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SWAP

MID-YEAR
REPORT
2014-2015
DRAFT

TABLE OF CONTENTS
ABBREVIATIONS ...................................................................................................................................... 6
EXECUTIVE SUMMARY ............................................................................................................................ 8
1

CHAPTER ONE: INTRODUCTION ..................................................................................................... 11


1.1

Background.............................................................................................................................. 11

1.2

Process of Developing the Mid Year Report ........................................................................... 11

1.3

Outline of the Report .............................................................................................................. 11

CHAPTER TWO: HEALTH SECTOR FINANCING ................................................................................ 13


2.1

Background.............................................................................................................................. 13

2.2

Performance of SWAp Pool Account ....................................................................................... 13

2.3

Performance of Discrete Partner Resources that pass through the MOH .............................. 14

2.4

Resources for the National Aids Commission and Discrete Project Pools .............................. 15

2.5

Health Regulatory Bodies ........................................................................................................ 17

2.6

Health Sector Training Institutions.......................................................................................... 17

2.7

Christian Health Association of Malawi (CHAM) ..................................................................... 18

2.8

Summary ................................................................................................................................. 18

Chapter 3: Health Systems Performance ....................................................................................... 19


3.1

Background.............................................................................................................................. 19

3.2

Human Resources for Health .................................................................................................. 19

3.2.1

Data Management............................................................................................................ 19

3.2.2

Training ............................................................................................................................. 19

3.2.3

Human Resource Management........................................................................................ 20

3.3

Drugs and Medical Supplies .................................................................................................... 21

3.4

Essential Equipment ................................................................................................................ 24

3.4.1
3.5

Infrastructure Development.................................................................................................... 27

3.5.1
4

Donation ........................................................................................................................... 27

Progress of Selected Projects ........................................................................................... 27

CHAPTER 4: PERFORMANCE OF HEALTH SERVICE DELIVERY ......................................................... 30


4.1

Background.............................................................................................................................. 30

4.2

Universal Access and Health Service Utilization ..................................................................... 30

4.2.1

Universal Access ............................................................................................................... 30

4.2.2

Health Service Utilisation ................................................................................................. 31

4.2.3

Referral System ................................................................................................................ 33

4.2.4

Hospital Attendance, Admissions and Deaths ................................................................. 33

4.2.5

Performance of Central Hospitals ................................................................................... 34

4.3

Disease Specific Progress Reports ........................................................................................... 35

4.3.1

Maternal Health ............................................................................................................... 35

4.3.2

Promotion / Prevention/Protection ................................................................................. 39

4.3.3

Malaria.............................................................................................................................. 41

4.3.4

Diarrheal diseases ............................................................................................................ 45

4.3.5

Tuberculosis...................................................................................................................... 47

4.3.6

Nutrition ........................................................................................................................... 48

4.3.7

Family Planning ................................................................................................................ 49

4.3.8

NCDS ................................................................................................................................. 50

4.3.9

Resilience of the Health System ....................................................................................... 57

CHAPTER 5: BEYOND 2015 REFORMS IN THE HEALTH SECTOR .................................................. 59


5.1

Introduction............................................................................................................................. 59

5.1.1

Reviewing the partnership with the Christian Health Association of Malawi (CHAM) .... 59

5.1.2

Establishing a Health Fund ............................................................................................... 60

5.1.3

Revitalization of Health Insurance Schemes .................................................................... 62

5.1.4

Reforming Hospital Operations ........................................................................................ 62

5.2

Improving Planning, Budgeting, Funding and Oversight Mechanisms of the Health ............. 63

FIGURES
Figure 1: Discrete Project Resources .................................................................................................... 16
Figure 2: NAC Pool Resources ............................................................................................................... 16
Figure 3: Facility Logistics Reporting Rate ............................................................................................ 24
Figure 4: Availability of basic equipment (N=997) ................................................................................ 25
Figure 5: Functional Status of Devices by Test Type ............................................................................. 26
Figure 6: Service contract and functional status of devices by test type ............................................. 26
Figure 7: Comparison of utilization rates and percentage of population not within 8kms of a
government facility ............................................................................................................................... 32
Figure 8: distribution of deaths by cause among children under-five .................................................. 34
Figure 9: Child Complications at Birth................................................................................................... 36
Figure 10 RMNCH Scorecard comparing both January to June 2014 (H1) to July to December 2014
(H2) by District ...................................................................................................................................... 37
Figure 12: Proportion of Children Immunized at District Level ............................................................ 40
Figure 13: Malaria Incidence Rates ....................................................................................................... 41
Figure 14: malaria death rates by district ............................................................................................. 42
Figure 15: percent distribution of diarrhea and dysentery cases in Malawi ........................................ 46
Figure 16: trends in diarrhea incidence rate......................................................................................... 46
Figure 17: distribution of diarrhea cases and deaths due diarrhea ...................................................... 47
Figure 18: distribution of new tb cases and population distribution ................................................... 48
Figure 19: Women Family Planning Method Utilization ....................................................................... 49
Figure 20: Age Distribution of Women Accessing Jadelle and Depo-Provera ...................................... 49
Figure 21: HMIS Road Traffic Injuries, July to December 2014 ............................................................ 51
Figure 22: HMIS Road Traffic Injuries, A Comparison Between July to December 2014 and January to
December 2013 ..................................................................................................................................... 52

TABLES
Table 1: 2014/15 SWAP POOL ACCOUNT PERFORMANCE ................................................................... 13
Table 2: Discrete Partner Disbursements through the MOH ................................................................ 15
Table 3: Health Sector Institutions Budget Performances .................................................................... 17
Table 4: Heath Sector Training Institutions Provisions and their Disbursements ................................ 17
Table 5: CHAM PE Budget and Expenditure as at 31st December 2014 .............................................. 18
Table 6: Financial Forecast of Medicines and Medical Supplies for Fiscal Year 2014/15 ..................... 21
Table 7: Stock out rates for tracked tracer commodities from July December 2014 ........................ 22
Table 9: hospital attendance, admissions, and deaths ......................................................................... 33
Table 10: performance of the four central hospitals in the country .................................................... 35
Table 11: Vaccination Coverage by District .......................................................................................... 40
Table 12: progress on selected malaria indicators ............................................................................... 42
Table 13: Central Hospitals Road Traffic Injuries, Deaths, and Case-fatality Rates, July to December
2014 ...................................................................................................................................................... 53
Table 14: District Road Traffic Injuries, Deaths, and Case-fatality Rates, July to December 2014 ....... 53
Table 15 All Injuries reported through HMIS at Kamuzu Central Hospital (KCH), July to December
2014 ...................................................................................................................................................... 54
Table 16 Mental Health Cases, reported from Kamuzu Central, Mzuzu Central, Queen Elizabeth
Central, July to December 2014 ............................................................................................................ 55
Table 17 Mental Health Cases, reported from Nkhata bay, Rumphi, and Balaka, July to December
2014 ...................................................................................................................................................... 56

ABBREVIATIONS
3PL
AIDS
AIPs
ANC
ARV
BEmOC
CDC
CDC
CHAI
CHAM
CMST
DfID
DHIS 2
EHP
EMS
EW
FICA
FY
GBV
GF
HFS
HIV
HMIS
HRH
HSAs
HSS
HSSP
HTIs
HTSS
IFMIS
iHRIS
IPTp
ITN
KCH
KCH
MCH
MIS
MOH
MOU
NAC
NHA
OFID
OJT
OPA
OPC

Third Party Logistics


Acquired Immunodeficiency Syndrome
Annual Implementation Plans
Antenatal Care
Antiretrovirals
Basic Emergency Obstetric Care
Centers for Disease Control and Prevention
Centres for Disease Control and Prevention
Clinton Health Access Initiative
Christian Health Association of Malawi
Central Medical Stores Trust
Department for International Development (UK Government)
District Health Information Software
Essential Health Package
Emergency Medical Services (EMS)
Establishment Warrant
Flanders International Cooperation Agency
Fiscal Year
Gender Based Violence
Global Fund
Health Financing Strategy
Human Immunodeficiency Virus
Health Management Information System (HMIS).
Human Resources for Health
Health Surveillance Assistants
Health System Strengthening
Health Sector Strategic Plan 2011-2016
Health Sector Training Institutions
Health Technology Support Services
Integrated Financial Management Information System
Integrated Human Resource Information System
Intermittent Preventive Treatment of malaria for pregnant women
Insecticide Treated Net
Kamuzu Central Hospital
Kamuzu Central Hospital
Mzuzu Central Hospital
Malaria Indicator Survey
Ministry of Health
Memorandum of Understanding
National Aids Commission
National Health Accounts
Open Fund for International Development
On the Job Training
Organization Performance Agreement
Office of the President and Cabinet
6

OPD
ORT
PE
PLHIV
QECH
RTI
SADC
SLAs
SPA
SWAp
TB
THE
UNHCR
USAID
VSUs
WHO
ZCH
ZMH

Outpatient Department
Other Recurrent Transactions (ORT)
Personal Emoluments (PE)
People living with HIV/AIDs
Queen Elizabeth Central Hospital
Road Traffic Incidents
Southern African Development Community
Service Level Agreements
Service Provision Assessment
Health Sector Wide Approach
Tuberculosis
Total Health Expenditure
United Nations High Commission for Refugees
United States Agency for International Development
Victim Support Units
World Health Organization
Zomba Central Hospital
Zomba Mental Hospital

EXECUTIVE SUMMARY
Overall performance in the health sector as measured by health outcomes has been mixed.
Preventable and communicable diseases still bear the majority of out-patient attendances
and admissions and are responsible for the majority of deaths. There were a total of
5,388,976 out-patient attendances with 340,089 admissions and a total of 9,107 reported
inpatient deaths.
Maternal, neonatal and child health outcomes remain a priority for this Ministry. Antenatal
care services are crucial for safe motherhood as they are instrumental in supporting early
identification of pregnancy related complications and allow for early treatment. In the first
half of the 2014/2015 financial year, the Ministry of Health recorded 31,741 women visiting
ANC in their first trimester of pregnancy out of 301,483 new pregnancies representing
10.5% which is far below the 2015 target of 17%. With respect to deliveries, in total there
were 240,527 recorded births at the facility level, of which, 230,700 (96%) happened at a
health facility. Considering expected projected births, the current recorded 240,527 births
represents 61% of total expected births indicating that many births may not be recorded at
the facility level. Consequently, this implies that some statistics need more robust
measurement.
Malaria continues to be one of the leading causes of morbidity and mortality. Malawi has
seen a decline in the incidence of malaria but that could also have been due to
underreporting of cases by health facilities. However, between 2012 Malaria Indicator
Survey (MIS) and the 2014 MIS there has been an increase in the number of pregnant
women receiving two or more doses of Intermittent Preventive Treatment of malaria for
pregnant women (IPTp) (55% to 63%), a greater percentage of pregnant women (51% to
62%) and children under 5 (56% to 67%) sleeping under an Insecticide Treated Net (ITN) and
a greater proportion of people with malaria that had access to treatment (24% to 31.2%).
Another major contributor to morbidity is Human Immunodeficiency Virus (HIV) / Acquired
Immunodeficiency Syndrome (AIDS). The most recent estimates suggest a national average
HIV incidence of 0.41 per 100 person-years among adults (1549). In 2013, over 50% of the
1 million People Living with HIV (PLHIV) were living in six of Malawis 28 districts, which
account together for 42% of the countrys population. The stabilising prevalence of HIV is
possibly due to greater access to treatment with a simultaneous drive to prevent new
infections. As of September 2014, 521,319 were on antiretrovirals (ARVs) representing 52%
of the estimated HIV positive population. 52% of all new infections in 2014 were estimated
to be among females and 36% of these were adolescent/young women (15-24 years).
Associated with HIV, there has been a dramatic increase in the number of confirmed
Tuberculosis (TB) cases between July to December 2013 and July to December 2014 (from
6,008 to 13,734 to) possibly reflecting increased access and use to near-patient rapid

diagnostic tests (GenXpert) with greater sensitivity than previous diagnostic tests (sputum
smear microscopy).
A significant proportion of diarrheal disease can be prevented through safe drinking-water
and adequate sanitation and hygiene. In 2014, the Environmental Health Directorate
reported that 78% of households had latrines compared to 64% in 2010. Percentage of
households with hand washing facilities went from 10% in 2010 to 24% in 2014.
Despite 96% of recorded births occurring at a health facility, Antenatal Care (ANC)
attendance in the first trimester (10.5%) was still lower than the target for 2015 (17%).
Among the four leading causes of death to children under five, the majority (58%) were due
to malaria, followed by 19.4% due to acute respiratory infections, 11.9% due to
malnutrition, and 10.8% due to diarrhea.
Positively, Malawi exceeded their target for the proportion of children under the age of one
year fully immunized by 4% to give a total of 89%. Comparing with targeted outcomes
measles (91%) is 1% above the targeted 90% and Pentavalent 3 (91%) is 2% short of the
targeted 93%. Despite this outstanding performance, immunisation rates for children for
some districts remain relatively low.
For the first time in the Mid Year Report there are reports on Gender Based Violence (GBV)
with 697 cases of GBV being reported in the One Stop Centers and 7,772 to Victim Support
Units (VSUs) between July and December 2014. Similarly, injuries resulting from road traffic
incidents (RTI) are also reported for the first time. In the period under review, 2,758 road
traffic injuries were reported at Central Hospitals, with over half of these reported at KCH.
By collecting and reporting data on GBV and RTI, the Ministry of Health can make efforts to
reduce cases of both.
Under Health System Strengthening (HSS), the Ministry of Health continued with its efforts
in the areas of training, recruitment, deployment and retention of health professionals to
deliver the essential health package; construction, rehabilitation and expansion of health
infrastructure focusing on building and maintenance of hospitals, health centers and staff
houses; capitalization of the Central Medical Stores Trust (CMST) to ensure efficiency of the
supply chain for essential drugs and medical supplies; improving financial and procurement
management systems to ensure efficient use of resources; and development and review of
policies and guidelines to provide strategic direction to all players in the health sector.
In terms of developments in the period under review, the outbreak of Ebola in some parts of
West Africa remained a very important threat in 2014 which required the country to
develop and implement a clear strategy for preventing the outbreak in the first place, and
containing it in the event of an outbreak. Another threat to the health system was the
flooding in the country which led to a cholera out-break which reappeared after three years.
In addition, as part of a program of wider Public Sector Reform launched in February 2015,
9

the Ministry of Health is reforming elements in the current system to deliver high quality,
efficient and effective health services. The initial reform areas include proposals to:

Review the Memorandum of Understanding (MOU) between the Christian Health


Association of Malawi (CHAM) and the Ministry of Health to broaden access of
health services especially by those in rural and hard-to-reach areas;
Establish a Health Fund to generate more resources for the Health Sector;
Revitalise the Medical Insurance Schemes of the country to broaden choice for
health service delivery systems; and
Reform hospital operations to improve their effectiveness and efficiencies in
delivering services.

