ehol ders

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts es Disc uss and agre e on Reco mm end atio ns from the eval uati on and surv eys/ studi es Dev elop cons ensu s on prop osed fram ewor k, build

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts ing bloc ks, strat egic inter vent ions and targ ets to be achi eved in the next POW , Iden tifie d gaps in infor mati on requ ired to deve

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts lop the next POW and agre e on met hod olog y for colle cting such infor mati on Dev elop men t of ToRs and choi ce of cons ulta nts, agre eme nt of and

Core MOH, DEV partners , UN , grou civil society , training p institutions , CHAM mee tings

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts com men ts on HSS P draft s, mon itori ng prog ress

Exte nde d TWG 's HR QA, M&E Fina nce and proc ure men t, EHP, (and spec ific

Various stakeholders, privatisation commission , Ministries of education and finance Local government

Dev elop men t of strat egie s for each area .

Eve
nt EHP area s) PP P, Drug s and med ical supp lies , hosp ital refor m, nutri tion HIV Lead cons ulta nt eng age d othe r cons ulta nts costi

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts

QA , HR ,

Eve
nt ng cons ulta nt Ann ual revi ew mee ting

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts

all stakeholders

com mun ity / publi c

Agr eem ent on fram ewor k and som e key inter vent ions and end orse men t of EHP inter vent ions Rep ort from Civil soci

Eve
nt disc ussi ons in all thre e regi ons carri ed out by civil soci ety stak ehol der/ cons ensu s me etin g

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts ety

Revi ew agai n of EHP and agre eme nt on strat egie s in othe r area s.

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts Agre ed indiv idual cond ition s and inter vent ions shou ld be sho wn in tabl e form at by servi ce deliv ery level 1st com men ts incor pora

1 st inter nal revi ew

core team

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts ted in docu men t 2nd com men ts incor pora ted in docu men t Disc ussi ons and pres enta tions on 5 key area s Agre ed on final chan

2nd Inter nal revi ew mee ting

all stakeholders

exte rnal revi ew mee ting

stakeholders, including EPND presentation on MGDS x

4th Final revi ew mee

Eve
nt ting end June

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts ges that nee d to be mad e Final Perf orm ance fram ewor k will be com plet ed Aug 19th reso urce enve lop to be finali zed once all com

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts mit men ts recei ved from part ners and adju stm ents mad e to costi ng and scen arios Pres enta tion and disc ussi ons on som e key area s

mid year revi ew

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts that nee ded to be chan ged

Req uest ed com mit men ts from part ners Rece ived com mit men ts from part ners and finali zed reso urce s

xx

Final infor mati on recei ved from part ners 27th July

Eve
nt enve lop Logf ram e costi ng revi ewe d and circu late d with perf orm ance fram ewor k

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts

xx

Final draft Cost ed logfr ame circu late d with perf orm ance fram ewor k awai ting mor e deta ils from part ners and revis ions to GF

Eve
nt

stakeholders

Mar 201 0

A p

Ma y

Jl

Sept

Nov

De c

Jan Fe b

Ma r

Ap

May

J Jly 2011

outp uts in Aug ust com men ts recei ved and incor pora ted from part ners and MOH

draft of HSS P circu late d and com men ts recei ved and adju sted zero -4

Annex 8: Leading 10 selected factors & diseases or injuries Malawi Top 10 risk factor Risk 1 2 3 4 5 6 7 8 9 10 Risk factor Unsafe sex Childhood and maternal underweight Unsafe water, sanitation and hygiene Zinc deficiency Vitamin A deficiency Indoor smoke from solid fuels High blood pressure Alcohol Tobacco Iron deficiency % of total 34.1 16.5 6.7 4.9 4.8 4.8 3.5 2.0 1.5 1.3 Rank 1 2 3 4 5 6 7 8 9 10 Top 10 diseases Disease HIV/AIDS Lower Respiratory Infections Malaria Diarrhoeal diseases Conditions arising from perinatal conditions Cerebrovascular disease Ischaemic heart disease Tuberculosis RTA Protein energy malnutrition

