Health Sector Strategic Plan III 2023-2030 - Reforming for Universal Health Coverage

1.1 Introduction to the HSSP III ................................................................................................................... 13

1.2 Methodology and conceptual framework for the HSSP III ..................................................................... 14

1.2.1 Conceptual framework for the HSSP III ......................................................................................... 14

1.2.2 Determining the Health Benefits Package and associated health system investment requirements 16

1.3 Background ........................................................................................................................................... 16

1.3.1 Organization of the Malawi Health Care System ........................................................................... 17

1.3.2 Legal, Policy and Development frameworks ................................................................................. 18

1.4 Organization of the HSSP III Document ................................................................................................ 21 Chapter 2: Situation Analysis ............................................................................................................ 22

2.1 Overview of the Chapter........................................................................................................................ 22

2.2 Progress of Ultimate and Intermediate Health Impacts ......................................................................... 22

2.2.1 Trends in Health Impacts .............................................................................................................. 22

2.2.2 Progress in Financial Risk Protection ............................................................................................ 23

2.2.3 Systems for Client feedback .......................................................................................................... 24

2.3 Health Service Delivery ......................................................................................................................... 25

2.3.1 Progress of Service Delivery ......................................................................................................... 25

2.3.2 Progress in Quality Management .................................................................................................. 32

2.3.3 Bottlenecks in Health Service Delivery .......................................................................................... 33

2.4 Social Determinants of Health ............................................................................................................... 33

2.4.1 Achievements in Social determinants of Health ............................................................................ 33

2.4.2 Bottlenecks in Social Determinants of Health ................................................................................ 34

2.5 Progress in the Implementation of Health Systems for Service Delivery ............................................... 34

2.5.1 Health Infrastructure and Medical Equipment ............................................................................... 34

2.5.2 Human Resources for Health ........................................................................................................ 36

2.5.3 Medical Products and Technology ................................................................................................ 39

2.5.4 Digital Health ................................................................................................................................. 39

2.5.5 Health Research and M&E ............................................................................................................ 40

2.5.6 Leadership and Governance ......................................................................................................... 41

2.5.7 Health Financing ........................................................................................................................... 41

2.6 Conclusion ............................................................................................................................................ 43 Chapter 3: The Vision of the Health Sector Strategic Plan III ........................................................ 44

3.1 Overview of Chapter.............................................................................................................................. 44

3.2 Vision, Mission, and Goal ...................................................................................................................... 44

3.2.1 Vision ............................................................................................................................................ 44

3.2.2 Mission .......................................................................................................................................... 44

3.2.3 Goal............................................................................................................................................... 44

3.3 Guiding Principles ................................................................................................................................. 45

3.4 Objectives ............................................................................................................................................. 46 Chapter 4: Health Benefits Package for HSSP III ............................................................................. 47

4.1 Introduction & Background .................................................................................................................... 47

4.2 HBP Definition process ......................................................................................................................... 48

4.2.1 Primary and Secondary Health Benefits Package ......................................................................... 48 2 | Malawi Health Sector Strategic Plan III 2023-2030

4.2.2 Tertiary Health Benefits Package .................................................................................................. 49 Chapter 5: HSSP III Strategic Interventions ..................................................................................... 50

5.1 Overview of Chapter.............................................................................................................................. 50

5.2 Strategic Interventions and Activities..................................................................................................... 51 Pillar 1: Service Delivery ............................................................................................................................ 51 Pillar 2: Social Determinants of Health ....................................................................................................... 52 Pillar 3: Infrastructure and Health Technologies ......................................................................................... 53 Pillar 4: Human Resources for Health ........................................................................................................ 55 Pillar 5: Medical Products and Technology ................................................................................................ 57 Pillar 6: Digital Health ................................................................................................................................. 59 Pillar 7: Research ....................................................................................................................................... 60 Pillar 8: Leadership and Governance ......................................................................................................... 61 Pillar 9: Health Financing ........................................................................................................................... 63 Chapter 6: HSSP III Costing and Prioritization................................................................................. 68

6.1 HBP Cost and Prioritization ................................................................................................................... 70

6.2 Prioritization of Health Workforce Costs ................................................................................................ 71 Chapter 7: Implementation Arrangements ....................................................................................... 75

7.1 Governance for “One Plan, One Budget, One M&E” ............................................................................. 75

7.2 Annual operational planning, associated governance processes for “One Plan” and budgeting ........... 76

7.3 Implementation of Annual Operational Plan, and Code of Conduct ...................................................... 78 Chapter 8: Monitoring and Evaluation Arrangements .................................................................... 80

8.1 Introduction to the chapter..................................................................................................................... 80

8.2 Overview of the Results Framework for the HSSP III ............................................................................ 80

8.3 Health Sector Data ................................................................................................................................ 81 8.4 Structure of the Health Information System for the HSSP III ................................................................. 82

8.5 Determining the Information requirements for the HSSP III Monitoring and Evaluation Framework ..... 84

8.6 M&E Coordination Structure .................................................................................................................. 84

8.7 General Digital Health and HIS Guiding Standards ............................................................................... 85 Annexes ............................................................................................................................................... 87 Annex 1: Detailed annual intervention implementation Plan for HSSP III ......................................................... 87 Annex 2: HSSP III M&E Matrix ........................................................................................................................ 104 3 | Malawi Health Sector Strategic Plan III 2023-2030 List of Tables Table 1: Distribution of health facilities by type and ownership ............................................................ 17 Table 2: Populations groups and their entitlements .............................................................................. 65 Table 3: Overview of prioritized areas within the HSSP III ................................................................... 70 Table 4: Criteria for Access Constraint of HBP Interventions ............................................................... 71 Table 5: HBP Cost per type of funding in relation to the Drug and Consumable Budget from 2021 Resource Mapping ................................................................................................................................ 71 Table 6: Projected workforce and workforce gaps in 2030, if the prioritized health workforce investment package is funded as proposed.......................................................................................... 73 Table 7: Data Sources for performance management .......................................................................... 82 Table 8: HSSP III Health Management Information Systems Modules at National, Central Hospital, District Council, and District level secondary and primary health facility levels .................................... 83 Table 9: Coordination responsibilities for Health Information System at all levels ............................... 85 4 | Malawi Health Sector Strategic Plan III 2023-2030 List of Figures Figure 1: Conceptual Framework for the HSSP III................................................................................ 15 Figure 2: Trends in Life Expectancy (by Gender) in Malawi ................................................................. 23 Figure 3: Leading causes of DALYs in in Malawi in 2019 ..................................................................... 24 Figure 4: Malawi’s Overall progress on Universal Health Coverage .................................................... 25 Figure 5: Trends in antenatal coverage (percentage of women that had 4+ ANC visits) ..................... 26 Figure 6: Trends in prevalence of overweight, wasting and underweight in children ........................... 27 Figure 7: Trends in percentage HIV Prevalence among adults, 15-49 years of age and HIV incidence per 1000 population (15-49) .................................................................................................................. 28 Figure 8: Incidence of Tuberculosis per 100,000 population per year .................................................. 29 Figure 9: Hospital performance in the implementation of COHSASA standards (in percent) .............. 33 Figure 10. Vacancy Rates by Cadre, from 2017 to 2021, for Public Facilities and CHAM Facilities that Provide Primary Care and Secondary Care, as Compared to the Establishment ................................ 38 Figure 11: Absorption Rates for Licensed Graduates by Cadre, per Early 2020 Graduate Mapping Exercise................................................................................................................................................. 38 Figure 12: UHC cost cube ..................................................................................................................... 48 Figure 13: HSSP III Interventions Logic ................................................................................................ 51 Figure 14: Financial Resource Need by Objective of HSSP III ............................................................. 69 Figure 15: Flow from planning and budgeting to implementation and monitoring ................................ 77 Figure 16: Joint planning, joint implementation, and joint monitoring ................................................... 79 Figure 17: HSSP III Results Logic ........................................................................................................ 81 Figure 18: Health Information System Structure for the HSSP III......................................................... 83 5 | Malawi Health Sector Strategic Plan III 2023-2030 Acknowledgements The Ministry of Health acknowledges all stakeholders that participated in the development of this strategic plan. These include Ministry of Health Directorates, District Health Offices, other Government Ministries, Departments and Agencies, Regulatory Bodies, International and Local Non-Governmental Organisations, Civil Society Organisations, Patient groups, Donors, private sector actors, UN agencies, Members of Parliament, academic institutions, and members of the general public. The HSSP III process was overseen by the Health Sector Working Group and managed by the HSSP III Secretariat that was hosted in the Department of Planning and Policy Development. The Senior management Team of the Ministry of Health provided overall policy guidance and vision for the HSSP III. The contributions of the members of these teams are duly acknowledged. The Ministry appreciates the health donor group (HDG) for their good will and support especially in the development of health sector reforms, particularly the “One Plan, One Budget and One M&E” and health financing reforms. The Ministry also acknowledges the HDG’s consistent engagement in the process. The Ministry also acknowledges technical partners that contributed significantly to the strategy, namely the Clinton Health Access Initiative (CHAI) health financing and human resources for health (HRH) teams for costing and HRH modelling support respectively, the University of York for supporting the development of the health benefit package (HBP) and the entire Thanzi La Onse modelling team for the novel model which will be instrumental for HSSP III implementation. We are also grateful to the HSSP III Lead Consultant for faithfully reflecting the vision of the Ministry for this strategy and coordinating with thematic Consultants. The inputs of Human Resource for Health, Equipment and Diagnostics and M&E Consultants are also duly acknowledged. Development of the strategy was made possible by the financing of the Ministry of Health, the World Bank, the Global Financing Facility, the Health Services Joint Fund, CHAI, Partners in Health, OXFAM, WHO, UNICEF and UNDP. The financial support of these institutions is accordingly appreciated. The MoH is committed to effectively providing its stewardship role in the implementation of the HSSP III to honour all the efforts and contributions that all the different stakeholders made in the development of this strategy. Dr Charles Mwansambo Secretary for Health January 2022 6 | Malawi Health Sector Strategic Plan III 2023-2030 Acronyms AMR Antimicrobial Resistance ANC Antenatal Care ART Antiretroviral Therapy BEmONC Basic Emergency Obstetric and Neonatal Care CDR Central Data Repository CEA Cost Effectiveness Analysis CEmONC Comprehensive Emergency Obstetric and Neonatal Care CH Central Hospital CHAM Christian Health Association in of Malawi iCHIS Community Health Information System CMED Central Monitoring and Evaluation Department CMR Child Mortality Rate CMST Central Medical Stores Trust CoM College of Medicine CPD Continuous Professional Development CSO Civil Society Organization DALY Disability Adjusted Life Year DC District Commissioner DEC District Executive Committee DFF Direct Facility Financing DHA Department of HIV/AIDS DHMT District Health Management Team DHRMD Department of Human Resource Management and Development DHO District Health Office DHIS District Health Information System DHS Demographic and Health Survey DIP District Implementation Plan DOTS Directly Observed Treatment, Short Course (for Tuberculosis) DPSM Department of Public Sector Management DPT Diphtheria, Pertussis and Tetanus EH Environmental Health eHIN Electronic Health Information Network EHP Essential Health Package EHRP Emergency Human Resource Plan EML Essential Medicines List EmONC Emergency Obstetric and Neonatal Care EMS Essential Medicines and Supplies ENAP Every Newborn Action Plan EPI Expanded Programme on Immunization FGD Focus Group Discussion GBV Gender-based violence GDP Gross Domestic Product GFATM Global Fund for the Fight against AIDS, Tuberculosis and Malaria GIZ Gesellschaft für Internationale Zusammenarbeit GoM Government of Malawi HBP Health Benefits Package HCMC Health Centre Management Committee HDP Health Development Partners 7 | Malawi Health Sector Strategic Plan III 2023-2030 HDU High Dependency Unit HEU Health Education Unit HIS Health Information System HMIS Health Management Information System HPV Human Papillomavirus HRH Human Resources for Health HRMIS Human Resources Management Information System HSA Health Surveillance Assistant HSJF Health Services Joint Fund HSS Health Systems Strengthening HSSP Health Sector Strategic Plan HSWG Health Sector Working Group ICT Information and Communications Technology ICU Intensive Care Unit IDSR Integrated Disease Surveillance and Reporting IEC Information Education and Communication IMCI Integrated Management of Childhood Illness IMR Infant Mortality Rate IPTp Intermittent Preventive Treatment during Pregnancy iHRS Integrated Human Resource Information System IRS Indoor Residual Spraying IUCD Intrauterine Contraceptive Device JAR Joint Annual Review LF Lymphatic Filariasis LLIN Long Lasting Insecticidal Nets LMIS Logistics Management Information System MCDA Multicriteria Decision Analysis M&E Monitoring and Evaluation MBTS Malawi Blood Transfusion Service MCH Maternal and Child Health mCPR Modern Contraceptive Prevalence Rate MDG(s) Millennium Development Goal(s) MDR Multi Drug Resistant MGDS Malawi Growth and Development Strategy MICS Multiple Indicators Cluster Survey MMR Maternal Mortality Ratio MoF Ministry of Finance MOH Ministry of Health MoLGRD Ministry of Local Government and Rural Development MoU Memorandum of Understanding MSTG Malawi Standard Treatment Guidelines MSCC Minimum Standards for Clinical Services MW2063 Malawi 2063 MIP-1 Malawi 2063 First 10-Year Implementation Plan NAO National Audit Office NCD Non-Communicable Disease NGO Non-Governmental Organization NHA National Health Accounts NHSRC National Health Sciences Research Committee NLGFC National Local Government Finance Committee NMCP National Malaria Control Programme NMR Neonatal Mortality Rate 8 | Malawi Health Sector Strategic Plan III 2023-2030 NRIS National Registration and Identification System NSO National Statistical Office NTDs Neglected Tropical Diseases OPC Office of the President and Cabinet ORS Oral Rehydration Solution PFM Public Financial Management PHC Primary Health Care PHL Public Health Laboratory PLHIV People Living with HIV PMRA Poisons Medicines Regulatory Authority PMTCT Prevention of Mother to Child Transmission of HIV PoW Program of Work QA Quality Assurance QECH Queen Elizabeth Central Hospital QI Quality Improvement QM Quality Management QMD Quality Management Directorate RUM Rational Use of Medicines SDGs Sustainable Development Goals SLA Service Level Agreement SEL Standard Equipment List SMT Senior Management SOPs Standard Operating Procedures SRHR Sexual and Reproductive Health Rights STH Soil Transmitted Helminths STI Sexually Transmitted Infection TFR Total Fertility Rate THE Total Health Expenditure TWG Technical Working Group U5MR Under-Five Mortality Rate UHC Universal Health Coverage UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VDC Village Development Committee VHC Village Health Committee WASH Water, Sanitation and Hygiene WHO World Health Organization YFHS Youth Friendly Health Services 9 | Malawi Health Sector Strategic Plan III 2023-2030 Foreword The Government of Malawi is committed to ensuring that people in Malawi attain the highest possible mental, physical, and social health and a high quality of life. The health sector contributes to this aspiration through the delivery of cost-effective, high quality, equitable and integrated health care within the available health financing. This is the path the HSSP III sets. The HSSP III has placed communities at the heart of service provision through the reform on integrated platforms of care that will aim to achieve holistic, and client focussed care. The HSSP III also aims to empower communities to take charge of their health through the introduction of equitable and community led domestic health financing mechanisms. Strengthened community oversight of local health care delivery is also a strong component of the proposed governance mechanisms in the HSSP III. The HSSP III has considered the effects of population growth, the structure of the Malawi population and urbanisation on health and the demand for health care in the design of health systems interventions such as infrastructure development. It has also accounted for other health determinants such as poverty, climate change, natural disasters and disease pandemics and defined priorities for multi- sectoral and inter-sectoral collaboration. The HSSP III will build strong and holistic health systems. Hence, it places joint processes for planning, budgeting, and reporting and their governance mechanisms at its centre. The HSSP III will build a performance management system and has outlined strong implementation arrangements to ensure its successful implementation. For human resources for health, a review of the existing health workforce capabilities will be conducted in order to build a health workforce that is responsive to changes in the burden of disease and many other factors. Capacities of training institutions will have to be built in order to train new health workforce cadres and increase numbers of the existing cadres. This must be done collaboratively between Government and its Development partners. The Government of Malawi is committed to increasing the health workforce subject to the country’s economic performance. It is my sincere hope, therefore, that since we have jointly formulated this strategic document, it will be the single most important point of reference for implementation and design of service delivery initiatives as it embodies our dream for a better health care delivery system and improved health for the people of Malawi. Honourable Khumbize Kandodo Chiponda, MP Minister of Health, Malawi December 2022 10 | Malawi Health Sector Strategic Plan III 2023-2030 Executive Summary III has therefore defined a Health Benefits Package (HBP) previously referred to as The Health Sector Strategic Plan III (HSSP III) Essential Health Package (EHP) in previous outlines the objectives, strategies and activities HSSPs to maximize population health given the needed to build upon progress during limited available resources. implementation of the Health Sector Strategic The HSSP III has the following objectives Plan II (HSSP II) and accelerate Malawi’s across nine priority areas: progress in achieving Malawi’s Universal Health Coverage (UHC) targets by 2030. The 1. Service Delivery: Increase equitable access to and improve quality of health HSSP III is motivated by Malawi 2063’s vision care services. of self-reliance and outlines how the health 2. Socio-Economic Determinants: To sector will contribute to the human capital improve overall health, environmental development and mindset-change pillars of the health and prevent disease through vision. In the spirit of inclusivity, the HSSP III addressing social determinants of development process was extensively health and burden of disease. 3. Infrastructure & Medical Equipment: To consultative and participatory, ensuring that the improve the availability, accessibility prioritization of resources and outcomes in the and quality of health infrastructure and plan reflect a shared vision. medical equipment at all levels of Notwithstanding a very challenging health care. 4. Human Resources: Improve the environment characterized by up to four waves availability of competent and motivated of the COVID-19 pandemic, the health sector human resources for health (HRH) for registered notable progress across impact level quality health service delivery that is performance measures. For example, maternal effective, efficient, and equitable. mortality ratio was at 349 deaths per 100,000 5. Medical Products and Technology: To live births in 2019 against the HSSP II target of improve the availability, quality, and rational utilization of medicines and 350 deaths per 100,000 live births; under-5 related medical supplies, balancing mortality rate was 39 per 1,000 live births in among the 3 P’s: patients, products, 2020 against the HSSP II target of 48 deaths and personnel. per 1,000 live births; infant mortality rate was 29 6. Digital Health: To develop a per 1,000 live births in 2020 against the HSSP sustainable and harmonized country II target of 34 deaths per 1,000 live births; and led digital health system that covers all the neonatal mortality rate was 19 per 1,000 live areas of service provision and enables efficient delivery of health services at births in 2020 against the HSSP II target of 22 all levels of the health system. deaths per 1,000 live births. In addition, the 7. Research: To promote and coordinate HSSP II HIV incidence target of 2 cases per a health research agenda in order to 1,000 adult population aged 15-49 years was generate high quality evidence surpassed and was at 1.21 in 2020. Despite required to inform the development of such progress, however, significant gaps in health and health care delivery. population health, service delivery and health 8. Leadership and Governance: To enhance effectiveness of leadership systems building blocks remain, and require and governance at all levels of the addressing in order to meet UHC goals by health sector. 2030. 9. Health Financing: To set a well- governed health financing architecture The goal of the HSSP III, therefore, is to move that is able to mobilize adequate towards UHC by improving health status, resources, distribute the resources in financial risk protection and client satisfaction. an efficient and equitable way, and It is recognized, however, that resources for strategically purchase services based health care delivery are inadequate. The HSSP 11 | Malawi Health Sector Strategic Plan III 2023-2030 on a well-defined benefit package in steer the “One Plan, One Budget, One Report” pursuit of UHC goals. process. The district stakeholder forum will Eleven reforms that are deemed game- provide overall multi-sectoral and partner changing, have been identified, informed by coordination at the district level. The Secretary high quality evidence as well as extensive for Health will oversee overall coordination of consultations. These are: in Service Delivery - the sector, while designated directors at the transitioning from vertical programming to national level will provide overall leadership of integrated platforms of care for service delivery; their respective thematic areas. The Director of in Health Workforce – 1) implementation of a Health and Social Services at the District performance management system, 2) Council shall provide overall technical development of a harmonized in-service coordination in line with Council governance training system for human resources for health arrangements. Government, Donors and linked to continuous professional development, Implementing partners will be guided by MOUs and 3) evidence-based matching of health and a Code of Conduct. workforce supply and demand; in Infrastructure In order to effectively monitor the HSSP III, 1) and Medical Equipment – 1) upgrading of urban the health information system will be health centres to community hospitals to decentralized to each decision-making entity at improve city primary and secondary care, and each level of the health system; 2) all partners 2) equipment inventory management to in the health sector will align and harmonize achieve procurement and utilization efficiency; their data systems to facilitate timely in Supply Chain - effective management and transmission of information to decision makers coordination across parallel supply chains while at all levels of the health system; 3) streamlined working towards greater systems integration and interoperable digital health systems will be through CMST by 2030; in Digital Health - imperative; 4) All efforts shall be made toward scaling up of digital health systems; in digitalizing service delivery at the point of care governance – 1) implementation of a “One and data shall be collected and extracted from Plan, One Budget, One M&E” system, and 2) these systems to support service delivery and increase provider autonomy; and in Health timely and accurate reporting. HSSP III will be Financing - strategic purchasing in health a living document and, in that spirit, MOH plans financing. to publish digital versions of future editions of The total cost of implementing the intervention HSSP III on MOH website to ensure that latest matrix for all the eight years is estimated at evidence is translated into strategic priorities. US$31.2 billion (MWK 32 trillion) representing the full resource need before the prioritization. For the 2023/24 FY, although the need was $4 billion, it was estimated from resource mapping round seven that only approximately $690 million ($537.1 million fungible funding and $153 million non-fungible Government and donor funding) would be available in total. Therefore, the 2023/24 needs were prioritised down for to fit within the $537.1 million envelope estimated. Assuming conservatively that this level of funding persists, the HSSP III will realistically be implemented at $4.7 billion, with an acceptable margin of error, over the eight years. The implementation of the HSSP III will be based on an HSSP III operational plan that will draw from the HSSP III intervention matrix. The Health Sector Working Group (HSWG) will 12 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Doctor counselling a paediatric patient at a health centre. mortality rate (NMR) from 27.9 deaths per 1,000 live births years in 2010 to 19.1 deaths Chapter 1: per 1,000 live births in 2020. Malawi’s Universal Health Coverage (UHC) Introduction and index, which measures progress of Countries are making in achieving UHC, was estimated at 48% in 2019 which compares favourably with Background countries in the same per capita Gross Domestic Product (GDP) range 1. Potential drivers of this remarkable performance include a highly efficient HIV response and effective

1.1 Introduction to the delivery of essential life-saving interventions. For HIV/AIDS, for example, the country’s HSSP III performance against the 95:95:95 targets stood Malawi’s population health and service delivery at 93:97:93 in 2021 (UNAIDS). HIV related level outcomes have improved over the past deaths have consequently declined from 6.25 decade albeit some gaps yet remain that deaths per 1,000 population in 2004 to 0.63 require addressing. For instance, Life deaths per 1,000 population in 2020. Other expectancy has increased from 55.6 years to service delivery improvements have come from 64.7 years between 2010 and 2020. This is progress in maternal, neonatal and child health mainly due to declines in the maternal mortality (MNCH) services especially through sustained rate (MMR) from 444 deaths per 100,000 live high rate of coverage of high impact preventive births years in 2010 to 349 deaths per 100,000 and curative health interventions including live births in 2017; reductions in under-five antenatal and delivery care, immunization, mortality rate (U5MR) from 84.2 deaths per distribution of Long-Lasting Insecticidal Nets 1,000 live births years in 2010 to 38.6 deaths (LLINs) and treatment of common infectious per 1,000 live births in 2020; reductions in infant diseases (UNICEF, 2018).2 mortality rate (IMR) from 52.4 deaths per 1,000 Despite the notable progress in population live births years in 2010 to 29 deaths per 1,000 health and service delivery outcomes, live births in 2020 and reductions in neonatal 1 2 The World Bank. (2022, June 03). World Bank Open UNICEF. (2018). Every Child Alive: The urgent need to Data. Retrieved from The World Bank: end newborn deaths. Retrieved from https://data.worldbank.org/ https://data.unicef.org/resources/every-child-alive- urgent-need-end-newborn-deaths/ 13 | Malawi Health Sector Strategic Plan III 2023-2030 significant gaps persist especially due to under HSSP III timing is critical because it coincides investments across health system building with the last eight years of the Sustainable blocks (MoH, 2001)3. This health sector Development Goals (SDG) period. The Ministry strategic plan takes an investment approach by of Health recognizes that to attain SDG targets prioritizing health service delivery, in 2030, there must be fundamental reforms implementing value generating health system and restructuring of the health system. Malawi interventions and undertaking a highly has made significant progress in service coordinated set of reforms for an efficient health delivery and health indicators as is shown later system able to withstand public health but this has been in the context of a fragmented emergencies and other shocks. health care system, both in health care delivery and health financing. Therefore, to accelerate The Health Sector Strategic Plan III (2023- progress towards SDG targets fragmentation 2030) is a pivotal document developed at an and other key bottlenecks must be addressed. opportune time when Malawi recently launched a new vision, the Malawi 2063, and its initial corresponding ten-year implementation plan,

1.2 Methodology and the Malawi 2063 First 10-Year implementation conceptual framework plan (MIP-1), (2021-2030)4. The HSSP III has for the HSSP III drawn on the Malawi 2063 principles of self- reliance and mindset change by specifying a 1.2.1 Conceptual framework for the reform package to set the health system HSSP III towards these ambitions and ensure a health The WHO building blocks frameworks was system that is fit for purpose. It also aligns to used to inform the thematic areas of the HSSP the multi-sectoral approach to human capital III according to which the objectives have been development laid out in the Vision. defined. The World Bank Flagship Control Knob While sustaining or simply refining many routine framework was used to guide a bottleneck interventions from previous HSSPs, the HSSP analysis and development of strategies and III is different in its conceptualization and deep activities to address the bottlenecks (Figure 1: understanding of the rapidly changing local and Conceptual Framework for the HSSP III). The international operating environment. A key inception report developed for the HSSP III highlight is its explicit recognition that the fiscal provides detailed methodology and key space situation is likely to be vulnerable, yet references for the approach (MOH 2021)5. with dedication to a purposely designed and Based on the World Bank framework, the goals evidenced informed catalytic reform package, of Universal Health Coverage (UHC) are to: 1) progress towards the 2030 Universal Health improve health status (both levels and Coverage targets for Malawi is recoverable and distribution of health); 2) provide adequate sustainable. Another departure is the “systems financial risk protection, ensuring that the and reforms” in the health systems building blocks approach underpinning its design in which the aim is to optimize functioning of each building block while sufficiently accounting for the intricate connectedness of the building blocks to achieve the service delivery and ultimate health goals. And finally, the HSSP III has taken practical steps to optimally decentralize service delivery and empowering communities to take full ownership of the system at service delivery level. 3 4 MoH. (2001). The Mid-Term Review of the Malawi Health National Planning Commission. (2020). Malawi 2063. Strategic Plan II. Lliongwe Lilongwe 3: National Planning Commission 5 MOH. (2021). HSSP III Development Inception Report 14 | Malawi Health Sector Strategic Plan III 2023-2030 population do not get impoverished as a result construction of infrastructure, ongoing of a weaker healthcare delivery system; and 3) procurement of equipment etc.8 Figure 1 ensure clients are satisfied with the health distinguishes routine and reform interventions. system (Maeda, et al., 2014).6 The framework The logic of the conceptual framework in Figure suggests three intermediate performance 1 is as follows. Effective implementation of the measures through which the UHC goals will be routine and reform interventions (strategies and achieved namely; 1) improved access to health their activities) will lead to the achievement of services, 2) improved/enhanced quality of the objectives (at the building block level). healthcare, and 3) efficiency in health service Improvements in the building blocks are then delivery.7 expected to lead to improvements in service At the objective level, the WHO Building Blocks delivery outcomes of health service access framework was utilized but the results were (including equity), quality and efficiency, and refined based on the results of the bottleneck ultimately improving health outcomes, client analysis. It guided the choice of investment satisfaction and financial risk protection. The areas and identification of routine HSSP III agreed reform package on the hand will deliver strategies and activities. The control knobs the fundamental changes to the processes in framework on the other hand informed the policies and institutional arrangements of the bottleneck analysis and identification and health sector, led by the Government, to prioritization of the reforms in each building increase the likelihood of implementation. 9 block. Routine interventions are defined here as Inside each building block, to guide the those needed to monitor or maintain a bottleneck analyses and interventions clinical/health service status quo for example prioritization, specific frameworks, for example, daily provision of consultations by clinicians, a supply chain cycle in supply chain, or the four daily lab tests, daily or scheduled provision of functions of health financing in health financing, community interventions, provision of were used. This ensured that all relevant gaps supervision and M&E services, ongoing Figure 1: Conceptual Framework for the HSSP III 6 8 Akiko Maeda et al. (2014). Goals of the Universal Health Egen's Medical Dictionary. (2011). Retrieved September Coverage. Washington DC: World Bank. Retrieved from 19, 2022, from https://medical- https://elibrary.worldbank.org/doi/10.1596/978-1-4648- dictionary.thefreedictionary.com/routine+intervention 9 0297-3_ch1 https://apps.who.int/iris/bitstream/handle/10665/127574/ 7 Roberts, Marc. et. al. (2009). Getting Health Reform WP_HlthSecRefm_Final%20Version.pdf;sequence=1 Right: A Guide to Improving Performance and Equity 15 | Malawi Health Sector Strategic Plan III 2023-2030 across the system or functions of the building ownership, flexibility and transparency, a block are identified, and their solutions are thus departure from the HSSP II which used the considered during prioritization. Further, the OneHealth tool. control knob framework was used to check the The process of setting impact indicator targets extent to which the organizational, financing, for HSSP III was rigorous yet pragmatic. For payment, regulatory and behavioural issues indicators that had 2030 targets already, for significantly undermined performance inside a example, those in the National Health Policy, building block, and this process was the basis these were adopted. For indicators that did not for identifying and prioritizing the reforms. have targets projected up to 2030, these were Therefore, the HSSP III takes a “systems and estimated first by benchmarking against other reforms” in the health systems building blocks African countries in the GDP per capita range approach and attempting to optimize up to USD1,036, the lower bound for functioning of each building block while classification into LMIC, which is MIP’s sufficiently accounting for the intricate classification target of 2030. Using this, the connectedness of the building blocks. achievement level of the best performing