The Health Sector Wide Approach (SWAp) adopted in 2004 is still an overarching framework
for planning, financing and monitoring implementation of the HSSP. In the period under
review, despite the setback due to Cashgate, Government continued to increase its
contribution to almost four times the previous years contribution to the SWAp Pool.
Furthermore, Norway supported the Health Sector Budget by directly providing resources to
Central Hospitals and District Hospitals through the discrete account, partially easing the
health financing gaps in service delivery. United Nations High Commission for Refugees
(UNHCR), Global Fund and Centers for Disease Control and Prevention (CDC) also supported
the Ministry of Health to implement national programs in the Health Sector. Going forward,
Government and Partners are working on developing a Common Funding Mechanism for
the Health Sector as well as Common Planning and Budgeting, and, Fiduciary Arrangement
that will allow efficient allocation and use of health sector resources in the Country.

10

CHAPTER ONE: INTRODUCTION

1.1 Background
As part of its mandate to achieve a state of health for all people in Malawi that would
enable them lead a quality and productive life, the Ministry of Health (MOH) is
implementing a Health Sector Strategic Plan 2011-2016 (HSSP) with its Partners within a
Health Sector Wide Approach (SWAp) arrangement. An important feature of the SWAp
arrangement is the joint implementation and monitoring and evaluation of the HSSP
between Government and its Donors and Implementing Partners. The overall objectives of
the Health Sector Strategic Plan include (i) Increasing coverage of the Essential Health
Package (EHP) interventions where particular attention has been given to impact and
quality; (ii) Strengthening the performance of the health system to support delivery of EHP
services; (iii) Reducing risk factors to health; and (iv) Improving equity and efficiency in the
delivery of quality EHP services. As part of the SWAp Arrangement, each Fiscal Year (FY), the
MOH develops and implements Annual Implementation Plans (AIPs) for the HSSP which are
reviewed jointly twice a year, at Annual and Mid-Year SWAp reviews. This report has been
prepared for the SWAp Mid Year review and covers the period June 2014 to December 2014
of the 2014/15 Fiscal Year. The report presents the progress on various programs, projects,
interventions, and activities.

1.2 Process of Developing the Mid Year Report


This report was prepared based on both quantitative and qualitative data. Quantitative data
mainly came from the District Health Information Software (DHIS 2) aggregated monthly
reports for the entire period. This data was used to calculate key indicators for monitoring
the performance of the Health Sector. Other key sources of information included: (i) The
Health Sector Strategic Plan 2011 2016; (ii) MOH activity plan for 2013/14; (iii) Sector
Performance Review Reports including the Organization Performance Agreement (OPA)
Reports, Zonal Health Reviews and Reports; Health Research Reports (iv) IFMIS Expenditure
Reports; (v) The Health Sector Working Group Reports; and (vi) Integrated Human Resource
Information System (iHRIS).

1.3 Outline of the Report


This SWAp Mid Year Report is organized in five chapters. Chapter Two presents the health
financing situation for the period under review. Chapter Three discusses the performance in
11

key health systems strengthening areas, focusing on human resources for health, essential
medicines and supplies, infrastructure and equipment. Chapter Four presents progress on
health service delivery and; Chapter Five highlights the key developments in the Health
Sector including the reform agenda the Ministry has embarked on as part of the
Government Wide Public Sector Reform Programme1.

Public Services Reform Commission: Making Malawi Work (Final Report) 2015

12

CHAPTER TWO: HEALTH SECTOR FINANCING

2.1 Background
The countrys Health Sector is financed largely by SWAp Pool Donor Partners who finance
the health sector through the Government System, Discrete Donor Partners who support
various initiatives and Projects, the private sector, and Non-Government Organizations.
Resource Mapping Round Three showed that a total of MK278.8 billion is available for the
2014/15 Fiscal Year. Of the available resources, approximately MK71.8 billion comes from
the MOH Pool representing 26% of the total resource envelope, MK56 billion comes from
the National AIDS Commission (NAC) Pool representing 20% and the rest MK151 billion are
Discrete Project resources which account for 54% of the total resources.
Of the MK71.8 billion SWAp Pool resources, the Governments contribution was MK65.8
billion (92%) while the balance of MK6 billion are from Pool Partners representing 8% of the
resources. This is unique in that before this Fiscal Year, Governments contribution to the
SWAp Pool was less than SWAp Pool Partners. This situation came about due to other SWAp
Pool Partners withholding resources following the Cashgate scandal.
The disbursed MK6 billion SWAp Pool resources predominantly came from the Norwegian
and Flemish Governments who provided their resources directly to the Central and District
Hospitals through a mechanism of Discrete Accounts. It must be emphasized that without
this arrangement in place, and, if Government had not increased its resources to the Health
Sector in the period under review, health service delivery would have been severely
paralyzed, leading to the reversal of many of the gains gains made in the Health Sector in
the past decade. It is important that as Government continues to strengthen its financial
management systems, and Donor Aid resumes in the future, Government continues with
the present efforts in health sector financing.

2.2 Performance of SWAp Pool Account


The SWAp Pool Account constitutes all health resources that go through the Ministry of
Health Headquarters, Central Hospitals and District Councils. In terms of the National
Budget, MOH Headquarters and Central Hospitals are part of Vote 310, and District Councils
are part of 900 series Votes. As shown in Table 1 below, in the 2014/15 Fiscal Year, the
SWAp Pool Account comprised both Vote 310 and 900 series. The total funding for the
Health Sector was MK65.8 billion covering Other Recurrent Transactions (ORT), Personal
Emoluments (PE) and Development (including Donor-funded and Infrastructure projects)
Budget resources.
TABLE 1: 2014/15 SWAP POOL ACCOUNT PERFORMANCE

13

Budget
Category
PE Vote 310
ORT Vote
310

2014/15 Approved
Provision (MK)

2014/15 Revised
Budget (MK)

Disbursements by Mid
Year (MK)

% Absorption
(MK)

29,037,646,770

29,037,646,770

18,616,342,437

64%

15,146,855,505

15,146,855,505

4,973,949,845

33%

44,184,502,275

44,184,502,275

23,590,292,282

53%

Govt Funded
Project
Resources

5,725,044,839

5,725,044,839

1,149,489,528

20%

Total Capital

5,725,044,839

5,725,044,839

1,149,489,528

20%

DHO ORT
DHO Drug
Budget
Total
Transfers to
DHO ORT
Total Health
Sector
Resources

6,000,000,000

6,000,000,000

3,320,101,507

55%

9,500,000,000

9,500,000,000

3,492,942,632

37%

15,500,000,000

15,500,000,000

6,813,044,139

44%

65,409,547,114

65,409,547,114

31,552,825,949

48%

Of the budgeted MK65.8 billion SWAp Pool resources, the expenditure at 31 December 2014
were MK32 billion representing absorption rate of 48%. PE had the highest absorption rate of
64%, indicating that there is a high likelihood that the Ministry is to exceed its 2014/15 PE
budget. This is to be expected due to the salary increases that were implemented inside the
2014/15 Fiscal Year. Considering the ORT Budget for the Ministry of Health, Central Hospitals
and Zonal Offices, a total of MK5 billion was spent against the annual revised budget of
MK15.1billion which represents an absorption rate of 33%. For DHOs, by 31st December
2014, the total expenditures on ORT was approximately MK6.8 billion, against a budgetary
provision of MK15.5 billion thus representing a budget utilization rate of 44% during the
reporting period. Coming to the Development Budget, a total of MK1.2 billion was used
against an annual Budget provision of MK5.7 billion. The low budget utilization on both the
ORT and Development Budget reflect the low funding that characterised the first quarter of
the 2014/15 Fiscal Year. The situation improved significantly in the second quarter, with
most cost centres being funded within or substantially over their cash flows, thereby easing
the budgetary pressures on both the ORT and Development Budgets.

2.3 Performance of Discrete Partner Resources that pass through the MOH
Table 2 shows that the total budget for Discrete Partner resources is projected at MK24.6
billion in the 2014/15 Fiscal Year. As of 31 December 2014, only about MK8.1 billion of these
resources were disbursed to various Projects. As the table depicts, Discrete Partners that
disbursed their resources to the Ministry of Health in the 2014/15 Fiscal Year included the
Global Fund, Norway/FICA, UNHCR, and Centres for Disease Control and Prevention (CDC).
Global Fund (GF) disbursed 15% of their commitment at MK2.7 billion against an annual
14

commitment of MK17.5 billion. Similarly, UNHCR disbursed 42% of their commitment at


MK36.5 million against an annual commitment of MK87.7 million. Norway/FICA disbursed
MK4.2 billion against MK5.2 billion representing 81% disbursement while CDC disbursed
MK1.1 billion against an annual commitment of MK1.9 billion reflecting a 61%
disbursement. Overall, therefore, disbursements for Discrete Partner resources through the
Ministry of Health were low at 33% in the first half of 2014/15 Fiscal Year.

TABLE 2: DISCRETE PARTNER DISBURSEMENTS THROUGH THE MOH

Discrete Donor

2014/15
Expected
Disbursements (MK)

Disbursement for Mid


Year (MK)

% Disbursed as at
December 2014 (MK)

Norway/FICA

5,202,003,261

4,205,743,959

81%

UNHCR

87,729,027

36,564,234

42%

Global Fund (GF)


Centres for Disease
Control
and
Prevention (CDC)

17,468,327,200

2,704,228,664

15%

1,867,095,646

1,148,144,102

61%

Total

24,625,155,134

8,094,680,959

33%

31

st

In terms of the priority areas, the resources from Global Fund (GF) are being used for the
implementation of Malaria, Tuberculosis (TB), and HIV/AIDS programmes. Funds from the
Centres for Disease Control & Prevention (CDC) are, through PEPFAR (Presidents Emergency
Fund for Aids Response), for the implementation of HIV/AIDS Response, though they have
also strengthened Prevention and Treatment of HIV- Tuberculosis, Maternal and Newborn
Health, Malaria, laboratory services through provision of training, supervision; and
management of the laboratory information system across the country. Similarly, resources
from Norway and FICA are targeted towards the provision of key priority items in Central and
District Hospitals such as rations and provisions, maintenance of motor vehicles, purchase of
fuel, payment for Service Level Agreements (SLAs) and other medical expenses, payment of
locum, and infrastructure maintenance.

2.4 Resources for the National Aids Commission and Discrete Project Pools
Resources for National Aids Commission (NAC) and Discrete Project Pools were projected at
MK56 billion and MK151 billion respectively in the 2014/15 Fiscal Year. Of the NAC Pool
Resources, Global Fund (GF) contributed MK47 billion while the balance of MK9 billion was
provided by World Bank (MK4.5 billion), DfID (MK2.8 billion), CDC (MK1.1 billion), and
Government of Malawi through Ministry of Health (MK600 million).

15

As for the Discrete Project Resources, out of the total projected inflow of MK151 billion,
USAID provided MK35 billion, Global Fund MK24 billion, DfID MK14 billion, CDC MK9 billion,
Norway MK9 billion, GAVI MK6 billion, Germany-KfW MK5 billion and all others MK50
billion. Figure 1 and
Figure 2 below depict the resources in the NAC and Discrete Project Pools which were made
available in the 2014/15 Fiscal Year.
FIGURE 1: DISCRETE PROJECT RESOURCES

USAID
Global Fund
MK35 billion

DfID
Norway

MK50 billion

CDC
MK24 billion

GAVI
Germany

MK5 billion
MK6 billion

MK14
MK9 billion
billion

All Others

MK9 billion

FIGURE 2: NAC POOL RESOURCES


MK1.1 billion
MK2.8 billion

MK0.6 billion

MK4.5 billion

Global Fund
World Bank
DfID
CDC
MK47 billion

Gov`t

16

2.5 Health Regulatory Bodies


The Ministry of Health also supports operations of Health Regulatory bodies to facilitate
monitoring of healthcare practitioners and facilities, provide information about industry
changes, promote safety and ensure legal compliance and quality services.
Table 3 below shows the 2014/15 Budget provisions for these Health Sector institutions and
their disbursements as of 31st December 2014. As the table depicts, all but three of the
Health Sector institutions were given over half of their annual appropriations from the
Ministry of Health. The Malawi Against Polio (MAP), Malawi Traditional Healers Umbrella
Organization (MTHUO), and Nurses and Midwives Organization of Malawi received over half
of their annual provisions; while the Pharmacy, Medicines and Poisons Board (PM&PB) and
Medical Council were only given 28% and 40% of their annual provisions respectively and
Malawi Blood Transfusion Services has not received any funding for the period under
review.
TABLE 3: HEALTH SECTOR INSTITUTIONS BUDGET PERFORMANCES
Institution
Malawi Against Polio
Malawi Blood Transfusion
Services
MTHUO
Pharmacy, Medicines and
Poisons Board (PM&PB)
Medical Council
Nurses and Midwife Council
of Malawi
Total

st

2014/15
Approved Disbursement for
Provisions (MK)
Mid Year (MK)
80,000,000

by % Disbursed as at 31
December 2014 (MK)
165%
131,812,638

165,000,000

0%
50%

30,000,000

15,000,000

5,612,253

1,547,635

28%

30,630,207

12,123,137

40%

74,747,540

37,741,363

385,990,000

198,224,773

50%
51%

2.6 Health Sector Training Institutions


Health Sector Training Institutions in Malawi (HTIs) provide pre and post training to health
workers as one way of enhancing the capacity of health workers in different areas of
specialization. In 2014/15 Fiscal Year, HTIs had a provision of MK6.1billion to support their
day-to-day operations as per the breakdown in
Table 4 below.
TABLE 4: HEATH SECTOR TRAINING INSTITUTIONS PROVISIONS AND THEIR DISBURSEMENTS
2014/15
Provisions Disbursement by Mid % Disbursed as at
Institution
(MK)
Year (MK)
December 2014 (MK)
Malawi College of Health 453,979,800
226,989,909
Sciences
50%
Kamuzu College of Nursing 2,430,758,389
1,026,264,065
42%

31

17

st

College of Medicine

3,214,104,063

1,602,721,191

Total

6,098,842,252

2,855,975,165

50%
47%

As the Table depicts, about K2.9 billion was disbursed by Ministry of Finance to these
institutions in the first half of the 2014/15 Fiscal Year reflecting a disbursement
performance of 47%. Malawi College of Health Sciences and College of Medicine each
received disbursements of about 50%. However, Kamuzu College of Nursing received about
47% of its annual provision.