% of deaths 33.6 11.3 7.8 7.6 3.2 2.8 2.6 2.4 1.3 1.0

ANNEX 9: AN EHP FOR MALAWI DEFINED BY LEVEL OF HEALTH CARE DELIVERY

Primary health care Strategy Community Health centre Secondary health care Community hospitals District hospitals Zomba mental, Rehabiliation Tertiary care Ref hospitals ( KCH, QECH, Zomba, Mzuzu) National national level HQ

Public health interventions Disease prevention and health promotion individuals / communities /settings
Implement Integrated vector control measures in all settings : community , schools orphanages , workplaces , Health facilities Provision of IRS services in high risk areas Promote and carry out drainage and larviciding of vector (mosquito) breeding sites in all settings Provision of LLITNs (HH level ) Provision of LLITNs Provision of LLITNs Provision of LLITNs Provision of LLITNs Provision of LLITNs Promote IRS Promote IRS Promote IRS Promote IRS Promote IRS Advocate for healthy environmental policies : Advocate for healthy settings : workplaces cities , learning institutions environmental impact assessment Advocate for companies to fulfill their corporate responsibilities towards health ( environmental control , and larvaciding etc) Develop communication strategies , and support districts to develop communication strategies based on priority areas /conditions

Promote healthy lifestyle /behavior change thro community mobilization IEC / advocacy and healthy settings programmes Early recognition of danger signs ,

Promote healthy village /workplace policies bylaws on drainage etc Community/social mobilisation IEC / advocacy on Early recognition of danger signs , mental health promotion , lifestyle, nutrition, disability

Community/social mobilisation IEC / advocacy on Early recognition of danger signs , mental health promotion , lifestyle, nutrition,

IEC / advocacy on Early recognition of danger signs , mental health promotion , lifestyle, nutrition,

IEC / advocacy on Early recognition of danger signs , mental health promotion , lifestyle, nutrition,

IEC / advocacy on Early recognition of danger signs , mental health promotion , lifestyle, nutrition,

IEC / advocacy on Early recognition of danger signs , mental health promotion , lifestyle, nutrition, patient support groups

Primary health care Strategy mental health promotion Promote safe water, sanitation and hygiene Address priority issues based on disease burden : Environmental & personal hygiene, safe water/sanitation , nutrition food service outlets inspections, border posts checks , Implementation of healthy settings /model villages programmes /cities workplaces , learning institutions , Community based family planning provision of contraceptives (through social marketing village clinics outreach and in hot spots,youth friendly outreach services, linkages with door to door HTC, safer sex negotiation (/subsidized water purification tablets , hygiene promotion (PHAST) through IEC Community Health centre

Secondary health care Community hospitals District hospitals Zomba mental, Rehabiliation

Tertiary care Ref hospitals ( KCH, QECH, Zomba, Mzuzu)

National national level HQ

(/subsidized water purification tablets , hygiene promotion (PHAST) through IEC

(/subsidized water purification tablets , hygiene promotion (PHAST) through IEC

Develop guidelines for healthy settings ( communities , workplaces etc) environmental health waste management etc

Promote healthy settings programme (workplace village , urban, healthy cities etc)

Outreach and supervision HP officers environmental health , HSA's

Outreach and supervision HP officers environmental health , HSA's

Outreach and supervision HP officers environmental health , HSA's

Healthy workplaces (health facilities )

Healthy workplaces (health facilities )

Advocate for healthy public policies , food and nutrition advertising, tobacco , alcohol road safety , workplace policies etc Development of guidelines policies standards etc, M&E research advocacy Revitalised communications strategy to promote uptake of family planning

Promote family planning ,

Integrated family planning through different entry points (FP, MCH, ART, HTC), promotion of safer sex (dual protection), benefits of spacing for health of mother and child. ,

Integrated family planning vasectomy , other surgery through different entry points (FP, MCH, ART, HTC),, related health promotion.

integrated family planning through different entry points (FP, MCH, ART, HTC),, related health promotion.

integrated family planning through different entry points (FP, MCH, ART, HTC),, related health promotion.

integrated family planning (through different entry points (FP, MCH, ART, HTC),, related health promotion.

