IMPROVING HEALTH SERVICESthroughSTRONGER SYSTEMS

FINAL REPORTTHE REDUCING CHILDMORBIDITY AND STRENGTHENINGHEALTH CARE SYSTEMS PROGRAM2003–2007

Funding for this report was provided by the US Agency for International Development (USAID)under the Reducing Child Morbidity and Strengthening Health Care Systems Program, coopera-tive agreement number 690-A-00-03-0017-00. The opinions expressed herein are those of theauthors and do not necessarily reflect the views of USAID.

CONTENTS

Malawians Confront Many Health Challenges . . . . . . . . .1

Major Achievements of the Program . . . . . . . . . . . . . . . .2

Expanding and Improving Health Services . . . . . . . . . . . .6

Strengthening Health Systems . . . . . . . . . . . . . . . . . . . .17

Fostering Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . .23

A list of acronyms appears inside the back cover.

CHEVENEE REAVIS

1

Asmall, landlocked country in southeastern Africa,Malawi is home to 13.1 million people and some ofthe harshest health statistics in the world. According

to a 2005 UNICEF study, one out of every eight children inMalawi will not live past their fifth birthday. High maternalmortality (984 women die for every 100,000 live births)

contributes to poor overall health of the families left behind.As the AIDS epidemic continues, nearly 80,000 adultssuccumb to this killer disease annually. AIDS mortality amongadults has also resulted in a dramatic increase in the numberof children who have lost one or both parents. Pediatric AIDS,primarily acquired through mother-to-child transmission,underlines the need for scaling up prevention activities.Between AIDS and infectious diseases, including tuberculosis,as well as malaria, famine, and poor access to child healthservices, high morbidity and mortality among children andadults continue to be a concern for Malawi’s Ministry ofHealth.

Malawi is primarily rural, which makes it challenging todeliver health services, especially in remote regions withoutmany roads. Literacy is low, and unemployment is high.Approximately 65 percent of Malawians live in poverty. TheAIDS epidemic has also reduced agricultural productiondramatically in Malawi, a country that depends heavily onagriculture. If these problems are not addressed, health careand other social services will deteriorate still further.

Migration and AIDS-related deaths among health careproviders are also affecting health services. The total numberof doctors currently serving in the Ministry of Health (MOH)and Christian Health Association of Malawi—a major serviceprovider—is only about 160, with a 63 percent vacancy rate.Nursing and other professional health staff are equally scarce. �

MALAWIANS CONFRONTMANY HEALTH CHALLENGES

ACCORDING TO A 2005 UNICEFSTUDY, ONE OUT OF EVERYEIGHT CHILDREN IN MALAWIWILL NOT LIVE PAST THEIRFIFTH BIRTHDAY.

CA

RMEN

URD

AN

ETA

2

The Reducing Child Morbidity and StrengtheningHealth Care Systems Program met these challengesthrough an implementation approach that aligned

program resources with a thorough understanding of thecurrent performance of the health sector. Program staff usedthese resources and applied their expertise to support aseries of well-planned activities to:

� improve prevention and management of childhoodillnesses;

� increase access to services and improve their quality;

� build management capacity at the district level;

� strengthen the management of central hospitals.

Management Sciences for Health (MSH) fostered flexible,bottom-up planning of activities, in close collaboration withDistrict Health Management Teams and central hospitalmanagement teams, and provided comprehensive support—a blend of training, technical assistance, equipment provision,essential renovation activities, and long-term mentoring—tocarry out those plans. All activities were aligned with theMOH’s strategic priorities: the 2004–10 Programme of Workdeveloped through the Sector-Wide Approach and theMalawi Essential Health Package. This model (see Figure 1)allowed the program to achieve substantial, sustainable resultsand improved service performance.

The program improved prevention and management ofchildhood illnesses at the district, hospital, and communitylevels. We achieved these improvements by strengthening the

THERE WERE ACHIEVEMENTSIN SERVICES AND SYSTEMSTHROUGHOUT THE EIGHTDISTRICTS IN WHICH WEWORKED.

MAJOR ACHIEVEMENTS OF THE PROGRAM

CH

EVEN

EE R

EAV

IS

SYSTEM PERFORMANCE

ASSESSMENT

EFFECTIVEDEPLOYMENT OF

PROGRAM RESOURCES

IMPLEMENTATIONAPPROACH

RESULTS• Training• Technical assistance• Equipment• Renovation• Mentoring

• Policy environment• Opportunities• Blockages

• Human• Financial

CH

EVEN

EE R

EAV

IS

Figure 1. Model of MSH Program Support

� Supported the expansion ofIntegrated Management of ChildhoodIllnesses (IMCI) by collaborating todevelop a national IMCI policy andfive-year strategic plan, revising IMCImaterials and introducing them intonational-level training institutions, andtraining more than 300 tutors, healthcare providers, and facilitators in IMCI

� Strengthened the Pediatric HospitalInitiative, a quality improvementapproach emphasizing appropriateemergency care and managementof children admitted tohospitals, resulting in morechildren receiving appropriatetreatment and lowering the number ofchild deaths

� Expanded HIV testing and counseling, reaching morethan 243,775 people, and established 48 sites forservices to prevent mother-to-child transmissionof HIV

� Increased community-based care for childmalnutrition through 60 sites in five districts

� Addressed high rates of malaria by introducingperiodic antimalarial therapy for pregnant women,increasing coverage from 53 percent to 80 percent ofwomen receiving prenatal care in seven districts