2.7 Christian Health Association of Malawi (CHAM)


Government of Malawi through the Ministry of Health pays salaries for health workers in
various Christian Health Association of Malawi (CHAM) facilities and training institutions in
the country. Out of the Personnel Emoluments (PE) provision of MK29 billion for Vote 310
for the 2014/15 Fiscal Year, CHAM had a PE provision of MK7 billion. Of these resources,
CHAM received K3.5 billion as at 31st December 2014 representing a budget utilization rate
of 50% as shown in Table 5 below.
TABLE 5: CHAM PE BUDGET AND EXPENDITURE AS AT 31ST DECEMBER 2014
Institution
CHAM
Total

2013/14 CHAM PE Provision


7,026,273,192
7,026,273,192

Disbursement for the year % Disbursed as at June


(MK)
2014 (MK)
3,511,411,460
50%
3,511,411,460
50%

2.8 Summary
This chapter has looked at the Fiscal Performance of the Health Sector in the first half of the
2014/15 Fiscal Year. The analysis of the health financing situation showed that there exist
severe funding gaps in the health sector. Of concern are the low disbursement rates in the
first half of the 2014/15 Fiscal Year. While the situation for SWAp resources improved in the
second quarter, there is need for Government and Partners, especially those committing to
the Development Budget, to find mechanisms that address the low disbursement rates that
characterized Discrete Partner Resources.

18

CHAPTER 3: HEALTH SYSTEMS PERFORMANCE

3.1 Background
This chapter looks at the health systems performance on key areas of focus in the HSSP such
as Human Resources for Health, Health Infrastructure, Medical Equipment, and Drugs and
Medical Supplies. The Human Resources section discusses the performance in terms of data
management, training and recruitment. The Drugs and Medical Supplies section reviews the
performance of the Ministry of Health in terms of maintaining availability of key medicines.
The Health Infrastructure section discusses progress of major projects that the Ministry
undertook between July and December 2014. Finally, the Medical Equipment section reviews
the state of equipment required for the delivery of health services.

3.2 Human Resources for Health


In 2014/15 Fiscal Year, the Department of Human Resources in the Ministry of Health had
four main intervention areas, namely; Data Management on Human Resource for Health;
Training; and; Human Resources Management.

3.2.1 Data Management


During the reporting period, the Ministry of Health has been able to update the Integrated
Human Resources Information System (iHRIS) using data collected from Human Resources
Headcount. One key use of the IHRIS platform is in the analysis of vacancy rates across
different cadres, Zones, Districts as well as Facility types. Based on the data from the iHRIS,
there has been some progress in the availability of human resources for health, with the
overall vacancy rate declining from 36% to 34% between June and December 2014.

3.2.2 Training
Pre- Service
Government continued to support students for pre-service training in various courses, and a
total of MK574,798,100 was spent on 1,006 students in various programmes.

In-service
The country continues to face a critical shortage of Medical Specialists across hospitals.
Consequently, in addition to implementing incentives to attract available specialists,
19

Government is currently sponsoring Health Workers in various specialization programs


including Medical Specialists, Paedatrics, Obstetrics and gynecology, Surgery, Anesthetists,
Radiologists and Histopathologists. To meet the expected demand for cancer related services
in Malawi, a cancer capacity building program was established in which four oncologists, 32
nurses, 14 radiotherapists, six from HTSS (haemotology, toxicology and histopathology), two
in nuclear medicine, and two medical engineers will be trained. As at April 2015, five
radiotherapists and two medical engineers have been sent to school. There is increasing
demand for further education, and while the Government cannot meet all the demand, there
is also need to regulate and coordinate in-services training to ensure trainings are consistent
with the needs of the Ministry and to avoid creating staff shortages due to many staff taking
leave for further studies.

3.2.3 Human Resource Management


Recruitment
Pre-service training institutions are the primary source for recruitment for the Ministry of
Health. These training institutions produce graduates every year, with 534 graduates
between July and December 2014. Out of these, the Ministry was able to recruit 207 nurse
midwives, 15 medical doctors and 80 medical assistants. The rest, mainly nurses, were
recruited by CHAM.
In addition, the Human Resources Department obtained an Establishment Warrant (EW)
from the Office of the President and Cabinet (OPC) to create 47 positions for laboratory
technologists. The EW will assist the Ministry to absorb 90% of laboratory technologists who
have graduated from different schools. However, this alone is not adequate to address the
human resources challenges that are affecting the provision of quality laboratory services in
the country. The Ministry, therefore, hopes that the request for more positions made in the
functional review submitted to the OPC, if approved, will address the current and future
challenges, and facilitate the much needed quality improvements in laboratory services.

Promotions
The Ministry has promoted 524 staff to different positions within the reporting period under
review. Notable among the promoted are the 249 Medical Assistants who have been
promoted to Senior Medical Assistants. The Department has also conducted promotional
interviews for 1,350 Health Surveillance Assistants (HSAs) to Senior Health Surveillance
Assistants (Grade L). Furthermore, to fill the vacancies created by these promotions, the
Department has also conducted interviews for HSAs so that those who are successful can
take up the 1,350 vacant positions that will be created.

20

Management and leadership


Strengthening management and leadership of the Ministry is key to ensuring effective and
efficient delivery of health services in the Country. Between July 2014 and December 2014,
93 District Health Management Team members from the Central region have completed the
first year of training on a Management Development programme. The trainings were
conducted with support from Johnson and Johnson through the University of Cape Town.
There have also been various other trainings in leadership and management, as well as
mentorship programmes for district staff aimed at improving the delivery of the health
systems. These trainings were and continue to be supported by Donors and Implementing
Partners in the Health Sector.

3.3 Drugs and Medical Supplies


In the period under review, improvements in the availability of essential medicines and
medical supplies have been sustained due to continued financial support from donors as well
as improved coordination amongst stakeholders. In addition to drug procurement,
Department for International Development (DfID) has supported provision of Third Party
Logistics (3PL) services to the CMST. The 3PL provider will support supply chain management
services at CMST and capacity building for CMST staff. These services commenced in July
2014 and will cover distribution of medicines and medical supplies from CMST to all health
facilities in Malawi.
Additionally, a quantification exercise to estimate the need for health commodities for the
2014/15 Fiscal Year was finalized. The results (Table 6) indicated that estimated USD 69
million worth of health commodities are needed to provide public health services for the
Fiscal Year 2014/15. This estimate is for essential medicines and supplies and does not
include program-supported commodities like HIV/AIDS, Malaria and Family Planning
commodities. These results will now be examined, alongside commodities already available
in the country and those on order from CMST, to determine the gap in availability that the
government will have to fill.

TABLE 6: FINANCIAL FORECAST OF MEDICINES AND MEDICAL SUPPLIES FOR FISCAL YEAR 2014/15
Product Category

Estimate

Tablets and Capsules


Injectable
Vaccines
Galenicals
Surgical Dressings
Sutures

K7,430,746,050 KK
K3,964,915,800
K549258300
K3,486,272,850
K2,368,892,250
K2,999,850,300

21

Surgical Equipment
Laboratory
X-Ray Films and Equipment
Dental
Additional Theater Supplies
Orthopedic Supplies

K5,802,536,700
K2,973,612,600
K850,914,000
K64,499,400
K177,184,800
K249,146,550

Total

K30,917,829,600

Health Technical Support Services (HTSS), with support from the USAID DELIVER PROJECT,
continue to provide support to improve logistics operations by building capacity in storage
practices, inventory management and logistics reporting. Through regular supportive
supervision and peer mentoring activities, HTSS is able to provide On the Job Training (OJT)
to personnel at District and Health Center levels. In the period under review, MOH
introduced the role of Zonal Pharmacists to further strengthen the zonal health supervision
teams. Since the establishment of these roles, we have seen commendable improvement in
reporting compliance and support available to subnational logistics operations. The roles are
currently occupied by Acting Zonal Pharmacists while the Ministry finalizes plans to fill these
positions permanently.

TABLE 7: STOCK OUT RATES FOR TRACKED TRACER COMMODITIES FROM JULY DECEMBER 2014
Tracer Commodities Tracked for the
Period

Jul

Aug

Sep

Oct

Dec

Average

LA 6x1
Sulphadoxine 500mg / pyrimethamine
25mg (SP)

3%

5%

4%

3%

7%

4%

5%

3%

2%

1%

2%

2%

Male Condoms

13%

10%

7%

6%

9%

9%

DEPOPROVERA

11%

14%

16%

13%

8%

12%

Zinc Sulphate Dispersible tablets


Chlorehexidine Digluconate, 7.1%, 10ml
solution

1%

4%

7%

8%

8%

6%

32%

47%

15%

0%

24%

10%

6%

8%

8%

22%

48%

17%

21%

35%

17%

0%

17%

RHZE 150/75/400/275
Amoxycillin 250mg

6%

13%

Ampicillin injection 500mg, PFR


Benzylpenicillin 3g (5MU), PFR

2%

5%

10%

7%

6%

6%

Cotrimoxazole 480mg

1%

2%

5%

5%

2%

3%

Cotrimoxazole 120mg

1%

7%

4%

5%

4%

4%

Determine HIV Test Kits

3%

11%

5%

3%

3%

5%

Dextrose (glucose) 5%, 500ml

2%

17%

8%

7%

5%

8%

Diazepam 5mg/ml, 2ml

5%

15%

9%

5%

8%

9%

3%

12%

12%

11%

7%

9%

4%

21%

13%

3%

5%

9%

4%

11%

20%

8%

9%

10%

Gentamicin 40mg/ml, 2ml


Glove disposable powdered
medium, 100 pieces
Glove surgeon's size 7 sterile, pair

latex

22

Tracer Commodities Tracked for the


Period

Jul

Aug

Sep

Oct

Dec

Average

Magnesium sulphate 50%, 2ml ampoule

1%

4%

2%

2%

4%

3%

Metronidazole 200mg
Oral rehydration salt, satchet (WHO
formula) for 1L solution

9%

30%

18%

17%

12%

17%

1%

6%

10%

13%

10%

8%

Oxytocin 10 IU/ml, 1ml

1%

4%

6%

6%

7%

5%

Malaria Rapid Diagnostic Test Kits

2%

4%

2%

3%

7%

4%

Tetanus antitoxin 1500 IU

7%

50%

0%

0%

14%

22%

15%

8%

5%

12%

Sodium Chloride injectable 0.9% 500ml


Amoxycillin 125mg/5ml suspension
Benzoic acid 6% + salicylic acid 3%
ointment

6%

10%

27%

21%

12%

15%

7%

26%

28%

18%

10%

18%

Ciprofloxacin 500mg
Clotrimazole
500mg
(tablets/pessaries)

16%

39%

25%

21%

14%

23%

3%

16%

10%

6%

7%

8%

Doxycycline,100mg

3%

6%

10%

11%

10%

8%

Erythromycin 250mg
Ferrous sulphate 200mg / folic acid 250
micrograms

6%

8%

23%

27%

9%

15%

16%

31%

16%

13%

5%

16%

Hydrochlorothiazide 25mg

10%

20%

16%

17%

14%

15%

Lignocaine hydrochloride 1%, 25ml

1%

4%

6%

4%

5%

4%

Paracetamol 500mg

3%

9%

22%

25%

19%

16%

Paracetamol syrup 120mg/5ml, 100ml

10%

15%

51%

52%

24%

30%

Praziquantel 600mg

7%

16%

12%

9%

5%

10%

Promethazine hydrochloride 25mg

2%

8%

8%

8%

7%

7%

Salbutamol 4mg
Bag tablet dispensing,
disposable 9 x 10cm

33%

33%

23%

14%

9%

22%

31%

36%

22%

18%

17%

25%

Bandage, WOW 10cm x 4m

23%

62%

53%

25%

21%

37%

Bandage, WOW 7.5cm x 4m

20%

52%

31%

15%

18%

27%

Cotton wool 500g

4%

7%

17%

19%

31%

16%

Plaster, zinc oxide 10cm x 5m

1%

26%

19%

6%

5%

11%

vaginal

polythene,

Table 7 shows the stock out rates of tracked commodities at the end of December 2014. The
table shows that while stock outs were kept to a minimum for some commodities, there still
exist significant challenges in the availability of essential medicines and medical supplies,
with stock-outs reaching as high as 62% for some commodities. These shortages and the root
causes leading to this situation must be addressed if the health sector is to register
substantial improvements in health outcomes to meet national and global targets.
In order to improve logistics operations, visibility into the operations of the logistics system
is essential. It is for this reason that HTSS has continued to make efforts to keep up the flow
of logistics reports from public health facilities. Beyond tracking the submission of reports,
HTSS is now tracking the timeliness of these reports as the decisions to be made are time23

sensitive and late reports are not only problematic but directly affect treatment and care. In
the period under review, HTSS has recorded an average reporting rate of 91% though a
slight dip to 85% was observed at the end of December 2014. Figure 3 below shows tracked
reporting rates.