1.2.2 Determining the Health country in the GDP range was adopted. For Benefits Package and some indicators, Malawi’s health outcomes were superior in this GDP range. As a result, associated health system these were based on programme targets and investment requirements validated at stakeholder’s workshop. At the The health system exists to deliver quality and health system outcome and output level, the efficient health services. This is summarized at targets are based on results of prioritization the intermediate goal level of the conceptual scenarios for the HBP, human resources, framework in Figure 1. Malawi’s health system reforms, and routine interventions. is severely resource constrained and therefore must provide a highly prioritized set of 1.3 Background interventions that have the greatest likelihood of Malawi is a landlocked country with a surface achieving the maximum population health area of 118,484 Km2 of which 94,276 Km2 is impact possible given existing constraints. land mass. It has an estimated population of Chapter 4 describes the methodology for the 19.4 million in 2022, 41% of which are under the definition of the Health Benefit Package (HBP) age of 15 and 15% are under the ages 5 – 1510. which then informed prioritization of health At an average annual growth rate of 2.69% per systems investments of the HSSP III. annum, the population is estimated to grow to The costs of the HSSP III in Chapter 6 were 23.1 million in 2030. Malawi has a young estimated for the 2023/2024 financial year (FY) population with 64% of the total population to 2030/2031 FY (three months into 2031). under the age of 15, 18% under the age of 5, Initial costing estimated the financial and only 3% above 65 years. Life expectancy requirements for a delivering the prioritized at birth is estimated at 65.62 years, for both need. Next, these costs were compared to the sexes, in 2022.11 An estimated 81.5% of the projected financial resources in the health population lives in the rural areas currently but sector, and then iteratively prioritized Malawi is predicted to experience an average downwards to ensure that the HSSP III fits annual urban population growth rate of 4.2% within the available resource envelope. This re- from 2013 to 203012, which is expected to exert prioritization was essential to direct limited pressure on urban health care delivery system. financial resources towards strategic reform Malawi’s Gross Domestic Product (GDP) per areas and priorities of the health sector for the capita in 2017 was estimated at USD5131. Real next eight years. The HSSP III was costed GDP growth for Malawi was reported as 4% in using Microsoft Excel to improve costing 2017.2 The economy is predominantly based in 10 National Statistical Office. Malawi Population and 12 Annual Economic Report 2021 Housing Census Report - 2018. Zomba, Malawi; 2019. 11 UNICEF 2015 16 | Malawi Health Sector Strategic Plan III 2023-2030 Table 1: Distribution of health facilities by type and ownership Facility Type Facility Owner Total Govt Private for profit CHAM Private non-profit NGO Clinic 20 233 7 46 46 352 Dispensary 49 2 2 8 1 62 Health Centre 364 4 109 7 5 489 Health Post 89 5 1 95 Hospital 49 9 41 1 100 Grand Total 571 248 164 62 53 1098 Source: Malawi Harmonized Health Facility Assessment (2019) agriculture, forestry and fishing contributing to household purchases increased from 30% to 23.2% of GDP in 2021.3 The health sector 55% over the same period.16 contributed 5.4% of GDP and 3.4% of annual growth of the economy in the same year.

1.3.1 Organization of the Malawi Informal employment is higher than formal Health Care System employment, estimated at 89% and 11% Health service delivery system in Malawi is respectively13. The mean and median earnings organized at three levels which are linked by a per month for the total economically active referral system: 1) Primary (community and population were estimated at USD 114 and facility), 2) Secondary, and 3) Tertiary. The USD 37, respectively. The economy is heavily services are delivered through a network of dependent on foreign development aid – for public, Non-Governmental Organizations example donor funding represented 58.6% of (NGOs), Private-not-for-Profit, and Private-for- total health expenditures (THE) between Profit providers. Table 1 shows the distribution 2015/16-2017/18 although the share declined of health facilities by type and ownership. to 55% in 2018/1914. Overall, Government owns the largest number Literacy is higher among men (83%) than of all health facility categories. women (72%) but with significant strides in After the Government, privately owned health narrowing gender disparities in education 15. and CHAM facilities are the most numerous. The median number of schooling years CHAM compliments public facilities through a completed has increased significantly over memorandum of understanding (MOU) with time: in 1992 it was estimated at 0.4 and 4.3 prioritization of Government support to CHAM years for women and men respectively facilities located outside a mandatory 8 Km compared with 5.6 years for women and 6.6 radius of public facilities from one another. In years for men in 2016. The 2015-16 Malawi 2016, there were a total of 5090 outreach Demographic and Health Survey has clinics, 79% of which were owned by demonstrated increased women empowerment Government while CHAM owned 19% of these. over time by various attributes. For example, Also, in the same year, there were 3542 village the percentage of women involved in decisions clinics, all of which were owned by about their health care increased from 55% in Government.17 2010 to 68% in 2015-16 and women’s Based on its mandate as stipulated in the 1998 involvement in decisions about major National Decentralization Policy, the Ministry of 13 The Malawi Labour Force Survey 2013 17 MOH. (2016). The Health Care System. Retrieved June 14 Ministry of Health, Malawi National Health Accounts 22, 2022, from Report for Fiscal Year 2018/19, Department of Planning https://www.health.gov.mw/index.php/2016-01-06-19- and Policy Development, Lilongwe 3 58-23/national-aids 15 Malawi Demographic and Health Survey 2015-2016 16 Malawi Demographic and Health Survey 2015-2016 17 | Malawi Health Sector Strategic Plan III 2023-2030 Health provides oversight to the health sector in multisectoral collaboration framework assumed Malawi. The Ministry of Health’s specific for successful achieve of the HSSP III goals. functions include strategic planning, policy

1.3.2.1 Legal framework making, standards setting, technical support, monitoring and evaluation, quality assurance, The Constitution of Malawi resource mobilization, and international The Constitution provides that the State shall representation. The Ministry is also responsible actively promote the welfare and development for the oversight of tertiary hospitals namely: of the people of Malawi by progressively Queen Elizabeth Central Hospital (QECH) in adopting and implementing policies and Blantyre, Zomba CH in Zomba City, Zomba legislation aimed at achieving the goals of Mental Hospital in Zomba City, Kamuzu Central health and social determinants of health. It Hospital (KCH) in Lilongwe City, and Mzuzu CH mandates the health sector “to provide in Mzuzu City. A proposal to fully decentralize adequate health care, commensurate with the the management of these hospitals to health needs of Malawian society and autonomous hospital boards was granted by international standards of health care.” Cabinet in 2018 though not fully implemented even now. Public Health Act (1948) At the district level, in line with the decentralized The Public Health Act consolidates the law architecture, District Councils oversee the regarding the preservation of public health in management, planning, execution, and Malawi. It addresses issues regarding evaluation of the health District Health Services infectious diseases and creates institutions for and budgets. The Council is comprised of ward responding to emerging public health councillors and other members like Traditional challenges. Authorities (Tas), MPs, representatives of Medical Practitioners and Dentists Act special interest groups among others, led by a (1987) Council Chairperson elected from the It provides for the establishment of the Medical members. The Council provides oversight to a Council of Malawi, the registration and Council Secretariat that is headed by a District disciplining of medical practitioners and Commissioner, with a number of directorates dentists, the regulation of training within Malawi under him (e.g., Administration, Finance, Public of medical personal and generally for the Works, Health and Social Services, Planning control and regulation of the medical profession and Development among others). The Council and practice in Malawi. establishes Service Committees to facilitate its work in particular areas of work. These Nurses and Midwives Act (1966) committees include a) Finance; b) It establishes a Nurses and Midwives Council Development; c) Education; d) Works; e) Health with the purpose of administering the and environment; f) Human Resources; and g) certification, licensing, and disciplining of Planning and Development. nurses and midwives.

1.3.2 Legal, Policy and Pharmacy and Medicines Regulatory Development frameworks Authority Act, 2019 This section highlights the legal, policy and It provides for the establishment of the strategical frameworks, within the health sector Pharmacy, Medicines and regulatory Authority and in other sectors that have a bearing in the which is mandated to regulate and control the effective implementation of this HSSP III. It also manufacture, importation, exportation, provides the international instruments that have distribution and sale of medicines and allied informed the design of this HSSP III. While substances and veterinary products, establish some will expire inside the HSSP III period, a functional system for pre- and post-marketing MOH will ensure effective representation and surveillance of safety, quality, efficacy and contribution to the formulation of their effectiveness of medical products and to successors, so that they fully embody the optimize the risk-benefit balance, establish, maintain and enforce standards for medicine 18 | Malawi Health Sector Strategic Plan III 2023-2030 quality control laboratories, among others key Public Procurement Act (2003) functions. It provides for the principles and procedures to HIV and AIDS (Prevention and Management) be applied in, and to regulate, the public Act, 2017 procurement of goods, works and services in Malawi, including in the health sector. This act stipulates directions for HIV prevention and management. It establishes the National AIDS Commission to implement, co-ordinate 1.3.2.2 Policy Framework and facilitate the national HIV response; National Health Policy (2018) manage and co-ordinate the implementation of Government Policies on HIV and AIDS; and The National Health Policy (2018-2030) provide technical support to Government in the provides the overall policy direction for the formulation and review of HIV and AIDS health sector. The second Health Sector policies. Strategic Plan was developed as a first strategic plan for the National Health Policy. Local Government Act (1998) This HSSP III will be the second and final The Local Government Act (1998) consolidates strategic vehicle towards the Malawi SDG and the law regarding local Government. It provides NHP goals for 2030. for health service delivery to be decentralized to National HIV and AIDS Policy (2022) district and city councils and empowers communities to be responsible for their own The National HIV and AIDS Policy aims at health and healthcare services. It also facilitating the evidence-based programming mandates the Ministry of Health to be and strengthening of the National HIV and AIDS responsive for health-related policies, trainings, response while recognizing the emerging and supervision. issues, gaps, challenges, and lessons learnt during the implementation of the first policy. Public Private Partnership Act (2011) National Multisector Nutrition Policy (2018) This act provides for partnerships between the public sector and private sector for the supply The National Nutrition Policy seeks to promote of infrastructure and delivery of services as evidence-based programming and means of contributing towards sustaining strengthening of the national nutrition economic growth, social development, and response. The NHP promotes good sanitation infrastructure development; and provides for and good hygiene practices and management the development and implementation of public of over-nutrition and non-communicable private partnership arrangements in Malawi for diseases. the delivery of infrastructure and services. National Decentralization Policy (1998) Public Financial Management (PFM) Act The Decentralization Policy seeks to create a (2022) democratic environment and institutions for It fosters and enhances effective and governance and development at the local level responsible economic and financial that facilitate grassroots participation in management by Government, including decision making. The Decentralization Policy adherence to policy objectives. It also provides supports the district health systems comprising accompanying accountability arrangements of community, primary and secondary service and specifies consequences for compliance delivery levels to accelerate the efforts of and non-compliance PFM rules. The Ministry of achieving of the health sector goals which Health must, in compliance with this Act, ensure include improving health status of Malawians, responsible economic and financial providing adequate financial risk protection, management of health sector resources and and improving client satisfaction. must be accountable for the same. Further, the National Education Sector Investment Plan Ministry must produce a national health sector (2020 – 2030) budget for the areas under its responsibility. 19 | Malawi Health Sector Strategic Plan III 2023-2030 The National Education Sector Investment Plan All United Nations (UN) member states outlines the framework for implementation of including Malawi adopted the Sustainable school health, water and sanitation, and Development Goals (SDGs) in 2015. Although hygiene; HIV and AIDS; gender and all of them contribute to health, SDG 3 falls investments in health training institutions. under the domain of the health sector. It aims to achieve healthy lives and well-being of all at National Gender Policy (2015) all ages. The targets of SDG 3 include the The Gender Policy seeks to mainstream gender following: in the national development process to Target 1: By 2030, reduce the global enhance participation of women and men, girls, maternal mortality ratio to less boys at individual, household, and community than 70 per 100,000 live births. levels for sustainable and equitable Target 2: By 2030, end preventable development. deaths of newborns and under National Health Promotion Policy (2013) five children. The National Health Promotion Policy was Target 3: By 2030, end the epidemics of developed to give direction for programming of AIDS, TB, Malaria and health promotion interventions. Neglected Tropical Diseases (NTDs), and combat hepatitis, Other relevant Policies water-borne diseases, and Health has strong linkages with other social and other communicable diseases. sectoral policies as a crossing-cutting issue. Target 4: By 2030, reduce by one-third These policies among others include but are premature mortality from not limited to the National Population Policy; NCDs through prevention and National Social Support Policy National Sports; treatment, and promote mental and Youth Development Policy. health and wellbeing. Target 5: Strengthen prevention and

1.3.2.3 National Development framework treatment of substance abuse, The Malawi 2063 including narcotic drug abuse and harmful use of alcohol. The Malawi 2063 (MW2063) envisions an Target 6: By 2020, halve deaths and inclusively wealthy and self-reliant injuries from road traffic industrialized upper middle-income country. It accidents. is planned to be operationalized through the Target 7: By 2030, achieve universal Malawi 2063 First 10-Year implementation plan access to sexual and (MIP-1), replaced the Malawi Growth and reproductive health care Development Strategy (MGDS) as the national services, including family development strategy which was planning, information and operationalising the Vision 2020. Malawi 2063 education, and the integration focuses on three pillars: agricultural productivity of reproductive health into & commercialization, industrialization, and national strategies and urbanization. These pillars are supported by programmes. seven enablers: human capital development, Target 8: Achieve universal health mindset change, effective governance systems coverage, including financial and institutions, enhanced public sector risk protection, access to performance, private sector dynamism, quality essential health care economic infrastructure, and environmental services, and access to safe, sustainability. Health falls under the human effective, quality, and capital development enabler. affordable essential medicines

1.3.2.4 International instruments and vaccines for all. Sustainable Development Goals (2016-2030) Target 9: By 2030, substantially reduce the number of deaths and illness from hazardous 20 | Malawi Health Sector Strategic Plan III 2023-2030 chemicals and air, water and promote and protect people’s health and well- soil pollution and being, at both population and individual levels, contamination through strong health systems; 2) Primary health care (PHC) and health services that are Paris Declaration on Aid Effectiveness high quality, safe, comprehensive, integrated, (2005) accessible, available and affordable for everyone and everywhere, provided with The Paris Declaration encourages developing compassion, respect and dignity by health countries to set their own strategies for poverty professionals who are well-trained, skilled, reduction, improve institutions and tackle motivated and committed; 3) Enabling and corruption. It outlines that donor countries are health-conducive environments in which to align behind these objectives using local individuals and communities are empowered systems and coordinate with simplifying their and engaged in maintaining and enhancing procedures and sharing information to avoid their health and well-being; and 4) Partners and duplication. Lastly, it stipulates that, developing stakeholders aligned in providing effective countries and donors are to shift focus to support to national health policies, strategies development results and results get measured, and plans.19 and donors and partners to be accountable for development results. The Accra Agenda for Action (AAA) in 2008 reaffirmed the Paris

1.4 Organization of the Declaration emphasizing the need to untie aid HSSP III Document and reduce fragmentation. The rest of the document is organized as The Paris Declaration proposes four main follows. Chapter 2 summarises the health areas for improvement which include 1) sector situation analysis report 20 that was Ownership – Countries have more say over produced to inform HSSP III priorities. Chapter their development processes through wider 3 provides the goal, vision, mission, and participation in development policy formulation, objectives of the HSSP III and these derive from stronger leadership on aid co-ordination and the National Health Policy (NHP) with slight more use of country systems for aid delivery; 2) modification informed by the bottleneck Inclusive partnerships – All partners, including analysis. Chapter 4 presents the Health donors in the OECD Development Assistance Benefits Package for the HSSP III. Chapter 5 Committee and developing countries, as well as presents the strategies for the HSSP III other donors, foundations and civil society, objectives based on results of the mid-term participate fully; 3) Delivering results – Aid is evaluation, the situation analysis that was focused on real and measurable impact on conducted as part of the HSSP III process and development; and 4) Capacity development – a bottleneck analysis based on consultations to build the ability of countries to manage their with stakeholders. Chapter 6 presents HSSP III own future also lies at the heart of the AAA. 18 costing and financing arrangements. Chapter 7 presents the implementation arrangements Astana Declaration on PHC while Chapter 8 presents monitoring and The Astana Declaration envisions: 1) evaluation arrangements. Governments and societies that prioritize, 18 19 OECD. (2005). Paris Declaration and Accra Agenda for WHO. (2018). Declaration of Astana. Retrieved from Action. Retrieved October 4th, 2022, from https://www.who.int/docs/default-source/primary- https://www.oecd.org/dac/effectiveness/parisdeclaration health/declaration/gcphc-declaration.pdf 20 andaccraagendaforaction.htm MOH. (2022). HSSP III Situation Analysis Report 21 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Patients waiting in a health facility.

2.2 Progress of Ultimate and Intermediate Chapter 2: Health Impacts Situation 2.2.1 Trends in Health Impacts

2.2.1.1 Life Expectancy Analysis Malawi has made significant progress in improving the health of its population. Average life expectancy has increased by 10 years over

2.1 Overview of the the last decade for both men and women (Figure 2). It is higher than the average life Chapter expectancy on the African continent of 62 years This chapter presents an overview of the old in 2020 and on par with many SADC situation of the health sector that informed countries.21 This is attributed mainly to HSSP III priorities. It also summarizes major improvements in adult and childhood health program interventions during HSSP II because of robust implementation of HIV implementation. Data for the situation analysis maternal and child health lifesaving have come from the mid-term review report for interventions. the HSSP II, routine survey and research data, administrative sources including the health management information system (HMIS) and international databases. The full report on which this chapter was based is available (MOH, 2022). 21 World Bank Data https://data.worldbank.org/ 22 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 2: Trends in Life Expectancy (by Gender) in Malawi 70.00 66.94 67.41 65.78 66.40 65.02 64.07 65.00 62.91 61.56 61.10 60.05 60.16 60.65 58.90 59.59 60.00 58.40 58.04 56.67 56.98 55.74 54.33 55.00 52.81 51.21 50.00 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 female male Source: World Bank - Statista 2022

2.2.1.2 Trends in Mortality and Burden of Figure 3 shows the leading causes of burden of Diseases disease from 2010 to 2019 for Malawi. While Mortality indicators have declined over the last communicable, maternal, and neonatal decade. Based on the DHS (2015) 22 and diseases continue to constitute a significant Multiple Indicators Cluster Survey (MICS) proportion of burden of disease, the burden of (2019)23, maternal mortality ratio has declined non-communicable diseases is increasing. from 439 per 100,000 live births in 2015 to 349 Over the last 10 years, there has been major per 100,000 live births in 2019 marginally progress in reducing the burden due to HIV & surpassing the HSSP II target of 350 per AIDS, with the attributable burden declining by 100,000 live births. Under-5 mortality rate has 12.35% from 2009 to 2019.26 Despite a declined from 63 per 1000 live births in 2015 to significant amount of programming around 39 per 1000 live births in 2020 surpassing the maternal and neonatal health and survival, this HSSP II target of 48 deaths per 1,000 live remains the highest burden of disease in births. Infant mortality rate and neonatal Malawi. mortality have had less of a decline but have 2.2.2 Progress in Financial Risk trended down with 42 and 27 deaths per 1000 Protection live births in 2015 to 29 and 19 deaths per 1000 in 2019 respectively surpassing the HSSP II Financial risk protection in health occurs when targets of 34 deaths per 1,000 live births and 22 individuals receive the healthcare services they deaths per 1,000 live births, respectively. require, and do not suffer undue financial hardship as a result. Based on recent data Similarly, mortality from HIV has decreased by (WHO, 2019), however, the financial risk greater than 50% since 2010 with a stable TB protection index for Malawi is very high, at death rate of 14 cases per 100,000 people in 97.45% (unadjusted for equity) and 94.1% 2020.24 However, non-communicable disease (adjusted for equity).27 Overall, Out-of-pocket and injury mortality has been on an increase over the last decade now accounting for over 40% of mortality in Malawi. 25 22 26 National Statistical Office (NSO) [Malawi] and ICF. Institute for Health Metrics and Evaluation (2022) 27 2017. Malawi Demographic and Health Survey 2015-16. This high financial protection index could also be due to Zomba, Malawi, and Rockville, Maryland, USA. NSO the non-use of services by the poor. Given that the and ICF. quality of care is poor in most public facilities due, inter 23 NSO. (2021). Multiple Indicator Cluster Survey (MICS) alia, to lack of medicines, poor households may forego 2019-20 care from private facilities or even buying prescription 24 World Bank Data https://data.worldbank.org/ medicines because they cannot afford it. 25 World Bank Data https://data.worldbank.org/ 23 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 3: Leading causes of DALYs in in Malawi in 2019 Source: Institute for Health Metrics and Evaluation expenditure on health as % of THE was at 2.2.3 Systems for Client feedback 11.9% in 2018/19 (MOH, 2022)28 however, this Ensuring satisfied clients is one of the ultimate was before the onset of the COVID-19 goals of service delivery. Until 2019, tracking of pandemic and the global economic meltdown. client satisfaction rates remained sporadic. The potential factors for this high performance From 2019 on, the MOH has pioneered the on financial risk protection include 1) the current routinization of client satisfaction surveys health financing design in which tax and donor across health facilities in the country. According funds are predominantly used to provide free to the Ombudsman data on overall client access to essential health services at public satisfaction, of the 3,987 users interviewed in and contracted non-state providers; 2) Public 2020, approximately 83% indicated being provision of health services to the majority of satisfied with the services they received from the population, 3) Subsidies and service level their providers. In 2022, the percentage of agreements with CHAM in geographical areas clients satisfied with services increased to without a public facility. Major threats to approximately 90%. The 2019 Harmonised sustained high performance in this indicator Health Facility Assessment showed that client include limited growth of GDP per capita, rising satisfaction29 on treatment from health facility costs of medical care, limited investment in the staff was 80%, on availability of staff was 81%, social protection sector, and limited coverage of and on availability of medicines was 74%. Service Level Agreements (SLAs) with non- Current limitations with tracking client state providers of healthcare in areas without satisfaction include: 1) lack of harmonization public health facilities. between routine data collection and periodic 28 MoH (2022) Malawi National Health Accounts for Fiscal conducted by ombudsmen, several additional Year 2018/19. Lilongwe, Malawi: Ministry of Health, dimensions have been introduced; we have indicated Department of Planning and Policy Development only a few of them. 29 The client satisfaction score in HSSP II was aggregated; the figure was 85 percent. However, in surveys 24 | Malawi Health Sector Strategic Plan III 2023-2030 national surveys; and 2) incomplete and under- progress in service delivery was recorded reporting of data. across EHP programme areas as follows.

2.3.1.1 Reproductive, Maternal,

2.3 Health Service Delivery Newborn, Child Health (RMNCH)

2.3.1 Progress of Service Delivery services The HSSP II objective for health service Adolescents constitute 24% of the total delivery was “to increase equitable access to population and require a wide range of Sexual and improve quality of health care services.” Reproductive Health Rights (SRHR) services This was to be achieved through the provision such as treatment for unwanted pregnancies of free EHP at all levels of care. The and sexually transmitted infections (STIs) interventions included in the revised EHP were including HIV (WHO, 2018). Approximately, as follows: Reproductive, Maternal, Neonatal 30.8% of adolescent females begin and Child Health (RMNCH), vaccine childbearing with a high number of preventable diseases, malaria, Integrated complications. Complications from pregnancy Management of Childhood Illnesses (IMCI), and childbirth are among the leading causes of community health, neglected tropical diseases death among girls aged 15-19 years old, (NTDs), HIV/AIDS, nutrition, tuberculosis (TB), constituting 20% of maternal mortality in non-communicable diseases (NCDs) and oral Malawi, with 14% of pregnancies in this age health. Overall, Malawi’s UHC coverage has group ending in abortion (MOH, 2020)30. improved over the years (Figure 4a), and when Furthermore, neonates born to very young compared against other Low-Income mothers are at greater risk of morbidity and Countries, shows great performance (Figure mortality. A recent health facility assessment 4b), pointing towards a very strong health showed that Youth Friendly Health Services Figure 4: Malawi’s Overall progress on Universal Health Coverage Trends in Malawi’s UHC Coverage Malawi’s UHC Coverage Compared with LMICs UHC Service Coverage Index (SDG 60 60 UHC Service Coverage Index (SDG 55 55 50 2017 2019 50 45 2015 45 3.8.1) 40 2010 40 3.8.1) 35 2005 35 30 25 2000 30 20 25 $- $1,000 $2,000 $- $1,000 $2,000 GDP per capita in current USD GDP per capita in current USD (Red - Malawi, Teal - SADC Countries, Grey - Remaining countries in SSA) Source: WHO and World Bank Data for Countries with annual per capital GDP not exceeding USD2500. Excludes countries with GDP per capita over $2,500, small island countries, and Somalia as well as Eritrea (both due to missing data). system organizationally. While the HSSP III (YFHS) remain under-utilized across a range of period is not yet complete, the first two years services likely due to poor service provision. point towards encouraging progress. The For example, Intrauterine Contraceptive Device (IUCD) was only provided to 19% of youth with 30 This is according to data presented in the report by the in 2020, presenting data most of which were up to the MoH on the Mid-term review of the HSSP II conducted year 2019. 25 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 5: Trends in antenatal coverage (percentage of women that had 4+ ANC visits) 40.3 37.4 Percentage of 31.4 31.9 32 32.3 32.3 28.1 29.2 women with 4+ 25.3 ANC visits 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 only 55% of adolescents receiving family to the pre-COVID-19 pandemic baseline of planning services.31 >90% from 2017 to 2019 (DHIS2). Despite a high institutional delivery rate, the neonatal The goal for RMNCH was to meet modern mortality rate has not declined, with most contraceptive prevalence rate (mCPR) of 60% deaths occurring intrapartum or immediately by 2020 for all women of reproductive age. 32 postpartum. Improvements are needed in early Significant progress has been made in neonatal care and immediate postnatal care increasing the mCPR in all women from 38.1% including additional staff, infrastructure, in 2012 to 48.3% in 2019 with married women equipment, and systems for high quality care. at 78.4% and many adolescents continuing to lack access to contraception33. Directly linked to The Integrated Management of Childhood achievements on mCPR are trends in the Total Illnesses (IMCI) approach was Fertility Rate (TFR). At the beginning of the utilized/implemented at health facilities to implementation of the HSSP II, TFR was at 4.4 improve quality of care for new-borns and (NSO, 2017) and by 2018 it slightly dropped to children. In the Demographic Health Survey in 4.2 according to the 2018 Malawi Population 2015-201636, 57% of children with diarrhoea and Housing Census (MPHC) (NSO, 2020). received oral rehydration and continued feeding and in the most recent Multiple At the start of HSSP II in 2017, only 24% of the Indicator Cluster Survey 2019-202037, 55.6% of pregnant women had their first antenatal visit during their first trimester, however, by 2019 it had increased to 27.6%.34 The proportion of women completing at least four visits or more during the years between 2017 and 2021 has increased by 8.3 percentage points (Figure 5)35. To improve the delivery of interventions on maternal and neonatal health, the MOH is scaling up the delivery of comprehensive emergency obstetric and neonatal care (CEmONC) and basic emergency obstetric and new-born care (BEmONC) services to decrease maternal and neonatal complications and mortality. The proportion of institutional deliveries in 2021 was 96% which has returned 31 35 Harmonized Health Facility Assessment 2018-19 Report National Statistical Office (NSO) [Malawi] and ICF. 32 Reproductive Health Directorate, Ministry of Health. The 2017. Malawi Demographic and Health Survey 2015-16. Malawi Family Planning Costed Implementation Plan, Zomba, Malawi, and Rockville, Maryland, USA. NSO 2016–2020. Government of Malawi. and ICF. 33 36 FP2030 Core Indicator Summary Sheet: 2018-2019 National Statistical Office (NSO) [Malawi] and ICF. Annual Progress Report. 2017. Malawi Demographic and Health Survey 2015-16. https://fp2030.org/sites/default/files/Data- Zomba, Malawi, and Rockville, Maryland, USA. NSO Hub/2019CI/Malawi_2019_CI_Handout.pdf and ICF. 34 37 NSO. (2021). Multiple Indicator Cluster Survey (MICS) NSO. (2021). Multiple Indicator Cluster Survey (MICS) 2019-20 2019-20 26 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 6: Trends in prevalence of overweight, wasting and underweight in children 25 Percentage of children under age 5 who are 20 20 17 15 13 12.8 11.7 10 malnourished 9 8 8 7 6 5 5 4.4 4 3 2.6 0 2000 2004 2010 2016 2019 Overweight Wasting Underweight Source: MDHS 2016, MICS 2020 children seeking care for acute respiratory 201141, NSO and ICF, 201742, NSO and infection received antibiotics. UNICEF, 202143). Similarly, the prevalence of wasting (low weight-for-height) has decreased The proportion of children who are fully from 3% in 2004 to 0.6% in 2019. Underweight vaccinated increased from 81% in 2017 to 89% status has decreased by almost half in the last in 201938 during HSSP II implementation (MTR 20 years from 26% in 2000 to 11.7% in 2020 2021). Between 2017 and 2020 the Expanded (NSO and ICF, 2017, NSO and UNICEF, 2021). Programme on Immunization (EPI) made a Key interventions for addressing malnutrition in number of achievements including: (i) children include growth monitoring and introduction of new vaccines namely Inactive screening for malnutrition and prompt referral to Polio Vaccine (IPV) and Human Papillomavirus malnutrition rehabilitation units for Vaccine (HPV); and (ii) switching from the comprehensive care. Further, the Ministry Measles Conjugate Vaccine (MCV) to Measles strengthened community involvement through Rubella Vaccine as recommended by WHO; revamping care groups in over 60% of villages and the introduction of malaria vaccine for across the country. children under 5 years old in 11 pilot implementation districts.