Primary health care Strategy Community targeting high risk behavior s, normative change Health centre

Secondary health care Community hospitals District hospitals Zomba mental, Rehabiliation

Tertiary care Ref hospitals ( KCH, QECH, Zomba, Mzuzu)

National national level HQ

Promote safer childbirth through referral , community based transport , danger signs , hygiene kits for mothers Promote safer sex among different segmented populations (MARPS, youth, men and women, vulnerable groups and settings, PLWH) Promote treatment contact tracing and safe sex IPT to pregnant women

SBCC : Promote safer childbirth : referral , community based transport , danger signs , hygiene kits for mothers Provision of condom (through social marketing village clinics etc ,

IEC distribute hygiene kits for pregnant mothers

IEC distribute hygiene kits for pregnant mothers

IEC distribute hygiene kits for pregnant mothers

IEC distribute hygiene kits for pregnant mothers

IEC distribute hygiene kits for pregnant mothers

Provision of condom (through social marketing village clinics etc ,

Provision of condom (through social marketing village clinics etc ,

Provision of condom (through social marketing village clinics etc ,

Provision of condom (through social marketing village clinics etc ,

Provision of condom (through social marketing village clinics etc ,

IEC on signs symptoms and contact tracing Promote , IEC re IPT for pregnant women

IEC on signs symptoms and contact tracing Provide CPT , PEP, IPT

IEC on signs symptoms and contact tracing Provide CPT , PEP, IPT

IEC on signs symptoms and contact tracing Provide CPT , PEP, IPT

IEC on signs symptoms and contact tracing Provide CPT , PEP, IPT

IEC on signs symptoms and contact tracing Provide CPT , PEP, IPT

Primary health care Strategy Immunize under fives and pregnant women ( vaccine prevent diseases ) Community Vaccinations Services through outreach, village clinics , mass catch up campaigns Passive and active detection of disease condition investigation of outbreaks etc Health centre Routine and targeted Vaccination Services TT

Secondary health care Community hospitals Routine and targeted Vaccination Services District hospitals Routine and targeted Vaccination Services Zomba mental, Rehabiliation

Tertiary care Ref hospitals ( KCH, QECH, Zomba, Mzuzu) Routine and targeted Vaccination Services

National national level HQ Development of guidelines policies standards etc, M&E research advocacy

Routine and targeted Vaccination Services

DIAGNOSIS /SCREENING
Improved diagnostic services Diagnostic services Diagnostic services Diagnostic services Diagnostic services Advanced diagnostics services Development of guidelines policies standards etc, M&E research advocacy

Radiology CD4 Ultrasonography, Promote screening for early detection of disease to prevent premature death and promote healthy lifestyles Conduct screening /health assessment at schools, workplaces, communities, (health promoting schools settings schools . Workplaces etc) outreach clinics on Conduct targeted and routine screening /health assessment on hypertension, mental health ( including addictions), nutrition , diabetes, Gender based violence and child abuse, hearing and other disabilities, TB HIV, Conduct targeted and routine screening /health assessment on hypertension, mental health ( including addictions), nutrition , diabetes, Gender based violence and child abuse, hearing and other disabilities, TB HIV,

Radiology CD4 Ultrasonography, Conduct targeted and routine screening /health assessment on hypertension, mental health ( including addictions), nutrition , diabetes, Gender based violence and child abuse, hearing and other disabilities, TB HIV,

Radiology Ultrasonography, Conduct targeted and routine screening /health assessment on hypertension, mental health ( including addictions), nutrition , diabetes, Gender based violence and child abuse, hearing and other disabilities, TB HIV,

Radiology CT and other CD4 (drug levels) ultrasound, Conduct targeted and routine screening /health assessment on hypertension, mental health ( including addictions), nutrition , diabetes, Gender based violence and child abuse, hearing and other disabilities, TB HIV,

guidelines policies standards on screening and referral systems for GBV /sexual abuse :

Case management and referral

Primary health care Strategy Provide General and Child health (newborn care , nutrition)through IMCI and other approaches ( ACHS) Community CTC , vitamin supplementation Health centre Treatment of moderate and severe malnutrition

Secondary health care Community hospitals Treatment of moderate and severe malnutrition District hospitals Treatment of moderate and severe malnutrition Zomba mental, Rehabiliation