FIGURE 3: FACILITY LOGISTICS REPORTING RATE

100%

95%
90%

90%

87%

85%

83%
86%

80%

86%

95%

90%
86%

95%

88%
85%

70%

60%
53%
50%

In the period under review, the much-needed support was provided by Partners of the
Ministry of Health that saw most Districts receive computers and internet access devices to
strengthen reporting capabilities at District-level. To ensure that the medicines and medical
supplies provided were and continue to be accounted for, assessments were done to identify
possible areas of leakage in the system. When complete, it is expected that implementable
recommendations will be submitted for consideration by the Ministry.

3.4 Essential Equipment


The Ministry of Health released the Service Provision Assessment (SPA) Report. The SPA
provides a comprehensive overview of the countrys health care services and its capacity to
provide quality care. The study used the definition of basic pieces of equipment that
should be available to guarantee its readiness for basic services as followed by the World
Health Organization (WHO) and the United States Agency for International Development
(USAID). Figure 4 reflects results from this survey.

24

FIGURE 4: AVAILABILITY OF BASIC EQUIPMENT (N=997)2

Procurement of various specialised equipment is in progress. For instance, there are four
mammography machines already delivered to sites and are awaiting installation in the
central hospitals. These will make screening for breast cancer available at the central
hospitals. Procurement of three digital radiography machines is at an advanced stage. These
will be allocated to Kamuzu Central Hospital (KCH), Mzuzu Central Hospital (MCH) and
Queen Elizabeth Central Hospital (QECH) and will address the problems that the central
hospitals face in meeting the demand for x-rays. Additionally, procurement of a ceilingmounted X-Ray machine for Salima district hospital and an X-Ray tube for Karonga district
hospital is underway. A thermos-luminescent dosimeter reader to aide in monitoring
occupational radiation exposure (of workers) was also donated by the International Atomic
Energy Agency and is awaiting installation and commissioning at Kamuzu Central Hospital.
Furthermore, procurement of five (5) standby generators to deal with power supply issues
in District Hospitals is in process and one has already been delivered to Mchinji District
Hospital. procurement of two (2) oxygen plants for KCH and QECH is underway.
Procurement of two (2) incinerators for KCH and QECH has been initiated. Basic equipment
for 60 BEmOC sites has been procured and some has already been delivered and
commissioned. Procurement of mortuary units for five district hospitals is completed, and
one mortuary unit has already been delivered to Mchinji District Hospital. The Ministry has
also procured Tecare autoclave parts for 21 machines.
Quality laboratory services are essential to the provision of quality care and treatment.
During the period under review, no new diagnostic equipment was procured and installed in
the laboratories. However, in order to establish the types of equipment and their
operational status, the Ministry of Health, with support from Clinton Health Access Initiative
2

Malawi Service Provision Assessment 2013-14

25

(CHAI), is mapping national laboratory equipment and soon the Ministry will undertake a
national laboratory quantification exercise based on the mapping results. The figures below
reflect results from the initial situational analysis in November 2014. Initial results indicate
that a lack of reagents is an important deterrent to provision of diagnostic services (Figure
5).
FIGURE 5: FUNCTIONAL STATUS OF DEVICES BY TEST TYPE

50.0%
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%

% Of devices not
functioning

% Of devices without
reagents

This reflects the difficulty faced when procuring reagents as there are large variations in the
brand of diagnostic machine used and each brand will require different reagents for the
same diagnostic test (see Figure 6).

FIGURE 6: SERVICE CONTRACT AND FUNCTIONAL STATUS OF DEVICES BY TEST TYPE


70.0%
60.0%
50.0%
40.0%
30.0%

% Of devices not functioning

20.0%

% Of devices with no current


service contract

10.0%
0.0%

Similarly, a large number of diagnostic machines do not remain on service contracts but
those that do are more likely to be functional.
26

3.4.1 Donation
The Ministry received medical equipment donations from various development partners as
listed below:
UNDP donated several basic equipment (oxygen concentrators, blood pressure
machines) and distributed these to several selected facilities.
Options donated Reproductive Health Department equipment (delivery instrument
sets, delivery beds, sterilisers) to Balaka, Ntcheu, Dedza and Mchinji district hospitals
and selected health centres within the district.
Norwegian Church Aid is renovating the main operating theatre at KCH and building
an ICU at KCH and will supply the equipment in both departments. The ICU and
Theatre equipment will be put under a service contract.
Russian Government donated ICU (ventilators) to ZCH following identified need at
ZCH for ICU equipment.
Egyptian Government supplied the ICU equipment (ventilators and patient monitors)
to ZCH and ophthalmology equipment to MCH.
Project Cure donated assorted medical equipment to KCH.

3.5 Infrastructure Development


The Ministry of Health has several infrastructure projects underway. The MOH development
budget for the 2014/15 FY was MK6.53 billion of which MK458 million was from
Development Partners. As of December 2014, the Ministry was allocated funding for the
Development Budget amounting to MK1.84 billion. Most of these resources were allocated in
the second quarter of the financial year (October-December 2014), since in the first quarter
there was only a supplementary budget as the full budget was not yet passed. This affected
the cash flow of the Ministry and subsequently had some negative implications on progress
of infrastructure projects since most outstanding payments to contractors could not be
settled leading to most of them moving out of the sites.

3.5.1 Progress of Selected Projects


Umoyo Houses
The Ministry of Health is currently constructing 140 new staff houses and 5 flats under the
Umoyo Housing Project to address accommodation problems faced by the health workforce.
As at the mid-2014/15 FY, progress was at an average of 60% for the staff houses and 50%
for the flats. This is against annual targets of 60% for the houses and 30% target for the flats.
Progress was hampered by cash-flow problems in 2013/14 FY and in the first quarter of
2014/15 FY which led to contractors abandoning their sites due to non-payment of
27

completed works. Presently, settlement of all outstanding payments is in progress and


contractors are remobilizing back to sites.
Construction of Health Centers
Construction is currently in progress for 15 health centers. Progress at mid-financial year was
at 15% against an annual target of 30%. Progress was stalled due to funding issues but
settling of outstanding payments is in process.
Rehabilitation of Central Hospitals
The Ministry of Health is currently carrying out rehabilitation works at the Queen Elizabeth
Central Hospital, Zomba Central Hospital (ZCH), Kamuzu Central Hospital, and Mzuzu Central
Hospital. Progress at QECH, was at 70% completion against the target of 80%. Zomba Central
Hospital had an annual target of 50% but no work had started by the middle of the financial
year because the project has just been retendered after being shelved for some time. For
Kamuzu Central Hospital, the annual target was 100% completion for the first phase of the
project, however, as of mid 2014/15 FY, progress was at 80% because of funding problems.
Mzuzu Central Hospital is currently constructing a CT scanner block and at December 2014
was at 38% progress. Similarly, Queen Elizabeth Central Hospital is also constructing a CT
Scanner block and at December 2014 progress was at 35%. Both have been delayed due to
issues with payments and this continues to remain a challenge.

Rehabilitation of District Hospitals


The annual target for rehabilitation works for both Balaka and Nsanje District Hospital were
100% and 80% completion; however, progress was at 40% and 50%, respectively. The
Ministry has initiated the procurement process for equipment for Balaka District Hospital
while the outstanding payment for Nsanje District Hospital Contractor, who is already onsite, is being processed.

Construction of Nkhata-Bay District Hospital


Construction of the new Nkhata-Bay district Hospital is at 97% completion against the target
of 100% by the end of the FY. Currently, installation of equipment and commissioning has
been done; however the project has delayed because of the additional works including the
construction of a Theatre and Tarmac Road to connect from the main road. A request has
been made to the Ministry of Finance to clear outstanding payments amounting to K844
million to ensure all payments are settled within the current financial year.

28

Construction of Phalombe District Hospital


Construction of the new Phalombe District Hospital is expected to continue in this Fiscal
Year. By the end of the period under review, the Ministry had just procured the services of
the requisite consultant for the Project and started the processes to recruit the contractor
for the project.

Upgrading of Health Centres


The Ministry of Health planned to complete rehabilitation works and upgrade Domasi,
Mponela and Edingeni Health Centres into Community Hospitals by the end of the 2014/15
FY. As of the middle of the FY, progress was only recorded at Domasi Health Centre and at
30% completion while retendering for procurement of Contractor has been initiated for
Mponela Community Hospital.

Cancer Centre Project


The initial consultant had finalized the Pre-contract stage that covered the Designs and Bills
of Quantities; however, the procurement process for a Consultant (Post Contract Stage) was
restarted in respect of the procurement procedures of Open Fund for International
Development (OFID), the Development Partner for the Project. The contract for the
consultant has just been signed and the consultant is preparing documents for the
procurement of Contractor Services.

CMST Warehouse Project


The construction of a new warehouse at Central Medical Stores Trust (CMST) was completed
and the building was handed over to the management of CMST who will be responsible for
the completion of other specialist works, for example, electrical works. The Project
Consultant is finalizing documentation to tender for Specialist Contractors after Global Fund
gave approval for the project.

29

CHAPTER 4: PERFORMANCE OF HEALTH SERVICE DELIVERY

4.1 Background
This chapter details the performance of health service delivery in the Health Sector in the
period under review. The chapter focuses on disease areas outlined in the Monitoring and
Evaluation Indicator list for the Health Sector Strategic Plan. It provides progress on health
service utilization, specifically focusing on the referral system (emergency transport by
ambulance), progress towards universal health coverage, Outpatient Department (OPD)
attendance, admissions and deaths; and progress in key programmes on maternal health
service delivery, malaria, child health, family planning, diarrheal diseases and tuberculosis.

4.2 Universal Access and Health Service Utilization


Provision of affordable equitable Health Services is one of the key determinants of health
status. Nevertheless, it is recognized that whilst the majority of the burden of disease in
Malawi is preventable, hence addressing the risk factors underlying these diseases remains
a key cost effectiveness strategy to interventions for protecting the countrys population
from vulnerability to disease and other health conditions. Therefore, although this section
largely focuses on provision of health services including health protection, the Ministry of
Health remain committed to addressing the social determinants of health.
4.2.1 Universal Access
Critical services such as maternal, neonatal and child health should lie within reasonable
reach for all Malawians. The policy of Government is that public health facilities should be
located within an 8 km radius to ensure that every household has access to a health facility
within reasonable walking distance. In 2014, the Services Provision Assessment (SPA) report
revealed that over two million people do not live within 8 km of public health facility.
Three main players; Ministry of Health, CHAM and other for profit or not-for-profit health
providers provide health services in Malawi. Based on the SPA report, Government facilities
account for 76% of health services provision, followed by CHAM (22%), whilst other service
providers provide the remaining 2% of health services. A key strategy to achieving universal
health access in Malawi, is maintaining a very good working relationship between
Government of Malawi and the partner service providers like CHAM, particularly through
strengthening the scope and coverage of Service Level Agreements (SLAs) to facilitate access
to essential health services in catchment areas served by CHAM. Presently, there are serious
gaps in access to free health services, particularly in remote areas where they are serviced
by CHAM. If these gaps are not addressed, the attainment of universal health coverage may
not be feasible.

30

Table 8 shows that there are 76 CHAM Facilities with SLAs in place, of which 45 are with
facilities which are far from Government Facilities and 31 are near Government Facilities. As
implicated in the HSSP, a proxy measure for universal geographical access to health services
is the number of people living within 8km of a health facility. This contrasts to the
Governments long-term objective of achieving universal access to the EHP for all Malawians
regardless of their geographical location.
TABLE 8: STATUS OF SLAS WITH FACILITIES AS AT 31ST DECEMBER 2014
Distance From Nearest Government Facility
8km or more
Total CHAM Facilities

Less than 8km

Total

115

60

175

With SLA

45

31

76

Without SLA

70

29

99

Furthermore, a series of studies have shown that despite the subsidised charges, utilisation
rates are significantly lower in CHAM facilities than in Government Facilities. Moreover,
when user fees are removed, utilisation rates in CHAM facilities have exponentially and
instantly increased and that the utilisation rates become comparable to those in
Government facilities. User fees in CHAM facilities, therefore, greatly limit the ability of
majority of Malawians in remote rural areas to access health services in those communities.
4.2.2 Health Service Utilisation
In the context of our country, where there are significant socioeconomic, geographical,
cultural, and other barriers to health services access, strengthening outpatient service
delivery and increasing utilization are fundamental to the achievement of the health-related
Millennium Development Goals (MDGs), namely: MDG 4 of reducing child mortality; MDG 5
of improving maternal health; and MDG 6 of combating HIV/AIDS, tuberculosis and malaria.
Health service utilisation rates reflect availability and quality of services. Low rates can be
indicative of poor availability and quality of services. Evidence from local and international
studies suggest that outpatient utilisation rates go up when barriers to using health services
are removed, for instance, by bringing the services closer to the people or reducing user
fees. World Health Organisation (WHO) International Standards suggest each individual to
visit a health facility, at least once in a year (one OPD visit per year). At half year, the graph
in Figure 7 below shows that in some Districts, utilisation rates are below 0.2. This could be
indicative of poor quality/lack of access.