3

� Supported the development and introduction ofimportant health policies, including the NationalHealth Policy, Central Hospital Reform Policy,National Transport Policy, Quality Assurance Policy,and IMCI Policy

� Improved infection prevention at district hospitals,resulting in one of the highest scores in Malawi forcleanliness and infection prevention at Salima DistrictHospital

� Renovated hospital wards to improve infectionprevention and quality of care, supplied utilities suchas water and electricity to health centers, andprovided equipment such as 90 radios to hospitalsand health centers to improve communications forpatient referrals and other emergencies

� Strengthened the decentralized annual budgetingand planning process, with all 28 districts

throughout Malawi now preparing andsubmitting standardized DistrictImplementation Plans

� Supported national implementation of theEssential Health Package to ensure that high-quality, equitable health services are providedin the eight focus districts

� Introduced improved management systems in twocentral hospitals and eight districts, for planning andbudgeting, financial management, human resource

management, drug supply management, transportmanagement, supervision, and quality assurance

KASUNGU

MZIMBA

SALIMA

MANGOCHI

BALAKA

MULANJECHIKWAWA

NTCHEU

*Lilongwe

*Blantyre

Lake Malawi

RESULTS OF THE REDUCING CHILD MORBIDITY ANDSTRENGTHENING HEALTH CARE SYSTEMSPROGRAM

CH

EVEN

EE R

EAV

IS

4

THE PROGRAM IMPROVEDPREVENTION AND MANAGEMENTOF CHILDHOOD ILLNESSES ATTHE DISTRICT, HOSPITAL, ANDCOMMUNITY LEVELS.

IN THIS PHOTO:Before the program, lines at Kasungu District Hospital were long, andit and other facilities were often ill equipped to prevent infection ortriage patients. Frequently, even emergency cases had to wait in line.

national Integrated Management of Childhood Illnesses(IMCI) Taskforce and building the capacity of district-levelstaff, community leaders, traditional health providers, andcaregivers to recognize the symptoms of common childhoodillnesses and take action to treat, refer, or seek care forchildren. The program also addressed other health issues thataffect both children and adults, including HIV/AIDS, malaria,and malnutrition, and developed appropriate systems andapproaches to meet the requirements of these healthconcerns.

Important initiatives such as prevention of mother-to-child transmission of HIV and community care for severeacute malnutrition were expanded, giving communitieseasier access to services. We improved quality of care byexpanding facility-based IMCI, strengthening the provision ofintermittent presumptive therapy for malaria in pregnantwomen, improving supervision of services, and putting inplace better referral systems between communities anddistrict hospitals.

We built management capacity at the district level bystrengthening the performance of the District HealthManagement Teams in eight districts of the country. Theprogram focused on management systems—planning andbudgeting, financial management, logistics management,human capacity development, transport management,communication systems, quality assurance systems, and healthmanagement information systems—and developing thecapacity of district-level managers and staff to use them.

Our work in strengthening the management of centralhospitals focused on Kamuzu Central Hospital in Lilongwe

CH

EVEN

EE R

EAV

IS

5

Figure 2. Health Services and SystemsServices provided by the program (in yellow ovals) weredirectly supported by improved systems (in tan).

and Queen Elizabeth Central Hospital (QECH) in Blantyre.The program prepared these two hospitals for autonomousmanagement by creating a policy framework that will enablethem to operate independently and by developing orstrengthening the full range of management systems theyneed. Other achievements included drafting of regulatoryinstruments—such as memoranda of understanding withtraining and research institutions, a Biomedical Ethics andResearch Policy, Central Hospital Reform Policy, NationalHealth Policy, and Malawi Health Bill—to supportdecentralized management.

This program created changes in the health services andsystems of Malawi that are likely to be sustained becauseprogram activities were fully integrated. Integration meansthat we made improvements in access to and delivery ofhealth services at all levels of the health sector in conjunctionwith developing supporting systems, reforming policies, andfully engaging stakeholders. Figure 2 shows the healthservices and systems on which we worked. �

MALARIA

SAFEMOTHERHOOD

INFECTIONPREVENTION

HOSPITAL MANAGEMENT

HOSPITAL REFORM

HEALTH MANAGEMENT INFORMATION

POLICY

DRUG MANAGEMENT

DISTRICT HEALTH MANAGEMENT TEAMS

ZONAL HEALTH OFFICES

REDUCING CHILD MORBIDITYAND STRENGTHENING

HEALTH CARE SYSTEMS

NUTRITION CHILD HEALTH

HIV/AIDS

CH

EVEN

EE R

EAV

IS

6

The program supported service delivery in manyareas, including combating child morbidity andmortality, expanding prevention and treatment of

HIV/AIDS and infectious diseases, improving the quality ofcare, and reducing maternal mortality.

SAVING CHILDREN’S LIVES

INTEGRATED MANAGEMENT OF CHILDHOODILLNESSES. IMCI is a key approach to the prevention and

management of childhood disease, so MSH worked closelywith the Ministry of Health to expand and strengthen theimplementation of IMCI. At the national level, we helped theMOH develop an IMCI policy and strategic plan. We alsoprovided technical assistance to shorten the training offacility-based providers from 11 to 6 days—an importantfactor in making training more accessible and less costly. Wesupported district-level implementation through training of233 providers, 36 tutors, and 40 facilitators. Districtsupervision of IMCI was encouraged, which contributed to

EXPANDING AND IMPROVING HEALTH SERVICES

CH

EVEN

EE R

EAV

IS

IN THIS PHOTO:Trainers in Kasungu

7

improved quality of care. Now during consultations, themajority of children (more than 80 percent, up from abaseline of less than 20 percent) are assessed for dangersigns; immunization status is assessed in more than 90percent of visits; and more than 70 percent of caregivers ofchildren with diarrhea were correctly advised to give thechildren extra fluids and continue feeding them.