Tertiary care Ref hospitals ( KCH, QECH, Zomba, Mzuzu) Treatment of moderate and severe malnutrition

National national level HQ Development of guidelines policies standards etc, M&E research advocacy IMCI guidelines accelerated child survival Referral systems set up for trauma

Home based care , early referral for childhood illness

Case management of uncomplicated illnesses conditions and referral for complicated cases including Mental health GBV and child sexual abuse , trauma (minor surgery )

Case management of uncomplicated illnesses conditions and referral for complicated cases including Mental health GBV and child sexual abuse , trauma

treatment of other illnesses conditions and treatment and referral for all cases including Mental health GBV, child sexual abuse , A&E trauma critical care HDU

treatment of other illnesses conditions and treatment and referral for all cases including Mental health GBV, child sexual abuse

treatment including major complicated surgery specialist OPD in Inpatient of other illnesses conditions and treatment and referral for all cases including Mental health GBV, child sexual abuse , A&E trauma critical care HDU , treatment of severe injuries

Provide mass treatment at community and schools for NTDs, schistosomiasis, soil helminths (deworming Outreach , village clinics , basic package of ANC PNC PMTCT Follow up case management and referral

Uncomplicated delivery

uncomplicated delivery and complications of delivery. (BEMoNC) PAC

uncomplicated delivery and complications of delivery PAC

Uncomplicated delivery and surgery

Development of guidelines policies standards etc, M&E research advocacy

Primary health care Strategy Community Health centre MVA post abortion care, , male circumcision , VIA FANC implant insertion/removal , BEMOnc Referral of complicated cases

Secondary health care Community hospitals MVA post abortion care, , male circumcision , VIA FANC implant insertion/removal , BEMOnc Referral of complicated cases District hospitals uncomplicated delivery and complications of delivery Cemoc, chryotherapy, comprehensive Fanc, gyneacology and obs services Zomba mental, Rehabiliation

Tertiary care Ref hospitals ( KCH, QECH, Zomba, Mzuzu) complicated delivery and complications of delivery

National national level HQ

(need more details on CHS )

Rehabilitation and palliative care

Home based care follow up for chronic/palliative Referral for HBC Referral for HBC treatment /case management of acute trauma and mental health and refer as necessary rehabilitation of clients with trauma , mental health conditions , referral ( both up and down ) Referral for HBC Development of guidelines policies standards etc, M&E research advocacy Development of guidelines policies standards etc, M&E research advocacy

Community based rehabilitation

rehabilitation of clients with trauma , mental health conditions , referral

rehabilitation of clients with trauma , mental health conditions , referral

rehabilitation of clients with trauma , mental health conditions , referral

treatment of cases of acute trauma and mental health and initial rehabilitation making disability aids )?MAP

Annex 10: Governance Structure for the Health Sector: National Level

Annex 11: Governance structure of the health sector: District level

Annex 12: HSSP core health performance indicators

155

No.

Indicator Health impact - Maternal Mortality Ratio (MMR) Neonatal Mortality Rate (NMR) - Infant Mortality Rate (IMR) - Under five Mortality Rate (U5MR) Coverag e of health Services - EHP coverage (% Facilities able to deliver EHP services) - % of pregnant women starting antenatal care during the first trimester - % of

Purpose

Data source DHS (NS0) DHS (NS0)

Monitoring Frequency
Quiennially

Aggre gation National/ District National/ District

Baseline (2010-11) 675/ 100000 31/1000

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16) 155/ 100000 12/1000

Comments

Impact

Impact

Quiennially

Impact

DHS (NS0) DHS (NS0)

Quiennially

National/ District National/ District

66/1000

45/1000

Impact

Quiennially

112/1000

78/1000

Outcome

HMIS

Annually

National

74%

77%

80%

83%

86%

90%

Outcome

HMIS

Annually

National

9%

11%

13%

15%

17%

20%

Outcome

HMIS

Annually

National

156

No.