31

Figure 7 below compares utilisation rates against percentage of population not living with
within 8 km of a government facility. Whilst this is not conclusive, there appears to be a
clear relationship between utilisation and access to or coverage of health services.
Utilisation is measured by outpatient department attendances over the population in the
district. More critically, some Districts with low utilisation rates such as Kasungu,
Nkhotakhota, Thyolo and Lilongwe have significant gaps in coverage. It is important to
undertake well-designed studies to determine the factors leading to intra-District and interDistrict variations.
FIGURE 7: COMPARISON OF UTILIZATION RATES AND PERCENTAGE OF POPULATION NOT WITHIN 8KMS OF A
GOVERNMENT FACILITY
80

70
1.00
60
0.8

0.80

0.7
0.7

0.7

34 34
33 33 33
0.5
0.5

0.5
0.4

0.4

0.4

0.40
0.3 18
0.2
15 15
14
14
14
0.2
7
0

4
0.0

20

22
0.3

0.4
24 24

28

47

49

50

43
37

0.60

0.20

46
39

0.5

40

0.5

0.4

0.4

0.4

30

0.3

0.3

20
0.2
0.1

0.1

10

% Popula on not within the 8km radius of a health facility

72
1.1

0.0

0.00

Ch
i ra
d
Ph zul
alo u
m
M be
ul
a
M nje
w
an
z
Ns a
an
Ka je
ro
ng
Zo a
m
ba
Nk Dow
ha a
ta
Ba
Sa y
lim
Nt a
Ch che
Lil ik u
on w a
gw w
e a
Ru
ra
l
Bl
N
an tc
ty his
re
i
Ru
ra
Th l
yo
M lo
zim
ba
De
M dza
a
Nk chin
ho ga
ta
ko
Ru ta
m
ph
i
Ne
M
an n o
go
Ka chi
su
ng
Ba u
lak
M a
ch
in
Ch j i
i
p
Lik a
om
a

U lisa on rate (average number of OPD visit per person per year)

1.20

U lisa on

% Popula on not within the 8km radius of a health facility

32

4.2.3 Referral System


Emergency medical transport is a critical component of pre-hospital care especially in trauma
cases. Further, emergency transport services also ensure access to maternal health services at
critical times in remote rural and in many cases poor urban areas. The general understanding is
that patients have better outcomes if provided with definitive care within 60 minutes of the
occurrence of injuries. Hence, pre-hospital care is mostly beneficial during the second phase of
the conditions such as trauma. This timely provision of care can limit or halt the cascade of
events that otherwise rapidly lead to death or lifelong disability. Without standard pre-hospital
care, people with good survival possibilities also die at the scene or en route to the hospital.
Literature shows that although Emergency Medical Services (EMS) constitute both pre-hospital
and hospital services, they have been neglected for many years especially in low-income
countries. For Malawi, almost all District Health Offices and Central Hospitals face critical
shortages of ambulances for emergency referral. Based on a Draft BeMoc Survey Report (March
2015):
Most complications of pregnancy are unpredictable but can be safely and successfully
managed if there is prompt access to emergency obstetric care. This sort of care is
typically not available in health centre; women have to be referred to higher levels of
care.
The Draft BeMOC survey report shows that overall, only 33% of facilities have a functioning
ambulance. Based on a ratio of 1 ambulance to 50,000 population, the national need for
ambulances is approximately 300 and as of December 2014, Malawi has about 100.

4.2.4 Hospital Attendance, Admissions and Deaths


Over the reporting period, there were a total of 5,388,976 out-patient attendances with
340,089 admissions and a total of 9,107 reported inpatient deaths.

TABLE 9: HOSPITAL ATTENDANCE, ADMISSIONS, AND DEATHS


Districts
OPD attendances
Admissions
Inpatient deaths

Central Hospitals

Total

5,024,404

364,572

5,388,976

258,615

81,474

340,089

5,639

3,468

9,107

33

Preventable and communicable diseases still bear the majority of out-patient attendances and
admissions and responsible for the majority of deaths. Between July to December 2014, 8,804
inpatient deaths were reported through Health Management Information System (HMIS).
Among the four leading causes of death to children under five, the majority (58%) are due to
malaria, followed by 19.4% due to acute respiratory infections, 11.9% due to malnutrition, and
10.8% due to diarrhea.
FIGURE 8: DISTRIBUTION OF DEATHS BY CAUSE AMONG CHILDREN UNDER-FIVE

4.2.5 Performance of Central Hospitals


Ideally, the Central Hospitals, Queens Elizabeth, Zomba, Kamuzu and Mzuzu should be
providing tertiary level care, focusing on conditions that cannot be managed by District
Hospitals and lower level providers of health care. However, presently, these Central Hospitals
currently operate like large primary and secondary level facilities based on the bulk of services
they provide. This role is further exacerbated by the lack of ability to provide highly specialised
services due to an acute shortage of specialist doctors in Malawi. Further, the unsatisfactory
performance of Central Hospitals in the country is heavily influenced by a lack of sufficient and
quality urban health facilities combined with few inputs to address the key risk factors that
impact on health status on both the poor and non-poor urban communities. Currently, an
expert group has been assigned to further develop proposals to speed up the reforms to enable
central hospitals to be fit for purpose in treating specialist cases referred from secondary
facilities.
The key indicators used to measure the quality of care in central hospitals include:

34

4.2.5.1 Average Length of Stay (ALOS)


This outcome indicator measures how much time patients spend in the hospital and can act as
part of proxy measure of quality of services. If the ALOS is in line with the national target, it
suggests that decisions about patients are made quickly and that they are diagnosed, given
appropriate treatment, and are rapidly discharged from the hospital. The ALOS was 7.1 days in
KCH, 5.2 in ZCH, 4.6 in QECH and 4.3 in MCH. A low ALOS is indicative of a well-functioning
hospital.

4.2.5.2 Bed Occupancy Rate


Bed Occupancy Rates measure on average what proportion of usable beds in a hospital were
utilized (or occupied) per month/quarter/year. A relatively high bed utilization (occupancy rate)
rate indicates a well-functioning hospital. Two central hospitals reported bed occupancy rates:
QECH (62.6%) and MCH (69%).
TABLE 10: PERFORMANCE OF THE FOUR CENTRAL HOSPITALS IN THE COUNTRY
Central
Hospital

OPD
attendance

Inpatient
days

Admissions

Inpatient
deaths

Total
discharges
deaths

ALOS

Mzuzu
Zomba
QECH
KCH
Total

51,266
41,636
194,216
77,454
364,572

40,214
76,962
146,602
117,658
381,436

9,871
13,830
38,804
18969
81,474

414
937
1,814
303
3,468

9301
14794
31936
16484
72,515

4.3
5.2
4.6
7.1
5.3

Gross in
patient
mortality
rate
4%
7%
5%
2%
4%

Bed
occupancy
rate
69%
62.6%
-

Of the total OPD attendances, 364,572 (6.8%) were at Central Hospital level. The majority of
OPD attendances at central hospital were recorded at QECH (194,216). QECH also had the
greatest number of admissions (38,804). Similarly, of the total number of admissions, 81,474
(24.0%) were recorded at Central Hospitals.

4.3 Disease Specific Progress Reports


4.3.1 Maternal Health
Antenatal care services are crucial for safe motherhood as they are instrumental in supporting
early identification of pregnancy related complications and allow for early treatment. The
health sector uses the number of women who attend ANC to facilitate identification and
management of obstetric complications such as pre-eclampsia, tetanus toxoid immunization,
intermittent preventive treatment for malaria during pregnancy (intermittent preventive
treatment in pregnancy, IPTp), and identification and management of infections including HIV,
35

syphilis and other sexually transmitted infections (STIs). ANC is also an opportunity to promote
the use of skilled attendance at birth and healthy behaviors such as breastfeeding, early
postnatal care, and planning for optimal pregnancy spacing. In the first half of the 2014/2015
financial year, the Ministry of Health recorded 31,741 women visiting ANC in their first
trimester of pregnancy out of 301,483 new pregnancies representing 10.5% which is far below
the 2015 target of 17%.
With respect to deliveries, in total there were 240,527 recorded births at the facility level of
which, 230,700 (96%) happened at a health facility. Considering expected projected births, the
current recorded 240,527 births represents 61% of total expected births indicating that many
births may not be recorded at the facility level. Of the recorded births that occurred at a health
facility, 97% (93% of total births), were conducted by skilled health workers. Delivery mode for
child births differed with 90% occurring spontaneously, 6.8% through Caesarean Section, 1.7%
through Breech and 1.4% through vacuum extraction.
A total of 30,341 birth complications were reported across facilities. Figure 9 shows asphyxia as
the leading complication (31.4%), followed by weight less than 2,500g (29%), and prematurity
(21.6%). Sepsis was recorded as the least cause of complications (6.4%). Alongside birth
complications, a total of 30,572 pregnancy related complications were reported with
obstruction/prolonged labor being the highest at 34%, followed by postpartum hemorrhage at
11.4% and eclampsia at 7.5%. Other causes of complication were antepartum hemorrhage at
4.6%, sepsis at 1% and ruptured uterus at 1%. Unclassified complications types accounted for
40% of the pregnancy complications. Emergency obstetric care was provided in the form of
oxytocin (94.7%), antibiotics (4.2%), anticonvulsives (0.5%), blood transfusion (0.4%), and
manual removal of placenta (0.2%). In terms of nutrient supplements, 34% of the pregnancies
did not receive a dose of the vitamin A. Additionally, tetracycline eye ointment was provided
only to the 16.7% of the births.

Percentage of Complication

FIGURE 9: CHILD COMPLICATIONS AT BIRTH


35
30
25
20
15
10
5
0
Weight less
2500g

Prematurity

Asphyxia

sepsis

Other

Complication Type

36

In terms of child survival, of total births, 2,277 (0.95%) were fresh stillbirths, 2,011 (0.84%) were
macerated stillbirths and 2,398 (1%) were neonatal births. Additionally, in 11% of the births,
breast-feeding did not start within 60 minutes of delivery.
Child, maternal and newborn health indicators varied widely across the 29 health districts as
illustrated in the Reproductive, Maternal, Neonatal and Child Health (RMNCH) Scorecard in
Figure 10. The national average for the percentage of pregnant women receiving serostatus
was 59% in the first half and 64% in the second half. In terms of subnational coverage,
performance ranged from 39% in Blantyre to 96% in Likoma and 39% in Chikwawa to 100% in
Mwanza in the first and second halves of the year respectively. For the percentage of pregnant
women and infants initiated on ART all the districts had high coverage rates with the lowest
coverage rates recorded for Blantyre at 77% in the first half and Mchinji at 73% in the second
half of the year. ART Coverage for known HIV positive infants was highest in Machinga and
Ntcheu with coverage rates of 99% and 97% respectively in the first half and Likoma with 100%
coverage in the second half.
FIGURE 10 RMNCH SCORECARD COMPARING BOTH JANUARY TO JUNE 2014 (H1) TO JULY TO DECEMBER 2014 (H2) BY
DISTRICT

37

For the percentage of women completing the first antenatal visit during the first trimester the
national average was at 9%, with subnational performance ranging from 5% to 18% in the first
half and 5% to 19% in the second half respectively. Improvements gained in the percentage of
pregnant women completing four ANC visits were marginal at a national average of 12% and
15% for the first and second half respectively. At subnational level performance ranged from
6% to 28% in the first half and 10% to 24% in the second half of the year. The percentage of
women having a postnatal visit two weeks after delivery also remains low at a national average
of 29% and 32% in the first and second halves of the year.
A key factor in determining maternal health is the Maternal Mortality Rate (MMR). In the
period under review, a total of 328 maternal deaths were reported Figure 11 shows reported
Maternal Deaths at Facility Level and includes Districts and Central Hospitals from both CHAM
and MOH .

38

Addressing causes of maternal mortality are complex. Factors like population size and
geographical location need to be taken into account and analysis is needed on primary factors
causing maternal death, referrals from districts of origin (Bwaila in Lilongwe, for example,
receives referrals from other districts) and disaggregation of deaths by private facilities.
Currently private facilities are required to report through Public Facilities.

FIGURE 11: TOTAL REPORTED MATERNAL DEATHS JULY -DECEMBER 2014


40
35
30
25
20
15
10
5

Chiradzulu-DHO
Thyolo-DHO
Likoma-DHO
Neno-DHO
Ntchisi-DHO
Chitipa-DHO
Mzimba-North-DHO
Mwanza-DHO
Nkhotakota-DHO
Balaka-DHO
Chikwawa-DHO
Mzimba-South-DHO
Phalombe-DHO
Nkhata-Bay-DHO
Rumphi-DHO
zomba central
Zomba-DHO
Blantyre-DHO
Dowa-DHO
Mzuzu Central Hospital
Nsanje-DHO
Salima-DHO
Karonga-DHO
Mulanje-DHO
Ntcheu-DHO
Machinga-DHO
Dedza-DHO
Kasungu-DHO
Mchinji-DHO
QECH
Lilongwe-DHO
Mangochi-DHO
KCH

4.3.2 Promotion / Prevention/Protection


Vaccinations are some of the most important tools available for preventing diseases.
Vaccinations not only protect children from developing a potentially serious disease but also
protect the community by reducing the spread of infectious disease. In the period under
review, 89% of children under the age of one year were fully immunized, 4% above the target
of 85%. Figure 12 below shows summary performance in terms of immunization. Comparing
with targeted outcomes measles (91%) is 1% above the targeted 90% and Pentavalent 3 (91%)
is 2% short of the targeted 93%.

39

FIGURE 12: PROPORTION OF CHILDREN IMMUNIZED AT DISTRICT LEVEL

Percentage (Target vs Current)

94
92
90
88
86
84
82
80
Fully Immunized

Measles
Current

Pentavalent 3

Target

In the districts, Table 11 shows that Dowa and Kasungu are of major concern and require
immediate corrective measures as they are below targets on Measles, Penta 3 and FIC. Steps to
improve vaccination of children under one year are also required in Ntchisi, Chitipa and Mzimba
to ensure that adequate children are immunized.
TABLE 11: VACCINATION COVERAGE BY DISTRICT
No.

District

Measles %cov

Penta 3 %cov

Dowa-DHO

79

76

Fully Immunized children %


covered
72

Kasungu-DHO

78

77

75

Nkhotakota-DHO

88

90

84

Ntchisi-DHO

77

73

81

Salima-DHO

90

94

90

Dedza-DHO

95

102

88

Lilongwe-DHO

90

89

88

Mchinji-DHO

84

81

83

Ntcheu-DHO

95

89

93

10

Chitipa-DHO

81

77

80

11

Karonga-DHO

91

93

91

12

Likoma-DHO

83

81

84

13

Mzimba

80

83

79

14

Nkhata-Bay-DHO

81

89

80

15

Rumphi-DHO

87

82

87

16

Balaka-DHO

93

89

88

40

No.