The program supplied essential equipment to 227facilities to further strengthen IMCI. Nutrition activities,improved drug supply and management referral systems, anddistribution of insecticide-treated mosquito nets alsocontributed to reducing morbidity and mortality amongchildren.

PEDIATRIC HOSPITAL INITIATIVE. To reduce the highchild mortality rate in Malawi, a major goal of this program,we scaled up integrated child health services through thePediatric Hospital Initiative (PHI). Because the quality ofservices at district hospitals tends to be better than that atlocal health clinics, pediatric hospital wards are always busy. Inthe past, Malawi’s hospitals have used a first-come, first-served approach to admitting patients.

The PHI improved the quality of care for children using alow-cost process that allows hospital staff to identify casemanagement problems and find solutions for them. Theprogram introduced:

� triaging pediatric patients based on an assessment oftheir need for urgent care;

� standard protocols for managing hospitalized childrenwith fever, pneumonia, diarrhea, malnutrition, and othercommon but serious conditions;

� essential equipment such as oxygen concentrators toeffectively manage emergencies.

This initiative is helping Malawi to make importantimprovements in child health indicators. For malaria,

IN THIS PHOTO:A health surveillance assistant in Kasunguprovides outreach services.

pneumonia, diarrhea, and malnutrition—the prime killers ofchildren in Malawi—hospitals are using the new triaging andcase management protocols to identify and treat priorityillnesses more precisely than ever before. In five districtswhere the initiative was launched in 2006, compliance withmanagement guidelines for fever and pneumonia rose from abaseline of 50 percent to more than 80 percent by July 2007.In four program districts, child mortality in hospitals declinedby 29 percent during the same period. In a fifth district,where reduced mortality was not seen, the District HealthManagement Team investigated and identified a number ofmanagement problems.

While the PHI introduced small improvements to basicmanagement of pediatric health care, the difference it hasmade has been undeniable. According to Margaret Chipeta,the head nurse at Kasungu District Hospital, “MSH hashelped us work as a team and has reinvigorated ourmotivation to improve the health care services in our district.More patients are using the health facilities because theservices are better.”

IN FOUR DISTRICTS, CHILDMORTALITY IN HOSPITALSDECLINED BY 29 PERCENTBECAUSE OF THE PEDIATRICHOSPITAL INITIATIVE.

CH

EVEN

EE R

EAV

IS

8

COMMUNITY THERAPEUTIC CARE FORMALNUTRITION. In 2006, with the support of the Officeof US Foreign Disaster Assistance (OFDA), the programbegan to rapidly scale up community therapeutic care (CTC)in the five districts of Malawi hardest hit by famine. Sixty newsites were set up to make it easier for people from thesurrounding communities to bring their children for services.CTC programs allowed malnourished children to be treatedas outpatients, saving families the expense and lost work timethat come with hospitalizing a child, thus enabling theprogram to reach more children. From January 2006 toJanuary 2007, 5,557 children with severe acute malnutritionwere enrolled in CTC. Of these, 86 percent were cured, 10percent dropped out of the program, 2 percent werereferred to nutrition rehabilitation units, and 2 percent died.

These results were possible because the program trainedmore than 2,200 health workers and nearly 1,550 volunteersto identify malnourished children, monitor their progress, andmake referrals for their further care when necessary.

June 11, 2007

Dear Madam,

Thank you for the official visit last August which focusedon malnourished children. On that day you visited me andCrispin Austin of Nkomera Village, who was hit by severemalnutrition and had been discharged from the CTCprogramme 15 days before our visit.

The number of malnourished children registered in mybook has gone up from 12 since you came here to 21. There isimprovement [in identifying children who need treatment].

As a CTC volunteer, I grew a soy crop this year andharvested a 50-kilo bag. . . . I want to learn more about how tomix soy flour with maize flour and how to prepare a delicioussoy porridge. This will enable me to bring correct informationto the community as well as parents who bring their childrento the Under-Fives Clinic. . . . [I am] committed to teachingparents to become self-reliant on soy, instead of relying ongovernmental and nongovernmental organizations forassistance, since it is grown locally.

I shall organize a cooking demonstration day. . . . I willdistribute phala [the highly nutritious soy and maize porridge]to the children. I will hire a photographer to show everyactivity in pictures.

I know that your visit was not the first and the last. Ibelieve you will come to see the changes.

Your faithful volunteer,Moffat Chiusti

IN THIS PHOTO:Margaret Kaseje, Country Director for Family Health International, tastingChiponde, an affordable nutritional supplement for children

IN THIS PHOTO:Community therapeuticcare volunteer at work inMulanje

A VOLUNTEER COMMITTED TOHELPING MALNOURISHED CHILDREN

SALL

IE C

RAIG

HU

BER

CH

EVEN

EE R

EAV

IS

9

Furthermore, MSH supported the development of a systemto provide Chiponde (a ready-to-use therapeutic food),implemented a supervisory system, and worked with theMinistry of Health to institutionalize these systems. Even afterthe food crisis abated and OFDA funding ended in January2007, the CTC program continued and expanded.Committed CTC volunteers continue to serve malnourishedchildren in their communities with enthusiasm.