2.3.1.2 Nutrition On nutrition, in the last 30 years, Malawi has reduced stunting (low height-for-age) to 35.35% in children under 5 years in 2020 which is by 20.65% points lower than in 1992 (NSO, 199539, NSO, 200840, NSO and ICF Macro, 38 EPI programme data 2016-2019. Zomba, Malawi, and Rockville, Maryland, USA. NSO 39 and ICF. NSO. (1995). Multiple Indicator Cluster Survey (MICS) 42 1995 National Statistical Office (NSO) [Malawi] and ICF. 40 2017. Malawi Demographic and Health Survey 2015-16. NSO. (2008). Multiple Indicator Cluster Survey (MICS) 2006 Zomba, Malawi, and Rockville, Maryland, USA. NSO 41 and ICF. National Statistical Office (NSO) [Malawi] and ICF. 43 2011. Malawi Demographic and Health Survey 2010. NSO. (2021). Multiple Indicator Cluster Survey (MICS) 2019-20 27 | Malawi Health Sector Strategic Plan III 2023-2030

2.3.1.3 Communicable Disease put in place, such as school bursaries for the 2.3.1.3.1 HIV/AIDS affected children, social cash transfers and workplace HIV programs which provided There has been sustained progress in monitory transfers to civil servants living with managing HIV/AIDS in Malawi. The overall HIV. Programmatic coordination key successes burden of HIV/AIDS has decreased with included 1) the enactment of the HIV and AIDS declining prevalence and incidence of HIV Prevention and Management Act of 2018 which among adults aged 15-49 from 9.1% and 3.42% provided effective management and in 2017 to 8.1% and 2.16% in 2020 respectively coordination of individuals with HIV 2) reform of (Figure 7). Consequently, the country has made the National AIDS Commission (NAC) from a significant progress on the 95:95:95 targets public trust to a statutory cooperation improving with attaining the 90:90:90 targets after 2019 the effectiveness, efficiency and relevant and currently at 93:97:93 as of 2021 (UNAIDS execution of this mandate and, 3) strengthening 2021). of the multi-sectoral and multi-disciplinary The HIV and AIDS national response plan has national, district, and community coordination four main pillars, prevention, treatment and structures resulting in an effective and case management, impact mitigation, and sustainable response. program coordination. For prevention, the 2.3.1.3.2 Tuberculosis Department of HIV/AIDS (DHA) continued scaling up awareness and behavioural change Tuberculosis incidence rate has declined from campaigns targeting key populations, 162 per 100,000 population in 2017 to 141 per adolescent girls, and young women, youths, 100,000 population in 2020 (Figure 8). TB and traditional leaders. It also scaled-up the treatment success rate is reported at 86% Voluntary Male Medical Circumcision (VMMC) (above the WHO target of 85%) with the TB and elimination of Mother to Child Transmission death rate decreasing from 19% in 2005 to 8% (e-MTCT) campaigns. For treatment and in 2014. Despite this progress, with the COVID- management, by 2019, 98% of pregnant 19 pandemic there has been an overall women who tested HIV positive were initiated decrease in service provision with a 3%-point on antiretroviral therapy (ART and by end of drop in health facilities offering TB services and 2022, almost all populations were transitioned only 50% of facilities able to directly diagnose to the integrase inhibitor, dolutegravir for TB.44 improved viral load suppression. To mitigate the adverse impacts of HIV, safety nets were Figure 7: Trends in percentage HIV Prevalence among adults, 15-49 years of age and HIV incidence per 1000 population (15-49) 12.0% 8 10.7% 10.5% 10.3% 10.1% 9.9% 9.7% 7 10.0% 9.4% 9.1% 8.8% 8.5% 6.75 8.1% 6 6.36 8.0% 5.86 5 5.31 6.0% 4.82 4 4.37 3.97 3.42 3 4.0% 2.89 2 2.39 2.0% 2.16 1 0.0% 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 44 HIV Prevalence among adults (15-49) HIV incidence per 1000 population (15-49) Harmonized Health Facility Assessment 2018-19 Report Source: UNAIDS 2020 28 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 8: Incidence of Tuberculosis per 100,000 population per year 400 338 350 316 291 300 261 228 250 197 176 162 200 153 146 141 150 100 50 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Source: World Bank On TB case management, the Ministry in 2019, surpassing the HSSP II target of 12 strengthened disease awareness campaigns deaths per 100,000 population in 2022. through print materials and radio (National Malaria Control Programme, 2019). documentaries which proved vital especially Key interventions to address malaria included: with the disruption to outreach awareness • Piloting potential for a malaria campaigns during the COVID-19 pandemic. vaccination program for children below The awareness campaigns focused on 24 months of age in Karonga, Nkhata- promoting sanitation practices to prevent the Bay, Ntchisi, Mchinji, Lilongwe Rural, spread of disease, addressing a risk factor of Balaka, Machinga, Mangochi, TB and multi-drug resistance TB. There was Phalombe, Chikwawa and Nsanje also an increase in Community Sputum districts where over 80% of the Collection Points (CSCP) with 1603 collection targeted population have been points in 2020 across the country. This helped reached. increase TB notification rates in the country. To • Sustaining provision of Intermittent improve patient management and notification Preventive Treatment (IPTp) services rates, NTP has been implementing an E-health through which pregnant women application for real time tracking of sample receive three doses of SP and Long- status and outcomes of diagnostic tests since Lasting Insecticidal Nets (LLINs). 2017. By 2020, the system was functional in 33 • Implementing the Indoor Residual sites including 7 mobile units. Spray (IRS) project in the malaria 2.3.1.3.3 Malaria hotspots of Mangochi, Balaka, The key objective of the National Malaria Nkhotakota and Nkhata-Bay districts. Control Programme (NMCP) is to reduce the

2.3.1.4 International Health Regulations incidence of malaria by 50% with current and Notifiable Infectious incidence at 228.5 per 1,000 people at risk in Diseases and other Public Health 2021, which has increased from 205.9 per Events 1,000 people at risk in 2020.45 Malaria requires a significant portion of health sector resources, 2.3.1.4.1 COVID-19 Pandemic, its effects on with an estimated 6 million cases per year the health system and accounting for 30% of all outpatient visits and interventions 34% of all hospitalizations (National Malaria The Malawi Government declared a state of Control Programme, 2019). national disaster due to COVID-199 on 20th March 2020. As of 29 October 2022, the Mortality due to malaria has declined from 19.6 country had reported 88,073 confirmed COVID- deaths per 100,000 population at the start of the 19 cases, of which 2,683 has died with an HSSP II to 8.4 deaths per 100,000 population overall case fatality ratio of 3.1%. To respond to 45 World Bank Data https://data.worldbank.org/ 29 | Malawi Health Sector Strategic Plan III 2023-2030 the COVID-19 pandemic, the following key Overall, these and other multi-sectoral interventions were implemented with success. interventions have been hugely successful. A Surveillance, rapid response, and case Presidential Taskforce report47 suggests that investigation key activities included building the approximately 240,368 COVID-19 cases were capacity of health care and other point of entry averted by the preventive measures put in workers for case detection, specimen place during the first four waves as of 28 collection, contact tracing and reporting, and February 2022. The report also suggests that producing regular epidemiological reports. At approximately 8,395 additional COVID-19 or all main points of entry in the country 46, COVID-19 related deaths were conceivably personnel were trained to offer effective averted by preventive measures put in place coronavirus and COVID-19 related port health across the four waves. Overall, the report services to arriving and departing travellers. shows that utilization of outpatient services did Laboratory capacity for diagnosis of SARS- not show detectable negative impacts over the CoV-2 was enhanced, notably through 16 RT- course of the first year of the Coronavirus PCR capable laboratories and 29 GeneXpert pandemic, 2020/2021 (1,233 per 1,000 capable sites as of February 2022. The population), compared to the previous financial National Laboratory Network has since been year, 2019/2020 (1,027 per 1000 population) capacitated for gene sequencing to detect suggesting that service utilization has resumed SARS-CoV-2 variants prevalent in the country. to pre-COVID -19 levels. Case management has been a critical 2.3.1.4.2 Other achievements in component of the COVID-19 response, International Health Regulations especially as there were many cases during the and Notifiable Infectious Diseases initial phases of the pandemic with clinical Malawi adopted the revised Integrated Disease disease that required specialized medical and Surveillance and Response (IDSR) strategy in nursing care. Units for care were established, 2022 to develop its national surveillance system and testing, treatment and care services were in line with the International Health Regulation offered for free to all. In order to reduce (IHR) requirements. IDSR monitors fifteen mortality, quality of clinical treatment and care notifiable diseases through the Epidemiology were enhanced through training and Unit of the Public Health Institute of Malawi mentorship. Isolation units at central hospitals, using the District Health Information System 2 and some district hospitals, were renovated and (DHIS2) and ONE HEALTH Surveillance expanded to allow for more bed space in Platform (OHSP). An integrated approach is anticipation of further surges in cases. key with all notifiable diseases, as such, one COVID-19 vaccines were launched in March platform would improve reporting and 2021 starting with high-risk populations such as response. front-line health care workers, social workers, For neglected tropical disease, Malawi individuals with comorbidities and elderly achieved elimination of trachoma and lymphatic populations. Since January 2022, vaccination, filariasis (LF) with significantly reduced and boasters, were extended to all aged 12 onchocerciasis, which is close to elimination. years and older. The national target is to There has been a reduction in schistosomiasis achieve at least 70% vaccine coverage in the by an estimated 36% points and soil transmitted Malawi population by the end of 2022 at the helminths (STH) by an estimated 20% points in latest. However, high levels of vaccine the past decade. hesitancy have resulted in a low level of coverage since the launch. In February 2020, 2.3.1.5 Non-Communicable Diseases less than 10% of the population had been fully Non-communicable diseases (NCDs) are the vaccinated. fastest growing cause of mortality and morbidity in Malawi with a growing share of the burden of 46 Kamuzu International Airport in Lilongwe, Chileka Mwanza, Mlodza Border in Mulanje, Chiponde Border in Airport in Blantyre, Songwe in Karonga, Mbirima Border Mangochi and Marka Border in Nsanje 47 in Chitipa, Mwami Border in Mchinji, Biriwiri Border in Government Of Malawi (2022) The Coronavirus Ntcheu, Dedza Border in Dedza, Mwanza Border in Pandemic in Malawi: Trailing the Waves 30 | Malawi Health Sector Strategic Plan III 2023-2030 disease.48 As of 2018, NCDs are estimated to ischemic health disease and 21.4% due to account for around a quarter of Disability- stroke.54 Adjusted Life Years (DALYs) (25.4%). NCDs 2.3.1.5.2 Diabetes are estimated to account for 32-40% of total deaths in Malawi, with 10% attributed to The contribution of diabetes has grown from cardiovascular conditions, 10% to cancers, 2% 1.4% in 2010 to 2.21% in 2019.55 An increase to chronic respiratory diseases, 1% to diabetes, in overweight and obesity rates is a growing and 9% to other NCDs (WHO 2018). concern, as they are risk factors for type 2 diabetes. Malawi also has a persistently high More than 60% of NCD DALYs occur before the proportion of patients with a low-body mass age of 40 and 62% are attributed to conditions index with insulin dependent diabetes.56 not related to common behavioural and Screening and care provision remains low with metabolic risk factors.49 However, the health only 4% of surveyed people reporting being care system in Malawi is under-equipped to screened and only 1.4% with elevated glucose care for patients with NCDs. The Service on treatment.46 Provision Assessment (SPA) 2013-2014 reported that less than 20% of facilities had 2.3.1.5.3 Chronic Respiratory Disease equipment and medications required to treat Chronic respiratory disease accounts for 5% of NCDs, and less than 35% of staff were trained DALYs from NCDs in Malawi primarily in care.50 stemming from asthma and chronic obstructive pulmonary disease.46 A recent systematic 2.3.1.5.1 Cardiovascular Disease review of literature demonstrated 10-12% of Cardiovascular diseases include hypertension, children in different settings exhibited wheezing stroke, ischemic heart disease, heart failure, and a high prevalence of abnormal rheumatic heart disease and more. These spirometry.57 Expanded training, recognition represent 15% of the total DALYs in Malawi. 51 and available equipment and medications are The estimate weighted age-standardized needed for rapid diagnosis and treatment. national hypertensive prevalence is 15.8% 52, with a large proportion of patients 2.3.1.5.4 Cancer uncontrolled.53 Thus, there are increased Neoplasm represents the highest DALY burden complications of ischemic heart disease and for NCDs in Malawi at 16%. Oesophageal stroke with the proportion of death due to these cancer is the highest DALY and cause of death, complications increasing between 2009 and with non-Hodgkin’s lymphoma and cervical 2019 with 23.1% of all deaths in Malawi due to cancer as the next largest contributors.58 Recognition and screening are still low with just 48 Malawi Ministry of Health. Malawi NCDI Poverty Uncontrolled Blood Pressure in Malawian Adults Living Commission. Malawi National NCDI Poverty with HIV and Hypertension. Global heart, 16(1), 81. Commission Report. 2018 https://doi.org/10.5334/gh.1081 http://www.ncdipoverty.org/malawi-report 54 GBD 2019 Diseases and Injuries Collaborators. Global 49 Malawi Ministry of Health. Malawi NCDI Poverty burden of 369 diseases and injuries in 204 countries Commission. Malawi National NCDI Poverty and territories, 1990-2019: a systematic analysis for the Commission Report. 2018 Global Burden of Disease Study 2019 [published http://www.ncdipoverty.org/malawi-report correction appears in Lancet. 2020 Nov 50 Malawi Ministry of Health. Service Provision 14;396(10262):1562]. Lancet. 2020;396(10258):1204- Assessment (SPA). Lilongwe, Malawi 1222. doi:10.1016/S0140-6736(20)30925-9 51 55 Global Burden of Disease, 2019. Institute for Health Metrics and Evaluation 52 56 Amberbir, A., Lin, S. H., Berman, J., Muula, A., Jacoby, Malawi National STEPwise Survey for Non- D., Wroe, E., Maliwichi-Nyirenda, C., Mwapasa, V., Communicable Diseases Risk Factors 2017 Report Crampin, A., Makwero, M., Singogo, E., Phiri, S., 57 Nightingale R, Jary H, Meghji J, Rylance S, Masiye J, Gordon, S., Tobe, S. W., Masiye, J., Newsome, B., Chiumia H, Rylance J, Mortimer K, Lesosky M. Non- Hosseinipour, M., Nyirenda, M. J., & van Oosterhout, J. communicable respiratory disease in Malawi: a J. (2019). Systematic Review of Hypertension and systematic review and meta-analysis. Malawi Med J. Diabetes Burden, Risk Factors, and Interventions for 2020 Jun;32(2):64-73. doi: 10.4314/mmj.v32i2.3. PMID: Prevention and Control in Malawi: The NCD BRITE 35140842; PMCID: PMC8788589. Consortium. Global heart, 14(2), 109–118. 58 Malawi Ministry of Health. Malawi NCDI Poverty https://doi.org/10.1016/j.gheart.2019.05.001 Commission. Malawi National NCDI Poverty 53 Hoffman, R. M., Chibwana, F., Kahn, D., Banda, B. A., Commission Report. 2018 Phiri, L., Chimombo, M., Kussen, C., Sigauke, H., http://www.ncdipoverty.org/malawi-report Moses, A., van Oosterhout, J. J., Phiri, S., Currier, J. W., Currier, J. S., & Moucheraud, C. (2021). High Rates of 31 | Malawi Health Sector Strategic Plan III 2023-2030 12% of women screened for cervical cancer Africa Trade and Facilitation Program, Trauma and no screening for other types of cancer care centres were approved, and these will be except Kaposi sarcoma in HIV clinics. used as emergency units in four districts of Dedza, Ntcheu, Balaka, and Neno while in 2.3.1.5.5 Neurological and Mental Health Blantyre, this will involve renovations of the Disorders Accidents Emergency and Trauma Centre at Neurological disorders account for an QECH. Then completed, these will significantly estimated 4.5% of the NCD burden with reduce the mortality and morbidity due to migraines and epilepsy representing the accidents along the M1 road. highest contributions. Whereas first line treatment for epilepsy is found readily, safe, 2.3.1.6 Antimicrobial Resistance and effective long-term treatment is scarce in Antimicrobial resistance (AMR) is increasingly Malawi. becoming a service deliver challenge. AMR occurs when microbes – bacteria, viruses, Mental health and substance use disorders fungi, and parasites – evolve in ways that account for 2.3% of total DALY burden in reduce medicine’s ability to fight them. Without Malawi and 9.5% of NCD DALYs but have very effective medicines, the number of people with little recognition and treatment due to staffing, severe microbial infections will increase, as will knowledge, and lack of treatment. Major the number of those who die from these depressive disorder contributes to the highest infections. The main drivers of AMR include DALY burden but has been found to rarely be misuse and overuse of antimicrobials; lack of diagnosed at primary health facilities.59 access to clean water and adequate sanitation 2.3.1.5.6 Injuries and emergency response for people and animals; poor infection Injuries represent 19% of all NCD burden of preventions and control measures in healthcare disease within Malawi with 12% of that burden facilities and farms; limited access to quality from unintentional injuries and 4% from affordable medicines, vaccines, and transport related injuries. Of unintentional diagnostics; and lack of awareness and injuries, falls are estimated to make up the knowledge about AMR. To address the AMR largest burden of disease (2.1% of NCD DALY). challenge, Malawi developed a national Between 2009 and 2020, up to 10,733 actional plan (NAP) on AMR, the Antimicrobial accidents were reported at KCH alone, of Resistance Strategy 2017-2022 which adopts a these, 2531 resulted in admissions. Of the One Health approach to AMR. admissions, by mode of transport, 29%, 20%,

2.3.2 Progress in Quality 17%, 10%, 7%, 5%, 12% were due to pedestrian, bicycle, motorcycle, car, lorry, Management minibus, and other, respectively. A review of The evidence on service delivery shows that motorcycle accidents show that these have Malawi has increased access to health care increased from 291 in 2017 to 1488 in 2020, but services and yet the country is still experiencing declined potentially due to travel restrictions, to poor outcomes in key indicators that are 1268 in 202160. sensitive to quality of care. To address this, MOH institutionalized the Quality Management In response to the increasing burden due to Directorate (QMD) to champion quality accidents and other emergencies, the MOH initiatives in the health sector. The Quality established the Emergency Response and Management Policy (2016 to 2022) identified Disaster Management Division to regulate and the following key priority areas, strengthening coordinate pre-hospital emergency medical leadership governance and social services, hospital emergency services, and the accountability, improving clinical practice skills, management of health advisory call centre and competencies, patient safety, people- (Chipatala Cha Pa Phone). Under the Southern centred care, research, monitoring and 59 Udedi M. (2014). The prevalence of depression among journal: the journal of Medical Association of patients and its detection by primary health care workers Malawi, 26(2), 34–3 at Matawale Health Centre (Zomba). Malawi medical 60 MOH (2022) Injuries Among motorcycle users – A policy brief prepared by Department of Planning, MOH 32 | Malawi Health Sector Strategic Plan III 2023-2030 evaluation capacity. Below is the progress 2.3.3 Bottlenecks in Health Service made during the implementation of HSSP II. To Delivery enhance leadership for quality management, The following challenges remain: tailored leadership and management manuals and trainings were created for central hospitals, • Lack of well-defined integration and District Health Management Teams (DHMT) streamlining in primary, secondary and and Health Facility Management Teams tertiary healthcare services. (HFMT). 150 DHMT members were trained • Lack of clear definition of what services across fifteen districts and 181 health facility in- belong at what level of care (i.e., charges were trained in 5 districts. On Health primary, secondary, and tertiary). Facility Accreditation, implementation of safe • Lack of clearly defined interdisciplinary care standards and Council for Health Service and multidisciplinary platforms for Accreditation of Southern Africa (COHSASA) specialty and sub-specialty health standards was initiated with improved service delivery. performance of health facilities implementing • Weak referral systems across the COHSASA standards after a year of levels of care. implementation (See Figure 9). • Lack of coordinated resources for The MOH developed national quality of care health. standards as a step towards international • Poor quality and lack of client safety in recognition. This will provide a unified healthcare service delivery; and performance measurement for health facilities • Weak client-centred and client trust in on a rating scale of 1 to 5 stars. Based on service delivery. adherence to these standards, the facilities with 5-star ratings will be designated as Centres of 2.4 Social Determinants of Excellence and will be used as a reference Health point in the rolling out of a countrywide programme covering public, private not-for- 2.4.1 Achievements in Social profit and private for-profit facilities. To improve determinants of Health quality of care, the MOH led harmonization of The Ministry of Health working in partnership the quality improvement (QI) approach and in- with other ministries and stakeholders made service training by joining the MNCH QOC some achievements in the implementation of network with implementation in nine districts. the HSSP II. These hinged on policy frameworks, legal instruments, and service provision to provide oversight and direction to Figure 9: Hospital performance in the implementation of COHSASA standards (in percent) 50 45 47 41 43 40 36 36 32 31 29 29 30 26 26 26 23 18 20 14 10 0 Kamuzu Ntcheu Dedza District Mchinji Mua Mission Nkhoma Our Lady of Kabudula Central District Hospital District Hospital Mission Mount Carmel Community Hospital Hospital Hospital Hospital Mission Hospital Hospital Baseline Progress 33 | Malawi Health Sector Strategic Plan III 2023-2030 the implementation of interventions that aim to entry services because of the increased reduce the environmental and social risk factors capacity in the domain. to health.

2.4.2 Bottlenecks in Social The Ministry developed a number of policy Determinants of Health documents that aim at harmonizing implementation arrangements by all The following challenges remain: stakeholders to avoid overlapping of mandates • High prevalence of preventable including the National Environmental Health medical conditions. Policy (2018), Household water treatment and • Weak financial capacity to access storage policy (2017), National Food Safety and health. Hygiene (2021), National Health Care Waste • Weak education system to address Management Policy (2022), National Sanitation health issues. and Hygiene Strategy (2018), National Health • Limited infrastructure and weak Communication Strategy (2017), National environmental conditions. Community Health Strategy (2017), National • Lack of inter-sectorial coordination in Water Policy (2021), Environmental preventing and responding to violence, Management policy (2017), National Road Map discrimination, accidents, and injuries. on Water Sanitation and Hygiene in health care • Food insecurity and poor nutrition facilities (2022). services. The Ministry participated in the development • Inhibitive societal institutions. and revision of legal instruments including, The • Weak disaster risk management and Public Health Act of 1948 (now completed climate change. pending presentation to Parliament through • Limited sectoral collaboration; and Ministry of Justice and Constitutional Affairs) • Weak port health. and Environmental Management Act (2017). Using the above legal instruments and policy 2.5 Progress in the frameworks, the health sector implemented a Implementation of variety of interventions. Sanitation and hygiene Health Systems for were promoted through participatory approaches. 53% of the total number of villages Service Delivery in Malawi attained Open Defecation Free (ODF) This section provides an overview of health status, up from 3% in 2011. In addition, 44.7% system interventions that were implemented of households have hand washing facilities, during the HSSP II period, organized by the while 58% of the health care facilities meet the thematic areas prioritized during the basic WASH services. Contributed to the in consultations for the HSSP III. These safe water supply coverage from 55% in 2016 interventions are drawn from the program to 67% in 2022. This resulted in reduced cases annual reports, Ministry of Health annual of diarrhoeal diseases including cholera. There progress reports as well as the HSSP II MTR was improvement in vector and vermin report. The bottlenecks encountered during the interventions leading to strengthened implementation of the programs are also sustainable vector and vermin control highlighted under each thematic area. measures i.e., indoor residual spraying (ISR) for Malaria control. General disease 2.5.1 Health Infrastructure and surveillance systems improved resulting in real Medical Equipment time reporting of notifiable and emerging

2.5.1.1 Achievements during HSSP II diseases such as COVID-19 and polio in both implementation inland and entry points. In the core function of food safety and hygiene, the country managed The Malawi National Health Policy seeks to to audit and inspect 56% of food premises from reduce travel distance to the nearest health 30% in 2016. During the implementation of the facility to within a 5km radius for every HSSP II, there was improved delivery of port of Malawian by 2030. The HSSP II target was to 34 | Malawi Health Sector Strategic Plan III 2023-2030 have a health facility within 8km radius from For an efficient referral process, the Malawi households. To achieve this, the MOH health sector needed about 300 ambulances at continued with construction, rehabilitation and the beginning of the HSSP II, against a stock of equipping of health facilities. serviceable ambulances of only 124 in 2017/18. To address the gap, a total of 191 ambulances Key construction works during the period were procured between 2019 and 2022 using included construction of the Lilongwe Government, World Bank and Global Fund neurosurgery by LIONS at KCH, completion of funding. the 250 bed Phalombe District Hospital, construction of Domasi and Mponela To increase efficiency of laboratory sample and Community Hospitals, and 8 new health centres results transportation, essential and urgent of which 5 are operational. During the period, drugs, blood products and other health 25 health posts were constructed, and another commodities between hard-to-reach health 55 were under construction, in hard-to-reach centres and district hospitals, MOH with support areas. MOH also completed construction of from partners introduced medical drone radiotherapy and brachytherapy bunkers at the technology in 8 districts of Nsanje, Chikwawa, National Cancer Centre in Lilongwe. With Zomba, Mangochi, Balaka, Kasungu, Ntchisi regard to rehabilitation, 14 health centres in the and Salima. The drone technology is northern region were rehabilitated, with new contributing tremendously to closing the gap on two-story maternity wing fully equipped at emergency deliveries of essential medicines Mapale in Mzuzu. At QECH, 5 infectious and reduction of turn over time of lab samples disease wards and the Intensive Care Unit and results from one week to just hours or two (ICU) were rehabilitated, thereby increasing the days at most. bed capacity from 6 to 16. Various district

2.5.1.2 Bottlenecks in Health hospitals as well as other health centres were Infrastructure and Medical also rehabilitated during the period. Equipment On medical equipment, industrial scale gas • Weak policies, guidelines and plants were procured for all central hospitals processes on acquisition, distribution, (except Zomba) and in district hospitals of installation, maintenance, use and Nkhatabay and Phalombe. At Mzuzu Central disposal of medical equipment. Hospital (MCH) the gas plant is not yet installed • Inadequate budget for medical as it is being shipped. Three more plants are equipment. being procured and contracts have already • Frequent breakdowns and lack of been signed for Mangochi, Bwaila and Kasungu quality assurance on the existing hospitals. These have improved therapy for medical equipment with increased patients in ICU, High Dependency Unit (HDU), downtime of equipment in the facilities. and paediatric wards, especially for neonates • Limited investment in technical support born prematurely. In addition to lowering cadres with weak institutional capacity hospital costs, they have also significantly of health technical support services lowered costs for health centres as they are function. now able to refill their cylinders at their nearest central or district hospital. • Under-decentralization of the health infrastructure and medical equipment To improve access to, efficiency and quality of budgets. digital radiography, MOH has embarked on a • Dilapidated and outdated infrastructure paradigm shift to migrate from analogue to for medical equipment; and digital radiography through the purchase of • Insufficient medical equipment and over 28 digital x-ray machines for all the central health infrastructure management and and district hospitals. At QECH, a state-of-the- capacity at all levels of service delivery. art CT scanner capable of producing 128 slices in one rotation was procured and installed. A 16-slice CT scanner procured for MCH has reduced its expenditures on referrals to KCH. 35 | Malawi Health Sector Strategic Plan III 2023-2030