District

Measles %cov

Penta 3 %cov

17

Machinga-DHO

108

106

Fully Immunized children %


covered
109

18

Mangochi-DHO

98

105

102

19

Mulanje-DHO

109

106

95

20

Phalombe-DHO

128

127

122

21

Zomba-DHO

88

86

89

22

Blantyre-DHO

91

89

93

23

Chikwawa-DHO

90

97

92

24

Chiradzulu-DHO

92

86

86

25

Mwanza-DHO

105

89

88

26

Neno-DHO

95

94

85

27

Nsanje-DHO

85

82

88

28

Thyolo-DHO

80

94

74

4.3.3 Malaria
Malaria is one of the major causes of morbidity and mortality in Malawi. Notably, the data
reporting rates for malaria are very low with only 62% of the facilities providing their reports in
the period under review. Underreporting was significant in the Central West and South West
Zones which reported 48% each. There were 1,072,258 confirmed reported cases of malaria
(62% reporting rate) with Lilongwe contributing the highest at 22%. Suspected cases of malaria
were at 1,762,614 representing a mid-year Incidence Rate of 223 per 1,000 in the population.
This represents a drop from the previous year which was at 230. This could be due to the fact
that data Months of January to March which account for most of the Malaria cases have not
been included. Figure 13 below shows that malaria incidences are declining in Malawi.
FIGURE 13: MALARIA INCIDENCE RATES
600

Incidence Rate

500

456

484

396

371

400

332

332

300

223

200
100
0
June,
2009

June,
2010

June,
2011

June,
2012

June,
2013

June,
2014

Dec,
2014

Period

41

In total there were 3,259 inpatient deaths due to Malaria. Figure 14 below shows percent
distribution of malaria deaths at district level. Note that the graph shows a slight decrease in
the December 2014 period this is largely due to seasonal variations.
FIGURE 14: MALARIA DEATH RATES BY DISTRICT
200
180
160
140
120
100
80
60
40
20

July to December 2013 Under 5

July to December 2013 Over 5

July to December 2014 Under 5

July to December 2014 Over 5

Thyolo

Nsanje

Neno

Mwanza

Chiradzulu

Chikwawa

Zomba

Blantyre

Phalombe

Mulanje

Machinga

Mangochi

Balaka

Rumphi

Mzimba S

Nkhata Bay

Mzimba N

Likoma

Chitipa

Karonga

Ntcheu

Mchinji

Dedza

Lilongwe

Salima

Ntchisi

Kasungu

Nkhotakota

Dowa

In terms of commodity usage, the following amounts were issued: RDTs (2 million), LA 1X6
(5,819,954 tablets), LA 2X6 (7,482,557 tablets), LA 3X6 (5,002,780 tablets), LA 4X6 (13,550,537
tablets) and SP (1,869,215 tablets). Furthermore, 1,407,000 Long Lasting Insecticide treated
nets (LLINs) were distributed to vulnerable populations including pregnant women.
Table 12 below shows progress against key malaria indicators in Malawi. Overall, there are
significant improvements in access to and availability of malaria prevention and treatment; with
the overall result that malaria incidence is on a decline since 2010.
TABLE 12: PROGRESS ON SELECTED MALARIA INDICATORS

42

Indicator

Baseline
2010 MIS

2012
MIS

2014
MIS

2016
Target

% of those suffering from malaria who have access to and are able to
use correct, affordable and appropriate treatment within 24 hours of
onset of symptoms

21.9

24

31.2

50.0

% of pregnant women who have access to and receive two or more


doses of IPTp for malaria prevention
% of pregnant women who have access to and receive three or more
doses of IPTp for malaria prevention
% of households owning at least one ITN
% of children under 5 years of age sleep under an ITN
% of pregnant women sleep under an ITN
% of outpatient suspected malaria cases who are confirmed by
parasitological diagnosis (HMIS)
Malaria incidence per 1000 population (HMIS)

60.3

55

63

70.0

No data

12.6

40.0

58.1
55.4
49.4
0

No
data
55
56
51
65

70
67
62
75

85
90
90
90

484

332

202

150

The following are key interventions by the National Malaria Control Programme (NMCP) in the
first half of the 2014/15 Financial Year.

LLINs distribution

Distributed 1,407,000 LLINs in November and December 2014 through mass distribution
campaigns in 7 districts

From June 2014 to February 2015, distributed 889,670 LLINs through health facilities
providing ANC services countrywide

NMCP distributed 93,400 LLINs in February and March 2015 to registered victims in 15
disaster affected districts under the National Disaster Management Policy.

Malaria Case Management

Only 44.7% (MICS 2014) pregnant women attended the four recommended ANC visits.

Only 63% (MIS 2014) pregnant women received two or more doses of Sulfadoxine
Pyrimethamine (SP).

The new IPTp guideline (SP at each ANC visit, at least three doses) and training manual is yet
to be rolled out to health workers.

430,000 pregnant women received LLINs in between July 2014 and February 2015.

43

As of March 2015, 66.4% of health workers had been trained on proper use of injectable
artesunate.

In 2014, 9,554,600 malaria Rapid Diagnostic Tests (mRDTs) were distributed for use at
health facility level.

While Clindamycin is recommended by policy, it is currently not available for use in early
pregnancy and newborns (less than 5kgs).

Implementation of mRDTs and use of rectal artesunate as pre-referral treatment for severe
malaria is expected to be implemented at the community level in 2015/2016.

Multiple Procurement and Supply Management (PSM) distribution agents remains a major
challenge for supply chain management.

Inadequate reporting and poor linkage between DHIS2, Laboratory Management


Information System (LMIS) in health facilities and the c-stock system at community level,
continue to be a key challenge in case management resulting in mismatch of reported cases
and health commodity consumption.

Behaviour Change Communication & Advocacy

NMCP, together with partners, developed second generation of Malaria Communication


Strategy for 2015-2020 in November 2014.

NMCP and partners conducted community sensitization and mobilization in the six districts
before, during and after the first phase of LLINs mass distribution campaign between
October 2014 and January 2015.

NMCP developed and distributed a range of Malaria Strategy for Behaviour Change
Communication (SBCC) materials in some parts of the country to improve community
mobilization, behavior change communication and advocacy from July 2014 to January
2015.

The NMCP runs radio programs and disseminated messages on radio.

Monitoring & Evaluation

44

The 2014 Malaria Indicator Survey was conducted and report ready for printing and
dissemination on 27 March 2015.

The 2014 Efficacy Study was conducted and awaits dissemination.

Conducted quarterly end user verification visits to selected 60 facilities in order to assess
consumption of malaria commodities in the facilities.

The pilot study on the use of mRDTs and ACTs in 26 schools in Zomba city by teachers was
completed and dissemination planned for March 2015

The pilot study on the use of rectal artesunate, mRDTs and ACTs in hard to reach areas in
Mchinji by Health Surveillance Assistants was completed.

The 2014 Service Provision Assessment was conducted and disseminated on January 27,
2015.

Consumption of malaria commodities and data reporting was assessed in 49 health facilities
distributed across the country conducted from November 2014.

c-Stock was rolled out nation-wide to all Health Surveillance Assistants in hard-to-reach
village clinics.

Program Management

Procured 5 vehicles in December 2014 through Global Fund.

The NMCP, together with partners, conducted quarterly Malaria Technical Working Group
(TWG) meetings in 2014

4.3.4 Diarrheal diseases


Diarrheal diseases are a major vulnerability for children under the age of 5. Although it is both
preventable and treatable, globally, diarrheal disease is the second leading cause of death in
children under five years old. In the period under review, there were 212,538 diarrheal
diseases, representing an Incidence Rate of 165 per 1,000 in under-fives. Figure 15 below shows
the proportion of total cases at district level for diarrhea and dysentery. The figure shows that
there were more cases of diarrhea in Lilongwe (15% of total cases), followed by Blantyre (8%)
and Mangochi (5%). In terms of dysentery, the figure shows that Blantyre had the highest cases
at 10% followed by Mangochi (9%) and Lilongwe (9%). Comparison of diarrhea and dysentery in
45

the figure shows an association between the two diseases at district level. Districts with high
diarrhea also have high dysentery and vice versa.

18
16
14
12
10
8
6
4
2
0
Dowa-DHO
Kasungu-DHO
Nkhotakota-DHO
Ntchisi-DHO
Salima-DHO
Dedza-DHO
Lilongwe-DHO
Mchinji-DHO
Ntcheu-DHO
Chitipa-DHO
Karonga-DHO
Likoma-DHO
Mzimba-North-DHO
Mzimba-South-DHO
Nkhata-Bay-DHO
Rumphi-DHO
Balaka-DHO
Machinga-DHO
Mangochi-DHO
Mulanje-DHO
Phalombe-DHO
Zomba-DHO
Blantyre-DHO
Chikwawa-DHO
Chiradzulu-DHO
Mwanza-DHO
Neno-DHO
Nsanje-DHO
Thyolo-DHO

Percent of Cases

FIGURE 15: PERCENT DISTRIBUTION OF DIARRHEA AND DYSENTERY CASES IN MALAWI

District
Percent Diarrhoea

Percent Dysentery

Comparing diarrhea cases over the last 18 months shows that the incidence rate of the disease
has a slight increase as shown by the trend line in Figure 16 below.
FIGURE 16: TRENDS IN DIARRHEA INCIDENCE RATE

Diarrhea Incidence Rate

180
160
140
120
100
80
60
40
20
0
Dec, 2013

June, 2014

Dec, 2014

Period
Diarrhoea Incidence Rate

Linear (Diarrhoea Incidence Rate)

46

In terms of deaths due to diarrhea, Figure 17 shows that Mulanje district had the largest (19%),
although it contributed the least cases of diarrhea at 3%. More deaths were also reported in
Nkhotakota (8%), Mchinji (7%), Mangochi (7%) and Chikhwawa (7%).

20
18
16
14
12
10
8
6
4
2
0
Dowa-DHO
Kasungu-DHO
Nkhotakota-DHO
Ntchisi-DHO
Salima-DHO
Dedza-DHO
Lilongwe-DHO
Mchinji-DHO
Ntcheu-DHO
Chitipa-DHO
Karonga-DHO
Likoma-DHO
Mzimba-North-DHO
Mzimba-South-DHO
Nkhata-Bay-DHO
Rumphi-DHO
Balaka-DHO
Machinga-DHO
Mangochi-DHO
Mulanje-DHO
Phalombe-DHO
Zomba-DHO
Blantyre-DHO
Chikwawa-DHO
Chiradzulu-DHO
Mwanza-DHO
Neno-DHO
Nsanje-DHO
Thyolo-DHO

Proportion of diarhea and deaths due to diarrhea

FIGURE 17: DISTRIBUTION OF DIARRHEA CASES AND DEATHS DUE DIARRHEA

District
Percent Diarrhoea

Percent Deaths due to Diarrhea

A significant proportion of diarrheal disease can be prevented through safe drinking-water and
adequate sanitation and hygiene. In 2014, the Environmental Health Directorate reported that
78% of households had latrines compared to 64% in 2010. Percentage of households with hand
washing facilities went from 10% in 2010 to 24% in 2014. This suggests other contributing
environmental factors may contribute to the prevalence of diarrhea.

4.3.5 Tuberculosis
In the period under review, July to December 2014, there were 13,734 confirmed new TB cases.
In the previous year, from July to December 2013, there were 6,008 new cases (Figure 18). Out
of that same cohort, by December 2014, 2,322 cases had completed treatment, and 1,342 were
cured (proved smear negative) at the end of treatment. In total, 312 inpatient TB deaths were
reported during this period.

47

FIGURE 18: DISTRIBUTION OF NEW TB CASES AND POPULATION DISTRIBUTION

4.3.6 Nutrition
During the July to December 2014 period, a total of 5,184 children were admitted in the CMAM
program. A total of 12,034 children were admitted in the Outpatient Therapeutic Programme
(OTP). Out of those admitted in OTP 8,572 were cured representing a cure rate of 90.7%, 1.5%
(122) died whilst in the programme and 6.5% (707) defaulted. The cure rate was above the
recommended sphere standard of cure rate of greater than 75%, and the death rate and
default rate were below the recommended sphere standard of death rate of less than 10% and
default rate of less than 15%, respectively.
Nutrition Rehabilitation Units (NRU) admitted a total of 2,931 children. Out of those admitted
in NRU 84.5% (1,965) were cured, 9.1% (98) died while admitted in the NRU. In the
Supplementary Feeding Programme (SFP), a total of 36,849 children were admitted and 33,003
were cured representing 88.9 % cure rate. For the Nutrition Care, Treatment and Support
(NCST) program targeting Adolescents and Adults, a total of 2,582 adults and adolescents were
admitted in the program. The revised National NCST Guidelines and training modules were
finalized and printed during the same period. The guidelines will facilitate the scaling up of the
program.

48

4.3.7 Family Planning


Family planning services are vital for birth control, child spacing and prevention of sexually
transmitted infections. In the period under review 745,282 units of Injectable Depoprovera
were used while 117,069 units of combined oral method were used. In terms of new women
accessing family planning services depoprovera has the highest number of women, followed by
Jadelle. Figure 19 shows that depoprovera is the leading family planning method at 60% of all
total women who accessed a family planning method, followed by Jadelle at 21%, Implanon and
Combined Oral at 6% each.

Percentage of Women Accessing Method

FIGURE 19: WOMEN FAMILY PLANNING METHOD UTILIZATION


70
60
60
50
40
30

21

20
10

6
0

A closer examination of the two most popular methods of family planning for women reveal
that women under the age of 25 prefer Depo-Provera while those between 25 and 34 years
prefer Jadelle. Women above 35 have no preference between these two methods. Figure 20
shows the distribution of women access to the Jadelle and Depo-Provera by age.