EXPANDING PREVENTION ANDCARE SERVICES FOR HIV/AIDS,TUBERCULOSIS, AND MALARIA

PREVENTION AND CARE SERVICES FOR HIV/AIDS.Until recently, HIV/AIDS testing, counseling, and treatmentservices in the program’s eight target districts were quitelimited. Today they are so common that, according to oneHIV/AIDS counselor at Chikwawa District Hospital, thestigma associated with AIDS has nearly disappeared. “Therehas been so much education about HIV that it is almost ascommonly known as malaria,” he says. At a nearby healthcenter, the medical assistant notes that patients used to comethrough the back door for HIV counseling and testing butnow enter through the waiting room.

Through this program, more than 243,775 people havebeen tested for HIV at hospitals, clinics, and community-based outreach initiatives. In addition to increased access totesting and counseling, the program bolstered HIV/AIDSservices through other activities. In 8 district hospitals and 40program-supported health centers, pregnant women areoffered HIV testing during prenatal care visits. If the result ispositive, these women are provided treatment to preventmother-to-child transmission of the virus. The number ofpregnant women who were tested increased from fewerthan 250 or 4 percent of all new prenatal patients in thequarter ending in December 2004 to more than 18,550 (85percent of all new prenatal patients) in the quarter ending in

After learning that her husband had had an affair,Beatrice Munyowa got tested and discovered shewas HIV-positive. Although at first she facedsome discrimination, she wanted to be openabout her status in order to raise awareness ofAIDS. She wanted people in her community tounderstand that anyone can get HIV, counteringthe misconception that married people do notneed to worry about becoming infected with thevirus.

During an MSH-supported communitymobilization visit, Beatrice learned about a newsupport group in her area. The communitymobilization team used dance and drama to helppeople understand the importance of knowingtheir status and realize that being HIV-positive isnot a death sentence because effective treatmentis available. Beatrice now accompanies teamsthroughout the district and tells her story. Shealso manages a support group for people livingwith HIV/AIDS and their friends and families. Thegroup—men and women, young and old—meetstwice a month. When one member encounters achallenge, the group finds solutions together.

Beatrice brings a message of hope to peoplewho are also HIV-positive. “I just want to talk topeople about HIV/AIDS and help themunderstand that you can still have a full life whenyou are HIV-positive,” she says. “This isimportant to me and I will never stop.”

AN HIV-POSITIVE WOMANLEADS A SUPPORT GROUP

ABOVE:Beatrice Munyowa, leader of asupport group for people livingwith AIDS

CH

EVEN

EE R

EAV

IS

June 2007 (see Figure 3). Through this testing activity, anincreasing number of pregnant women are also beingreferred for antiretroviral treatment.

MSH has also helped develop and introduce systems tosupport this HIV/AIDS work. Through joint problem-solving,we improved access to testing by reviewing referral practicesand identifying barriers to access. Locally developed solutionsgreatly boosted the number of people with access to HIVtesting: more people wanted to know their status, and morepregnant women, more tuberculosis (TB) clients, and morehospitalized patients were tested.

All districts in Malawi, not just the eight program districts,have included HIV activities in their District ImplementationPlans for the current fiscal year as a result of MSH’s supportand training. A handbook for management of HIV testing andcounseling sites is now available, as is a job aid for HIV testingin pediatric and adult wards.

TUBERCULOSIS. Working with the National TuberculosisControl Program, MSH provided antibiotics (cotrimoxazolepreventive therapy) to newly diagnosed HIV-positive TBpatients and introduced active case-finding for TB at HIVtesting sites. In program districts, more than two-thirds of allnewly diagnosed tuberculosis patients are now tested forHIV. The program trained more than 1,050 staff working inover 100 facilities to provide cotrimoxazole therapy to wardoff the opportunistic infections that often plague those livingwith AIDS. We also collaborated with the TB program toensure that appropriate TB activities were included in districtworkplans.

MALARIA PREVENTION AND TREATMENT. To combatmalaria, the program undertook efforts to strengthen thedemand for preventive services, especially intermittentpresumptive treatment (IPT) for pregnant women, and toincrease the use of bed nets and other mosquito reductioninitiatives. We supported the implementation of directly

THROUGH THIS PROGRAM, MORETHAN 243,775 PEOPLE HAVE BEENTESTED FOR HIV.

CH

EVEN

EE R

EAV

IS

OCT–DEC

JAN–MAR

APR–JUN

JUL–SEP

OCT–DEC

JAN–MAR

APR–JUN

JUL–SEP

OCT–DEC

JAN–MAR

APR–JUN

2004 2005 2006 2007

PERCENT

10

40

30

20

50

60

70

80

90

100

10

Figure 3. Percentage of Pregnant Women Tested as a Proportion of All New Prenatal Visits

LEFT:Laboratory technician at Kasungu District Hospital

DISTRIBUTION OF BED NETSIN MULANJE PROTECTSTHOUSANDS AGAINSTMALARIA

Collaboration among the Mulanje District HealthOffice, MSH, and Population Services International(PSI) led to the sale of subsidized insecticide-treated nets (ITNs) in four communities in 2006. Injust five days, PSI sold more than 1,400 nets—adramatic increase over the 904 ITNs distributed inMulanje in the first eight months of 2006. Each ITNcan protect several family members frommosquitoes, so the impact of these sales goes farbeyond the 1,400 nets sold.

This campaign was successful because the DistrictHealth Management Team, with assistance fromMSH and PSI, laid the groundwork in advance bytargeting underserved areas and sending healthsurveillance assistants and the District Information,Education, and Communication Officer to informthe communities about the sales campaign. Thesehealth workers conveyed health messages aboutITNs, including the recommendation that peopleregularly sleep under nets to protect themselvesfrom mosquito bites.

