How to Make System Wide Changes for Newborns: Malawi Experience

Dr. Ann Phoya, RNM, PhD Global Newborn Health Conference Johannesburg, RSA 17th April 2013

Presentation Outline
Health Demographics before system wide changes Justification for system wide changes

Focus areas for system wide changes

The Malawi Health Sector Strategic Plan and the

Essential health care package Health System Strengthening Strategies Achievements Challenges & Opportunities

Health demographics before Wide System Changes: MDHS 2004

Population:11.8 MMR: 984 IMR: 76 NMR: 36 U/5MR: 145 SAD: 57 CPR: 48% TFR: 6

Source: DHS 2004

Health indicators before system wide changes: POW 2004

Vacancy rate: 65%
Health human resource

density: 3 per 10,000

Health facilities able to

deliver full EHP: 13% Budget allocation for health: > 7% Health Centers meeting staff norms: 10%

Justification for implementing System wide changes / strengthening

To improve performance of the sector To align health services to the changing health needs To deliver public health services in line with

government policy

Focus areas for system wide changes

POLICY
Inputs
Human Resources Equipment/Drugs Infrastructure Finance

Operations
Financial management systems Systems of training Patient care protocols Monitoring systems

Outputs
Process indicators Impact/Outcome indicators

Framework for System Wide Changes

Adopting a Sector Wide Approach ( SWAP) for planning, managing

and financing health service delivery Designing a Health Sector strategic Plan HSSP) addressing priority areas using multi-sectoral approach Defining an essential health package ( EHP) of interventions within the HSSP ( free of charge) includes maternal and newborn health Decentralization of Service delivery to District Assemblies

The Malawi Health Sector Strategic Plan

Human Resources Support to District teams

stewardship , Governance & financing

Core Business: Health Services Delivery (EHP)

Supply chain management

Infrastructure Development and service delivery

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Improving Essential Basic Equipment

STRATEGIES FOR SYSTEM WIDE CHANGES

Strategy 1. Integrated delivery of The Malawi Essential Health Package at community, health center and Hospital level
Vaccine preventable

diseases Malaria MNH including FP Tuberculosis HIV and AIDS & STIs ARI including pneumonia

Neglected Tropical diseases Non communicable

Diseases Nutritional disorders Trauma & Common injuries Ear, Eye infections Skin conditions Diarrheal diseases

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Strategy 1: Delivery of the EHP Component of MNH

Use of services agreements (SLA) with other health providers Use of services agreements (SLA) with other health providers

for MNH

Strengthening

Referral system at community level

Components of maternal and newborn care interventions in the EHP

Pre-pregnancy interventions

through youth and adolescent reproductive health Services Pregnancy Care services Intra-partum services CEmONC and BEmONC Postnatal care services

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Strategy 2: Increasing Human Resources for Health: Emergency Human Resource Program
Expanding infrastructure of training colleges, and support for student fees to increase intake of students for pre-service trainings Introduction of a new cadre - community midwives Increasing number of salaried Community Health workers: Health Surveillance Assistants Establishment of Health Service Commission and delinking health workers from civil service commission for speedy promotions and recruitment

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Increasing Human Resources for Health Increasing the HRH

Task shifting and task-

sharing Improving retention through salary top ups and housing, accelerated post basic training Preparatory support for licensure examinations
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Strategy 3: Strengthening Health Information Systems

Integration of community-based maternal

and neonatal care (CBMNC) indicators within the national HIS pregnancy identification

CBMNC facilitating birth notification and Birth Registration underway Use of mobile health application for easy

data capture

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Strategy 4. Strentghening Supply Chain Management

Reforming the Central Medical Stores and the national

Supply chain system

Improve supply chain to avoid episodes of stock

outs of essential newborn commodities:

Injectable antibiotics Antenatal Corticosteroid (ANCS) Resuscitation Equipment Amoxicillin

Use of mobile health to improve visibility of drug stock

levels at community levels

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5. Strategy 5: Improving Health Financing

Flexible funding mechanisms to accommodate

policies of different partners (common basket fund vs vertical funding) Use of resources mapping tool to track and redirect resources in the health sector Encouraging DPs to support existing national or district plans than stand alone projects
Pilot PBI/RBF to improve MNH outcome Financing strategy in place to explore alternative

mechanisms of health financing

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Strategy 6: Improving Access

Institutionalization of Total Quality Improvements in service

delivery Building and , renovation of primary health facilities to provide the essential health package including BEmONC services Standardization of essential equipment for different levels of health facilities for easy maintenance and procurement

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Improving Access to Referral Care & Work environment: New NkotaKota District hospital

Strategy 7:. Strenthening. Leadership and Governance

Creation of Platforms for Coordination of all sector players, and

forums for assessing sector performance i.e. Health sector review groups Technical working groups such as EHP, SRH and their subcommittees Annual & Biannual Reviews Financing Agreement and Memoranda of understanding with different groups MOH taking lead in identifying strategic interventions that are evidence based
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Achievements:

114% increas e
53% increas e

Improvements in the health workforce likely contributed to progress for newborn survival
Source: Zimba E, Kinney MV, Kachale F et al. 2012. Newborn survival in Malawi: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3):iii88iii103 Data: DFID, Management Sciences for Health. 2010. Evaluation of Malawis Emergency Human Resource Progromme. Cambridge, MA: Manageme nt

Achievements

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Challenges
Some development partners preferring project approach

and seeking attribution for their funds, Partners preference for funding direct program delivery and not and system strengthening Private health sector expanding but not contributing to HRH development Inadequate funding for the HSSP from both Government and partners, Geographical access still a problem
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Opportunities
Political commitment for MDG 4 &

5 very high: Presidential safe motherhood initiative for maternal and neonatal health
Governance structures in place to

promote accountability for MNH & other services Government commitment high to improve health budget through alternative financing mechanisms

ZIKOMO
THANK YOU FOR YOUR ATTENTION
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