FIGURE 20: AGE DISTRIBUTION OF WOMEN ACCESSING JADELLE AND DEPO-PROVERA

49

Precent of women in age group

40
35
30
25

20
15
10
5
0
Less than
20

20-24

25-29

30-34

35-39

40-44

45-48

49 (+)

Age Group
Depoprovera

Jadelle

13 procedures of vasectomy were conducted while 46,937 units of male condoms were issued.
Those accessing family planning services were largely women (81%) while 20% were men. This
means that there is very low uptake of family planning services by men.

4.3.8 NCDS
4.3.8.1 Gender based violence
Gender based violence has significant impacts on physical and mental health with an estimated
28 percent of women (15-49 age group) ever experiencing physical violence in the form of
beating, hitting, or battering since the age of 15. Seventy-two percent of children aged 1-14
years experienced psychological aggression or physical punishment during the previous one
month (Gender-Based Violence Baseline Survey Report 20123).
Services to deal with GBV are delivered by the Police under the Ministry of Home Affairs in the
form of Victim Support Units and One Stop Centers at central and district hospitals. One Stop
Services are provided at Blantyre Central Hospital, Zomba Central Hospital, Lilongwe Central
Hospital, Mzuzu Central Hospital and Nkhatabay District Hospital, Chiradzulu District Hospital,
Dedza District Hospital, Mchinji District Hospital, Dowa District Hospital and Mauwa Community
Hospital Chiradzulu. They are located within hospitals with linkages to other services based
outside the hospital. Referral mechanisms have been established so that police investigators,
prosecutors, and social welfare are all involved when a case is registered at the hospital. Case
review meetings are encouraged each month to review how cases were handled. These

National Statistics Office, Government of Malawi

50

meetings help address any gaps in the provision of services. Linkages to NGOs and faith-based
organisations ensure that psychosocial services are provided to victims of abuse. Between July
and December 2014, 697 cases of GBV were reported in the One Stop Centers. During this time,
370 of these cases were from four centers in Mzuzu, Lilongwe, Zomba, and Blantyre. Across
Malawi, there are 182 Victim Support Units. In 2014, a total of 15,213 cases of GBV were
reported to VSUs, and 7,772 of which occurred between July and December. Data on referrals
from VSUs to hospitals is expected, but not yet available.

4.3.8.2 Injuries as a result of road traffic incidents


Road traffic accident injuries and deaths are a large problem in Malawi. This includes injuries
and deaths to drivers and passengers, pedestrians, and bicyclists. Data is not yet available to
disaggregate the burden of road traffic morbidity and mortality experienced by each of these
groups. When available, this data will provide valuable information to assist in reducing risk
factors such as lack of reflective clothing, drunk driving, and operating unsafe vehicles.
Figure 16, below, shows the number of clinic visits due to road traffic accidents reported by
each district between July to December 2014; and Figure 17 shows a comparison between this
and the number of road traffic accidents reported through HMIS during 2013. It should be
expected that, during 2014 (July to December), half or less injuries were reported than in 2013
(January to December). This is often, but not always, the case. Table 13 and Table 14 shows the
number of road traffic injuries reported to four District Hospitals and each District, resulting
deaths reported, and case-fatality rates. The overall case-fatality rate for road traffic injuries,
across Malawi, according to facility-based HMIS data, is 1.3%.
FIGURE 21: HMIS ROAD TRAFFIC INJURIES, JULY TO DECEMBER 2014

51

RTIs July-Dec 2014


Mangochi-DHO

Lilongwe-DHO

Mulanje-DHO

Machinga-DHO

Dedza-DHO

Balaka-DHO

Karonga-DHO

Mchinji-DHO

Dowa-DHO

Chitipa-DHO

Ntcheu-DHO

Blantyre-DHO

Ntchisi-DHO

Kasungu-DHO

Rumphi-DHO

Salima-DHO

Nkhotakota-DHO

Nsanje-DHO

Nkhata-Bay-DHO

Mzimba-North-DHO

Chikwawa-DHO

Chiradzulu-DHO

Thyolo-DHO

Mzimba-South-DHO

Mwanza-DHO

Phalombe-DHO

Zomba-DHO

Neno-DHO

Likoma-DHO

1000

900

800

700

600

500

400

300

200

100

FIGURE 22: HMIS ROAD TRAFFIC INJURIES, A COMPARISON BETWEEN JULY TO DECEMBER 2014 AND JANUARY TO
DECEMBER 2013
2500

2000

1500

1000

500

RTIs Jan-Dec 2013

52

TABLE 13: CENTRAL HOSPITALS ROAD TRAFFIC INJURIES, DEATHS, AND CASE-FATALITY RATES, JULY TO DECEMBER 2014
Central Hospital
Mzuzu
KCH
Queens
Zomba

HMIS
Injuries
244
1,526
845
143

Traffic

HMIS Traffic Injury


Deaths
8
N/A
15
6

Case fatality rate


(%)
3
N/A
2
4

TABLE 14: DISTRICT ROAD TRAFFIC INJURIES, DEATHS, AND CASE-FATALITY RATES, JULY TO DECEMBER 2014
District
Likoma-DHO
Phalombe-DHO
Mzimba-North-DHO
Nsanje-DHO
Nkhotakota-DHO
Salima-DHO
Rumphi-DHO
Chitipa-DHO
Mchinji-DHO
Karonga-DHO
Dedza-DHO
Machinga-DHO
Mulanje-DHO
Mangochi-DHO
Lilongwe-DHO
Dowa-DHO
Ntcheu-DHO
Balaka-DHO
Kasungu-DHO
Blantyre-DHO
Nkhata-Bay-DHO
Chiradzulu-DHO
Thyolo-DHO
Mzimba-South-DHO
Ntchisi-DHO
Zomba-DHO
Chikwawa-DHO
Mwanza-DHO
Neno-DHO

HMIS
Injuries
0
9
90
115
120
128
150
270
289
336
432
494
542
909
863
281
269
347
168
218
107
43
31
27
205
7
51
14
5

Traffic

HMIS Traffic Injury


Deaths
0
1
0
2
1
4
3
0
2
3
3
4
0
3
3
2
9
29
11
0
0
2
0
0
0
0
4
0
0

Case fatality rate


(%)
0
11
0
2
1
3
2
0
1
1
1
1
0
0
0
1
3
8
7
0
0
5
0
0
0
0
8
0
0

Table 15 shows all injuries reported through HMIS for Kamuzu Central Hospital (KCH) between
July and December 2014. As seen in the table, fractures represent 60% of all injuries reported,

53

followed in number by falls (17%), road traffic accidents (15%), burns (5%), stab wounds (1%),
and head injuries (1%).
TABLE 15 ALL INJURIES REPORTED THROUGH HMIS AT KAMUZU CENTRAL HOSPITAL (KCH), JULY TO DECEMBER 2014
Diagnosis
RTA Cases
Fall
Gun shot
Burn
Stab Wound
Head Injury
Fractures
Trauma amp
Trauma - new
Poisoning
Trauma - IPD

Number of Patients

Percentage (%)

1,526
1,777
38
521
148
134
6,109
28
0
17
1

15
17
0
5
1
1
59
0
0
0
0

4.3.8.3 Mental Health


The prevalence of mental illness is not yet known in Malawi as a full survey has not been
carried out. Diagnosis remains a challenge and severe shortage of qualified staff to both
diagnose and treat mental illnesses affects the ability of the Ministry of Health to provide
quality mental health services. Largely because treatment of mental illness relies not only on
medication but also quality counselling and therapy provided by a range of personnel.
The following mental health posts are available in public health services: Psychiatrist;
Psychiatric Clinical Officer; Psychiatric Nurse; Occupational Therapist. The following posts are
not available in public health services but are available in other institutions: Clinical
Psychologists; Counsellors.
Currently there is no Government Psychiatrist, no Clinical Psychologist and no Counsellor in
public health facilities; The facilities rely on University of Malawi-based Psychiatrists and Clinical
Psychologists.
Mental health services are currently available at the following institutions:
1. Zomba Mental Hospital is the only national referral mental hospital which provides both
outpatient and inpatient services to adults and children and has a bed capacity of 333.
2. The Bwaila Psychiatric Unit, which is located in the Kamuzu Central Hospital and has 30
beds.

54

3. St. John of God Community Services located in Mzuzu provides both outpatient and
inpatient services and also provides substance and drug addiction rehabilitation
programmes. It has a capacity of has 39 beds.
4. District hospitals which provide some basic mental health services, patients with a mental
illness are admitted in the medical wards and Emergency mental health services that are
also provided at district hospitals as part of general wards. Each District Hospital runs a
static clinic and outreach mental health services.
Table 16 below shows a breakdown of the mental health issues reported at Kamuzu Central
Hospital, Mzuzu Central Hospital, Queen Elizabeth Central Hospital, and Zomba Mental
Hospital. Table 10 shows the breakdown between three reporting districts. Not all hospitals are
using the same classification of mental disorder. The introduction of reporting mental health
illnesses against the ICD (International Classification of Diseases) is being rolled out.
Schizophrenia remains the highest cause of admission and Outpatients, epilepsy is following
though diagnosis of epilepsy remains a challenge due to over classification.
TABLE 16 MENTAL HEALTH CASES, REPORTED FROM KAMUZU CENTRAL, MZUZU CENTRAL, QUEEN ELIZABETH CENTRAL,
JULY TO DECEMBER 2014
Mzuzu

QECH

KCH

Total

Acute

200

56

263

Chronic

262

273

Epilepsy

531

1801

94

2426

Total

993

1866

103

2962

55

DIAGNOSIS
ORGANIC MENTAL DISORDER (CHRONIC)
ORGANIC MENTAL DISORDER (ACUTE)
ALCOHOL USE MENTAL DISORDER
DRUG USE MENTAL DISORDER
SCHIZOPHRENIA
ACUTE & TRANSIENT PSYCHOTIC DISORDER
SCHIZO-AFFECTIVE DISORDER
MOOD AFFECTIVE DISORDER (MANIC)
MOOD AFFECTIVE DISORDER (BIPOLAR)
MOOD AFFECTIVE DISORDER (DEPRESSION)
ANXIETY DISORDER
STRESS REACTION ADJUSTMENT DISORDER
DISSOCIATIVE CONVERSION DISORDER
SOMATOFORM DISORDER
PUERPERAL MENTAL DISORDER
PERSONALITY/BEHAVIOUR DISORDER
MENTAL RETARDATION
PSYCHOLOGICAL DEVELOPMENT DISORDER
HYPERKINETIC CONDUCT DISORDER
EPILEPSY
OTHERS
TOTAL

ICD 10
CODE
F00 -03
F04-06
F10
F11-19
F20
F23
F26
F30
F31
F32
F40-42
F43
F44
F46
F53
F60-69
F70-79
F80-89
F90-91
G40

NEW CASES (OUTPATIENT)


Male
Female

SUBSEQUENT CASES (OUTPATIENT)


Male
Female

INPATIENT
Male

Female

0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
2
0
2
14
4
24

0
1
4
4
17
2
3
1
1
0
0
0
0
0
0
0
0
0
0
0
1
34

0
0
0
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4
0
7

1
2
0
0
3
0
0
0
2
2
0
0
0
0
0
0
0
0
0
0
0
10

0
0
0
0
4
2
0
0
0
0
0
0
0
0
0
0
2
0
1
20
0
29

22
3
10
39
512
12
68
37
54
18
4
0
0
1
0
0
3
0
2
148
13
946

1
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
2
0
1
70
7
82

9
7
0
2
333
6
69
28
57
28
8
1
0
1
6
1
2
0
0
180
10
750

0
0
0
1
2
1
0
1
0
1
0
0
0
0
0
0
0
0
1
0
1
8

3
4
12
85
151
7
32
20
37
1
1
1
0
0
0
0
1
0
0
20
8
383

TABLE 17 MENTAL HEALTH CASES, REPORTED FROM NKHATA BAY, RUMPHI, AND BALAKA, JULY TO DECEMBER 2014
Acute & Transient Psychotic Disorder
Alcohol Use Mental Disorder

Nkhata-Bay-DHO

Rumphi-DHO

Anxiety Disorder

Balaka-DHO
34
2

Dissociative Conversion Disorder


Drug Use Mental Disorder

31

Epilepsy

294

109

336

Mood Affective Disorder (Depression)

10

Mood Affective Disorder (Manic)

19

Organic Mental Disorder (Acute)

14

Organic Mental Disorder (Chronic)

30

124

Others

Schizo-Affective Disorder

Schizophrenia

125

42

363

Hyperkinetic Conduct Disorder


Mental Retardation

TOTA

0-15 yrs 16+ yrs 0-15 yrs 16+ yrs 0-15 yrs 16+ yrs 0-15 yrs 16+ yrs 0-15 yrs 16+ yrs 0-15 yrs 16+ yrs

Mood Affective Disorder (Bipolar)

Personality/Behaviour Disorder
Psychological Development Disorder
Puerperal Mental Disorder

Somatoform Disorder
Stress Reaction Adjustment Disorder

56

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
2

9
4
1
1
75
13
20
20
48
4
3
3
0
0
9
1
1
0
0
6
4
222

45
21
27
13
110
43
19
10
19
54
16

15

13

46
48
249

4.3.9 Resilience of the Health System


Recently, there have been two major events that have impacted how the health system has
been run here in Malawi. First, the Ebola outbreak in West Africa required the Countrys health
system to bolster infection control, monitor the progress of the outbreak in West Africa, and
set-up services that could respond if the disease ever came to this region. Second, the MOH
responded to severe flooding in southern Malawi with disaster relief and resources for affected
districts. Cholera and future food security still remains a concern.
4.3.9.1 Response to the Ebola Threat
Ebola Virus Disease (EVD) was first reported between November and December 2013, but was
only confirmed in March 2014, in Guinea. The affected countries are Guinea, Sierra Leone,
Liberia, Nigeria and Senegal. Due to the magnitude of the outbreak, the affected countries
declared the outbreak a state emergency and the World Health Organization (WHO) also
declared EVD a Public Health Emergency of International Concern (PHEIC) and the worst EVD
outbreak in history.
As a response to this threat and to meet its obligations with the International Health
regulations, the Ministry of Health together with its partners has developed an EVD
Preparedness Plan. This preparedness plan proposed measures that will prevent introduction of
the Ebola virus to Malawi as well as ensure preparedness for prompt detection and appropriate
response to limit morbidity and mortality. A number of partners contributed towards the
preparedness plan including World Bank, WHO, UNICEF and CDC, MSF and others.