LESSONS LEARNED. MSH had previouslysupported the sale of nets by local ITNcommittees, an approach that involved extensivetraining and supervision of the committees andassistance in development of financial managementand stock management systems. From a cost-benefit perspective, selling nets through thecollaborative mass-campaign approach appears tobe far superior to selling nets through ITNcommittees.

11

IN THIS PHOTO:Women redipping mosquitonets, which must beretreated with insecticideevery six months

RUD

I TH

ETA

RD

12

observed therapy (DOT) for IPT using a problem-solvingapproach. For example, we helped staff identify and resolvepatient flow problems. We provided buckets and mugs forwater so that patients could take their antimalarial medicineswhile at the clinic. We also trained health workers in theappropriate timing of IPT and dispelled the myth thatantimalarials cannot be taken on an empty stomach.

From a baseline of 53 percent, IPT increased to 80percent in seven of the eight target districts. While extensiveactivities in all districts increased distribution of insecticide-treated bed nets (see previous page), this activity ceased atthe end of 2006 when the MOH introduced distribution offree bed nets.

The program also contributed to improving the quality ofmalaria treatment for children at health centers and districthospitals. Support for the introduction of IMCI was crucial tofortify malaria treatment, as were new systems and tools.Those included a malaria case management tool, regularcase-management review meetings at district hospitals, andguidelines for prenatal care of women with malaria(developed in collaboration with the National MalariaControl Program).

IMPROVING QUALITY OF SERVICES

INFECTION PREVENTION. While the concept ofinfection prevention is simple, changing attitudes andawareness about it in Malawi, as in many countries, is asignificant challenge. In a recent speech, Minister of HealthMarjorie Ngaunje referred to hospital-acquired infections as amajor cause of patient morbidity and mortality. She urged allhospitals to adhere to strict infection prevention measures.The eight district hospitals supported through this programworked hard to meet new standards for infection preventionset by the Ministry of Health.

HARD WORK BY THE HOSPITALMANAGEMENT AND STAFF ANDTHE SURROUNDINGCOMMUNITY IN SALIMA ISPAYING OFF.

RUD

I TH

ETA

RD

13

BALAKA

PERCENT

10

40

30

20

50

60

70

80

90

100

MULAN

JE

KASUNG

U

MZIMBA

MAN

GOCH

I

CHIKWAW

A

NTCH

EU

SALIMA

NOTE:Baseline assessments were performed for four hospitals in 2003 and four hospitals in 2005; final assessments were done in 2006 and 2007.

Baseline

Final

With help from MSH, one of these hospitals—SalimaDistrict Hospital—assessed its obstacles to infectionprevention and identified challenges to overcome. Forexample, hospital staff did not have proper equipment ortraining to sterilize medical equipment; important protocols,such as proper waste disposal and equipment disinfection,were not in place; and patients and their families contributedto unsanitary conditions by littering the hospital building andgrounds.

MSH helped the Salima Hospital management team drawup a plan to work with its staff and nearby communities toput new protocols for infection prevention in place.Education sessions helped the community understand its rolein keeping the hospital clean, and training programs helpedstaff incorporate activities into their daily routines to supportthe hospital’s goal of becoming an infection-free facility.

This hard work by the hospital management and staff andthe surrounding community in Salima, as in other districts, ispaying off (see Figure 4). In February 2007, Salima DistrictHospital, once reputed to be one of Malawi’s worst districthospitals, received one of the highest scores for cleanlinessand infection prevention in all of Malawi. Now the hospitalfloors gleam and fresh air blows through sparkling cleanwindows. Local newspaper clippings praising the hospital’snew standards of cleanliness hang on bulletin boards. One

Figure 4. Scores from Assessments of Infection Preventionin Eight District Hospitals

14

REDUCING THE NUMBER OFMATERNAL DEATHS

Maternal mortality rates in Malawi are among the highest insouthern Africa: 984 per 100,000 live births. To address thisserious health issue, the program helped the District HealthManagement Team (DHMT) in Kasungu conduct routinematernal death audits, which revealed many factors thatcontribute to maternal deaths. Some women in labor arrivedat health facilities by ambulance but had to wait in the vehiclefor nearly an hour before receiving attention. When wordspread about this lack of attention to care, and in placeswhere ambulances were not available, some women soughtthe services of traditional birth attendants, who do not havesufficient training or equipment to manage complicatedbirths.

To address these findings, MSH helped the DHMTs in theeight program districts strengthen emergency referrals byinstalling or repairing 90 radios and developing localtransport policies to speed up and streamline ambulanceservice. Ambulance drivers in Kasungu were trained inemergency triage and customer service, thus decreasingwaiting times for women in labor. MSH supported fourDHMTs in organizing discussions with traditional authorities

BOTTOM:Clinician at Kasungu DistrictHospital

headline reads, “Salima District Hospital, Clean at Last!” Thestaff is committed to continuing this progress.

Salima District Health Officer Florence Bwanali recallsthat during the first months of the MSH-led infectionprevention initiatives, the hospital staff felt demoralized. “Nowthe staff are willing to work because I make sure that theteam is motivated,” she says. “Now all of us are very happyand this award is going to keep our morale high.”

OTHER QUALITY INITIATIVES. The introduction ofbimonthly referral meetings in the southern region alsocontributed greatly to the quality of service delivery. Throughthe meetings, a standard referral form was introduced, andregular reviews of referral feedback, training of districtclinicians in patient management, and district visits byspecialists from central hospitals were established. Theproject trained trainers in emergency triage, assessment, andtreatment, and produced a training DVD for district trainers.