2.5.2 Human Resources for Health facilities that provide primary and secondary care, from 60% to 51%. Cadre-specific changes

2.5.2.1 Achievements in Human in vacancy rates are depicted in Figure 10 Resources for Health below – note that in addition to wide variances The HRH objective in the HSSP II was to in vacancy rate by cadre, the vacancy rates by improve availability, retention, performance, cadre displayed below are an aggregate and motivation of health sector workers for nationwide. There is also wide variance within effective, efficient and equitable health service cadres, depending on the district and rural / delivery. The HRH interventions focused on urban / peri-urban status of the health facility. improving the retention of health workers; improving recruitment, development, and While the decrease in vacancy rate is notable, performance management; enforcement of and despite all the progress reported above at public service policies, regulations and the policy and implementation level, the procedures; improving quality and coordination numbers are still lower than the projected need. of training; and strengthening HR planning For example, the population to health worker process to incorporate evidence-based ratio which, in 2020, was at 2.85 health workers planning. per 1,000 population against the WHO target of 4.45 per 1,000. There has been significant progress towards improving the HRH situation. During the HSSP Between 2020 and 2022, in response to the II period, to improve performance management COVID-19 pandemic, the Ministry of Health and increase retention, government rolled out a recruited 5,622 health workers of different performance management system, introduced cadres including 179 medical doctors, 325 performance contracts at senior HRH levels, nursing officers and 86 clinical officers and 233 and conducted annual salary reviews across laboratory personnel. However, the Ministry the civil service. To continue the path towards was unable to recruit key positions including decentralization, government also senior anaesthetic clinical officers, oncology decentralized payroll management to district nurse specialists, Orthopaedic nurse councils and restructured positions at district specialists, theatre nursing officers, medical level, including introduction of the position of physicists, and nuclear medicine technologists Director of Health and Social Services. To for the Lilongwe Institute of Orthopaedic and improve policy coordination, the MOH led the Neurosurgery and Cancer Treatment Centre development and implementation of the HRH despite advertising the vacancies. Presumably Strategic Plan, completed an approved from a lack of available and interested functional review of central hospitals with many specialists in the national labour pool. more functional reviews at the district level that In pre-service training, key activities are pending approval, and strengthened the implemented included revision of training Health Service Commission with new office syllabi and curricula for certificate in midwifery, space and increased funding. Lastly, to registered nursing and midwifery, clinical increase retention of health workers, the officer, and medical assistant levels. Ministry constructed new housing units Introduction of the direct entry nursing degree especially in rural areas, supported in-service programs in adult health, child health, mental trainings and continuous professional health and psychiatric, community health and development programs. The Ministry also midwifery as well as accreditations of additional provided allowances to healthcare workers for health training institutions were done during working outside of their contracted hours to HSSP II implementation. Furthermore, joint meet the increased health workforce demand at monitoring and evaluation of nursing and the peak of COVID-19 pandemic. midwifery training institutions, regional and On the production side, during the HSSP II national stakeholders’ meetings (training period, output from across health training colleges, teaching hospitals, professional institutions production averaged 3000 per year. associations, partners) were done to monitor The result is a decrease in the overall vacancy and discuss issues affecting nursing and rate of generalist cadres in public and CHAM midwifery education as well possible solutions 36 | Malawi Health Sector Strategic Plan III 2023-2030 to improve the quality of nursing and midwifery • Sub-optimal production at training education. institutions and lack of coordination between the institutions and Also, for in-service training, the Ministry government on matching supply and facilitated upgrading of hundreds of healthcare demand of pre-service training with workers, including nurse midwife technicians to health sector targets. registered nurses, nursing, and midwifery officers to nursing and midwifery specialists in • Ineffective policy development and reproductive health, maternal and child health planning functions for human and others; as well as Doctor of Philosophy in resources for health; ineffective and inter-professional development. Medical inequitable absorption, recruitment, officers have also been upgraded to specialists selection, deployment, and distribution in areas such as medical physics, radiation of HRH. oncology, surgery, anaesthesia and accidents • Ineffective staff development and emergencies. These efforts were on top of strategies, policies, procedures, and numerous other trainings that were undertaken practices including limited ability to at the district, facility, and community levels. appropriately promote workers who These trainings have assisted health care train in upgrade programs and return to professionals to have capacity skills to be able the public health workforce. to manage programs at all levels of care. • Ineffective performance management policies, procedures, and practices; limited incentives and capacity to retain

2.5.2.2 Bottlenecks in Human Resources the health workforce especially in rural for Health and other hard-to-reach areas amidst high vacancy rates and resultant • High vacancy rates with poor attrition rates to the private workforce absorption. This is partly due to and international workforce; and challenges with aligning inter- • Limited digital innovations and use of ministerial and intersectoral partners existing technological platforms for HR on increasing financing of management. remuneration and benefits. 37 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 10. Vacancy Rates by Cadre, from 2017 to 2021, for Public Facilities and CHAM Facilities that Provide Primary Care and Secondary Care, as Compared to the Establishment -150% -100% -50% 0% 50% 100% 29% Medical Officer / Specialist 37% Clinical Officer / Technician 67% 63% Medical Assistant 30% 11% Nurse/Midwifery Officer 34% 40% Nurse Midwife Technician 65% 54% 33% Pharmacist 38% 81% Pharmacy Technician 81% Pharmacy Assistant 83% 36% -13% -128% Lab Officer Lab Technician 57% 45% 81% Lab Assistant 75% Overall 60% 51% Vacancy Rate against Establishment (2017) Vacancy Rate against Establishment (2021) Figure 11: Absorption Rates for Licensed Graduates by Cadre, per Early 2020 Graduate Mapping Exercise Lab Assistant 76% Lab Technician 76% Lab Officer 82% Pharmacy Assistant 97% Pharmacy Technician 100% Pharmacist 85% Nurse Midwife Technician 70% Nurse Midwifery Officer 78% Medical Assistant 70% Clinical Officer 62% Medical Officer 93% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 38 | Malawi Health Sector Strategic Plan III 2023-2030

2.5.3 Medical Products and 2.5.3.2 Challenges in Medical Products and Technology Technology • Shortage of essential medicines

2.5.3.1 Achievements in Medical availability. Products and Technology • Weak policy and regulatory framework To improve the overall coordination and for quality assurance of medicines and functioning of the supply chain for medical medical products. products and technologies, the Ministry and • Sub-optimal decentralization of critical stakeholders successfully reviewed the Malawi supply chain management functions. Standard Treatment Guidelines (MSTG) and • Weak short, medium, and long-term essential medicines list which was awaiting quantification, costing and budget approval from senior management. It also execution for medicines and medical developed the Malawi Supply Chain supplies. Transformation Plan which will guide the supply • Inefficient procurement of health chain integration agenda for the Ministry and commodities. address to a greater extent, existing • Inefficient warehousing and distribution bottlenecks in procurement, warehousing, of medicines and medical supplies. transportation, storage at facility level, as well • Sub-optimal distribution and use of as support efficient medicine utilization at medicines and medical technological facility level. services. During the period, the MOH continued to • Weak execution and monitoring of the strengthen USAID supported Logistics medicines and medical supplies Management Information System (OpenLMIS) budget; and and adopted the UNDP funded electronic • Inefficient and unsafe utilization of Health Information Network (eHIN) in 2020 to medicines and medical supplies at facilitate real time End-to-End commodity health facility level. tracking. The online OpenLMIS has improved ordering medicines from CMST as well as 2.5.4 Digital Health reporting of commodity usage by district 2.5.4.1 Achievements in Digital Health hospitals and central hospitals. The eHIN on MOH’s digital health reform aims to enhance the other hand has improved tracking of the efficiency in health service delivery and dispensing activities in the supply chain. These precision in medicine. A major development in efforts are already addressing critical supply this area was the establishment of the Digital chain challenges of transparency, data visibility Health Division. Through the digital health and accountability of health commodities in the strategy, this will provide digital health supply chain governance, coordination, and leadership in the To enhance regulation of medicines and country. During the period, digital health medical technologies, Government through the infrastructure substantially expanded, including Poisons Medicines Regulatory Authority the extension of the Government Wide Area (PMRA) enacted the PMRA Act No. 9 of 2019. Network (GWAN) from District Council offices The PMRA was in the process of reviewing to District Health offices and some other other related regulations in an effort to prevent selected health facilities, as well as solar power conflicts hindering its regulatory role. A backup systems to more than 100 facilities to functional review of the PMRA had also already support the use of digital health solutions. This concluded in 2021 and was still awaiting will increase internet access to health facilities. Government approval. To enhance the visibility A milestone was the development and of its work, the PMRA implemented various deployment of an Interoperability Architecture initiatives including creating a website on the to support with interoperability of digital health Medsafe 360 platform. systems. So far, software components under the interoperability architecture include Interoperability Layer, Master Health Facility 39 | Malawi Health Sector Strategic Plan III 2023-2030 Registry, the Master Patient Index and • Weak security of information and ICT Terminology Registry. The Interoperability systems; and Architecture is already currently facilitating the • Lack of interoperability among the sharing of data between HMIS DHIS 2 and country’s digital health systems. OpenLMIS (Drugs and Essential Medicines data platform), HMIS DHIS 2 and DHA MIS, 2.5.5 Health Research and M&E HMIS DHIS 2 and Integrated Supportive 2.5.5.1 Achievements in Health Supervision System, among other systems. Research and M&E During the period, MOH, through support Stronger monitoring and evaluation (M&E) are various implementing partners and the critical for providing the intelligence for Department of Computer Science at the evidence-based decision-making and University of Malawi is developing the performance monitoring. During the HSSP II integrated Community Health Information implementation, the following interventions System (iCHIS), a digital system that combines were implemented to strengthen health software, hardware, people, and processes to research and M&E. Over 250 statistical clerks support informed decision making and action were recruited and trained in data taken by community health workers. This management, with particular focus on DHIS2. A game-changing digital health intervention will mobile DHIS2 was introduced in 15 districts and also demonstrate the potential that exist when MOH had secured over 2000 tablets as part of funder invest in in locally conceived and the roll out of the mobile DHIS2. In the area of executed solutions in addressing local needs health research, the Ministry through the Public sustainably and cost-effectively. Health Institute of Malawi strengthened the District Health Emergency Response Teams in Another milestone is the establishment of the all the districts in the country. The teams play Central Data Repository (CDR) for patient level acritical role on the response to COVID-19, data. The CDR working together with the cholera, and polio outbreak. The Ministry also Master Patient Index is a starting point for the collaborated with the Ministry of Agriculture on Shared Health Record where a patient can anthrax outbreak response in Balaka District. move with their electronic health record from one health facility to another. On customization 2.5.5.2 Challenges in Health Research and deployment of electronic learning and M&E (eLearning) for Continuous Professional • HMIS remains under-developed Development (CPD), the Ministry has made conceptually to support effective Reproductive Health and Digital Health performance management. modules available for online learning by • No effective system to track activity healthcare workers. implementation and thus basis for

2.5.4.2 Challenges in Digital Health assessing implementation progress limiting evaluation impact • Weak coordination of digital health • Extreme fragmented and vertical investments in the health system. programming, thereby undermining a • Lack of reliable Information and sector-led monitoring and evaluation Communications Technology (ICT) platform. infrastructure to enable utilization of • Poor data quality which is a barrier to digital health systems. effective use of evidence and decision • Lack of capacity among communities making on service quality, availability, and health workers to utilize digital and continuity of healthcare; and health investments. • Weak appetite by national and • Lack of continuity of care through international funders to develop local shared health records; with ineffective capacities to conduct research (people, alignment between monitoring and skills, funding) in part due to weak evaluation needs of health sector research-policy makers engagement strategies and digital health solutions mechanisms. currently being deployed. 40 | Malawi Health Sector Strategic Plan III 2023-2030

2.5.6 Leadership and Governance • Weak accountability mechanisms and performance management at service

2.5.6.1 Achievements in Leadership and provider level, particularly due to Governance ineffective decentralization and On leadership and governance, the Ministry autonomy of health service providers; continued to use technical working groups and (TWGs) as a platform for coordination and joint • Ineffective stakeholder oversight and decision-making. TWGs, however, proliferated coordination health sector leading to duplication and poor coordination. stakeholders, their activities, and The more than anticipated increase in the resources at all levels. number if TWGs attributed to the multiplicity of donor The vertical and horizontal feedback 2.5.7 Health Financing mechanism of the TWG system has mostly 2.5.7.1 Achievements in Health financing been weak; TWG reports have not fed into the In 2018/19 fiscal year, per capita THE was HSWG and there has been only modest US$39.9, marginally increasing from 39.5 in progress with decentralization. Functional 2017/1862. In addition to being stagnant for the reviews for districts were done for some past decade, this is far below the WHO districts, leading to more stability in district recommended US$86 per capita expenditure health leadership with minimal transfers and a on health for optimal implementation of district leadership training was rolled out in 15 Universal Health Coverage63. A simulation of out of the 29 district health offices. So far, over per capital THE forecasts that by 2030 it will be 200 health centre managers were trained in approximately US$50, suggesting sustained health management and there were 400 and serious fiscal space constraints over the established hospital ombudsmen to promote HSSP III period. The 2018/19 NHA showed that health workers’ accountability to the 58% of THE was donor funding and 42% was community. The Ministry, however, did not have from domestic sources. Critically, compared a devolution plan partly owing to an outdated with the SADC regional average per capita national decentralization policy. spending of US$240.9 in 2019, the 2018/19

2.5.6.2 Challenges in Leadership and NHA also shows that Malawi’s health Governance investment was the lowest in the Southern • Leadership capacities to plan, execute African Development Community (SADC) and evaluate policies and plans remain region. Against this background, the HSSP II weak at all levels of the health sector, a target was to implement health financing problem compounded by proliferation interventions for increasing domestic health of national strategic plans, from a total financing as well as ensuring efficient use of of 19 at the collapse of the Health Pool available funding. Fund in 2013/13 to 56 in 2019/2061. On revenue mobilization, the MOH scaled up • Agenda setting suboptimal and optional paying services in central hospitals and laborious, with inconstancies in policy piloted paying wards in two district hospitals direction, ineffective policy (Nkhata-Bay and Nkhotakota). Government engagement arrangements. also developed health sector specific • Weak implementation, enforcement guidelines for Public Private Partnerships to and monitoring of health sector policy, increase domestic financing through private legal and regulatory frameworks at sector participation. Also, the proportion of national and sub-national levels. health insurance expenditure rose from 5.2% in 2017/18 to 9.8% in 2018/19 indicating the increasing importance pf health insurance in 61 63 Ministry of Health. 2022. Resource Mapping Studies World Health Organization (WHO). 2015. Raising Rounds 5, 6, &7. Department of Planning and Policy Revenues for Health in Support of UHC: Strategic Development, Lilongwe 3 Issues for Policy Makers. Geneva: World Health 62 Ministry of Health. 2022. Malawi National Health Organization. Accounts Report For Fiscal Year 2018/19, Department of Planning and Policy Development, Lilongwe 3 41 | Malawi Health Sector Strategic Plan III 2023-2030 financing healthcare over time in Malawi. The the new financial management introduction of a medical insurance scheme for information system is designed to cater civil servants in 2021 is likely to enhance the to budget planning, execution and role of private health insurance schemes. monitoring and evaluation needs at Overall, the domestic share of private health national, sub-national, and service financing schemes to the THE marginally provider levels; and increased from 42% in 2017/18 to 45% in • Moving towards strategic purchasing 2018/19. by strengthening resource allocation frameworks and processes to allocate In the recent 2018/19 NHA, the US$39.9 came funds explicitly based on population, from 166 financing sources and was executed need, and the volume of services by 264 implementing partners. On a positive produced; and concurrently introducing note, of the 166 financing sources, 10 effective provider payment organizations control 97% of the total health mechanisms that increase sector funding, providing an opportunity for effectiveness of resource allocation greater aid effectiveness through coordination, and PFM such as effective joint planning, execution and M&E arrangements. Particularly with respect to Implementation of the above and other related enhancing efficiency at the service delivery recommendations was already underway. The level, results of Public Expenditure Reviews64, Health Services Joint Fund (HSJF), a multi- health sector PFM assessments at national and donor fund pooling arrangement outside of the subnational levels 65, and health budget mainstream Government PFM system which process reviews66 commissioned during the was initiated towards the end of the HSSP I, HSSP II period have underscored the need for: was strengthened during the HSSP II period. Current Development Partners financing the • Strengthening the role of district health sector through the HSJF are the German management in PFM and re- Government through KFW, The Norwegian engineering health community Government, and the United Kingdom. To governance structures to provide access funding, implementing partners must effective PFM oversight across budget demonstrate alignment to the HSSP II at the planning, execution, and evaluation; activity level – a key milestone towards the One • Enhancing autonomy of providers at Plan, One Budget, and One M&E agenda of the health facility level by clarifying their HSSP III. Notable achievements include functions vis-a-vis district implementing an organizational review, management, recognizing health strengthening the joint Government, Donor and facilities as spending units, and Implementing Agency oversight arrangement, instituting effective performance enhanced fiduciary oversight, recruitment of management measures to guarantee full-time coordination staff, and initiating design optimal access, quality, and efficiency and implementation of robust performance of health care delivery; management systems for the Fund. As a result, • Making spending more flexible to allow this has seen increasing donor confidence, as managers to opportunely respond and evidenced by increased allocation to the HSJF, adjust to community needs; from US$1.186 million in the 2015/16 Fiscal • Unifying payment systems to Year to US$19.2 million in 2022. encourage donors to align with Additional donor financing coordination and government systems while ensuring alignment strengthening initiatives were also 64 World Bank. 2020. Malawi Public Expenditure Review World Bank. 2020: Strengthening Expenditure for Human Capital. https://openknowledge.worldbank.org/handle/10986/358 World Bank, Washington, DC. © World Bank. 65 License: CC BY 3.0 IGO. 66 https://openknowledge.worldbank.org/handle/10986/358 UNICEF Malawi. 2021. Immunization and Nutrition 55 License: CC BY 3.0 IGO. Supplies Budget Process Mapping. Available 65 World Bank. 2021. Public Financial Management in the https://www.unicef.org/esa/documents/unicef-malawi- Health Sector in Malawi: Opportunities to Strengthen immunization-and-nutrition-supplies-budget-process- Service Delivery at the Local Level. Health, Nutrition and mapping Population Policy Brief. World Bank, Washington, DC. © 42 | Malawi Health Sector Strategic Plan III 2023-2030 introduced during the HSSP II period. In 2022, through the UK funded Thanzi la Onse project, through support from the Umoyo Wathu, a joint Government facilitated the establishment of the UN funded project by the FCDO programme, Health Economics and Policy Unit at the the MOH initiated implementation of direct Kamuzu University of Health Sciences. facility financing (DFF) through which donor Sustained through an FCDO grant via the funds will be channelled directly to health HSJF, this unit will increase the production and facilities. In preparation for eventual transfer of uptake of relevant and policy-oriented research funds to facilities, a pilot is being implemented and analysis, as well as local capacity building in Rumphi where the District Council, the in health policy, planning, financing, and District Health Management Team, and Health economics. Facility Management Committees are being

2.5.7.2 Challenges in Health Financing trained on how to manage funds and oversee service provision. Concurrently an evaluation is • Weak capacity to mobilize adequate, being designed to be executed alongside the sustainable, and predictable funds for DFF implementation and will inform decisions the health sector to optimally deliver on optimal designs for DFF scale-up. The work essential health services; is being led by a multi-stakeholder DFF project • Substantial inefficiency and inequity in implementation committee comprising MOH, pooling and management of resources Health Donor Group, Ministry of Finance, for the health sector; District Councils, National Local Government • Underdeveloped strategic purchasing Finance Committee, and Ministry of Local measures across the healthcare Government and Rural Development. service delivery continuum; and • Weak institutional arrangements and A similar programme is being implemented systems for effective health financing at under the US funded Government to all levels of the health system Government (G2G) arrangement in which US funds are channelled directly to district councils

2.6 Conclusion in beneficiary districts. At the time of this report, the G2G pilot was underway in Zomba and Overall, while Malawi’s health sector has seen Mangochi districts. Under the U.S. funded G2G, sustained progress across health systems, the U.S. has provided 5.3 million U.S. Dollars to service delivery impacts, and ultimate health the Ministry of Finance (MoF) to pay for 155 impacts, serious gaps exist and must be health, social welfare, and support staff in addressed in order to meet Malawi’s Universal Zomba and Mangochi Districts. It has also Health Coverage aspirations. While health provided US$2.1 million and US$3.04 million to financing remains a serious bottleneck to the Zomba and Mangochi District Councils navigate during the HSSP III, important respectively to strengthen health systems that bottlenecks were observed across all health are vital to improving outcomes in MCH, systems building blocks, causing avoidable nutrition, and HIV. The G2G approach is a inefficiencies, limitations in access, and gaps in milestone in that Government of Malawi quality of care. Given the serious fiscal space systems are used, thereby building institutional challenges for health situation for Malawi, capacity to promote self-reliance and long-term forecast to manifest throughout the HSSP III sustainability. period, addressing health systems bottlenecks will require a “business unusual” approach. To To better coordinate the health financing carry out "business unusual" the health sector function, in 2021, Government created the must focus on value-for-money-informed Health Financing Division within the implementation, performance management, Department of Planning and Policy and speedy execution of catalytic reforms Development in the MOH. The Division has across all priority areas, anchoring all efforts on already facilitated the development of a national effective and decisive leadership across all health financing strategy which will levels of the health system. The next chapters operationalize the financing strategies outlined provide a framework through which these will in Chapter 5: of this HSSP III. Concurrently, be addressed in the HSSP period up to 2030. 43 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Health worker leads a session. Chapter 3: The Vision of the Health Sector Strategic Plan III

3.1 Overview of Chapter 3.2.2 Mission The mission of the Ministry of Health is to This chapter provides an overview of the overall provide strategic leadership for the delivery of a vision, mission, goal, guiding principles and comprehensive range of quality, accessible, objectives for the HSSP III. The vision, mission and efficient health services to all Malawians and goal were derived from the National Health through the creation and sustenance of a strong Policy, while the objectives were derived from health system. the HSSP II with modifications to accommodate emerging areas of digital health and research. 3.2.3 Goal Each HSSP III objective is assigned a pillar, The goal of the HSSP III is to improve the health and then mapped into the WHO Building Blocks status of all Malawians and increase client that are outlined in Chapter 5. satisfaction and financial risk protection towards attainment of Universal Health

3.2 Vision, Mission, and Coverage. Progress towards this goal will be Goal measured through long-term impact on health status, client satisfaction and financial risk

3.2.1 Vision protection; as well as intermediate impacts (i.e., The vision of the health sector is to achieve a service delivery) dimensions of access, quality state of health for all the people of Malawi that and efficiency as presented in Chapter 8: and would enable them to lead a quality and in the monitoring and evaluation matrix in productive life. Annex 2 on HSSP III M&E Matrix. 44 | Malawi Health Sector Strategic Plan III 2023-2030

3.3 Guiding Principles people in Malawi – including vulnerable population and residents of hard-to- The guiding principles of the HSSP III are taken reach areas –receive the same high from HSSP II67, Malawi 206368 as well as the quality health care regardless of geographic location or socio-economic HSSP III Development Inception Report 69. factors. They demonstrate Government’s commitment vi. Gender Sensitivity: Gender towards attaining equitable, accessible, mainstreaming shall be central in the affordable, and sustainable high-quality planning and implementation of all evidence-based health care. The following are health policies and programmes. the guiding principles for the HSSP III: vii. Ethics: The ethical models that promote shared values, confidentiality, i. Solidarity: In the HSSP III, the solidarity fairness, safety, and efficacy in both the principle means “every individual provision of health care and health care contributes to financing of health research shall be adhered to. services based on their ability to pay, viii. Client Centeredness: Service provision regardless of income or social will be considerate of the peoples’ standing, and has the same access to personal circumstances, preferences, the services provided by public or values, family situations and lifestyles. contracted providers”70. This is in ix. Efficiency and Effectiveness: All keeping with the Umunthu71, an stakeholders shall be expected to use underpinning principle of the Malawian available resources for health society. efficiently and effectively to maximize ii. Community Empowerment: The HSSP health gains. III design is based on enabling x. Integration of Health Service Delivery: communities to gain greater control of This will be promoted to leverage their health outcomes. This includes efficiency and effectiveness in decision-making for service delivery addressing health needs of the people and the health systems that affect of Malawi. access, as well as quality and xi. Evidence-Based Decision-Making: efficiency of the services provided. This Health sector strategies and activities stance is rooted in the democratic are chosen and pursued to achieve the principle of power to the people and optimal possible ‘outcome,’ based on decentralized governance to enable value, effectiveness and quality, as realization of this principle. informed by the best available iii. Decentralization: Health service evidence. provision and management shall be in xii. Value for Money: Demonstration of line with the Local Government Act value for money shall be a routine 1998, which entails devolving health requirement for Government and service delivery at all levels to Donor funded programmes and community health governance projects under the HSSP III. structures and alignment with Local xiii. Sustainability: A central requirement of Government structures. any system of UHC is that the range of iv. Transparency and Accountability: The services made available to the HSSP III design creates effective population is consistent with the funds internal and external accountability available to it. Realistic planning is institutions and measures at service essential to ensuring successful provider level and eliminates risk of implementation of activities and diffusion of responsibility. All other achievement of targets. accountability measures must build upon strong community governance and oversight. v. Human Rights-Based Approach and Equity: The HSSP III has been developed to attempt to ensure all 67 71 MoH (2017). Malawi Health Sector Strategic Plan I Kayange, G.M. (2018). Conceptual Analysis of (2017 – 2022) Ubuntu/Umunthu and Meaning. In: Meaning and Truth in 68 National Planning Commission (2020). Malawi 2063 African Philosophy. Philosophical Studies Series, vol 69 MOH. (2021). HSSP III Development Inception Report 135. Springer, Cham. https://doi.org/10.1007/978-3-030- 70 Saltman Israel Journal of Health Policy Research 2015, 01962-4_8 4:5 http://www.ijhpr.org/content/4/1/5 45 | Malawi Health Sector Strategic Plan III 2023-2030

3.4 Objectives 5. Improve the availability, quality and rational utilization of medicines and The objectives of the HSSP III focus on two related medical supplies, balancing the main aspects: 1) strengthening health systems 3 P’s: patients, products, and personnel. inputs for the delivery of integrated platforms of 6. Develop a sustainable and harmonized care with financing through an enhanced health country-led digital health system that service package-based Health Benefits covers all areas of service provision Package and 2) confronting social and enables efficient delivery of health determinants of health that put communities at services at all levels of the health risk for disease. The HSSP III objectives are system. therefore to: 7. Promote and coordinate a health research agenda in order to generate 1. Increase equitable access to and high-quality evidence required to improve the quality of health care inform the development of health and services. health care delivery. 2. Improve overall health, environmental 8. Enhance the effectiveness of health, and disease prevention through leadership and governance at all levels addressing social determinants of of health sector. health and burden of disease. 9. Set a well-governed health financing 3. Improve the availability, accessibility architecture that is able to mobilize and quality of health infrastructure and adequate resources, distribute the medical equipment at all levels of resources in an efficient and equitable health care. way, and strategically purchase 4. Improve availability of competent and services based on a well-defined motivated human resources for health benefit package in pursuit of UHC for quality health service delivery that is goals. effective, efficient, and equitable. 46 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Health workers attend to a mother and child. Chapter 4: Health Benefits Package for HSSP III HSSPs, Malawi has defined the EHP, but it is

4.1 Introduction & important to clarify that the EHP is not a care Background delivery platform for describing “essential services”. Rather, it is a prioritization Sustainable Development Goal target 3.8 is to mechanism to maximize population health. ‘Achieve Universal Health Coverage (UHC), Therefore, in the HSSP III it will be referred to including financial risk protection, access to as the HBP. quality essential healthcare services and access to safe, effective, quality, and affordable Despite defining HBPs over the past 20 years, essential medicines and vaccines for all’ by implementation of the HBPs at the service 2030.72 However, the resources available for delivery level has been difficult. A district health health service delivery are limited especially in expenditure tracking study estimated that about Low- and Middle-Income Countries (LMICs), so 20% of resources were spent on non-HBP not all services can be provided free of charge related conditions (Mwase, Bowie, Kaluwa, & in public facilities. Health Benefits Packages Chirwa, 2010).74 It was recognised during (HBPs) – sometimes called Essential Health HSSP III development that the current list Packages (EHPs) - are an increasingly based HBP design is incompatible with the common way of explicitly defining which health current health system configuration, inhibiting services are provided free of charge or at a its success. This incompatibility arose because reduced cost as the basis of UHC. 73 In past 1) Malawi provides health services free at the 72 United Nations Economic and Social Council. Progress http://www.worldbank.org/en/topic/health/publication/uni towards the sustainable development goals. New York versal-health-coverage-study-series (accessed 7 May 2017 2022). 74 http://www.un.org/ga/search/view_doc.asp?symbol=E/2 Mwase, T., Bowie, C., Kaluwa, S., and Chirwa, M. 017/66&Lang=E (2010). District Health Expenditure Pattern. Lilongwe, 73 The World Bank. Universal Health Coverage Study Malawi: Ministry of Health Series (UNICO). 2017 47 | Malawi Health Sector Strategic Plan III 2023-2030 point of service; as such health systems technical experts, Civil Society Organisations resources have already spent by the time a (CSOs), bilateral donors and implementing client is diagnosed as either requiring HBP or partners. All five tertiary hospitals were also non-HBP services. 2) The reimbursement for visited. health systems inputs such as the health workforce is not linked to HBP delivery. 3) For

4.2.1 Primary and Secondary co-morbid patients, treating only HBP-related Health Benefits Package conditions can lead to sub-optimal benefit if Primary and secondary HBP prioritized HBP-related and non HBP-related conditions interventions were created through cost- are dependent and 4) some interventions by effectiveness analysis (CEA) and multi-criteria their nature must be delivered as a package to decision analysis (MCDA). CEA assisted in provide full health benefit. prioritizing interventions that maximized For the HSSP III, the list-based approach is population health within limited resources. MCDA was incorporated to i) develop a maintained as a transitory measure for defining integrated platforms of care. The integrated practicable and rigorous prioritization platforms of care will be defined for each level framework methodology based on a set of of the health system, health systems inputs agreed upon criteria and ii) incorporate social required to deliver holistic, and client focussed and equity dimensions into decision-making75. According to the UHC cube, there are trade-offs care within resource constraints. New health financing mechanisms defined in Chapter 5 will across the breadth of health services, take effect that are compatible with the population coverage, and proportion of costs integrated care approach. that are covered (Figure 12)76. Making sound choices requires a combination of technical This chapter presents the current HSSP III HBP judgements (e.g., CEA) and socio-political for 2023 – 2030 formulated through an priorities. MCDA is a flexible decision evidence-based and highly participatory framework for this. approach incorporating dimensions of equity, feasibility, and financial risk protection to Figure 12: UHC cost cube maximize population health with limited funding resources. The results of this chapter informed a broader analysis of the bottlenecks undermining service delivery and therefore UHC. The interventions chapter and the budget prioritization process were heavily informed by the HBP design. While the HBP design also took into account systems constraints, including financing and human resources.