Indicator Health impact pregnant women completin g 4 ANC visits -% of eligible pregnant women receiving at least two doses of intermitte nt preventiv e therapy Proportio n of births attended by skilled health personnel -Penta III coverage Proportio n of 1 year-old children immunize d against measles Proportio n of 1 year-old children fully

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11)

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

Outcome

DHS (NS0)

Quiennially

National

60%

80%

90%

Outcome

HMIS WMS

Annually

National

58% 75%

60% 76%

65% 77%

70% 78%

75% 79%

80% 80%

10 11

Outcome Outcome

EPI EPI

Annually Annually

National/ District National/ District

89% 88%

90% 89%

91% 89%

92% 89%

93% 90%

94% 90%

12

Outcome

HMIS

Annually

National/ District

63.7%

157

No.

Indicator Health impact immunize d -% of pregnant women who slept under an insecticid e treated net (ITN) the previous night -% of under 5 children who slept under an insecticid e treated net (ITN) the previous night -Neonatal postnatal care (PNC) within 48 hours for deliveries outside the health facility - % of women who received postpartu

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11)

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

13

Outcome

DHS (NS0)

Quiennially

National/ District

49.4%

75%

80%

14

Outcome

DHS (NSO)

Quiennially

National/ District

55.4%

75%

80%

15

Output

DHS (NS0)

Quiennially

National

Baseline to be established from DHS 2010

16

Output

DHS (NS0)

Quiennially

National/ District

10%

15%

20%

25%

25%

30%

158

No.

Indicator Health impact m care after delivery by skilled health worker within seven days Prevalenc e of HIV among 15-24 year old pregnant women attending ANC -% of HIV+ pregnant women who were on ART at the end of their pregnanc y (to reduce mother to child transmiss ion and for their own health) - % of health facilities

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11)

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

17

Outcome

DHS (NS0)

Quiennially

National

12%

9%

6%

????

18

Outcome

HIV /AIDS Progra mme

Annually

National

35%

68%

75%

78%

80%

82%

19

Output

Environ mental Health

Annually

National/ District

35%

55%

159

No.

Indicator Health impact satisfying health centre waste managem ent standards -% surveyed populatio n satisfied with health services (by gender and rural/urba n) Coverag e of Health Determi nants -% of househol ds with an improved toilet -% of househol ds with access to safe water supply - % of children

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11)

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

20

Outcome

SDSS (MHE N)

Annually

National

83.6% (urban) 76.4% (rural)

85% (urban) 85% (rural)

90% (urban) 90% (rural)

21

Output

DHS (NS0)

Quiennially

National/ District

46%

60%

22

Output

DHS/ MICS NS0)

Quiennially

National/ District

88% (MICS 2006)

23

Outcome

DHS (NS0)

Quiennially

National/ District

47.1% (DHS

160

No.

Indicator Health impact that are stunted - % of children that are wasted Coverag e of Risk factors Contrace ptive Prevalenc e Rate (modern methods) Health systems Outputs (availabi lity, access, quality, safety) - OPD service utilization (OPD visits per 1000 populatio n) -#&% of fully functional health centres offering basic EmOC

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11) 2010)

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

24

Outcome

DHS (NS0)

Quiennially

National/ District

4.0% (DHS 2010)

25

Outcome

DHS (NSO)

Quiennially

National

42% (DHS 2010)

50%

60%

26

Output

HMIS

Annually

National/ District

1316/ 1000 pop

>1000/ 1000 pop

>1000/ 1000 pop

>1000/ 1000 pop

>1000/ 1000 pop

>1000/ 1000 pop

27

Output

HMIS

Annually

National

98 90%

119 92%

122 94%

126 96%

130 98%

134 100%

161

No.

Indicator Health impact services - % of non public providers in hard to reach areas signed SLAs with DHOs -% of monthly drug deliveries monitore d by health facility committe es - % of health facilities with stock outs of tracer medicines in last 7 days (TT vaccine, LA, Oxytocin, ORS, Cotrimoxazole, Diazepam Inj., All Rapid HIV Test kits,

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11)

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

28

Output

HMIS

Annually

National/ District

76

29

Output

HMIS

Annually

National/ District

85%

87%

89%

92%

95%

95%

30

Input

LMIS

Annually

National/ District

TT vaccine= 98% LA=98% Oxytocin= 95% ORS= 97% Cotrimoxazole= 99% Diazepam Inj.= 94% All Rapid HIV Test kits=89% TB drugs= 99%