MSH also supported infection prevention work in thetwo central hospitals, which were accredited and have sincemaintained their accreditation. The support includedprocurement of materials, training, and involvement ininternal assessments. Introducing complaint boxes at QECHgreatly improved staff attitudes toward work and punctuality.Over time, the number of negative comments dropped by30 percent, and the number of compliments increased.

CH

EVEN

EE R

EAV

IS

CH

EVEN

EE R

EAV

IS

15

and birth attendants to help these community leadersrecognize early danger signs in labor and to promotereferrals for delivery at fully equipped and staffed healthfacilities.

In remote areas, traditional birth attendants werepartnered with hospital staff to make sure pregnant womenwith complications are promptly referred to hospitals andreceive adequate attention upon their arrival. Training fortraditional birth attendants included attention to infectionprevention and record-keeping to help nearby facilities trackthe number of women giving birth in neighboringcommunities. To improve attitudes toward hospitals,volunteers were trained to greet women on arrival at thehospital and escort them to the maternity ward.

With the strengthening of emergency referral services, arenewed commitment to customer satisfaction, and formalpartnerships with local communities, Kasungu District Hospitalrecorded a dramatic reduction in maternal mortality, from 52maternal deaths (1.2 percent of all mothers delivering) in 2005to 29 (0.8 percent) in 2006, and the Kasungu maternity ward isnow busier than ever. �

LESSONS LEARNED ABOUTEXPANDING HEALTH SERVICES

� Work on-site with staff to help them identifyproblems and find practical solutions—oftensolutions are simple.

� Adhere to the guidelines in the MOH’s nationalEssential Health Package.

� Plan for expansion by making sure that all requiredinputs (trained staff, equipment, necessary supplies,effective supervision and support) are in place whenexpansion begins.

THE PROGRAM HELPED MAKESURE PREGNANT WOMEN WITHCOMPLICATIONS ARE PROMPTLYGIVEN ADEQUATE ATTENTION.

TOP:MSH staff member andnurse from Kasungu DistrictHospital showing a patientregister to a traditional birthattendant

BOTTOM:Nurses in their newinfection prevention T-shirts

RUD

I TH

ETA

RD

CH

EVEN

EE R

EAV

IS

16

Community

Health Center

District

Zone

National

IndividualsHouseholdsVolunteers

Health Center Staff

District HospitalsDistrict Health Management Teams

Zonal Health Teams

USAID and Other DonorsPolicymakers/Ministry of HealthCentral Hospitals

PARTNERS LEVELS

CA

RMEN

URD

AN

ETA

Figure 5. Partners and Levels in the Health System

17

STRENGTHENINGHEALTH SYSTEMS

Improved health services depend on strong systems inMalawi, as elsewhere in the world. For example, theprogram combined its efforts to underpin the referral

system—essential for emergency care of children andpregnant women—with adequate transport and a radiocommunication network. This integrated approach to allprogram activities involved working at multiple levels: central,health zones, districts, and communities (see Figure 5). Thiswork benefited both the eight program districts and, throughcentral and zonal initiatives, all districts of the country. Inaddition, MSH assisted two central hospitals withimprovements in important management systems. Partnersat every level were essential to the program’s success.

DISTRICT PLANNING. Although the MOH introducedthe process of District Implementation Plans (DIPs) someyears ago, it was clear at the beginning of this program thatthe MOH’s mandate for the development and use of DIPswas not routinely followed. The program’s charge to assistwith improved management at the district level began withassisting the central MOH Planning Directorate in the reviewand revision of guidelines for DIPs.

The MSH team supported the districts to make suretheir plans were linked with the priorities of nationalprograms such as those for TB and malaria. When zonalhealth offices were introduced in 2005, the program assistedthese offices so that zonal staff could support thedevelopment of DIPs.

All districts in Malawi now routinely submit annual DIPsaccording to the standardized guidelines. The quality of health

care has improved because proper planning and budgetinghave led to funding for essential equipment for infectionprevention and other equipment such as radios for bettercommunication between hospitals and lower-level servicesites.

Greater involvement of stakeholders—mission hospitals,nongovernmental organizations, district assemblies—indeveloping and reviewing plans has increased support fromMOH staff in implementing the plans. MSH has activelypromoted regular quarterly review of the implementation ofDIPs, which has strengthened the capacity of district staff tomanage programs. Program coordinators now know howmany of their planned activities have been implemented,what the expenditure was for activities, and how they needto alter planned activities to achieve better results. DIPs weredrawn up efficiently in 2007 because the development ofDIP guidelines was timely and the development of plans alsobegan on time—a significant step forward.

PROGRAM COORDINATORSNOW KNOW HOW MANY OFTHEIR PLANNED ACTIVITIES HAVEBEEN IMPLEMENTED, WHAT THEEXPENDITURE FOR ACTIVITIESWAS, AND HOW THEY NEED TOALTER ACTIVITIES TO ACHIEVEBETTER RESULTS.

IN THIS PHOTO: Partners at every level were essentialto the program’s success.

CA

RMEN

URD

AN

ETA

CH

EVEN

EE R

EAV

IS

18

HEALTH ZONES. With the creation by the MOH of fivehealth zones to supervise and support districts, the programbegan providing operational support to two zonal offices inDecember 2005. MSH first provided support to the MOHto develop a set of clinical and managerial supervisory toolsfor zonal offices and to define zones’ roles, responsibilities,and reporting mechanisms. The program’s technical andoperational support enabled the establishment of adecentralized supervision mechanism, filling a sorely neededfunction.