4.2 HBP Definition process The development and prioritization of the HBP for the HSSP III was highly consultative with experts and health workers from all levels of the health system represented. Development of the A list of 305 potential interventions for the HBP primary and secondary HBP were done in at primary and secondary levels was compiled. consultation and collaboration with MOH A review of available literature for similar programmes and departments, the Essential contexts identified cost-effectiveness data for Health Package technical working group (EHP 145 interventions. Medicines and medical TWG), district health offices, central hospitals, supplies costs from Malawi, epidemiological 75 76 What's in, what's out: designing benefits for universal Baltussen, R., Niessen, L. Priority setting of health health coverage / edited by Amanda Glassman, Ursula interventions: the need for multi-criteria decision Giedion, and Peter C. Smith, (2017). analysis. Cost Eff Resour Alloc 4, 14 (2006). https://lccn.loc.gov/2017019856 https://doi.org/10.1186/1478-7547-4-14 48 | Malawi Health Sector Strategic Plan III 2023-2030 data for the population in need, and demand in digital edition on MOH website) with 71% constraints were utilized to estimate the total having cost-effectiveness data that could avert net health benefit of each intervention. over 31 million DALYs in 2023 with expected Interventions with the greatest health- increases annually through 2030. generating potential given estimated constraints were prioritized. Interventions were

4.2.2 Tertiary Health Benefits considered cost-effective if the estimated cost Package per DALY averted for an intervention was equal A tertiary HBP cannot be designed in the same to or less than the cost-effectiveness threshold way as the primary and secondary packages of $65 per DALY averted. due to the complexity of tertiary care. In Concurrently, a participatory MCDA process addition, tertiary care would rarely be cost- was conducted regardless of the availability of effective at the Malawi cost-effectiveness CEA data. Inclusion criteria for MCDA were threshold of $65 per DALY averted77. The arguments against a list based HBP also apply severity of disease or potential disease, the effectiveness of the intervention, poverty more in the context of tertiary care. In addition, reduction, vulnerable population, and level of each tertiary hospital is unique and an HBP- care taken from the values and objectives of the specific HBP has to be defined for each tertiary HSSP III. The MCDA criteria were assigned hospital. weights. The proposed interventions for the The definition of the hospital specific tertiary HBP were scored against the inclusion criteria HBPs commenced with the collection of health and a final weighted average was calculated. systems inputs by specialty and central hospital Initial prioritization of the primary and to inform the development of tertiary platforms secondary interventions was done using CEA of care. The consultations focussed on current platforms of care, required inputs of staff, results and validated by MCDA methods. Where CEA evidence was not available, only infrastructure, equipment, medicines, medical MCDA scores were used. After this, supplies, and envisioned future platforms of prioritization was iterative, adjusting coverage care. This process also generated interventions levels until the package was within the that were included in the HSSP III intervention matrix. The work to define tertiary platforms of estimated resource envelope. care will be ongoing in the first years of the The final primary and secondary HBP includes HSSP III. 115 interventions (Annex 3: HBP data available 77 Woods, BS, Revill, P, Sculpher, MJ & Claxton, KP 2016, estimates and the need for further research' Value in 'Country-level cost-effectiveness thresholds: initial Health, vol 19, no. 8, pp. 929–935. 49 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: A mother and child at a Health Facility. Chapter 5: HSSP III Strategic Interventions the HBP package as prioritized by Government.

5.1 Overview of Chapter These strategies are based on an analysis of The situation analysis chapter has the bottlenecks in delivery of HBP interventions demonstrated the progress and gaps in the prioritized analysis, informed by the situation health service delivery, which if well-funded and analysis and a robust participatory process with fully implemented can optimize the delivery of stakeholders at all levels of the health system ( Figure 13). Below shows the interventions logic strategy, the summary of activities to be underpinning the intervention matrix in Annex 1: implemented is presented in detail in Annex 1: Detailed annual intervention implementation Detailed annual intervention implementation Plan for HSSP III. The objectives and Plan for HSSP III. Further details, below the interventions are highly interrelated, and it is the activity level in the intervention logic (Figure optimization in each objective that is assumed 13), are contained in a costing matrix which has to drive the service delivery and ultimate goals sub-activities, and associated costs. For of the HSSP III. programming based on the HSSP III, the costing matrix will be used to provide details on This chapter presents the strategies under each each activity. objective (HSSP III Pillar) and, under each 50 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 13: HSSP III Interventions Logic programs but require a comprehensive platform

