Malawi: Overcoming Health System Hurdles

Malawi: Overcoming Health System Hurdles

Health systems are failing to meet the needs of the most vulnerable in Africa. In many cases, health care services either do not exist or are not reaching the people who need them, prompting researchers to ask: What can be done to strengthen health systems in Africa?

A new study, funded by the Disease Control Priorities Project (DCPP), aims to answer just that question by examining factors that help or hinder the health systems in African countries from delivering services to those in need. Specifically, the research will explore to what extent priority interventions as recommended in the second edition of Disease Control Priorities in Developing Countries (DCP2), are successfully delivered through the public health care system.

This work, supported by a team at the London School of Hygiene and Tropical Medicine and the Ministry of Health in Malawi, will examine the delivery of key services in Malawi. It will focus on the implementation of Malawi’s Essential Health Package (EHP), which, although not specifically derived from DCP2, is a set of locally defined priority interventions for the Malawi health care sector with similar emphasis as that recommended by DCP2. It will explore the limitations of the system at the service delivery level, which prevent these priority interventions from taking effect. The study will seek to identify the system-level bottlenecks that delay implementation of these interventions. To study these health system constraints, the team proposes to focus on the following services to illuminate specific points that may then be generalised to the system more broadly:

• Assisted deliveries;

• Treatment for opportunistic infections related to HIV;

• Treatment of children with acute respiratory infections; and

• Treatment of malaria.

The aim of the study is to explore the constraints to the uptake of priority interventions such as those recommended by DCP2 in a country like Malawi, given its existing health infrastructure, health financing, and human resources constraints. In addition, the study will explore how the health system can be strengthened to improve implementation of such recommendations. Objectives are:

• To document the extent to which Malawi’s Essential Health Package reflects the priorities outlined in DCP2;

• Using four tracer interventions, to explore the extent to which these interventions are available and being delivered in line with the EHP at the primary-care level in facilities in three districts of Malawi;

• To explore and, where possible, quantify the factors that enable or constrain the delivery of these interventions in these facilities;

• At district, regional, and national levels to identify the causes of factors that constrain service delivery (these factors may impact directly at facility level or may impede policy implementation at a higher level);

• To explore the views of those working in the Malawi health system on how to successfully overcome these constraints; and

• To make recommendations on specific measures to strengthen the health system and to more effectively implement existing policies.

The study will involve a review of existing information from Malawi, a facility survey in three districts, and interviews with key individuals at the national, zonal, district, and facility level. The analysis will triangulate findings and then highlight how constraints at various levels of the system manifest at service delivery and are coped with. The work will be undertaken with the Ministry of Health and its subordinate structures, such as the Zonal Support Offices and District Health Offices, so that the analyses produced reflect both policymakers’ and service practitioners’ needs, perspectives, and priorities.

Dissemination will take place through a workshop and feedback session in Malawi, including feedback to the district health offices that are part of the research. Preliminary findings are expected to be available in time to feed into the Sector-wide approach (SWAp) review process in September 2007. Wider dissemination will be part of the network activities related to the DCPP. The analytical work will be summarized in working papers and meeting reports. It is envisaged that some findings will also be published in peer-reviewed journals.

Current state of research

The Malawi National Health Sciences Research Committee approved the study proposal in June 2007. Local project staff have been identified, and work began in-country on June 13. After finalisation of research tools and piloting the methods, the health facility survey will be conducted throughout June and July. Preliminary results from the facility survey are expected by late August.