TT vaccine= 100% LA=100% Oxytocin= 100% ORS= 100% Cotrimoxazole= 100% Diazepam Inj.=100% All Rapid HIV Test kits=100 % TB drugs=

TT vaccine= 100% LA=100% Oxytocin= 100% ORS= 100% Cotrimoxazole= 100% Diazepam Inj.=100% All Rapid HIV Test kits=100% TB drugs= 100% Magnesiu

TT vaccine= 100% LA=100% Oxytocin = 100% ORS= 100% Cotrimoxazole= 100% Diazepam Inj.=100 % All Rapid HIV Test kits=100 % TB

TT vaccine= 100% LA=100% Oxytocin = 100% ORS= 100% Cotrimoxazole= 100% Diazepam Inj.=100 % All Rapid HIV Test kits=100 % TB

TT vaccine= 100% LA=100% Oxytocin= 100% ORS= 100% Cotrimoxazole= 100% Diazepam Inj.=100% All Rapid HIV Test kits=100 % TB drugs=

Baselines for 6 tracer medicine s to be establish ed

162

No.

Indicator Health impact TB drugs Magnesiu m Sulphate, Gentamic in, Metronida zole, Ampicillin , Benzyl penicillin, Safe Blood, RDTs)

Purpose

Data source

Monitoring Frequency

Aggre gation

Baseline (2010-11) Magnesiu m Sulphate= Gentamici n= Metronida zole= Ampicillin = Benzyl penicillin = Safe Blood= RDTs=

Target (2011-12) 100% Magnesiu m Sulphate= Gentamici n= Metronida zole= Ampicillin = Benzyl penicillin = Safe Blood= RDTs= 70%

Target (2012-13) m Sulphate= Gentamici n= Metronidaz ole= Ampicillin = Benzyl penicillin= Safe Blood= RDTs=

Target (2013-14) drugs= 100% Magnesi um Sulphate = Gentamic in= Metronida zole= Ampicillin = Benzyl penicillin = Safe Blood= RDTs= 80%

Target (2014-15) drugs= 100% Magnesi um Sulphate = Gentamic in= Metronida zole= Ampicillin = Benzyl penicillin = Safe Blood= RDTs= 85%

Target (2015-16) 100% Magnesiu m Sulphate= Gentamici n= Metronida zole= Ampicillin = Benzyl penicillin= Safe Blood= RDTs= 90%

Comments

31

32

33 34

- % of health facilities supervise d and written feedback provided -% facilities reporting data (according to national guidelines) -% districts reporting timely data - Bed occupanc y rate Health Investm ent

Output

HMIS

Annually

National/ District

63%

75%

Output

HMIS

Annually

National/ District

96%

96%

96%

98%

98%

100%

Output Outcome

HMIS Surve y

Annually Annually

National National

52% 50%

60% 55%

65% 60%

70% 65%

80% 70%

90% 80%

163

No.

Indicator Health impact -% health facilities with functionin g equipmen t in line with standard equipmen t list at time of visit -% health facilities with functionin g water, electricity & communi cation at time of visit -% health centres with minimum staff norms to offer EHP services - % GoM budget allocated to health sector

Purpose

Data source PAMIS

Monitoring Frequency Annually

Aggre gation National/ District

Baseline (2010-11) Baseline to be establishe d

Target (2011-12)

Target (2012-13)

Target (2013-14)

Target (2014-15)

Target (2015-16)

Comments

35

Input

36

Input

HMIS

Annually

National/ District

79% w 81% e 90% c

100% w 100% e 100% c

37

Input

HMIS

Annually

National/ District

Clinician= 30% Nurses/M ws=50% EHO/HA= 48% Composite=19% 12.4%

Clinician= 40% Nurses/M ws=55% EHO/HA= 50% Composite=25%

Clinician= 50% Nurses/Mw s=60% EHO/HA= 55% Composite=30%

Clinician= 60% Nurses/M ws=65% EHO/HA= 60% Composite=35% 13%

Clinician= 70% Nurses/M ws=70% EHO/HA= 65% Composite=40%

Clinician= 80% Nurses/M ws=75% EHO/HA= 70% Composite=45% 15%

38

Input

MOF

Annually

National

164

165