MSH initiated mentoring for zonal staff to improve drugmanagement, data collection, and transport management inthe districts within zones. Through the mentoring process, webuilt the capacity of both zonal and district staff: 55 pharmacytechnicians, assistant statisticians, transport officers, and health

HOW SERVICES HAVE BENEFITEDFROM BETTER SUPERVISION

� Free IPT services were implemented for pregnantwomen at Kankao Rural Hospital in Balaka.

� Wells were repaired, making water available at twohealth facilities in Mulanje.

� Supervisors helped identify and provide vital suppliesand equipment, such as hurricane lamps andkerosene and pails for mobile clinics, enabling healthcenter staff to provide services such as deliveriesafter hours.

� Reuse of syringes and gloves stopped at two facilitiesin Mangochi with improved enforcement of infectionprevention.

� In Salima, the DHMT increased the number ofoutreach sites after noticing low immunizationcoverage in the catchment area of Lifuwu HealthCenter.

IN THIS PHOTO:Women getting water at thehospital

PHO

TOG

RAPH

ER N

AM

E

RUDI THETARD

19

administrators, and 28 focal persons for health managementinformation systems for the entire country, benefited fromthis assistance. More regular supervision of district staff isnow contributing to better management of services andquality of care.

DISTRICT SUPERVISION. Routine supportive supervisionof health facilities has been very challenging in Malawi.Supervision has typically been erratic, vertically driven, andnot always supportive. MSH worked with the DHMTs torestructure supervision by introducing multipurposesupervisors and cluster supervision, whereby a supervisor orteam of supervisors supports two to five health centers. Thisapproach not only reduces duplicative work but alsoprovides more regular supervision: by the end of theprogram, 90 percent of facilities were receiving supervisionevery six months, compared to 44 percent at the beginning.We also helped DHMTs conduct regular quarterly reviewsof supervisory visits so that the findings from supervisoryvisits would be discussed with managers and solutions toproblems found.

STRENGTHENING HEALTH MANAGEMENTINFORMATION SYSTEMS. Encouraging the use of data bymanagers was a key component of the MSH program. Facilitystaff were trained to collect data correctly, report in a timelyway, and interpret data through the use of simple graphs.Data quality was improved in three districts, leading to 34facilities being accredited in meeting criteria for data qualityand timeliness of reports. Timely reporting rates rose from abaseline of 59 percent to 86 percent. The informationsystems work made it possible to create an evidence-baseddistrict planning and review process: these had been twoseparate and unrelated activities before the MSH program.

MORE REGULAR SUPERVISION OFDISTRICT STAFF IS NOWCONTRIBUTING TO BETTERMANAGEMENT OF SERVICES ANDQUALITY OF CARE.

CH

EVEN

EE R

EAV

IS

SCO

TT M

CKE

OW

N

PHARMACEUTICAL MANAGEMENT. The programstrengthened drug management primarily at the district level:227 drug stores were reorganized and upgraded, and thetimely submission of drug order forms increased from 30percent in 2003 to more than 90 percent in 2007. Drugpilferage was reduced by instituting regular stock checks anduse of stock cards and by engaging health center advisorycommittees in checking the quantities of drugs received byhealth centers. MSH helped pharmacy technicians acquireskills in supervising drug management at health facilities andcoordinating district and hospital drug committees.

TOP:Pharmacy technician atChikwawa District Hospital

BOTTOM:District Health ManagementTeam in Chikwawa

20

TRANSPORT MANAGEMENT. With the MOH, districthospitals, and DHMTs, MSH strengthened transportmanagement, with a focus on making sure referral systemsfunction well. We facilitated the finalization of a nationaltransport policy and guidelines. After the guidelines forQECH were disseminated to all transport users in thehospital, reports showed significant reductions in fuelconsumption.

At the district level, we helped develop transportguidelines and professionalize transport management.Transport guidelines mandated the use of vehicle logbooks,submission of trip requests before travel, and control ofvehicles after hours, when misuse of official vehicles is

greatest. These efforts reduced expenditure on fuel at thedistrict level and increased the availability of ambulances atthe community level to provide transport for emergencies.Overall, establishment of these guidelines reduced the totalnumber of kilometers traveled and redirected scarceresources to patient care instead of administrative activities(see Figure 6).

CENTRAL HOSPITAL MANAGEMENT.To improve thequality of care, especially for people living with AIDS, at thecentral hospitals in Lilongwe and Blantyre and to allow thehospitals to function as autonomous units, the programhelped develop a trust fund mechanism and strengthenedhospital management systems. For example, pharmaceuticalmanagement was strengthened at both hospitals.Improvements included a new stock control system,introduction of pharmaceutical ordering books andspreadsheets to track pharmaceutical consumption by costcenter, production of a pharmacy bulletin for prescribers, andmonthly production of Central Medical Stores reports. AtQECH, the pharmacy was renovated, and improvedsupervision, storage, dispensing, and security were institutedin the pharmacy. At Kamuzu Central Hospital, installation ofan electronic pharmaceutical inventory and control system(ePICS) strengthened stock management. Other systemsimprovements in these hospitals included planning andbudgeting, finance, human resources, transport, supervision,and quality assurance. �

TOP:Medical transport in Ntcheu,illustrating the problems thatMSH addressed

OPPOSITE:Waiting at the Mbalachandatobacco estate clinic

CH

EVEN

EE R

EAV

IS

AV

ER

AG

E K

ILO

ME

TE

RS

(tho

usan

ds)

Patient and Facility Support

Administration

2005 2006

10

40

30

20

50

Figure 6. Distance Traveled for Patient and FacilitySupport vs. Administration (Monthly Average)

in Mangochi

21

LESSONS LEARNED ABOUTSTRENGTHENING HEALTHSYSTEMS

� Design activities with the leadership andparticipation of the central MOH, since jointly ledinterventions will be the most successful.