5.2 Strategic Interventions of care - from primary to tertiary care - that and Activities considers individuals’ needs holistically, placing the client and community at the centre of health Pillar 1: Service Delivery services. The MOH will define platforms of care The objective for this pillar is to “increase delivery in order to achieve this. A platform of equitable access to and improve quality of care is defined as a configuration of health health care services.” Changing health needs, systems inputs and processes required to ambitious health goals and public expectations provide total care appropriately and cost- are raising the bar for health systems to effectively at the different levels of the health produce better health outcomes and greater care system e.g., primary, secondary and social value. As access to health care tertiary. At the tertiary level, this will include the improves, there is need for equitable establishment of centres of excellence in the distribution of health care measured on quality areas where central hospitals have and competency that is centred on the client comparative advantage. This will include, but experience.78 Quality of care will become an not be limited to ophthalmology, orthopaedics even larger driver as utilization of health and neurosurgery, cardiology, and systems increases and burden of disease shifts cardiothoracic surgery. Platforms of care will to more complex conditions that require enhance coordination and increased efficiency knowledgeable and flexible workforce. and effectiveness to sustain high quality of Strategy 1.1 Design systems to create care. A strategy on integrated service delivery integrated platforms of care for will be developed guide implementation of pillar primary to tertiary level one. Integrated, people-centred quality services Strategy 1.2 Promote quality and client cannot be organized around vertical disease safety in health care service 78 Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018 Nov;6(11): e1196-e1252. doi: 10.1016/S2214- 109X(18)30386-3. 51 | Malawi Health Sector Strategic Plan III 2023-2030 delivery across the continuum Pillar 2: Social Determinants of of care from community to Health tertiary levels The objective of this pillar is “to improve overall Due to the focus on vertical disease programs, Malawi does not have a clearly defined health, environmental health and prevent harmonized standards of care with aligned disease through addressing social corresponding inputs for each level of care. determinants of health and burden of disease.” There have been efforts to identify standards of Health is influenced by a multitude of non- medical and environmental factors. There is care through quality improvement on the path to accreditation but has not been unified need for implementation of evidence-based throughout all aspects of care on a platform effective preventative and environmental model. In this strategy through the development approach within the health care system to of unified standards of care for community, prevent disease, accident, and injury. This requires timely assessment and response to primary, secondary, and tertiary levels, we will emphasize a culture of quality and client safety the growing burden of climate change effects, through provider performance adhering to natural disaster, disease pandemics, and evidence-based standards with continuous access to health and safe water and food. This improvement, enforcement of client safety work is multi-sectoral and inter-sectoral requiring collaboration amongst diverse areas mechanisms and decentralized performance- based financing mechanisms. and ministries including legal, medical, environmental, education, cultural, religion, Strategy 1.3 Strengthen client-centered policy, and politics. Strategies to improve care and patient trust at all overall health demand systems to be agile and levels of the healthcare system adaptive to respond to people’s changing and To improve access, health outcomes and diverse needs in a rapidly evolving confidence in the health care system, people- environment. centred care must be at the centre of all intentions and work. This requires that there be Strategy 2.1 Drive wellness and healthy promotion, empowerment and monitoring of lifestyle practices in the community and health care system client rights and trust but also the health care workforce from management to direct provision Wellness is not just a physical convention but of care. Ensuring and enforcing service requires promotion of mental, preventative, and charters with client and community input is vital social community health including diet, physical to meet the needs of communities, disease exercise, and freedom to live without discrimination or stigma. To attain this goal, burden, and equitable access to high-quality, respectful care. Malawi must integrate healthy practices through an inter-sectoral approach targeting special populations such as youth, vulnerable, Reform 1: Integrated platforms of care and those living with chronic disease, not just The reform will see transitioning from vertical within the health care system but in programming to integrated platforms of care communities, workplaces, schools, religious for service delivery. This will involve and social organizations. developing and implementing a strategic Strategy 2.2 Increase access to safe food, plan for integrated service delivery which will water sanitation and hygiene define and deliver integrated platforms of (WASH), housing and working care and maximize synergies across environments programmes. This will significantly reduce Significant disease burden is attributable to planning, execution and evaluation social determinants of health and requires inefficiencies that come with fragmented improvements in educational attainment, service delivery housing, workspaces, piped water access, toilet, trade, and agricultural practices. It must include reducing illness and death due to hazardous chemicals and vectors of disease in 52 | Malawi Health Sector Strategic Plan III 2023-2030 air, water and soil pollution and contamination. actions and community building. Additionally, The Government in collaboration with partners prevention, treatment, and rehabilitation and stakeholders in the water sector will services for victims/survivors of violence and implement interventions to improve access to injuries must be strengthened. sanitary facilities, and collaborate with players Strategy 2.6 Address health and health in the water, housing, and food sectors to delivery effects of climate implement interventions for increasing access change to clean water, safe homes and workplaces, Climate change effects are felt throughout the and ensure food safety. health system from changing transmission of Strategy 2.3 Strengthen occupational disease to adding to food and water scarcity to health affecting fragile health infrastructure. The Government and health sector will work to Significant collaborative research, evaluation, promote and maintain the highest degree of policy, and implementation processes are physical, mental, and social health in all required to address climate change and workplaces. Working conditions and environment including meteorology, environment must be conducive to maximize environmental, education, agriculture, and safety and health of employees through infrastructure stakeholders and ministries. The effective managerial systems and personnel health sector will contribute to improve policies. monitoring systems and the capacity of healthcare providers to use data for priority Strategy 2.4 Strengthen pandemic, disaster setting at different levels. preparedness response and surveillance of eradicated diseases Malawi has seen the severe effects of emerging Pillar 3: Infrastructure and Health pandemics (i.e., COVID-19, Monkeypox), re- Technologies emerging outbreaks (i.e., polio, cholera, The objective of this pillar is “to improve the typhoid) and disasters (i.e., Cyclones Ida, Ana availability, accessibility and quality of health and Gombe) in the past 5 years. These infrastructure and medical equipment at all emergencies require a rapid, flexible, and multi- levels of health care.” To effectively deliver sectoral response with efficiently integrating high-quality health care, the health care system inputs such as human resources with a must have immediate access to adequate and background of continuous surveillance and functioning patient-centred infrastructure and preparation through sector wide health systems medical equipment for diagnosis and treatment. strengthening (HSS). In addition to filling the gap of these system Strategy 2.5 Strengthen inter-sectoral inputs for platforms of care, development of prevention and response to measurement tools and efficient maintenance violence, discrimination, of infrastructure and equipment is critical. This accidents, and injury objective will address infrastructure building block bottlenecks with an integrated capital Accidents and injury prevention and response have been proven to decrease mortality and investment plan providing the link between morbidity through inter-sectoral programs that medical infrastructure, equipment, and human address road and community safety through resources for health. preventative legislation, enforcement of laws Strategy 3.1 Construct new health and awareness and timely reaction and infrastructure to meet service delivery treatment. Violence and discrimination are needs often the result of power imbalances between The MOH will continue with construction of new people and groups, and is often seen due to health infrastructure to reduce travel distances disease, gender, wealth, religion, and politics. including for referrals. This will include These power imbalances and injury and construction of new district hospitals in the accident prevention must be addressed cities of Lilongwe, Blantyre, Zomba, and Mzuzu through sensitization, and intolerance of such to decongest central hospitals in these districts, 53 | Malawi Health Sector Strategic Plan III 2023-2030 as well as new district hospitals in Rumphi, Preventive maintenance is key to increasing the Dowa and Chikwawa to replace the current life and functionality of medical equipment to structures. Trauma management centres along screen, diagnose and provide treatment for the main M1 road will be established to manage patients. In Malawi with the significant amount road traffic injuries and prevent avoidable of donated equipment and lack of systematic deaths. In line with the Capital Investment Plan equipment management and maintenance prioritization, construction of new community systems, there is a lack of maintenance of hospitals, health centres, health posts, equipment leading to poor functioning and non- maternity units, laboratory and radiology units, use. There must be improvement in these specialized construction at central hospitals systems to deliver timely and excellent care and staff houses will be prioritized. with the understanding that maintenance is not just the actual planned work on medical Strategy 3.2 Rehabilitation, upgrading, equipment but also quality control maintenance and equipping of measurement, ensuring functioning non- health infrastructure to meet medical/administrative equipment to facilitate service delivery needs program management and ensuring RMUs Based on the Capital Investment Plan, the have sufficient human resource capacity and activities under this strategy will include equipment to perform their function. rehabilitating and maintaining health facilities with expanding existing health infrastructure to Strategy 3.5 Strengthen transport and respond to increased demand. A focus will be referral at all levels of ensuring maintenance of all facilities to healthcare delivery system maintain high-quality services. To reduce travel The re-engineering of platforms of care with the distances to referral facility, urban health and Health Benefits Package requires referral selected health centres will be upgraded to mechanisms to be redesigned and community hospitals, and health posts to health strengthened to ensure patients optimally reach centres especially in hard-to-reach areas. All the next level of care. Without efficient referral health facilities must be provided with access to systems patients often cannot access lifesaving reliable sources of power and water for care and pay out of pocket for self-transport. functioning and expanding care delivery. Activities planned under this strategy include enhancing ambulance management and Strategy 3.3 Strengthen procurement, patient transport for effective and efficient acquisition, distribution, and services and, scaling up of the use of installation of equipment technologies for on-demand transportation, Under this strategy, activities will aim to particularly drones. This will entail that all types improve efficiency in the procurement, of transport are readily available and increased acquisition of infrastructure and medical community participation in the management of equipment in line with the integrated standards these important assets for effective referral. of care per level, the Health Benefits Package, Digitalizing transport and referral processes at and the adjusted Standard Equipment Lists in all levels of care will increase effectiveness and line with standards. There is significant need to efficiency of the referral arrangements. review procurement processes to ensure adequate user representation, streamline Strategy 3.6 Strengthen evidence-based brands of medical equipment, minimize the management of infrastructure number of service contracts, and optimize and medical equipment number and training for maintenance engineers The activities planned under this strategy and users for all equipment. Maximization of include strengthening decentralization of efficiency and timeliness of these activities are infrastructure planning, and monitoring of vital for timely care delivery and patient-centred implementation execution by district councils care. and community oversight entities. Coordination between the Directorate of Health Technical Strategy 3.4 Strengthen maintenance and Support Services, the Directorate of Planning use of equipment and Policy Development, and infrastructure 54 | Malawi Health Sector Strategic Plan III 2023-2030 units at central hospital and district council level Pillar 4: Human Resources for must be utilized to reduce diffusion of Health responsibility and duplication of investment. The objective for this pillar is “to improve the Guidelines on donation of infrastructure and medical equipment will be updated in line with availability of competent and motivated human integrated standards of care for platforms at resources for health for quality health service primary, secondary and tertiary levels, and the delivery that is effective, efficient and Health Benefits Package. Investment decisions equitable.” Delivering high-quality patient centred care, development, and sustainability will be regularly informed by evidence from surveys and digital tracking tools on status of of human resources for health is very critical in infrastructure and equipment functionality, as achieving universal health coverage. An well as efficiency studies on medical equipment examination of the disease burden, capacities procurement and utilization. required, and which cadres can perform which functions most efficiently and effectively is vital to provide the optimal platforms of care. To Reform 2: Value for money in health achieve this objective there is a critical need to technologies acquisition and utilization link performance management of all cadres and This will involve developing and levels within the health system with implementing real time equipment inventory actualization of high-quality care. The management systems and ensuring systems underpinnings of performance management for achieving efficiency and accountability in include national integrated strategic HRH acquisition of health technologies, optimal plans, skill building, reinforcing capacities and distribution and efficient utilization of talent management and competitive and fair acquired technologies. compensation. Strategy 4.1 Enhance recruitment, selection, deployment, and Reform 3: Efficiency of Gatekeeping for equitable distribution of human Centres of Excellence resources for health This reform will involve upgrading of urban HRH productivity in Malawi requires highly health centres to community hospitals, and competent, motivated personnel and equally community hospitals in the cities to full distributes human resources for health and hospitals to deliver gate-keeping primary high-quality care efficiently. Increasing care and secondary care services, production of the health workforce is one of the respectively. The goal will be to ensure these essential priorities in the health sector to deliver upgraded facilities deliver services at the the primary, secondary and tertiary platforms of level of or surpassing that currently delivered care. Employing best practices for staff at central hospitals when clients in recruitment and selection as well as immediate catchment areas of central decentralizing the recruitment to sub national hospitals by-pass their nearest health levels is essential. This requires timely facilities. By shifting primary care and the functional reviews aligned to standards of care, bulk of secondary care away from central evidence on the demand for health services hospitals, the reform will facilitate the and burden of disease, cadres who can perform establishment of centres of excellence as required services and quantification of need at financial, human, and other health systems each level of care including at the community for central hospitals are refocused to improve level. Furthermore, rationalizing and ensuring on existing and potential capacity in tertiary equitable staff deployments as aligned to services. evidence on the demand for health services is vital. Strategy 4.2 Optimize production at training institutions and strengthen coordination between the 55 | Malawi Health Sector Strategic Plan III 2023-2030 institutions and health sector and mentorship. Optimizing the health needs workforce through a fair and formalized It is imperative to ensure more effective and employment package requires clear roles and efficient use of resources with alignment to expectations, guidelines with coordinated individual and community health needs. One career pathways for growth and promotion example is pre-service production of prioritized through talent management, and retention training programs which are coordinated and strategies. meet quality standards that are in alignment Strategy 4.5 Institute and provide for with long-term HRH recruitment requirements competitive remuneration, from community to tertiary levels. This must be benefits, and working done through a holistic sector wide approach conditions for human rather individual programs or strategic plans. resources for health The Ministry of Health in collaboration with Civil Within this strategy, innovative and competitive Service Commissions and employers must remuneration and benefiting interventions will instil professional behaviour with regulatory be developed. Incentives to motivate and retain bodies enforcing accreditation standards at health workers in hard-to-reach areas will be training institutions and throughout the health designed and working conditions will be sector. improved to increase staff retention within the Strategy 4.3 Improve staff development health system. This is critical to ensure staff are strategies, policies, motivated to provide high quality care to the procedures, and practices for communities they serve. human resources for health Strategy 4.6 Generate reliable data and Building capacity through staff development to build capacity for evidence- improve human capital will increase based health workforce productivity and performance. All newly decision-making through recruited and redeployed health workers must digital innovations and be properly oriented to their role. Once placed, technological platforms for an intensified supervision/mentorship/ human resource management coaching program must be instilled for cadres Building the capacity of HR practitioners to across all levels of care as linked to the CPD conduct evidence-based decision-making is system, which in turn links to renewal of vital in health sector, including use of enterprise licensure. A harmonized CPD system must resource planning (ERP) systems, tools, and align to service delivery needs, and be inclusive technologies such as the Integrated Human of professional behaviour and client Resource Information System (iHRIS). iHRIS satisfaction, ensuring quality assurance and and Human Resources Management return on investment. Information System (HRMIS) systems must be Strategy 4.4 Strengthen and enforce integrated with expansion of digital performance management infrastructure to enable implementation of policies, procedures, and iHRIS and ensure regular data validation of all practices HRH databases. Within the health sector of Malawi there is vital need to motivate and build out passion in health care workers. Therefore, there is need to Reform 4: Performance for Results enforce performance contracting, performance This reform will focus on development and appraisals and consequence management implementation of a robust performance across the entire health sector with linking management system that is linked to performance appraisals to job description and implementation of strategic and operational work plans. Policies need to be put in place to plans at the national/district/facility levels and review existing supervision lines with enforcing all Ministry of Health employee promotions, monitoring regulation of health worker training incentives, and disciplinary systems. and practice as well as supportive supervision 56 | Malawi Health Sector Strategic Plan III 2023-2030 Reform 5: Health Workforce Optimization in HSSP III and below which also consider the 13 domains in supply chain management, using This reform will entail evaluating and re- the logistics cycle as a framework. engineering health worker cadres to reflect the changing pattern of the burden of disease Strategy 5.1 Procure sufficient medicines and numbers of patients. It will involve and commodities to deliver phasing out some cadres based on health services both within and evidence, re-orienting other existing cadres beyond the Health Benefits into new roles and introducing new ones, as Package necessary. This will entail rethinking of the As outlined under implementation cadres and competencies needed to deliver arrangements of Health Benefits Package, the defined platforms of care. This will also HSSP III will aim to align the HBP with the entail rationalizing pre-service and in-service integrated standards of care, with the MSTG to training to ensure it supports the training guide diagnosis and treatment to ensure that all requirements of this workforce optimization HBP interventions can be delivered. During reform while fully recognizing other implementation, it will be necessary to align the objectives of health training institutions that funding need for medicines required to deliver are under the education sector. the HBP with the resources available to ensure there are no stock outs within the package. In addition, procurement of commodities to deliver Reform 6: Integration of In-service the primary, secondary, and tertiary services Training outside of the HBP is necessary to ensure UHC alignment. This will focus on developing and implementing an integrated in-service Strategy 5.2 Enhance the quantification and training curriculum that is linked to a forecasting processes by coordinated Continuing Professional improving the quality of data Development (CPD) system to generate inputs used and building the efficiency savings and enhance capacity of key stakeholders to performance. It will also ensure that health collect and utilize the data workers have requisite competencies to Quantification and forecasting are critical in deliver comprehensive care. planning for timely and sufficient availability of supplies at point of care. Quantification requires robust and periodically available service Pillar 5: Medical Products and delivery and stock data to ensure all variables Technology are well considered when predicting the need for commodities especially for products that The objective of this pillar is “to improve the have a high degree of known seasonality to availability, quality, and rational utilization of improve availability during high-demand medicines and related medical supplies, periods. In addition, interoperability of data balancing among the 3 P’s: patients, products, collection and analysis systems need to be and personnel”. Care delivery platforms at all improved to ensure robustness of data for levels of care will require availability and access forecasting. to high-quality essential medications and medical supplies to provide adequate care to Strategy 5.3 Improve procurement address the changing burden of disease. practices to ensure best-value, Reforms to address shortages of essential flexible procurement medicines required to deliver care with the Inefficient procurement of health commodities prioritized Health Benefits Package are critical along with associated policies pose a major to address quality of care throughout the life challenge for cost-effective procurement with course of the HSSP III. The already developed limited financial resources. While key “Master Supply Chain Transformation Plan performance indicators for the procurement (MSCTP) 2021-2026” acts as a guiding process within the country may help to identify document for strategies and activities outlined and resolve bottlenecks, a multi-year planning 57 | Malawi Health Sector Strategic Plan III 2023-2030 for commodities informed by robust Strategy 5.6 Improve medicine quality quantification both at the national and through increased Quality subnational level is required. The value of “Buy Assurance (QA) capacity Malawi” needs to be strengthened along with including testing, auditing, and increasing flexibility to CMST for procurement licensing to reduce capital tie ups in contractual Weak policy and regulatory framework for obligations. quality assurance of medicines and medical products need to be redressed through Strategy 5.4 Improve warehousing and improved pharmacovigilance mechanisms, distribution infrastructure, while also building capacity of PMRA to carry practices, and processes to out appropriate quality control functions at all maintain product quality and levels. In addition, initiatives aiming at shelf life improving Malawi Blood Transfusion Services Plugging gaps in warehousing and supply chain (MBTS) practices to ensure blood safety in infrastructure, practices, and processes is blood transfusion centres, and all other centres critical to ensure timely and adequate utilizing blood components is needed to resolve distribution of essential medicines at all levels challenges related to poor blood practices. of care. Financing for warehousing distribution Further, diagnostic capacity will be expanded in of both essential medicines required to deliver line with the service delivery integration reform, HBP and those outside of HBP are needed to the redefined platforms of care, re-engineered be planned on an ongoing basis to ensure a human resource capacity and other service well-functioning supply chain. This would also delivery considerations of the HSSP III. require quantification, in adequate detail, the cost of warehouse and distribution from port-to- Strategy 5.7 Harmonize and expand client and identifying areas of cost efficiencies. implementation of information Policies and processes will be updated through systems to improve end-to-end revision of the SOP for warehousing, (e2e) visibility in the distribution, and reporting, as well as aligning pharmaceutical supply chain pharmaceutical waste management guidelines Improving accessibility of quality information for per the updated standards of care to minimize evidence-based decision making remains a key wastage. Potential for new technologies, such challenge in Malawi based on the situational as drone transportation, will be evaluated, and analysis. Expanding and creating an enabling where proven cost-effective and feasible, digital ecosystem at all health facilities will help implemented to ensure efficient and reliable in strengthening timely data reporting and distribution of products. robust data quality. This would include rolling out installations of OpenLMIS software and Strategy 5.5 Increase rational drug use and eHIN to all health facilities, identifying deter/prevent pilferage at all appropriate data collection tools while building levels capacity of health facilities in reporting data. Regular updates to standards of care and the Inter-operability is necessary to avoid HBP necessitate a need to review and update duplication and parallel systems while building the dispensing guidelines to support and mechanisms to build cross linkages between monitor the rational use of medicines (RUM) CMST and district pharmacy managers and and medical supplies. Pilferage is a commonly hospitals. cited challenge for medicines at all levels of care and needs to be addressed through Strategy 5.8 Improve capacity to oversee, revisiting and reinforcing the role of the Drug supervise, and coordinate Theft Investigation Unit (DTIU), while also across all supply chains and assessing the value lost due to pilferage. This stakeholders. would also mean strengthening stock Policy and oversight over medicines and management and record keeping practices at medical supplies budget, and implementation the point of care and packaging labelling to arrangement is important to understand the deter pilferage. bottlenecks and challenges faced in supply 58 | Malawi Health Sector Strategic Plan III 2023-2030 chain as well as coordination between achieve a data-driven ordering and supply stakeholders at all points of care. Creation of a chain at all levels of decision making; 2) Logistics Management Unit (LMU) will be integrating planning, coordination, considered to coordinate among parallel supply management and monitoring and evaluation chains, including vaccines, likely within HTSS, activities of the supply chain; and, 3) working under the assumption that donors will continue towards greater systems integration through to fund those systems. It is proposed to lobby CMST by 2030 for inclusion of CSO representatives on CMST board to enhance transparency and accountability during the awards of “public Pillar 6: Digital Health contracts". Clarity on responsibilities among The objective of this pillar is “to develop a Ministries of Health, Ministry of Finance, sustainable and harmonized country led digital NLGFC, CMST, and District Councils over the health system that covers all areas of service supply chain management functions of provision and enables efficient delivery of medicines and related health products is health services at all levels of the health needed to ensure effective and efficient system.” The HSSP III focuses on sustainable execution of responsibilities. and holistic development of digital health as a means of contributing to the SDG 3 goal of Strategy 5.9 Develop procedures and Universal Health Coverage. A holistic and establishment of temporary integrated approach to digital health mechanisms that adapt to development is consistent with the integrated predict, detect, and respond to platforms of care approach and people-centred emergencies focus in Chapter 8. Information generation is COVID-19 pandemic and other emergencies then a resultant, nevertheless an integral part of have disrupted supply chains across the world 79 such a digital health system. This objective while creating additional demand pressures on hence includes strategies on development of existing overburdened supply chains systems. health information systems, building a data use Building resilience based on the lessons learnt culture and HSSP III monitoring and evaluation. from the pandemic through linking supply chain efforts with the Public Health Institute of Malawi, Strategy 6.1 Improve coordination of digital building local manufacturing capabilities, health investments to increase planning for surge capacity requirement, and efficiency. adaptive transportation technologies could be This will require strengthening of leadership key for the future. Revising and implementing and governance structures for management of the Emergency Supply Chain Playbook digital health interventions and creating an processes during emergencies would be enabling environment for effective considered. implementation of digital health solutions. It will also entail assessing new digital health needs Reform 7: Supply Chain Transformation against the capabilities of existing core systems, such as the DHIS2, to avoid This reform will aim to identify and address unnecessary duplication and waste of inefficiencies at the procurement, resources. If it is deemed that new digital health warehousing, distribution, and utilization solutions are required, then they must pass the stages of the supply chain system for sustainability criterion. medicines and medical products. This will involve generating the relevant evidence, Strategy 6.2 Establish a reliable ICT and implementing the prioritized infrastructure that enables interventions including 1) harmonizing and utilization of digital health digitalizing quantification and tracking systems system for medicines and consumables to 79 Javid Moosavi, Amir M. Fathollahi-Fard, Maxim A. management strategies; International Journal of Dulebenets; 1-2, Supply chain disruption during the Disaster Risk Reduction; 2022, COVID-19 pandemic: Recognizing potential disruption https://doi.org/10.1016/j.ijdrr.2022.102983 59 | Malawi Health Sector Strategic Plan III 2023-2030 ICT infrastructure and energy development implementation of disaster recovery standard needs of health facilities and health sector operating procedures. establishments will be drawn from an integrated Strategy 6.6 Promote continuity of care health sector capital investment plan (CIP). through the shared health This CIP will also define requirements for ICT record devices such as computers, tablets, printers, The MOH will lead efforts to ensure that and mobile phones that are required at all levels longitudinal and cross-sectional patient health of the health system. records are accessible at the point of service Strategy 6.3 Build the capacity of clients, delivery. The key activity will be to implement a communities, health care comprehensive and integrated, user centred workers, and IT personnel to and secure Electronic Health Record (EHR) participate in and benefit from system. In addition, the MOH will strengthen the digital health interventions identification of clients and staff across the To attain the full benefit of digital health, it is health system. critical to increase the capacity of the health workforce to utilize digital health interventions. This will be achieved through innovative and Reform 8: Fully decentralized and cost-effective knowledge sharing mechanisms digitalized HMIS for each Decision- that would include regular integrated Making Unit supervision, on-job coaching, and mentorship. This reform, leveraging on present and future For clients and communities, awareness raising investments in digital health, will aim to activities will be implemented to achieve deliver fully decentralized yet optimally acceptability and build their capacity and integrated, fit for purpose, HMISs at the confidence in the use of digital health community, health facility, district, central interventions. hospital, HSSP III objective, and national Strategy 6.4 Leverage technology to levels. This will be based on fast-tracked increase access to and quality delivery of user-driven Electronic Health of service delivery Record (EHR) and decision-making needs of The HSSP III aims to use innovative digital decision-making units at national, health health technologies to increase access and facility, districts, and community levels. quality of health care. This will be done through Through deployment and interoperability, a increasing coverage of existing digital health shared EHR across levels of care will allow solutions and leveraging the use of predictive for patient-level data to inform progress, in analytics and big data. All these digital health real-time, of service delivery. With each interventions must, however, be aligned with facility treated as an entity that has common the comprehensive digital health architecture as well as unique decision-making and and to the platforms of care within service information. Combined with resource use delivery. and other data, each decision-making unit will then have a custom, but integrated HMIS Strategy 6.5 Improve security of information as detailed in Chapter 8. and ICT systems This will entail the development and deployment of standardized security management processes in order to promote Pillar 7: Research acceptable use of data and related tools and The objective for this pillar is “to promote and ensure that digital health information and users coordinate the conduct of health research in are protected from threats of any kind, order to generate high quality evidence malwares, breach of privacy, and misuse of required to inform the development of health information. Ethics in digital health delivery will and health care delivery” Research and its be strengthened to promote privacy and evaluations will build the evidence base to security of clients’ data. The MOH will also choose standards and platforms to achieve a conduct a risk analysis and enforce high functioning health system with ability to 60 | Malawi Health Sector Strategic Plan III 2023-2030 make decisions for maximizing population external funds to priority health research health. institutions and local think-tanks. Strategy 7.4 Strengthen the sharing and Strategy 7.1 To build health research accessibility of data across capacity in public, private, systems to enable use. research and academic The MOH will lead efforts to ensure that institutions longitudinal and cross-sectional patient health Health research leadership, management and records are accessible at the point of service governance are critical to achieve this strategy. delivery. The key activity will be to implement a This will entail strengthening relevant research comprehensive and integrated, user centred ethics committees (RECs), strengthening and secure Electronic Health Record (EHR) adherence to National Health Sciences system. In addition, the MOH will enforce Research Committee (NHSRC), Standard linkage of EHR, HMIS and the National Operating Procedures (SOPs), enforcing Registration and Identification System (NRIS) ethical standards on the conduct of health primarily through requiring that every Malawian research and developing legislation and policy present their national ID or birth registration as on Intellectual Property rights. a requirement to access publicly funded Strategy 7.2 To achieve the development of healthcare. evidence-based policies in Strategy 7.5 Effectively monitor and health through intensification evaluate HSSP III of knowledge generation, implementation translation, and utilization of To effectively monitor the HSSP III, its research performance indicators and logical framework The HSSP III will strengthen coordination of must be integrated into health information health research knowledge generation, systems. Then all stakeholders including research knowledge translation and knowledge private health facilities must align and adhere to sharing. Knowledge generation should include the HSSP III reporting requirements. Parallel analysis of routinely collected and survey data, data validation processes by MOH departments compilation, and analysis of disease & events and partners must be integrated, and routine surveillance data to support detection of data collection and reporting tools and systems outbreaks and implementation of International must be rationalized and harmonized. Systems Health Regulations (IHR). Research for generating impact data such as national civil transparency and accessibility of evidence registration, the generation of vital statistics and generated from clinical trials and national health-related surveys must be implementation science should be strengthened and aligned to key HSSP III strengthened through mechanisms such as an evaluation cycles. open research repository and translation from implementation. Pillar 8: Leadership and Strategy 7.3 To ensure that portals for Governance research funding are accessed The objective of this pillar is “to enhance and that there are adequate effectiveness of leadership and governance at funds to finance health all levels of the health sector.” Leadership research in Malawi development and governance are at the centre The HSSP III will aim to build capacity to write of production of high-quality care and health research grant proposals and market achievement of UHC in Malawi. Political and them to prospective funders. This will help individual level commitment to change through make research self-sustaining and build supportive behavioural architecture following research careers thereby positioning the health real-time data and health outcomes is required. sector to provide local solutions to health care Commitment to continuous learning and quest challenges. A key intervention to stimulating of for highest quality health systems within the this local capacity building will be deliberate resources available. For leadership and efforts by Government to channel domestic and governance to work there is need to reinforce 61 | Malawi Health Sector Strategic Plan III 2023-2030 the compliance with policies, laws, and engagement fostering through a holistic regulations, strengthen the role of coordination integrated approach. with the private sector and other key Strategy 8.3 Enhance financial stakeholders in the health sector, and management to strengthen strengthen management of decentralized accountability of funds health systems by district leaders. Despite adverse macro-fiscal conditions, Strategy 8.1 Develop and implement a “One fiduciary concerns, and donors shifting funding Plan, One Budget and One toward vertical disease program, there has M&E” system in order to been significant improvements in health service strengthen alignment and delivery over the past two decades in Malawi. harmonization of donor and Government financial management processes government funds towards require ex-ante commitment control, with all health sector priorities spending routed through the financial The integration and coordination of the “One management information system checked for Plan, One Budget, One M&E” system is critical appropriations and available budget. To to the success of the HSSP III, and incremental enhance the accountability and financial steps need to be made for efficiency, efficacy prudence there must be routine audits to and improved health outcomes with strengthen accountability and transparency of institutionalizing accountability to citizens and Government funds and routine financial users. Annual HSSP III Operational Plans must management activities including the processing be prioritized to consolidate selected activities of salaries. from Government and partners (from the national, central hospital, and district levels), Strategy 8.4 Improve governance, including and enforce alignment and harmonization of stakeholder oversight, coordination, and Government and donor funding annually in line implementation at all levels of with the principles of aid effectiveness and the health service delivery development cooperation. Health sector MOUs system must be to align to the HSSP III with transparent The Ministry of Health provides the oversight tools for monitoring and evaluating adherence. leadership and coordination to ensure that the Conducting Joint Annual Reviews, zonal health sector achieves its stated goals and reviews, and district reviews as an integrated objectives through its programs and system with a common set of integrated institutions. The local Government ensures that indicators (e.g., tracking progress on DIP the coordination, accountability, implementation and the National Health implementation, and management of health Indicators Handbook) is vital to monitor annual activities at a decentralized level in order to HSSP III implementation. improve service delivery and coverage of health Strategy 8.2 Strengthen policies, services, improved quality, and cost guidelines, and frameworks effectiveness. To effectively work together including at the multi-sectoral there must be enhancement of sector-wide level governance structures with strengthening of Regularly updating legal frameworks, roles and oversight communities from leadership to responsibilities regarding all health services community levels. and community health programs is crucial. Following updates, compliance to these must Reform 9: “One Plan, One Budget and be reinforced amongst all stakeholders. It is One M&E” necessary to ensure that other national sectoral HSSP III will enforce implementation of “One plans that are closely linked to health, including Plan, One Budget and One M&E” at the education, agriculture, gender, and WASH national, tertiary and district levels in order to integrate social determinants of health during strengthen alignment and harmonization of planning and implementation. These plans at a donor and Government funds. Under this policy level must be developed from reform, health systems development will implementation and incorporate community domicile into the HSSP III alone, with a 62 | Malawi Health Sector Strategic Plan III 2023-2030 maximum of one sub-strategy per HSSP III For the health benefit package, at the very pillar; Exceptions will require endorsement of minimum, the WHO recommended investing up the Health Sector Working Group. to USD86 per capita per year. Malawi’s total Consequently, all programme and technical health expenditure has been stuck department functions will be planned in an approximately USD40 per capita per year over integrated manner through operational plans the past decade. This means that significant with joint prioritization of activities. Joint efforts will be required to achieve the UHC goal planning is critical for systems-wide resource of this strategy. Further, the evidence that allocation and integrated health care Malawi has a far more superior UHC index delivery. compared to countries with the same level of health financing and outperforms a large number of countries with higher per capita Reform 10: Community-led PFM national incomes suggests current organization Oversight of the health system remains overall efficient, although evidence suggests scope for more This reform will re-orient community efficiency gains exists. The MOH will therefore oversight by establishing effective principle- undertake and fast-track implementation of agent arrangements between communities revenue mobilization activities across domestic as owners of the health system on the one and donor pools, as well as efficiency reforms hand, and providers at tertiary, secondary across all the pillars of this strategic plan. and primary healthcare levels. It will entail To mobilize more domestic revenue for health, establishing robust evidence on scalable and the MOH and stakeholders will enhance sustainable cost-effective community advocacy for increased and sustained oversight arrangements including the Government allocations from approximately organizational and capacity building options 10% currently to the Abuja target of 15% of total to get the best possible health Government budget as a demonstration of decentralization, fiscal and service delivery Government’s commitment to UHC. Within the results. health sector, paying services will be optimally developed and scaled at all levels of the health systems to tap from health financing currently Pillar 9: Health Financing spent as out-of-pocket and private health The objective of this pillar is “to set a well- insurance. Consequently, the MOH will governed health financing architecture that is facilitate development of optional paying able to mobilize adequate resources, distribute services at tertiary, secondary and qualifying the resources in an efficient and equitable way, urban health centres, to allow providers to and strategically purchase services based on a deliver services complementary to the HBP with well-defined benefit package in pursuit of UHC additional personal or insurance-based goals.” The first three strategies under this payment. Additional revenue will come from objective aim to improve the performance of imposing fees on food handler certification, each of the four health financing functions of provision of fumigation services, and revenue mobilization, risk pooling, resource contracting with employers to provide medical allocation, and provider payment, while the fitness certification. fourth strategy will aim to build institutional Additionally, MOH will promote, regulate, capacity for the health financing function. The following activities will be implemented under and scale up community-based resource each strategy. mobilization and management arrangements. This HSSP III aims to devolve Strategy 9.1 Mobilize adequate, some of the revenue mobilization sustainable, and predictable responsibilities to the clients of the health funds for the health sector to system. There will be establishment of optimally deliver essential community health funds based on individual health services contributions and corporate contributions to a 63 | Malawi Health Sector Strategic Plan III 2023-2030 community managed account. The specific enhancing reforms to create efficiency savings form of these community funds will differentiate with which to expand access and quality of based on community specific socioeconomic care. This will be achieved notably through the profiling with complete community ownership of provider management reforms highlighted later their local health funds. At the national level, the in this chapter, and through efficiency Direct Facility Financing scheme under the enhancing reforms and systems strengthening Health Services Joint Fund as well as all initiatives across the pillars of this HSSP III. results-based financing scheme will be These provider level efficiency reforms will designed to catalyse community ownership of cover domestic and international sources of these locally mobilized resources. health financing. For the HSSP III period, donor financing will Strategy 9.2 Improve efficiency and equity remain a critical source of health financing in in pooling and management of Malawi. Maintaining donor expenditures on resources for the health sector health even at pre-COVID-19 levels will require In line with the decentralization policy, MOH will significant institutional changes in the MOH, coordinate with MoF, NLGFC, Malawi Local particularly moving towards a more proactive Government Association and other relevant mobilization of international funds as well as entities in capacitating district councils and commitment to efficiency through increasing central hospital boards to manage public funds disbursements rates, ensuring high utilization meant for service delivery. The implication of rates, and guaranteeing value for money. The this is that district councils and central hospital major focus will be to develop the capacity of boards will be responsible for budgets on the district health system to manage donor operations, staffing, medicines, and funds, empowering communities to proactively infrastructure development, rehabilitation, and provide oversight of health funds; and replacement for primary health facilities. For strengthening the evidence base locally for donor funding, fund holding arrangements will responsive health economics and financing be based on balancing the accountability needs assessments. of the funding source, and the One plan, One budget and One M&E reform outlined in the Also, private health insurance will be implementation arrangements chapter. The encouraged, 1) as a source of financing for pooling arrangements for donor funds will aim optional cover for taxpayers who may opt out of to increase coordination of Government and public healthcare consumption leaving the donor financing to ensure focus on health limited tax and donor funding to cover those HSSP III priorities through efficient coordination living in poverty; and 2) to provide additional in planning and implementation. MOH will work health cost coverage for services not in the with relevant Government entities to strengthen HBP. The MOH will strengthen the regulatory PFM so that in future most donor financing can framework for private insurance, such through be channelled directly to primary level. the development of relevant legislation, establish a health insurance regulatory body, The Health Services Joint Fund (HSJF), a and develop inspectorate capacity within this multi-donor fund established in 2015 to provide new body. a shared funding mechanism for Malawi’s health sector donors, will be strengthened In the programming of the HSSP III, it is through increased management capacity, recognized that the domestic economy and increasing the funding levels, and attracting international aid may not grow at the pace more donors. Over the HSSP III period, the goal enough to generate the funds with which to of the fund will be to catalyse direct district and break the USD86 per capita barrier by 2039. central hospital budget support as well as direct Consequently, using observed trends in health budget transfers to service providers. Further expenditure for the past two decades, a target enhancements will include increased joint of USD50 by 2030 remains the most feasible planning, execution, and evaluation ambition. To mitigate against this serious fiscal arrangements with top ten discrete funding space constraints, the MOH and stakeholders pools including the Global Fund to Fight will fast track implementation of efficiency 64 | Malawi Health Sector Strategic Plan III 2023-2030 Tuberculosis, HIV/AIDS, and Malaria; GAVI, Within the health sector, at the national level, a the Vaccine Alliance; US Government agencies three-stage resource allocation process will be and the World Bank. followed. First, the total budget from Government and donor pools will be MOH will also support and provide a conducive established through aggregate resource environment for Government-to-Government mapping ahead of the annual budget Financing Arrangements as efficient preparation process. The second stage will mechanisms for transfers from a foreign involve allocating the budget across national, Government agency to a Malawi Government tertiary, and district levels. For tertiary hospitals, entity, thereby cutting unnecessary allocations will be based on the designated administrative costs that diminish resources mandate, planned output and predetermined made available to providers. The resources will performance measures. The third stage will be planned, executed, and evaluated using the involve resource allocation to departments at principles of a decentralized budget, where the tertiary level; and across service delivery at resources will be allocated to and executed at the district level. To preserve the value of the the level where implementation of the funded health sector budget and guarantee the activities take place. maintenance of volume and quality of services, For partners not able to join the HSJF and who budgets for service providers at each level will can implement the Government-to-Government be increased each year by not less than 10% of arrangement, the principle of One plan, One the total health sector budget in the previous budget and One M&E Plan shall apply. Donors year. will be required to provide funding to activities As the projected annual per capita that are prioritized in the District Implementation expenditures fall far short of the minimum Plan or the HSSP III. In all cases, for non- required to deliver an optimally designed Government funds, MoUs and associated HBP, health benefits rationing mechanisms codes of conduct will be enforced to ensuring and criteria for accessing entitled services that partners that have not pooled their funding will be regularly reviewed and strengthened. are aligned to the “One Plan, One Budget, One Several key principles will inform access to care M&E” philosophy. in public health facilities: 1) feasibility of Strategy 9.3 Develop and implement enforcing the HBP, 2) use of national strategic purchasing measures identification cards for service provision, and 3) across the healthcare service a unified beneficiary registry to determine which delivery continuum individuals are exempt from initial and Interventions under this strategy will strengthen additional pre-payments when accessing care. resource allocation arrangements at national, Table 2 shows the population groups and their tertiary hospital, district council levels, to entitlements under this HSSP III achieve allocative efficiency and equity in the Table 2: Populations groups and their entitlements distribution of healthcare financing, thereby achieving the health service delivery and Population Entitlement ultimate goals of the HSSP III. At the health Group sector level, resource allocation processes will Identified Clients identified as poor and apply to Government and donor funds. For Poor and vulnerable groups will qualify for Government health budget, MOH will agree Vulnerable free services, accessing the HBP Groups free of charge at public health with Treasury to reach the 15% Abuja target by facilities. The identification of 202680. For donor budgets, the MOU with each these clients will be based on donor shall establish aggregate forecasting producing a national ID and commitments, including any earmarking, in the evidence from the Unified next three years through the resource mapping Beneficiary Registry. process. Formal Malawian formal sector Sector employees without any health 80 United Nations. (2016). Abuja Declaration – Outcome Document of the Habitat III Africa Regional Meeting 65 | Malawi Health Sector Strategic Plan III 2023-2030 Population Entitlement For the HSSP III, the following fund holding Group arrangements shall be introduced or Employees insurance will access the HBP strengthened. The general principle of without free of charge at public facilities fundholding arrangements under the strategic health since they have already made plan is that health funds should be allocated to insurance their contributions through PAYE. and devolved into the service delivery level cover Catchment populations whose only service provider is a responsible, and directly accountable for Government contracted faith- implementation success and failure. based provider shall be exempt While there has been progress in fiscal from paying the user fees on decentralization, gaps remain across key areas services covered in the HBP. Access to Government and CHAM namely: Procurement of biomedical facilities by this group will require equipment; Maintenance of biomedical production of a combination of equipment; Construction, expansion, and national ID, employer ID and rehabilitation of health facilities; Supply chain Taxpayer Identification Number to management of drugs; and Recruitment and identify the user. deployment of health personnel. MOH will work Formal The solidarity principal is based with relevant Ministries and departments to Sector on risk pooling of the poor and facilitate full decentralization of these budget Employees non-poor, sick and health and lines, away from MOH and National Local on Private young and older. The pooled Government Finance Committee (NLGFC) to Health funds will allow for a health benefit Insurance package consistent with the total central hospitals and district councils. At district Scheme pooled revenue. All formal sector councils, MOH will facilitate further employees on medical insurance decentralization of the health financing to health schemes will only use health facilities including establishing and sustaining services in the public sector on stronger accountability and oversight structures production of a health insurance and mechanisms at each fundholding level ID. For the insured services, including health facilities. providers shall claim from the insurance companies. For non- MOH will ensure a unified disbursement and covered services, free access will fundholding arrangement for all donor initiatives be confined to the services in the that transfer funds directly to District Council, HBP. including a performance monitoring framework Non-Poor To use a Government or to ensure only cost-effective result-oriented Informal contracted faith-based service initiatives are scaled up and sustained. During Sector provider, the non-poor in the informal sector will be required to MOH will develop legal instruments for sound contribute to the cost of care public financial management at the facility level through an insurance scheme or including a performance framework for pay the full cost of care at the measuring PFM progress of each facility in real- point of access. These will require time and proactively implementing responsive production of a national ID. capacity building programmes. After five years, Non- All non-nationals with residency the DFF will be promoted as a mechanism nationals status for six months or more will through which health sector funds across access public or contracted Government and donor pools will be disbursed facilities on production of 1) to service providers. residence permit, 2) insurance cover, or 3) proof of exemption Strategy 9.4 Establish and strengthen (for example, PAYE certification). institutional arrangements and Non-residents and those staying systems for effective health less than six months will require financing at all levels of the comprehensive health insurance cover to access health services in health system the public sector. The health financing interventions for the HSSP III assume a very proactive rather than passive resource mobilization drive that had 66 | Malawi Health Sector Strategic Plan III 2023-2030 characterized previous HSSPs. Toward this, Health Sciences Health Economics and Policy MOH and stakeholders will sustain capacity Unit, the Health Economics, Policy, and Ethics strengthening of the Health Financing Division Thinktank, and the Annual Health Financing (HFD). This will focus on the HFD’s capacity to Summit. These health financing coordination coordinate, implement and monitor the HFS. It efforts will be anchored in a sound health will also be responsible for increasing its financing management information delivered as capacity to coordinate health financing and a module in the re-engineered Health planning capacity development at the building Management Information Systems outlined in block level, central hospital, district council, and Chapter 8. district level service provider level. The HFD will also enhance collaboration Reform 10: Expanding domestic mechanisms between key Ministries, resources and robust provider payment Departments and Agencies (MDAs) for arrangements effective implementation of the health financing This will involve introduction of contributions building block. These will include Ministry of from non-poor informal sector and Finance (MoF), Ministry of Local Government concurrent enforcement of the use of (MoLG), National Local Government Finance appropriate identification in order to identify Committee (NLGFC), and the National Audit those eligible for user fee exemptions. A Office (NAO). It will further involve establishing strategic purchasing reform will be new institutions such as a Health Technology introduced and will focus on the creation of Assessment, Private Public Partnerships, a robust resource allocation frameworks and health insurance regulation, etc., that are processes, and implementation of determined relevant for sound functioning of the intelligence-based provider payment health financing building block. This capacity mechanisms to better align resource will be supported through continued investment allocation, budget execution and the Health in evidence, particularly in health economics Benefit Package. and financing analysis capacity, coordinated through the joint MOH-Kamuzu University of 67 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Medication and supplies. Chapter 6: HSSP III Costing and Prioritization This chapter summarizes the costing and next eight years, in alignment with “One Plan, prioritization results for interventions in the One Budget, One Report.” Costing and HSSP III. Through this process, the costs to prioritization processes are covered in greater deliver the full set of HSSP III interventions from detail in Annex 4 available in digital edition on FY 2023/2024 to FY 2030/2031 were MOH website. estimated. Next, these costs were compared The total cost of implementing the intervention against the projected financial resources matrix for all the eight years is estimated at available in the health sector, and then US$31.2 billion (MWK 32 trillion) representing iteratively prioritized downwards through a the full resource need before the prioritization consultative process between Government and process. The cost per capita in the first year is health sector donors to ensure that the HSSP $78.7, and $172.12 on average over the eight III fits within the available resource envelope. years of HSSP III. Figure 14 shows detailed This prioritization is essential to direct limited HSSP III costs by each objective. financial resources towards strategic reform areas and priorities of the health sector for the 68 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 14: Financial Resource Need by Objective of HSSP III USD MILLIONS Service Delivery Social Determinants of Health 7,000 Infrastructure and Medical Equipment Human Resources for Health Medical Products Measurement, Monitoring, Evaluation and Research Leadership And Governance Health Financing 53 6,000 Research 45 2001 5,000 39 1647 4,000 36 1407 626 40 3,000 1126 2085 39 1703 32 927 1506 2,000 2467 782 1082 30 848 653 555 1,000 1993 219 1575 1746 1371 1016 1123 715 836 0 15 18 21 21 23 29 31 41 FY FY FY FY FY FY FY FY 2023/24 2024/25 2025/26 2026/27 2027/28 2028/29 2029/30 2030/31 Next, a realistic estimate of resources available • Medicines, commodities, and supply for allocation to health sector priorities were chain costs for an access-constrained, identified using the MOH’s Resource Mapping realistic Health Benefits Package Round 7 data. Fungible resources (assumed to scenario be available for re-allocation by the budget • Upgrading of health centres to be holder to priorities in HSSP III) were estimated community hospitals, for decongesting at $537.1 million for FY 2024/2025 out of a total central hospitals in urban areas of $689.8 million health sector funding per • Rehabilitation of central hospitals as Resource Mapping Round 7 for FY 2019/20; per the Capital Investment Plan this excludes non-fungible resources such as • Prioritized equipment from the the government’s current operational budgets Standard Equipment List to deliver the and payroll, as well as donor program Health Benefits Package at all levels of management and administrative costs. care Through multiple consultative stakeholder • A proportion of unfunded discussions, the HSSP III was prioritized for the administration costs of central implementation year of FY 2024/2025 in order hospitals and District Health Offices to fit within the existing resource envelope and • A proportion of health workforce pre- therefore more effectively enable resource service education and salaries for both allocation through the “One Plan, One Budget, facility- and community-based cadres, One Report” approach. Overall, the total as described further in section 6.2 resource need of $4.0 billion in FY 2024/2025 below was highly prioritized downwards to match the • A proportion of other prioritized resource envelope of $537.1 million. activities from the HSSP III intervention matrix, as prioritized by stakeholders These prioritized areas of investment include: during the consultative workshops • The eleven "game-changer" reforms in the HS SP III 69 | Malawi Health Sector Strategic Plan III 2023-2030 Table 3: Overview of prioritized areas within the HSSP III Description of Prioritized Area Resource Allocation Eleven “game-changer” reform activities $41,624,147 Drugs and commodities + 20% supply chain costs for a realistic, access- $400,055,821 constrained Health Benefits Package Capital Investment - Upgrade Health Centres to Community Hospitals from Capital $8,381,421 Investment Plan Capital Investment – Rehabilitation of Central Hospitals from Capital Investment $7,640,047 Plan Prioritized equipment costs from the Standard Equipment List in order to deliver the $6,626,768 Health Benefits Package at all levels of care Health Workforce – absorb existing graduates from training institutions; train, $59,652,839 recruit, and equip HSAs and SHSAs to meet National Community Health Strategy targets of 1 HSA to 1000 population; pre-service education and salaries for Community Midwifery Assistants; a proportion of costs to provide high-quality pre- service education 11% of unfunded admin costs at DHOs and central hospitals, as estimated from $498,485 the HSSP II Operational Plan 10% of other prioritized activities from the HSSP III intervention Matrix (activities $12,566,688 whose prioritization score is >=150% of the expected average score) Total Fungible Resources Prioritized $537,046,215 MOH Personal Emolument budget and other administrative overheads (estimated from RM 7, FY 2019/20) - considered non-fungible but available to overall health $60,10,0000 sector Donor budgets including program staff salaries, and administrative overheads (estimated from RM 7, FY 2019/20) - considered non-fungible but available to $92,741,959 overall health sector Total Health Sector Resources (estimated from RM7, FY 2019/20) $689,820,411 One limitation of the prioritization process is that it was primarily based on consultative