Malawi introduced screening of passengers at Chileka and Kamuzu International Airports. At


the beginning of August all other ports of entry, both land, air and lake commenced screening
procedures shortly afterwards. Screening procedures included taking temperatures and
passengers from affected countries were obliged to fill in a health declaration forms. All border
staff at all ports of entry were trained in Standard Operating Procedures (SOPs) for Point of
Entry.
The Emergency Risk Management Committee (under the instruction of Department of Disaster
risk Management Affairs, DoDMA) and technical task force are in place and met every few
weeks since the outbreak was declared.
Rapid Response Teams have been appointed and trained in all the central and district hospitals
as a first line to respond to any suspected cases. Standing Operating Procedures (SOP) have
been developed to provide a guide on how to detect a case of Ebola, how a
suspected/confirmed case of Ebola can be handled
57

Three central hospitals (Queens Elizabeths in Blantyre, Mzuzu Central Hospital and Kamuzu
Central in Lilongwe) and six border districts have been designated as treatment and
management centres for Ebola. Laboratory staff have been trained specially for handling of
potential Ebola infected specimens and protocols in place for transfer of suspected specimens
to South Africa.
Standard Operating Procedures on Infection Prevention and Control were developed, Personal
Protective Equipment (PPEs) and other Infection Prevention and Control materials were
procured and distributed, and, Health Workers in Infection Prevention and Control were
trained.
IEC materials such as posters, leaflets, fact sheets were developed and a number of press
briefings and press conferences. Four toll free lines were set up with mobile phone companies
for the general public to get information on Ebola.
4.3.9.2 Response to the Floods and Subsequent Cholera Threat
As a result of severe flooding in Southern Malawi in January 2015, an estimated 638,000 people
were affected with 79 deaths and 174,000 people displaced from the three most affected
districts (Nsanje, Chikwawa and Phalombe). The Department of Surveys estimates that 63,531
hectares of land have been submersed by flood waters.

Relief efforts were coordinated by Department of Disaster Management Affairs and the MOH
coordinated health interventions and oversaw the development of a response plan through the
Emergency Health and Nutrition Cluster. Various partners contributed to the plan in the form of
logistics, dignity kits, essential drugs, mosquito nets and water and sanitation and surveillance.
A cholera epidemic in Mozambique resulted in a number of cholera cases being reported in
Malawi. Since 11 February 2015, Malawi has registered 88 cholera cases with two deaths. The
affected districts are Nsanje (78 cases, 2 deaths), Dedza (1 case), Lilongwe (1 case) and
Mwanza (8 cases, 0 deaths). In Nsanje, cases are mostly being imported from an outbreak at
Jambawe illegal Gold Mine in Mutarare district - Mozambique, while in Mwanza they are from
Moartize in Mozambique. There are concerns that camp residents without access to water and
sanitation are particularly vulnerable to cholera.

58

CHAPTER 5: BEYOND 2015 REFORMS IN THE HEALTH SECTOR

5.1 Introduction
The Ministry of Health is proposing the following policy reforms aimed at improving the
delivery of Health Services in the Country, as part of the Government-wide Public Sector
Reform Agenda. If these reforms are implemented, alongside other key strategies and relevant
Government Wide Reforms, particularly, the introduction of the National Identification System,
it is hoped that the Ministry of Health will increase its likelihood of achieving its mandate and
objectives stated above. Several issues were identified as part of the reform process, namely,
improved access to health services needed to be improved, quality of health services needed to
be improved and the health sector should be more financially sustainable. Consequently, four
major reform areas were proposed and are discussed below.

5.1.1 Reviewing the partnership with the Christian Health Association of Malawi (CHAM)
The purpose of the reform to revise the Partnership Agreement between the Ministry of Health
(MOH) and the Christian Health Association of Malawi (CHAM) to improve access to, and
utilization of, essential health services at CHAM facilities as well as eliminate inequalities in
health services provision across the country. CHAM is a very important partner in the Health
Sector. It accounts for approximately 22% of Health Service delivery in the Country with
Government accounting for 76% and other private and not for profit health facilities accounting
for the remaining 2%. The working relationship between the Ministry of Health and CHAM is
governed by a Memorandum of Understanding (MOU), which was signed in December 2002
and expired in 2007, meaning that the process of reviewing this arrangement is long overdue.
The fundamental principle in the expired MOU is that the Ministry of Health pays salaries for all
CHAM health workers, in return, CHAM offers its services to the catchment population at prices
lower than the market prices, allowing users to access services at prices below those prevailing
in private-for-profit health facilities. The MOU also provides for Service Level Agreements (SLAs)
through which CHAM Facilities provide services to mothers and children and in return DHOs
reimburse for their expenses. SLAs allow mothers and children to access maternal, neonatal
and child health services at CHAM facilities for free. Presently, there are 76 CHAM Facilities with
SLAs in place, of which 45 are with facilities that are far from Government Facilities and 31 are
near Government Facilities. The reform aims to find options for increasing SLA to cover all
CHAM facilities that are 8km or more away from a Government Facility as well as expand the
scope of SLA coverage to the entire EHP. This will be in line with the primary objective of the
Ministry of Health of ensuring universal health coverage in the Country.
59

This reform is built on evidence that show that despite the subsidised charges, utilization rates
are significantly lower in CHAM facilities than in Government Facilities. Further, when user fees
are removed, utilization rates in CHAM facilities have exponentially and instantly increased, and
that the utilization rates become comparable to those in Government facilities. Studies in
Malawi and elsewhere have shown that user fees in facilities greatly limit the access to health
services for the majority of Malawians, especially the poor and those in remote rural areas. The
present arrangement with CHAM is, therefore, in sharp contrast to the Governments long-term
objective of universal access of the essential health package to all Malawians regardless of their
geographical location. The objective of Universal Health Coverage cannot be realised unless
free paying services sections are introduced in CHAM facilities in catchment areas where no
alternative public facilities exist. It is, therefore, imperative that the arrangement with CHAM
Facilities be revised to accommodate this principle, and to remove the current inequalities in
health care access entailed by the current MOU between MOH and CHAM.
It is expected that the immediate impact of the policy change is that it will increase access to
and utilization of health care for communities around CHAM Facilities, thereby facilitating the
achievement of Universal Health Coverage. More importantly, the policy change will contribute
to improved health outcomes of communities around CHAM facilities, thereby positioning the
Country towards a right path for achieving post 2015 Health Development Goals. In addition, it
will reduce catastrophic payments poor communities around CHAM Facilities make in order to
access health care, and hence lead to improved livelihoods. All these issues and principles will
need to be negotiated and argued by parties to the Agreement in due course.

5.1.2 Establishing a Health Fund


The countrys health sector is currently experiencing huge challenges at all levels to meet the
vision and aspirations of the sector with regard to delivering a comprehensive range of quality,
equitable, accessible and efficient health service to all the people of Malawi that leads to
quality and productive life. The extent of the problems has been confirmed by the four studies
that Ministry carried out between 2013 and 2014. These included: Drug Quantification Study,
Service Provision Assessment Study, the Resource Mapping for Health Third Round Survey, and
the fifth round of National Health Accounts study.
The studies found that Malawian health system faces serious absolute inadequate financial
resources to fund the Essential Health Package (EHP) and broader health services. For instance,
the total health resources available in 2011/12 financial years only translated to $39.3 per
capita per annum which is the lowest in the Southern African Development Community (SADC)
region -whose average was US$141 per capita per annum in 2011/12. Government expenditure
alone (excluding pool donors) was only US$7.6 per capita per annum in Malawi the lowest in
60

the SADC region -whose average was US$147 per capita annum in 2011/12. These resources
were inadequate to fund the basic cost-effective interventions estimated at $54 per capita per
annum (WHO World Health Report 2010).
Looking in the future, it appears there will be similar situation of serious absolute inadequacy of
financial resources. In 2014/15 financial year only US$500 million would be available against
the estimated costs of US$1.1 billion mostly driven by health systems costs (Human Resources
for Health (HRH) and infrastructure), all of which face very large gaps.
Due to inadequate financial resources, the quality of health service provision has not been
effective. Currently the healthcare system constantly experiences persistent shortages of
essential medicines and medical supplies; critical shortages and malfunctioning of medical
devices and equipment; inadequate and dilapidating hospital infrastructure; acute shortage of
Human Resources for Health; poor food for in-patients; unsatisfactory operations of the
ambulance services; frequent disconnections of utilities (water and electricity); unmotivated
staff which has led to high attrition rates, weak diagnostics and laboratory services; poor
outreach programs on disease prevention and surveillance; and general shoddy delivery of
health service across the board.
It is against this background that the Ministry of Health and its key stakeholders came up with a
Health Financing Strategy (HFS) to assist with mobilizing additional financial resources for the
Health sector. Many alternative financing mechanisms were developed and out of those, five
financing mechanisms were proposed for the health fund where they would be pooled and
managed. Currently, an Expert Panel on the Health Fund has been set up to review these.
What is a Health Fund?
A Health Fund is an independent Fund, normally established by law that pools and manage
health resources for the purpose of purchasing health services and goods for the entitled
population of the country. The Health fund is normally established by an Act of Parliament. The
provisions of the Act specify how the health fund is financed, method of collecting the funds,
uses or applications of the funds, benefit package (service or good) that the fund pays and the
entitled beneficiaries
Health Funds are established as mechanisms of financing and purchasing the healthcare more
effectively and efficiently than traditional methods of financing the healthcare. In Malawi,
where the public healthcare system is underfunded and coupled with inefficiencies, alternative
ways of financing the health sector more efficiently is paramount if access and quality of
healthcare provision is to be improved.

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The setting up of the Health Fund will allow the country to have a separate and independent
pool of funding streams for the health sector. The Fund will also be used as a tool to manage
revenues from other income-generating mechanisms thereby creating a self-sustaining
financing stream. Various measures are under discussion that may help generate revenue
generation for the health sector.

5.1.3 Revitalization of Health Insurance Schemes


In light of both the over reliance on donor funds to finance the Health Sector and the need for a
sustainable, reliable financial system for the health sector, a revitalization of the medical
insurance was proposed as part of the 2014 Health Financing Summit as a potential
intervention in the health sector. A revitalised Health Insurance Scheme can both increase
equitable access to health care services by providing an alternative to direct out-of-pocket
expenditure and act as a source of government revenue to increase resources available for
health.
Consequently, the Ministry of Health is exploring the potential and feasibility of revitalizing the
Health Insurance Scheme. Presently, the Government of Malawi, is seeking technical advice
from consultants to assess the feasibility of implementing such a revitalized insurance scheme.
To implement and provide advice on these reforms, Expert Panels have been set-up to ensure
that the Government of Malawi makes an informed decision moving forward. Each Expert Panel
reports to a larger coordination group which then reports to Senior Management at the
Ministry of Health. These reforms are significant pieces of work and will require involvement of
valued partners and the community.

5.1.4 Reforming Hospital Operations


Theoretically, Primary Health Care is accessed at the District level with much more complicated
care provided at Central Hospitals. However, this does not happen as Central Hospitals
currently operate like large primary and secondary level facilities based on the bulk of services
they provide. This role is further exacerbated by the lack of ability to provide highly specialised
services due to an acute shortage of specialist doctors in Malawi and a lack of sufficient and
quality urban health facilities. As reported in the National Health Accounts (NHA), just under
half (44.9%) of Total Health Expenditure (THE) was spent on curative services and more
specifically 29.8% went to hospitals. To further improve the efficiency, strengthen primary care
services, improve transparency and operations of Central Hospitals across the country, the
Ministry of Health is focusing on the following three areas, namely:
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make all Central Hospitals Trusts to be run by independent Boards;


implement the policy of hiring Directors of Health Services at the District Level to manage
both the Primary and Secondary level health services at the District. It is hoped that the
reformation of District Health Management Teams will allow a more appropriate
investment in all levels of care and prevention in the District. This expected increased
investment in primary and preventive care will both strengthen the overall health system
and be cost effective; and;
delink non-core services from the Hospitals across the country. The development of
Hospital Trusts will increase the capacity of central hospitals to provide specialised referral
services by increasing their decision making powers as well as allowing them to focus on the
provision of specialised care. Delinking non-core services from public hospitals will ensure
that providers of health care concentrate in areas of their core competency while the
Government taps from the private sector expertise and efficiency in the provision of the
priority non-core services.

5.2 Improving Planning, Budgeting, Funding and Oversight Mechanisms of the Health
As a result of concerns raised in a number of forums over the withdrawal of direct donor
support to the health sector, the Minister of Health called for a meeting between Development
Partners, Senior Management for the Ministry of Health, and, Ministry of Finance on the last
day of the Annual Joint Sector Review 2013/14 (28 October 2014). The Minister proposed that
a Taskforce should be formed to review and develop mechanisms that would enable and
facilitate donor partners to channel funding to the health sector.
Ten people were assigned to the Taskforce and it was agreed that consultants should be
engaged as soon as possible to draft a concept note to present to the wider Taskforce. A
concept note was produced and presented to the Taskforce donor partners and senior
management with a road map that was endorsed at a meeting of the Taskforce in January
2015. Task teams were formed to address the following areas:

Planning, budgeting and harmonization which included key tasks such as development of a
planning, budgeting and reporting template that reflects all sources of funding and
identified gaps, a functional review of Technical Working Groups, the Health Sector Review
Group and technical assistance;
Fiduciary oversight;
Common funding mechanisms.

This would include revision and development of any financing agreements or MOUs.
Substantial progress has been made against the road map with a draft planning and budgeting

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framework nearly completed, Terms of Reference for a common audit drafted and discussions
with donor partners are at an advanced stage.

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