� Focus on those areas where districts and centralhospitals need support and initiate activities onlyat their request.

� Use MOH systems and approaches as the basisfor interventions, applying a joint problem-solvingand performance-improvement approach toidentify and address needs.

� Consider unplanned, additional activities carefully.It is better to support implementation of feweractivities and complete them rather than tryingto do more with limited success.

� Look at systems strengthening holistically:support not only training but also other needssuch as materials, technical assistance, and thelong-term supervision and support required forsustainability.

CH

EVEN

EE R

EAV

IS

WORK BENEFITED BOTH THEEIGHT PROGRAM DISTRICTS AND,THROUGH CENTRAL ANDZONAL INITIATIVES, ALLDISTRICTS OF THE COUNTRY.

22

THESE ADVANCES WERE NOTGAINED WITHOUT CHALLENGES,AND FOSTERING SUSTAINABILITYWAS FOREMOST IN THE MINDS OFTHOSE WHO PLANNED ANDIMPLEMENTED THIS PROGRAM.

CA

RMEN

URD

AN

ETA

23

The achievements of this program were many:children’s health improved and deaths were averted.Mothers have a better chance of surviving

childbirth. More than 243,775 men, women, and childrenwere tested for HIV, including pregnant women who, if HIVpositive, were treated so that their children had a betterchance of not being infected during childbirth. More familiesreceived and used bed nets to prevent malaria.

Many citizens of Malawi were trained to modify health-related behaviors and outcomes—from leaders andmanagers in the Ministry of Health to nurses and healthassistants serving in simple rural health clinics to communityvolunteers who assisted with identifying and referringthousands of malnourished children for treatment. Policieswere introduced, materials and equipment provided tosupport health services, and systems developed to ensurethat health services are well managed and deliveredeffectively and efficiently.

LESSONS LEARNED ABOUTSUSTAINABILITY

These advances were not gained without challenges, andfostering sustainability was foremost in the minds of thosewho planned and implemented this program. Lessonslearned about improving and managing childhood illnesses,increasing access to and quality of services, and buildingmanagement capacity at the district level and in centralhospitals are highlighted elsewhere in this report. Severallessons are worth summarizing here:

FOSTERING SUSTAINABILITY

� Taking a comprehensive approach to all programactivities to ensure integration of systems and services isa prerequisite for success.

� Working in partnership to identify barriers andperformance gaps and to design and implement flexibleapproaches to remove them promotes ownership andcommitment to improved services and systems.

� Using a participatory approach that engages allstakeholders—MOH leaders, managers and serviceproviders from all levels of the health system, and healthcare consumers—leads to better acceptance andapplication of new policies and approaches, improvingchances of sustained performance.

� Providing the right amount of assistance at the rightplace, combined with coaching and mentoring and clear

CA

RMEN

URD

AN

ETA

CH

EVEN

EE R

EAV

IS

IN THIS PHOTO:Local chief in Salima, who helpsmobilize the community oncommunity therapeutic care formalnutrition

24

exit strategies, instead of “doing things for people”increases the acceptability of new approaches andsystems.

The results of the systems strengthening interventions ofthis program, summarized in USAID’s external end-of-projectevaluation, were:

� progress was made in all eight districts;

� the data show improvements in the performance ofdistrict health systems;

� there were positive differences between MSH-supporteddistricts and others.

Staff shortages and turnover are significant threats tosustainability and were largely beyond the scope of thisprogram. However, a newly instilled pride in accomplish-ments—improvements in infection prevention, enhanced

pediatric hospital services, acquisition and application of newskills in the integrated management of childhood illnesses,expanded knowledge of how to identify and managemalnourished children, and many other innovationsintroduced through this program—hold promise for thefuture. New staff have been inspired to pursue careers inhealth care provision or management and those who alreadyhold positions have been motivated to continue.

This program introduced many new approaches andsystems that have been demonstrated to work well in Malawi.These proven interventions have caught the attention of thewider health-sector community, both implementers anddonors, who are supporting their adaptation throughout thecountry. Thus, many of the initiatives described in this reporthave a good chance of continuing to contribute to theimproved health and well-being of the citizens of Malawi. �

CH

EVEN

EE R

EAV

IS

ACRONYMS

AIDS acquired immune deficiency syndromeCTC community therapeutic careDHMT District Health Management TeamDIP District Implementation PlanDOT directly observed therapyEPI Expanded Programme of ImmunizationHIV human immunodeficiency virusIMCI Integrated Management of Childhood IllnessesIPT intermittent presumptive treatmentITN insecticide-treated netMOH Ministry of HealthMSH Management Sciences for HealthOFDA Office of US Foreign Disaster AssistancePHI Pediatric Hospital InitiativePSI Population Services InternationalQECH Queen Elizabeth Central HospitalTB tuberculosisUSAID United States Agency for International

Development

COVER PHOTO BY CARMEN URDANETA • DESIGN BY ERIN DOWLING

CH

EVEN

EE R

EAV

IS

784 Memorial Drive • Cambridge, MA 02139-4613 USA617.250.9500 • 617.250.9090 (FAX)www.msh.org • communications@msh.org

To order copies of this booklet, please send an e-mail to bookstore@msh.org