6.1 HBP Cost and discussions amongst health stakeholders as Prioritization Malawi does not currently have robust data on The Health Benefit Package (HBP) provides the relative cost-effectiveness of different cost of medicines and medical supplies health systems pillars compared to one required to deliver the prioritized interventions another, i.e., whether health workforce, in Annex 3: HBP data available in digital edition governance, or supply chain are relatively more on MOH website. To calculate the number of cost-effective investments compared to one visits for each HBP intervention, we utilized the other, and what the optimal mix of these health product of i) target population taken from the systems inputs would be. In addition, fungible Malawi Census81 for the specific year, ii) resource estimates are based on historical population in need (PIN) of the intervention budget data from the MOH Resource Mapping from available literature, program targets and exercise; the actual available resources that prevalence and/or incidence data iii) demand can be re-allocated to HSSP III priorities may constraint from available literature, DHS/MICS vary and will depend on self-reported estimates surveys for the proportion of patients seeking obtained from donors for each year of HSSP III care for the intervention and iv) access implementation. constraint which was required due to limited funding. Access constraints were not added for non-fungible donor interventions, as this funding is tagged to specific interventions with 81 National Statistical Office. Population and Housing Report – 2018. Zomba, 2019. 70 | Malawi Health Sector Strategic Plan III 2023-2030 full funding of drugs and consumables. (CMST) cost list and supplemented from MOH However, interventions for which drugs and recent procurements and the UNICEF drug cost commodities are funded with GoM budgets and database. The total cost of the drugs and fungible donor funding (assumed) required consumables was multiplied by the total access constraints to fit within the budget from number of visits for each intervention and Resource Mapping round 7 data. This means summed across all interventions for the total that only a proportion of the total calculated cost. amount of drugs and consumables can be With the addition of the access constraint, afforded and provided. The access constraint about 80% of the expected visits will be covered restricts drugs and consumable purchasing with just 28% of fungible and GoM funded from 46% to 65% of the total need with activities. Currently, costs for the 81 prioritization done depending on maximising interventions utilizing drugs and consumables patient DALYs averted or MCDA score (Table meet the annual resource allocation for drugs 4) and consumables by the GoM and donors in Medicines and medical supplies were mapped 2022 (Table 5). However, in the immediate and quantified per patient for each intervention. future, there is a need for alignment of the Costs for medicines and medical supplies were budget to increase access for GoM and fungible taken from the Central Medical Stores Trust donor funded interventions. Table 4: Criteria for Access Constraint of HBP Interventions Access Number of interventions DALY criteria MCDA criteria Constraint* (total 115) (out of a total score of 3) 46% 30 <30,000 <2.4 58% 17 >10,000 to <100,000 2.4-2.89 65%^ 23 >100,000 >2.8 100% 45 Donor funding Donor funding * The proportion of the total drugs and consumables that can be purchased for the interventions due to resource envelope ^Additions of vaginal delivery, Caesarean section delivery and newborn sepsis despite not fitting in developed criteria Table 5: HBP Cost per type of funding in relation to the Drug and Consumable Budget from 2021 Resource Mapping Type of funding Cost of activities within the type As a percentage of drug and of funding ($USD) consumable budget from Resource Mapping R7 (FY 2019/20) Non-fungible donor-funded 173.6 million 101% activities Fungible donor and Government 117.1 million 99% of Malawi activities Total cost 290.7 million 101% costs within the available resource

6.2 Prioritization of Health envelope Workforce Costs For the HSSP III, as a part of the consultative This section provides a deep dive on the process between Government and health prioritized package of health workforce sector donors to ensure that the HSSP III fits investments, which was rigorously modelled within the available resource envelope, a and prioritized as they represent one of the workforce target-setting model was run for largest cost drivers of the HSSP III. several scenarios of varying levels of service coverage and quality, to determine the Step 1: Iterative revisions of service delivery associated optimal health workforce targets. targets, and their corresponding health Targets were then fed into a pre-service workforce targets, to fit health workforce pipeline model and intervention planning tool to 71 | Malawi Health Sector Strategic Plan III 2023-2030 determine the associated pre-service education cost of this prioritized intervention for costs. Through continuous iterations between FY2024/2025. government and donors, the health workforce Next, maintaining baseline pre-service targets were gradually scaled down until the education enrolment in FY2024/2025 was associated salary and pre-service costs prioritized and fully funded at $6.7M. As required to meet the targets fit into the realistic operating costs of training institutions and resource envelope projections for the Malawi salaries of current faculty are covered by the health sector. This envelope was determined to Ministry of Education, this only included be $59.7 million for the health workforce in scholarship costs. Scholarships included FY2024/2025. FY2024/2025 enrolment and all students The following section describes how this currently in the pipeline regardless of their amount was prioritized across various health starting year,83,84 as the next best value-for- workforce interventions. A detailed description money is to complete the pipeline for students of the data sources, approach, and results for who are partway through their education and each scenario that was run in the model are have already had costs invested in their pre- summarized in Annex 4 available in digital service education. edition on MOH website and detailed in the Then, HSA and SHSA scale-up to their accompanying document titled “Detailed Annex respective targets (1 HSA to 1000 population, for the Health Workforce Interventions of the and 1 SHSA to 10 HSAs) was fully funded, as a Malawi Health Sector Strategic Plan (HSSP III) strong community health workforce will not only for 2023-2030”. strengthen equitable access to care, but also Step 2: Prioritizing health workforce increase service provision of primary care. interventions for the access-constrained, Given the significant resource constraints for status quo quality FY2024/2025 package the HSSP III, investments in the community health workforce also tend to be cost-effective The $59.7 million for health workforce relative to cadres at higher levels of the health interventions in FY2024/2025 was prioritized system. Salaries, pre-service education, and with a focus on value-for-money and supplies for HSAs were costed at a total of strengthening the community health workforce. $15.8M for FY2024/2025. First, absorption of graduates from pre-service CMAs were also prioritized as a critical training programs in FY2024/2025 was fully community health workforce cadre that funded, as it is poor value-for-money to not increase access to care and service provision absorb trainees that have already had pre- of primary care. The HSSP III prioritizes an service capacity and scholarship costs invested intervention package of $15.6M in CMAs in in them.82 The projected number of graduates FY2024/2025, including salaries for the in FY2024/2025 was distributed across districts FY2024/2025 CMA graduating class, proportional to the service delivery need, and scholarships for all CMA trainees enrolled at then multiplied by the inflated average gross baseline in FY2024/2025, and selected annual pay for each cadre to arrive at the $5.4M 82 Included in this calculation were FY2024/2025 were costed, but not students who enrolled in a two-year graduates of generalist cadres and paediatric specialist program in FY2022/2023 as those students will have cadres. Due to a lack of available, quality data at the graduated. 84 time of publication, the calculation excludes other FY2024/25 enrolment was assumed to be an average specialist cadres and the unabsorbed trainees currently of enrolment in all years that the program has been in the labor market. Community-based cadres were operational since 2012. Students currently in the excluded as those costs are addressed separately. No pipeline are extrapolated from a combination of FY 2023/2024 graduates were included, as assumptions available data and in recent years where data is not yet around the absorption rate are difficult to determine available, the average of previous years as described amidst insufficient clarity around availability of funding above. Included in this calculation were FY2024/25 for salaries in that year. The calculation also assumed graduates of generalist cadres and paediatric specialist optimal licensing exam schedules and recruitment drive cadres. However, due to a lack of available, quality data timing that would enable recent graduates to enter the at the time of publication, the calculation excludes other workforce in the same fiscal year that they graduated in. specialist cadres and the unabsorbed trainees currently 83 For example, all students enrolled in a three-year in the labor market. Community-based cadres were program that started in FY2022/2023 and FY2023/24 excluded as those costs are addressed separately. 72 | Malawi Health Sector Strategic Plan III 2023-2030 investments to improve the quality of education constrained Health Benefits Package at for CMAs at baseline enrolment. status-quo quality of care. The capacity of Malawi’ health system to provide even the Finally, the remaining $16.1M was allocated most basic of services will be greatly towards improving the quality of pre-service reduced, even at status quo levels of quality training at baseline enrolment. The domain with of care. Improving quality of care of Malawi the most direct link to quality of education is will require substantial increases in faculty, as training institutions have indicated investment in the health workforce. that infrastructure and equipment can be reconfigured to accommodate more students. As there is an over $400M gap between the The full faculty training and salary costs to allocation for health workforce interventions in reach the ideal student: faculty ratios for FY2024/2025 and what was needed to staff and baseline enrolment were therefore prioritized deliver the targets in even the most highly for the intervention package. Additionally, prioritized, access-constrained Health Benefits selected infrastructure and skills lab equipment Package scenario, there are no funds needs were also included, though given prioritized to scale-up pre-service training, as resource constraints, these are only a subset of even provision of a high-quality education at the full suite of infrastructure and equipment baseline levels of enrolment is not possible. investments needed to ensure high-quality pre- Even if all health workforce trainees are service education. These costs were also consistently and completely absorbed into the allocated across the various training programs public health workforce each year until 2030, for each health workforce cadre proportional to maintaining baseline enrolment is projected to their need. result in staffing levels in 2030 that are still 20% below what is needed to provide care for the Despite a proposed $60M additional most highly prioritized, access-constrained investment in health workforce in scenario of the Health Benefits Package with FY2024/2025, staffing levels in 2030 will still status-quo quality of care. Gaps by cadre vary be insufficient to deliver even the most and can be seen below: highly prioritized scenario: an access- Table 6: Projected workforce and workforce gaps in 2030, if the prioritized health workforce investment package is funded as proposed Cadre Projected workforce Workforce needed in Projected Projecte in 2030 after 2030 to provide access- Gap in d Gap in prioritized, resource constrained Health 2030 (#) 2030 (%) constrained HSSP III Benefits Package at investments * status quo quality of care Medical Officer / Specialist 831 1817 986 54% Clinical Officer / Technician 2710 2710 0 0% Nursing/Midwifery Officer 3302 3302 0 0% Nursing/Midwifery 9318 11212 1894 17% Technician Pharmacist 190 131 0 0% Pharmacy Technician 272 783 511 65% Pharmacy Assistant 698 698 0 0% Lab Officer 496 1144 648 57% Lab Technician 743 1298 555 43% Lab Assistant 238 238 0 0% *Projected workforce if baseline is maintained and absorbed, or for cadres producing beyond their target, if enrolment is scaled down to target and absorbed If patterns of historic resource availability for meaningful, system-wide improvement in health workforce interventions continue, it will quality of care. A first step is to align the existing greatly hamper Malawi’s ability to achieve resource envelope towards the prioritized 73 | Malawi Health Sector Strategic Plan III 2023-2030 health workforce interventions in the HSSP III, improvement in Malawi to become a reality. The per the “One Plan, One Budget, One Report” financing and resource mobilization sections approach. Additionally, substantial increases in can be referred to for possible solutions to investment in health workforce – from both increase health sector funding to address these government and donors – will be required for gaps. expansion of health care access and quality 74 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Health workers conduct a meeting. Chapter 7: Implementation Arrangements One M&E reform.” This is informed by the

7.1 “ evidence on proliferation of health sector Plan, One Budget, One National Strategic Plans (NSPs) over the last M&E” 15 years, as well as evidence that just ten organizations fund over 90% of the health Implementation of the HSSP III will require sector budget, which provides a strong strong leadership and governance with opportunity for efficiency gains through aid responsibility amongst all health sector harmonization85. stakeholders in Malawi. It will be implemented To increase the Government’s necessary under the health sector partner alignment and directive to set priorities across the health coordination arrangement within an established sector, guarantee partner alignment, and decentralized health service delivery system. harmonize implementation procedures and The system and structures established by the information sharing, the HSSP III proposes that Government of Malawi at the national, central all health systems activities are jointly planned, and district level system levels will be defined in prioritized, implemented, and monitored. this chapter with roles clearly stated for a Through the HSSP III development process, standardized stakeholder engagement the MOH and Development Partners adopted process. There will be a strict requirement for the “One Plan, One Budget, One M&E Report” stakeholder alignment to the strategies and model, with a commitment to reduce to only activities of the HSSP III, enforced by MOUs necessary National Strategic Plans per HSSP and a code of conduct agreed by all III Pillar. This chapter sets out the governance stakeholders. At the heart of the structures and implementation arrangements implementation arrangements in this chapter is necessary to deliver this key reform. the actualization of “One Plan, One Budget and 85 Resource Mapping and Expenditure Tracking (Round7). 75 | Malawi Health Sector Strategic Plan III 2023-2030

7.2 Annual operational The HSSP III is based on the best-available evidence to ensure reliability and accuracy in planning, associated estimating resource needs and to achieve its governance processes ambitions. However, given the eight-year timeframe of the HSSP III, the planning and “ ” costing will be flexible and revised annually via budgeting the HSSP III Operational Plan, based on emerging technical evidence and priorities in While the HSSP III covers 8 years, it will be relation to changing evidence, diagnostic planned and operationalized annually. The capabilities, and quality improvement. HSSP III Implementation Plan will be implemented using the Annual HSSP III All planned activities and associated costs will Operational Plan which has been detailed be jointly prioritized as part of the annual HSSP enough to guide execution and monitoring, III Operational Plan process across all thereby increasing Government ownership and departments, with defined and transparent effectiveness of Development Partner technical prioritization criteria. The aim is to support and financial assistance. The “One Plan” will Government and partner decision-making on include an integrated, transparent joint the optimal areas of investment given limited planning, implementation coordination, and health sector resources. For the latter, the monitoring, including through the national, Resource Mapping and National Health zonal, and DIP review platforms that will enable Accounts (NHA) results will provide estimates ongoing refinement of the intervention and of the available funding envelope. Leveraging monitoring and evaluation matrices through the existing work on the MOH Resource Mapping Annual HSSP III Operational Plan. They will exercise and partner mapping for the District further become vehicles for monitoring and Implementation Plans, a mechanism will be evaluation efforts, complemented by developed (in cooperation and agreement with performance management mechanisms to key partners) that allows for partners to directly incentivize improved delivery of the HSSP III. “sign up” to fund the Government’s priorities at both the national and district level. The priorities for the HSSP III are based on planning and costing for the full health system Once the HSSP III has been signed off, the in harmonized platforms of care for primary, indicative outline of activities for the eight years secondary, and tertiary levels, rather than will become the framework for the Annual through the lens of vertical disease programs. HSSP III Operational Plan. At the beginning of MOH directorates, disease programs, and each annual planning and budgeting cycle and districts (via District Implementation Plans) based on the HSSP III activities for the have integrated their priorities into the HSSP III respective year, the MOH Department for and will iterate on these priorities through the Planning and Policy Development (DPPD) will annual HSSP III Operational Plans to ensure separate out activities by building block (Figure their evolving priorities are fully and accurately 15) reflected in the “One Plan.” 76 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 15: Flow from planning and budgeting to implementation and monitoring Once completed, the repurposed HSWG will The process to establish the Vote 310 come together to develop an “Indicative Priority component of the Operational Plan will be List” for the entire health sector. The HSWG, initiated with DPPD presenting relevant parts of with Terms of References outlined in the the “Indicative Priority List” at the Strategic Guidelines for Malawi 2063 Pillar and Enabler Hearing meeting with the Ministry of Finance. It Coordination Groups, will be fit-for-purpose to will be fully established with the approval of the steer the “One Plan, One Budget, One M&E annual budget by Parliament. The processes to Report” process. The HSWG is envisaged to approve the Operational Plan will not change include MoH Directors, with representatives significantly from the status quo, but from central hospitals, districts, Health Donors stakeholders who are not directly involved in Group (HDG), implementing partners, and non- the Vote 310 process, such as district state actors including civil society. Critical representatives, will be informed on progress TWGs will continue to cascade technical and receive the final Vote 310 component of the expertise and decision-making upwards into Operational Plan. The process and documents the HSWG. will be publicly shared with all stakeholders for transparency, alignment, and complementarity The HSWG will jointly endorse and adopt the of activity planning. “Indicative Priority List,” which will become the unified list of priority activities for the whole of When referring to the “Indicative Priority List,” the health sector as the first step of the annual the District Implementation Plans will HSSP III Operational Plan. The “Indicative consolidate three main components, which will Priority List” will subsequently be used as the be embedded into the planning tools foundation for planning and budgeting themselves: processes and negotiations. Internally, this i. Health centres: Suggest activities includes processes in advance and preparation based on a review of health centre of Vote 310 (Ministry of Health) and Vote 900 needs and gaps against the standards series (District Councils) budgets. Externally, in the PHC platform of care, and this includes partner negotiations and the inclusive of NGO, CSO, and signing or re-confirming of memoranda of community leader perspectives. understanding (MOU) and the partner code of ii. District hospitals: Suggest activities conducts (CoCs). based on a review of district hospital As new technologies, diagnostic and treatment needs and gaps against the standards capabilities, priorities, and financing in the secondary platform of care. mechanisms adjust, there will be need to adjust iii. DHMT and program coordinators: the HBP accordingly with standards of care. Above-facility level activities from Additionally, it is expected that within the first 3- health centres and district hospitals, 5 years of the HSSP III, the HBP will transition such as supervision and other district- from a list-based model to platforms of care to level coordination and monitoring align with health service delivery reforms. activities, based on the “Indicative 77 | Malawi Health Sector Strategic Plan III 2023-2030 Priority List” and tailored to the “Indicative Priority List” and DIPs to ensure individual district context and needs. alignment with national and local Government priorities. The process of preparing the Vote 900 component of the Operational Plan with Donor and partner proposals must be agreed information sharing and engagement between upon by Senior Management (SMT) and then MOH HQ and districts requires improvement. HSWG for adoption, with the subsequent To achieve alignment, DHMTs must hold formal partner MOU87 signed with MOH and all zonal-level meetings, including central involved District Councils. Lastly, the relevant MOH/DPPD, to ensure national and district Head of Mission should also sign against the alignment around the “Indicative Priority List” partner code of conduct. and its relevance to the specific district context, Once Vote 310, Vote 900 and partner as well as utilize data from integrated reviews negotiations have concluded, the DPPD will such as the Joint Annual Review (JAR). Once consolidate these three data sources to achieve District Councils have submitted cross-sector one unified document, the annual Operational plans and budgets (including the DIP tool Plan. information in Vote 900 format) to Ministry of Local Government and Rural Development, the

7.3 Implementation of 29 Directors of Health and Social Services should share final DIP tools with MOH/DPPD. Annual Operational During the process of negotiation with partners Plan, and Code of and resource allocation, the “Indicative Priority Conduct List” will be jointly endorsed by the HSWG, with all donors and partners filling out a partner entry The Health Sector Working Group (HSWG) and checklist as part of joint planning of new funding the district stakeholder forum will provide entering the health sector. Subsequently continued multi-sectoral and multi partner partners should meet with technical focal coordination. At the national level, the persons, either the director for the respective Secretary to Health (SH) oversees building block or the Secretary to Health (SH) if implementation of the health system and is multiple building blocks are involved. The supported by directors. Directors will provide director or the SH will introduce the agenda to technical guidance for relevant areas and the relevant TWGs86 to review and recommend oversee budget execution, while TWG will changes as needed. The review includes provide technical guidance and coordinate with mapping of project funding against the partners. 86 87 While many TWGs exist already, the number and scope MOU will only be signed once, while partner code of of TWGs is envisaged to be reformed to better align with conduct is to be signed annually as part of the the “One Plan, One Budget, One Report” model and Operational Plan process. associated health systems building blocks. 78 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 16: Joint planning, joint implementation, and joint monitoring Government budgets and funds will be To achieve “One Plan, One Budget, One M&E executed using the Public Financial Report,” Government expects all that partners, Management (PFM) system and against the implementing partners, and other relevant Operational Plan. Process included in actors in the health sector, will sign up to a code execution of the budgets are expected to of conduct (CoC). The CoC outlines basic largely follow established processes with principles for engagement for operationalizing service delivery devolved to District Councils the HSSP III across planning, implementation and tertiary hospitals. and monitoring and evaluation cycle and will encompass the partner entry checklist described above. 79 | Malawi Health Sector Strategic Plan III 2023-2030 Photo: Health workers convene at a meeting. Chapter 8: Monitoring and Evaluation Arrangements robust evidence informed decision making at all

8.1 Introduction to the levels of the health system. chapter This chapter provides the Digital Health and

8.2 Overview of the Health Information System arrangements for Results Framework for optimal monitoring and evaluation of the HSSP the HSSP III III. It builds upon the heavy technical and financial investment already made in digital In line with the intervention logic presented in health and aligns this to the HSSP III results Chapter 5, the basic structure for the M&E management framework to ensure timely and system for the HSSP III is presented in Figure 17 below. 80 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 17: HSSP III Results Logic At the ultimate impact level, the framework will financial risk protection and client satisfaction. track progress towards the overall goal of the The HSSP III specifies one broad deliverable, HSSP III. The health system exists to contribute called outcome, at the objective (pillar) level. to the attainment of population health, with UHC Achieving each outcome will require effective as the end goal. In order to contribute to these implementation of the strategies under each population level health impacts, the health pillar. Each strategy, therefore, will be system shall deliver desired high quality health measured using a broad output. Therefore, services. That is, the goal of the health sector there is one outcome for each objective; and for to deliver health services, which in turn, each strategy, there is one output. Activity contributes to achievement of population targets are defined, and a set of activities health. At the health system level, therefore, targets/milestones will need to be achieved in progress will be tracked using intermediate order to achieve the output. The milestones for (service delivery) data elements and impact these activities are not fixed in the HSSP III. indicators. The majority of the indicators to They will therefore be agreed upon annually, measure ultimate and intermediate impacts along with the inputs needed to achieve them. derive directly from the existing core indicators This will occur during the annual planning for the Malawi health system which in process at each level of service delivery, in themselves are contextualized based on WHO alignment with the processes outlined in guidance on SDG-aligned health system Chapter 7 on HSSP III implementation indicators. arrangements. Progress in each of the health systems pillars (building blocks) is important to achieve its

8.3 Health Sector Data respective service delivery goals of access, Table 7 below shows the sources from which quality, and efficiency, and eventually the the Ministry will get data for performance ultimate goals of improved health status, measurement of HSSP III interventions. 81 | Malawi Health Sector Strategic Plan III 2023-2030 Table 7: Data Sources for performance management Data Source Type Data Source Routine Data Health Management Information System (HMIS) Human Resource Information System (HRIS) Integrated Disease Surveillance and Response (IDSR) Logistics Management Information System (LMIS) Laboratory Information Management System (LIMS) Civil Registration and Vital Statistics (CRVS) from medical certification of cause of death (MCCoD), cause of death (COD) coding, verbal autopsy (VA) data for community deaths and birth registration data Health Facility Survey Service Availability and Readiness Assessment (SARA)/Service Provision Assessment (SPA) Household Survey Malawi Demographic Health Survey (MDHS) Multiple Indicator Cluster Survey (MICS) Malaria Indicator Survey Population-based HIV Impact Assessments (PHIA) Welfare Monitoring Survey (WMS)

8.4 Structure of the Health Information System for the HSSP III To facilitate information for effective monitoring Management System for all stakeholders in the and evaluation of the HSSP III, the MOH will health sector. All applications for community sustain and fast track the implementation of the level supporting and health service delivery Health Information System Architecture of 2016 should align to the iCHIS through the as modified and shown in Figure 18.88 This is interoperability architecture implemented by the based on extensive work undertaken by CMED Digital Health Division, in close collaboration and Digital Health Division within the Ministry, with the CHSS for the pillar domain knowledge. with support from collaborating partners. It is As community members are the clients of also informed by the specific information needs service providers, the iCHIS will be linked to the of the HSSP III intervention logic and facility through the integrated hospital implementation arrangements which places electronic health record system which will responsibility of planning, implementation and manage patient services at individual level. The monitoring and evaluation at management integrated hospital electronic health record team of each institution at national, tertiary system will share individual level service hospital, district council, secondary health delivery data with the patient level Central Data facility, primary health facility and community Repository (CDR)/the data lake as the Shared levels. The structure provides for level specific Health Record service provided by the Ministry. MISs starting from community, facility, district, and national levels. At the community level, the Integrated Community Health Information System (iCHIS) will be the primary digital health and Information 88 Based on Concepts agreed in 2016 and revised in 2020; modified in the HSSP III to suit the specific monitoring and evaluation requirements 82 | Malawi Health Sector Strategic Plan III 2023-2030 Figure 18: Health Information System Structure for the HSSP III health system; 2) the Interoperability architecture for Malawi’s national health The data from the CDR will be aggregated and information systems will require aligning with shared with the District Health Management the HSSP III monitoring and evaluation Information System which will be the system for framework; 3) All partners in the health sector monitoring the HSSP III results framework at will align and harmonize their data systems, the district and national levels. In keeping with despite paper or digital, so facilitate timely the governance arrangements outlined in transmission of information to decision makers Chapter 7 as well as the results logic outlined at all levels of the health system. 4) All efforts above, from primary facility, secondary facility, shall be made toward digitalize service delivery District Council, Central Hospital, and National at the point of care and data shall be collected level, the programme specific management and extracted from these systems to support information system shall have modules and with timely and accurate reporting. At minimum, dashboards at the impact and intermediate a decentralized health management impact levels. These dashboards will be information system will be implemented at each integrated into a harmonized dashboard decision-making entity at each level of the platform at HSSP III level and available to all health system with the following modules in other levels Table 8 below. The fundamental principal guiding the HIS and Table 8: HSSP III Health Management Information Digital Health solutions for HSSP III is that Systems Modules at National, Central Hospital, decision makers at each level will be serviced District Council, and District level secondary and with their information requirements for primary health facility levels optimized decision-making, before processing HSSP III Impact Monitoring and submitting information requirements of Implementation Modules upstream decision makers. The key Monitoring Modules implications for this are that 1) the health • Service Delivery • Intermediate information system will be decentralized to • Social Impacts (Access, each decision-making entity at each level of the Determinants of Quality and Health Efficiency) • Human Resources 83 | Malawi Health Sector Strategic Plan III 2023-2030 • Infrastructure and • Population monitoring with MOH Senior Management, Medical (Health Status, Central Hospitals and District Councils, Equipment Client including forming the basis for assessing • Medical Products Satisfaction, effectiveness of partner supports. and Technology Financial Risk Protection) • Health Information Setting baselines and target for HSSPs System and Digital including this one has consistently met the Health challenge of unavailability of NSO survey data • Research at the time of developing the strategies. To • Leadership and improve on this, MOH Statistics Unit will be Governance capacitated to take leadership of all surveys • Health Financing that are important for health sector programming and align them to planning timeframes.

8.5 Determining the 8.6 M&E Coordination Information Structure requirements for the At the national level, the CMED will coordinate implementation of monitoring and evaluation HSSP III Monitoring system while Digital Health Division will oversee digital health solutions servicing both and Evaluation the M&E needs as well as digital requirements Framework for sound implementation of strategies and activities in each of the HSSP III pillars. As the The information for monitoring and evaluating Service Delivery Building Block is complex, of the HSSP III will be determined as follows. Quality Management will coordinate technical Evaluation questions will be developed across and clinical processes related to both digital the results and decision-making chain. First, an health and determination of the M&E requirements of programmes and departments assessment will be undertaken to determine falling within the health service delivery building which questions can be addressed based on block. Data quality assurance for the service data already being collected through the delivery, human resources, infrastructure and existing Health Information Systems, CRVS medical equipment building blocks will be system and periodic surveys. For the evaluation coordinated by the Quality Management questions not addressed through administrative Division. information management systems or surveys, a For purposes of the HSSP III, the integrated determination will be made on which questions Community Health Information System (iCHIS) could be addressed by revising and adapting will be the anchor system for all theme-specific existing information systems and surveys. The modules implied in the theory of change of the relevant administrative data sources will then HSSP III and linked with health facility be adapted accordingly, and stakeholders for integrated hospital electronic health records the relevant surveys will be engaged to system and with other systems of relevance. To the extent possible, where similar indicators determine feasibility of adapting the survey exist, opportunities shall be explored for instruments, either paper or digital tools, as well mainstreaming health information for joint data as aligning the timeframes to the HSSP III collection and processing at minimum. needs. For any outstanding questions, data collection process and systems will be Table 9 below shows the levels of coordination, the office that has ultimate responsibility for determined as appropriate. Within the first year performance, the office tasked with of implementation, all baseline information will coordination responsibilities and the point for be established and will form the basis for validating data into the health information performance contract and performance system. 84 | Malawi Health Sector Strategic Plan III 2023-2030 Table 9: Coordination responsibilities for Health Information System at all levels Coordination Level Performance Coordinating Position Validation Point Contract Holder Overall Coordination of M&E DPPD DPPD M&E TWG, AJSR, HSWG Coordination of HIS DD-CMED Chief Economist M&E TWG, AJSR, HSWG Technical Advisor on QMD/ M&E Coordinators at TWGs by Pillar Service Delivery Pillar Deputy Director level Clinical/ Information Nursing/ Preventive Coordination of Digital DPPD Deputy Director - DHD Digital Health TWG plus TWGs in Health Pillar Coordination of the Health DD-CMED Chief Statistician HSWG, M&E TWG, NSO Statistical System HSSP III Pillar Directors M&E Focal Persons at M&E TWG and other relevant Chief Officer Level TWGs for Pillars Programme level Programme M&E Focal Persons at Service Delivery TWG and any Directors/ Officer Level relevant TWG Managers Central Hospital level Directors Chief Hospital Hospital Boards and TWGs, Zonal Administrator and National Reviews District Council DHSS M&E Officer - Health District Council, District Stakeholder Forum, Zonal and National Reviews District Hospital Facility Manager M&E Coordinator Facility Management Committee, District Council, District Stakeholder Forum, Zonal and National Reviews Community Hospital Facility Management Senior M&E Assistant Community Hospital Management Team (Upgraded HMIS data Committee, District Council, Clerks) District Stakeholder Forum Health Centre Facility Management M&E Assistant (Upgraded Health Centre Management Team HMIS Data Clerks) Committee, Extended DHMT Community Level Facility Management HSA Facility Management Team, Health Team Facility Management Committee • Strategies outlined in the Digital Health

8.7 General Digital Health Strategy of MOH and HIS Guiding • Strategies stipulated in the HIS and Standards M&E Strategy of MOH • Integrated Quality of Care standards The health information system and relevant • Any HIS Standard Operating digital health solutions will be based on the Procedures (SOP) that apply to the following standards: proposed solution • Requirements of the Health Sector • Public Services ICT Standards of 2004 Strategic Plan • Principles of Digital Development – • National Health Information Systems www.digitalprinciples.org Policy of MOH • National Digital Health Policy of MOH 85 | Malawi Health Sector Strategic Plan III 2023-2030 • Principles of Donor Alignment for Any existing standards and guidelines Digital Health – endorsed by MOH for Digital Health systems. www.digitalinvestmentprinciples.org • Stipulations in the 5-Point Call to Action for Health Measurement and Accountability Post-2015 86 | Malawi Health Sector Strategic Plan III 2023-2030 Annexes

Annex 1: Detailed annual intervention implementation Plan for HSSP III STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS Objective 1: To improve equitable access to quality health care services 1.1 Design systems to create integrated platforms of care for primary to 1.1.1 Re-define services for integrated primary to tertiary level platform of care 1,2,5,8 tertiary level 1.1 Design systems to create integrated platforms of care for primary to 1.1.2 Develop document/system to integrate and streamline standards and guidelines such 1,2,3,4,6 tertiary level as Standard Treatment Guidelines, Essential Medicines List, Minimum Standards for Clinical Care, Standard Equipment List, and health workforce planning 1.1 Design systems to create integrated platforms of care for primary to 1.1.3 Identify specialty and sub-specialty service delivery platforms 1,2,3,4 tertiary level 1.1 Design systems to create integrated platforms of care for primary to 1.1.4 Ensure interdisciplinary and multidisciplinary approach to platforms of specialty and 1,2,3,4,5,6,7,8 tertiary level sub-specialty care 1.1 Design systems to create integrated platforms of care for primary to 1.1.5 Review and reinforce clear referral systems across the levels of care 1,2,3,4,5,6,7,8 tertiary level 1.2 Promote quality and client safety in health care service delivery across 1.2.1 Develop, distribute, and reinforce implementation of integrated SOPs, protocols and 1,2,3,4,5,6,7,8 the continuum of care from community to tertiary levels guidelines to all facilities 1.2 Promote quality and client safety in health care service delivery across 1.2.2 Develop and implement guidelines in delegation and task-shifting, taking into account 1,2,3,4,5,6,7,8 the continuum of care from community to tertiary levels scope of practice 1.2 Promote quality and client safety in health care service delivery across 1.2.3 Reinforce QI initiatives at all levels of patient care. 1,2,3,4,5,6,7,8 the continuum of care from community to tertiary levels 1.2 Promote quality and client safety in health care service delivery across 1.2.4 Establish and implement health facility standards of care and accreditation system 1,2,3,4,5,6,7,8 the continuum of care from community to tertiary levels 1.2 Promote quality and client safety in health care service delivery across 1.2.5 Review and enforce standard documentation of all client encounters across the levels of 1,2,3,4,5,6,7,8 the continuum of care from community to tertiary levels care 1.2 Promote quality and client safety in health care service delivery across 1.2.6 Create and enforce patient safety mechanisms across levels and platforms of care 1,2 the continuum of care from community to tertiary levels 87 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 1.2 Promote quality and client safety in health care service delivery across 1.2.7 Design and implement screening services across all levels of care for amendable 1,2,3 the continuum of care from community to tertiary levels illness/disease 1.3 Strengthen client-centred care and patient trust at all levels of the 1.3.1 Promote, empower, and monitor provider/client rights and responsibilities at all levels 1,2,3,4,5,6,7,8 healthcare system 1.3 Strengthen client-centred care and patient trust at all levels of the 1.3.2 Ensure and enforce service charters are in place for each facility 2,3 healthcare system Objective 2: To strengthen preventive health services and capacity to address social determinants of health to reduce the burden on health care system 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.1 Develop, pre-test, and regulate Information Education and Communication (IEC) 1,2,3,4,5,6,7,8 health care system materials 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.2 Conduct research on cultural beliefs and practices negatively affecting health and on 1,2,3,5,8 health care system innovative approaches to address these beliefs 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.3 Conduct community dialogue sessions and engagement/advocacy meetings on cultural 1,2,3,4,5,6,7,8 health care system beliefs and practices negatively affecting health and to empower the community to own and promote their health 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.4 Conduct community sensitization through various channels of communication, 1,2,3,4,5,6,7,8 health care system integrated across disease areas including prevention and management of disease stratified for age, economic and workplace with broad range of information modes with focus on emerging high burden diseases such as NCDs and mental health 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.5 Review health education and promotion packages with stakeholders, civic 1,2,3,4,5,6,7,8 health care system organizations, schools, health system workplaces, churches and more to ensure incorporation of health prevention and management strategies with appropriate access platforms 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.6 Employ social media platform via a multisectoral approach to ensure youth are engaged 1,2,3,4,5,6,7,8 health care system and empowered on issues that affect them including SRHR, recreational drug use, mental health, violence, and abuse 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.7 Engage Ministry of Education to incorporate and strengthen health education, social 1,2,3,4,5,6,7,8 health care system and life skill empowerment programs in schools on emerging health issues including NCDs, recreational drug abuse, violence, SRHR and more 2.1 Drive wellness and healthy lifestyle practices in the community and 2.1.8 Integration of health education programs for NCDs and mental health into pre-existing 1,2,3,4,5,6,7,8 health care system delivery platforms of communicable diseases in the community and at all levels of the health system 88 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 2.2 Increase access to safe food, water sanitation and hygiene (WASH), 2.2.1 Ensure high quality food safety and processes 1,2,3,4,5,6,7,8 housing and working environments 2.2 Increase access to safe food, water sanitation and hygiene (WASH), 2.2.2 Inspect, redesign, and improve work and living environments on health, safety, 1,2,3,4,5,6,7,8 housing and working environments occupational, and environmental standards 2.2 Increase access to safe food, water sanitation and hygiene (WASH), 2.2.3 Ensure safe water and sanitation facilities in all communities 1,2,3,4,5,6,7,8 housing and working environments 2.2 Increase access to safe food, water sanitation and hygiene (WASH), 2.2.4 Conduct multi-sectoral meetings to approve, monitor, and evaluate housing and 1,2,3,4,5,6,7,8 housing and working environments structural designs from design up construction 2.3 Strengthen occupational health 2.3.1 Develop OHS standards at every level 1,2,3,4,5,6,7,8 2.3 Strengthen occupational health 2.3.2 Enforce occupational health and safety standards at all levels 1,2,3,4,5,6,7,8 2.3 Strengthen occupational health 2.3.3 Conduct investigations of OHS incidences and conditions 1,2,3,4,5,6,7,8 2.4 Strengthen vector and vermin control, pandemic, disaster 2.4.1 Develop and implement an integrated, intersectoral approach for vector and vermin 1,2,3,5,7 preparedness response and surveillance of diseases control including needs assessment 2.4 Strengthen vector and vermin control, pandemic, disaster 2.4.2 Conduct operational research on entomology including establishing entomological preparedness response and surveillance of diseases laboratories for evidence-based vector and vermin control measures 2.4 Strengthen vector and vermin control, pandemic, disaster 2.4.3 Develop a standard, coordinated intersectoral plan, assessment and M&E tools for 1,2,3,4,5,6,7,8 preparedness response and surveillance of diseases pandemic or disaster response 2.4 Strengthen vector and vermin control, pandemic, disaster 2.4.4 Conduct coordination and surveillance meetings with the Ministry of Agriculture’s 1,2,3,4,5,6,7,8 preparedness response and surveillance of diseases Animal Health Department on surveillance and response of zoonotic diseases 2.4 Strengthen vector and vermin control, pandemic, disaster 2.4.5 Conduct outbreaks/epidemic/pandemic investigations 1,2,3,4,5,6,7,8 preparedness response and surveillance of diseases 2.5 Strengthen intersectoral prevention and response to violence, 2.5.1 Facilitate establishment of traffic accidents coordination structures and response at all 1,2,3,4,5,6,7,8 discrimination, accidents, and injury levels 2.5 Strengthen intersectoral prevention and response to violence, 2.5.2 Enact policy and laws to limit traffic accidents through intersectoral collaboration 1,2,3,4,5,6,7,8 discrimination, accidents, and injury 2.5 Strengthen intersectoral prevention and response to violence, 2.5.3 Creation of legal and educational tools to prevent common non-traffic accidents 1,2,3,4,5,6,7,8 discrimination, accidents, and injury 2.5 Strengthen intersectoral prevention and response to violence, 2.5.4 Promote policies and laws that equalize gender discrimination, place according 1,2,3,4,5,6,7,8 discrimination, accidents, and injury consequences on SGBV including minors and respond to physical, economic and emotional abuse 89 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 2.6 Address health and health delivery effects of climate change 2.6.1 Complete intersectoral assessment of current and projected climate change effects on 1,2,3,4 health in Malawi 2.6 Address health and health delivery effects of climate change 2.6.2 Participate in development of mitigation plan with emphasis on health and health 2,3,4,5,6 delivery response 2.6 Address health and health delivery effects of climate change 2.6.3 Create policies, operational plans and laws such as limiting deforestation to mitigate 1,2,3,4,5 health and health system effects Objective 3: Improve the availability, accessibility and quality of health infrastructure and medical equipment at all levels of health care 3.1 Strengthen evidence-based management and construction new health 3.1.1 Construct new health infrastructure, including new district hospitals, new community 1,2,3,4,5,6,7,8 infrastructure to meet burden of disease and service delivery needs hospitals, new health centres, new health posts, new maternity units, new staff houses, construction of laboratories, construction of ultrasound rooms, x-ray room construction, and other new specialized construction at central hospitals, including speeding up construction of stalled projects 3.1 Strengthen evidence-based management and construction new health 3.1.2 Establish Trauma Management Centres in the hospitals along the M1 road to manage 1,2,3,4,5,6,7,8 infrastructure to meet burden of disease and service delivery needs road traffic injuries 3.1 Strengthen evidence-based management and construction new health 3.1.3 Promote joint planning, consultations, and monitoring for equipment and infrastructure 1,2,3,4,5,6,7,8 infrastructure to meet burden of disease and service delivery needs between the Directorate of Health Technical Support Services, the Directorate of Planning and Policy Development, and infrastructure units at District Council 3.1 Strengthen evidence-based management and construction new health 3.1.4 Publish and distribute standard designs for new infrastructure at all levels of care 1,2,7,8 infrastructure to meet burden of disease and service delivery needs 3.2 Upgrade, rehabilitate and maintain health infrastructure to meet 3.2.1 Rehabilitate and maintain health facilities, including general rehabilitation, maternity unit 1,2,3,4,5,6,7,8 burden of disease and service delivery needs rehabilitation, expansion of the health facility, expansion of wards, staff house rehabilitation, and water/power for health facilities, taking into account the cost of infrastructure maintenance at 2% of asset value stipulated in the PAM policy of 2002 and to accommodate requirements of modern equipment 3.2 Upgrade, rehabilitate and maintain health infrastructure to meet 3.2.2 Upgrade some health posts to health centres to decongest district hospitals 2,3,4,5,6,7,8 burden of disease and service delivery needs 3.2 Upgrade, rehabilitate and maintain health infrastructure to meet 3.2.3 Upgrade all urban health centres to community hospitals in order to decongest central 1,3,4,5,6,7,8 burden of disease and service delivery needs hospitals 3.2 Upgrade, rehabilitate and maintain health infrastructure to meet 3.2.4 Ensure health facilities have access to reliable sources of power and water, including 1,2,3,4,5,6,7,8 burden of disease and service delivery needs fuel for generators, installation of water pumps and water tanks, and connection to the electricity grid 90 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 3.3 Strengthen procurement, acquisition, distribution, and installation of 3.3.1 Procure medical equipment for primary health facilities according to the Standard 1,2,3,4,5,6,7,8 equipment Equipment List 3.3 Strengthen procurement, acquisition, distribution, and installation of 3.3.2 Procure medical equipment for secondary health facilities according to the Standard 1,2,3,4,5,6,7,8 equipment Equipment List 3.3 Strengthen procurement, acquisition, distribution, and installation of 3.3.3 Procure medical equipment for tertiary health facilities according to the Standard 1,2,3,4,5,6,7,8 equipment Equipment List and for advanced care based on tertiary hospital consultations 3.3 Strengthen procurement, acquisition, distribution, and installation of 3.3.4 Procure plant and non-medical/administrative equipment to facilitate program 2,3,4,5 equipment management for delivery of the HSSP III based on the standard equipment list and gap analysis (e.g., office furniture in the District Health Office or in health facilities) 3.3 Strengthen procurement, acquisition, distribution, and installation of 3.3.5 Develop and implement policy on procurement and disposal of medical equipment 1,2,3,4,5,6,7,8 equipment based on review of procurement processes and including representation of HTSS in procurement processes 3.3 Strengthen procurement, acquisition, distribution, and installation of 3.3.6 Develop and implement policy on procurement and disposal of radioactive equipment equipment and material 3.4 Strengthen evidence-based management, maintenance and use of all 3.4.1 Maintain medical equipment and plant in primary health care facilities, including quality 1,2,3,4,5,6,7,8 equipment control checks and planned preventative maintenance, taking into account the cost of equipment maintenance at 5% of asset value stipulated in PAM policy of 2002 3.4 Strengthen evidence-based management, maintenance and use of all 3.4.2 Maintain medical equipment in secondary health care facilities, including quality control 1,2,3,4,5,6,7,8 equipment checks and planned preventative maintenance, taking into account the cost of equipment maintenance at 5% of asset value stipulated in PAM policy of 2002 3.4 Strengthen evidence-based management, maintenance and use of all 3.4.3 Maintain medical equipment in tertiary health care facilities, including quality control 1,2,3,4,5,6,7,8 equipment checks and planned preventative maintenance, taking into account the cost of equipment maintenance at 5% of asset value stipulated in PAM policy of 2002 3.4 Strengthen evidence-based management, maintenance and use of all 3.4.5 Ensure RMUs have sufficient human resource capacity and equipment to perform their equipment function 3.4 Strengthen evidence-based management, maintenance and use of all 3.4.6 Review and publish Standard Equipment List for primary, secondary, and tertiary health 1,2,3,4,5,6,7,8 equipment facilities and ensure alignment with other guidelines such as the Health Benefits Package and Standard Treatment Guidelines 3.4 Strengthen evidence-based management, maintenance and use of all 3.4.7 Track equipment functionality and developing equipment purchasing/maintenance 1,2,3,4,5,6,7,8 equipment plans, accordingly, including a survey for medical equipment and plant in all primary, secondary, and tertiary health facilities once every 3 years and an up-to-date inventory of medical equipment at each point of care 91 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 3.4 Strengthen evidence-based management, maintenance, and use of all 3.4.8 Initiate the formulation of the legal instruments to aid the enforcement of equipment equipment donation policy and guidelines 3.5 Strengthen transport and referral at all levels of healthcare delivery 3.5.1 Enhance ambulance management and patient transport for effective and efficient 1,2,3,4,5,6,7,8 system services, including availability of utility vehicles, boats, and fuel 3.5 Strengthen transport and referral at all levels of healthcare delivery 3.5.2 Procure transport facilities (vehicles, bicycles, and motorcycles) for community health 1,2,3,4,5,6,7,8 system services Objective 4: Improve the availability of competent and motivated human resources for health for quality health service delivery that is effective, efficient, and equitable 4.1 Enhance recruitment, selection, deployment, and equitable distribution 4.1.1 Recruit sufficient health workers to deliver the primary and secondary platform of care, 1,2,3,4,5,6,7,8 of human resources for health as estimated by the workforce optimization model and specialist planning for the tertiary level 4.1 Enhance recruitment, selection, deployment, and equitable distribution 4.1.2 Staff emergency operations centers (EOCs) with physicians, veterinarians, 1,2,3,4,5,6,7,8 of human resources for health epidemiologists, and microbiologists 4.1 Enhance recruitment, selection, deployment, and equitable distribution 4.1.3 Conduct regular functional reviews aligned to evidence on the demand for health of human resources for health services, such as the workforce optimization model and estimates of health workforce needed to deliver the tertiary platform of care, and including review of appropriate cadres to deliver each level of care (e.g., phase-out of the Medical Assistant cadre and replacement with Clinical Officers/Technicians) 4.1 Enhance recruitment, selection, deployment, and equitable distribution 4.1.4 Rationalize and ensure equitable staff deployments as aligned to evidence on the 1,2 of human resources for health demand for health services, such as the workforce optimization model and estimates of health workforce needed to deliver the tertiary platform of care 4.1 Enhance recruitment, selection, deployment, and equitable distribution 4.1.5 Employ best practices for staff recruitment and selection 1,2,3,4,5,6,7,8 of human resources for health 4.1 Enhance recruitment, selection, deployment, and equitable distribution 4.1.6 Decentralize recruitment to sub national levels 1,2,3,4,5,6,7,8 of human resources for health 4.2 Optimize production at training institutions and strengthen coordination 4.2.1 Increase pre-service volumes for prioritized training programmes in alignment with the 1,2,3,4,5,6,7,8 between the institutions and health sector needs long-term HRH recruitment requirements, as estimated by the workforce optimization model for primary/secondary care and specialist planning for the tertiary level 4.2 Optimize production at training institutions and strengthen coordination 4.2.2 Develop and roll out interventions to strengthen coordination and quality assurance 1,2,3,4,5,6,7,8 between the institutions and health sector needs monitoring for pre-service training programs 4.2 Optimize production at training institutions and strengthen coordination 4.2.3 Embed professional behaviour and customer service teaching in training programmes 1,2,3,4,5,6,7,8 between the institutions and health sector needs 92 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 4.2 Optimize production at training institutions and strengthen coordination 4.2.4 Enforce accreditation standards for training institutions (by regulatory bodies) 1,2,3,4,5,6,7,8 between the institutions and health sector needs 4.3 Improve staff development strategies, policies, procedures, and 4.3.1 Conduct a role set analysis for all cadres and accordingly induct/orient newly recruited, 1,2,3,4,5,6,7,8 practices for human resources for health promoted or redeployed human resource for health 4.3 Improve staff development strategies, policies, procedures, and 4.3.2 Develop and implement a harmonized continuous professional development (CPD) 1,2,3,4,5,6,7,8 practices for human resources for health system linked to renewal of licensure 4.3 Improve staff development strategies, policies, procedures, and 4.3.3 Develop and implement the harmonized in-service training curriculum for all cadres of 1,2,3,4,5,6,7,8 practices for human resources for health the health workforce, as embedded within the CPD system, aligned to service delivery needs, and inclusive of professional behaviour and client satisfaction 4.3 Improve staff development strategies, policies, procedures, and 4.3.4 Monitor the CPD system, inclusive of harmonized in-service training, for quality 1,2,3,4,5,6,7,8 practices for human resources for health assurance and return on investment 4.3 Improve staff development strategies, policies, procedures, and 4.3.5 Intensify supervision/mentorship/coaching programs for cadres across all levels of care 1,2,3,4,5,6,7,8 practices for human resources for health as linked to the CPD system 4.3 Improve staff development strategies, policies, procedures, and 4.3.6 Design and implement internships, fellowships, and residency programs for human 1,2,3,4,5,6,7,8 practices for human resources for health resources for health 4.4 Strengthen and enforce performance management policies, 4.4.1 Develop and implement a robust performance management system that is linked to 2,3,4,5,6,7,8 procedures, and practices implementation of strategic and operational plans at the national/district/facility levels and linked to health worker promotions, incentives, and disciplinary systems 4.4 Strengthen and enforce performance management policies, 4.4.2 Conduct regular reviews of existing supervision lines to enable implementation of 3 procedures and practices performance management 4.4 Strengthen and enforce performance management policies, 4.4.3 Enforce robust regulation of health workers, their training and practice, including 1,2,3,4,5,6,7,8 procedures and practices development, review, and enforcement of health service regulations and disciplinary procedures 4.4 Strengthen and enforce performance management policies, 4.4.4 Re-structure clear and coordinated career pathways for career growth 2,3,4 procedures and practices 4.4 Strengthen and enforce performance management policies, 4.4.5 Develop and implement talent management and retention strategies and policies 1,2,3 procedures and practices 4.5 Institute and provide for competitive remuneration, benefits, and 4.5.1 Develop innovative and competitive remuneration and benefits interventions 1,2,3 working conditions for human resources for health 4.5 Institute and provide for competitive remuneration, benefits, and 4.5.2 Design and implement incentives to motivate and retain health workers in hard-to-reach 1,2,3,4,5,6,7,8 working conditions for human resources for health areas 93 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 4.5 Institute and provide for competitive remuneration, benefits, and 4.5.3 Improve working conditions to improve staff retention 1,2,3,4,5,6,7,8 working conditions for human resources for health 4.6 Generate reliable data and build capacity for evidence-based health 4.6.1 Build the capacity of HR practitioners to conduct evidence-based decision-making, 1,2,3,4,5,6,7,8 workforce decision-making through digital innovations and technological including use of enterprise resource planning (ERP) systems, tools and technologies such as platforms for human resource management iHRIS at all levels 4.6 Generate reliable data and build capacity for evidence-based health 4.6.2 Integrate iHRIS and HRMIS systems 1,2,3,4,5,6,7,8 workforce decision-making through digital innovations and technological platforms for human resource management 4.6 Generate reliable data and build capacity for evidence-based health 4.6.3 Procure IT infrastructure to enable HRH digital innovations such as iHRIS 1,2,3,4,5,6,7,8 workforce decision-making through digital innovations and technological platforms for human resource management 4.6 Generate reliable data and build capacity for evidence-based health 4.6.4 Conduct regular data validation of all HRH databases, including iHRIS, personnel 1,2,3,4,5,6,7,8 workforce decision-making through digital innovations and technological records, payroll audits, among others platforms for human resource management Objective 5: To improve the availability, quality, and rational utilization of medicines and related medical supplies, balanc 3 ’ : , , . 5.1 Enhance data driven quantification and forecasting processes to 5.1.1 Procure sufficient commodities and supplies (inclusive of freight/clearance/tendering 1,2,3,4,5,6,7,8 inform best-value and flexible procurement of medicines and commodities costs) to deliver the primary, secondary, and tertiary HBP, which will be provided free to to deliver health services both within and beyond the Health Benefits charge to the end user Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.2 Adopt innovative methods to conduct supply chain and procurement processes for 1,2,3,4,5,6,7,8 inform best-value and flexible procurement of medicines and commodities central hospitals and specialty centres to reflect patients’ needs. to deliver health services both within and beyond the Health Benefits Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.3 Ensure availability of quality and timely data for forecasting, especially for products that 1,2,3,4 inform best-value and flexible procurement of medicines and commodities have a high degree of known seasonality to improve availability during high-demand periods to deliver health services both within and beyond the Health Benefits Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.4 Enhance the functionality of the interoperability layer to assimilate various data 1 inform best-value and flexible procurement of medicines and commodities collection systems to deliver health services both within and beyond the Health Benefits Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.5 Develop and implement key performance indicators (KPIs) of the procurement process 1 inform best-value and flexible procurement of medicines and commodities to identify and resolve bottlenecks 94 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS to deliver health services both within and beyond the Health Benefits Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.6 Introduce and conduct multi-year planning for commodities at national and sub-national 1,2,3,4,5,6,7,8 inform best-value and flexible procurement of medicines and commodities levels to deliver health services both within and beyond the Health Benefits Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.7 Increase use of “framework contracts” that provide flexibility to CMST in procurement, 1 inform best-value and flexible procurement of medicines and commodities reducing capital tied to fixed contracts (e.g., contract for a ceiling of 1,000 units, committing to to deliver health services both within and beyond the Health Benefits only 500, but willingness to pay an increased price for the balance) Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.8 Set standard for prequalification of vendors to central and district hospitals in light of 1,2,3,4,5,6,7,8 inform best-value and flexible procurement of medicines and commodities decentralization to deliver health services both within and beyond the Health Benefits Package 5.1 Enhance data driven quantification and forecasting processes to 5.1.9 Review and disseminate the PMRA drug donations guidelines and develop clear 1 inform best-value and flexible procurement of medicines and commodities mechanisms for improving CMST accountability for expired products including processes for to deliver health services both within and beyond the Health Benefits channelling donations directly to districts Package 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.1 Fully fund costs of warehousing and distribution for commodities and supplies to deliver 1,2,3,4,5,6,7,8 processes to maintain product quality and shelf life the primary, secondary, and tertiary HBP 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.2 Fully fund costs of warehousing and distribution for commodities and supplies to deliver processes to maintain product quality and shelf life the primary, secondary, and tertiary services outside of the HBP 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.3 Continue to promote creation of community distribution 1,2,3,4,5,6,7,8 processes to maintain product quality and shelf life 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.4 Update the current SOP manual for warehousing, distribution, and reporting processes to maintain product quality and shelf life 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.5 Develop and implement measures aimed at reducing and eliminating waste, using the 1,2,3,4,5,6,7,8 processes to maintain product quality and shelf life pharmaceutical waste management guidelines 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.6 Inspect shelf life of medicines both at procurement level and at service delivery point 1,2,3,4,5,6,7,8 processes to maintain product quality and shelf life level 5.2 Improve warehousing and distribution infrastructure, practices, and 5.2.7 Distribute commodities across health facilities based on accurate, timely and complete 1,2,3,4,5,6,7,8 processes to maintain product quality and shelf life logistics data for each facility 95 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 5.3 Increase rational drug use and deter/prevent pilferage at all levels 5.3.1 Review dispensing practices to support and monitor the rational use of medicines and 1,2,3,4,5,6,7,8 medical supplies 5.3 Increase rational drug use and deter/prevent pilferage at all levels 5.3.2 Revisit and reinforce the role of the Drug Theft Investigation Unit (DTIU) to institute and 1,2,3,4,5,6,7,8 sustain mechanisms that deter individuals from misuse of drugs, and clearly sanctions those charged with theft of drugs 5.3 Increase rational drug use and deter/prevent pilferage at all levels 5.3.3 Re-assess the volume/value of reported theft and determine reasonable measures to 1,2,3,4,5,6,7,8 address leakages 5.3 Increase rational drug use and deter/prevent pilferage at all levels 5.3.4 Consider requiring package labelling (e.g., “Property of MOH”) to reduce pilferage/arbitrage 5.4 Improve medicine quality through increased QA capacity including 5.4.1 Improve pharmaco-vigilance efforts overall, including post-market surveillance (PMS) 1,3,5,7 testing, auditing, and licensing 5.4 Improve medicine quality through increased QA capacity including 5.4.2 Build technical capacity in PMRA to support auditing and licensing of pharmaceutical 1,3,5,7 testing, auditing, and licensing facilities 5.4 Improve medicine quality through increased QA capacity including 5.4.3 Improve capacity of PMRA National Quality Control Laboratory for testing quality of 1,3,5,7 testing, auditing, and licensing drugs and other health commodities (e.g., condoms) 5.4 Improve medicine quality through increased QA capacity including 5.4.4 Review possible barriers to registration of medicines to encourage more suppliers 1 testing, auditing, and licensing 5.4 Improve medicine quality through increased QA capacity including 5.4.5 Incorporate traditional medicine policy into QA activities testing, auditing, and licensing 5.4 Improve medicine quality through increased QA capacity including 5.4.6 Support initiatives aiming at improving Malawi Blood Transfusion Services (MBTS) 1,3,4,5,6,7,8 testing, auditing, and licensing practices to ensure blood safety in blood transfusion centres and all other centres utilizing blood components 5.5 Harmonize and expand implementation of information systems to 5.5.1 Continue the roll-out of installations of OpenLMIS software and eHIN in all health 1,2,3,4,5,6,7,8 improve end-to-end (e2e) visibility in the pharmaceutical supply chain centres (all data is captured, but some facilities use paper forms which are entered into the system at other sites) 5.5 Harmonize and expand implementation of information systems to 5.5.2 Assess the value of each electronic data collection tool (e.g., eHIN, C-stock, 1,2,3,4,5,6,7,8 improve end-to-end (e2e) visibility in the pharmaceutical supply chain OpenLMIS, WMS, ERP) and work towards greater integration in support of the Digital Supply Chain Strategy and Architecture (DSCS&A) of 2021 5.5 Harmonize and expand implementation of information systems to 5.5.3 Create master data mechanisms like traceability (in support of GS1) and inter- 1,2,3 improve end-to-end (e2e) visibility in the pharmaceutical supply chain operability to avoid duplication in medicines and locations as approved by the MOH in 2020 96 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 5.5 Harmonize and expand implementation of information systems to 5.5.4 Considering the cost-benefit of extending the MIS beyond the pharmacy level to 1,2,3,4,5,6,7,8 improve end-to-end (e2e) visibility in the pharmaceutical supply chain departments and wards, e.g., prescription forms at facility levels, which would require electronic medical records or patient management system 5.5 Harmonize and expand implementation of information systems to 5.5.5 Integrate into existing systems, tools that allows generation of streamlined information improve end-to-end (e2e) visibility in the pharmaceutical supply chain on purchased and donated stock 5.5 Harmonize and expand implementation of information systems to 5.5.6 Support coordination and information sharing between CMST and district pharmacy 1 improve end-to-end (e2e) visibility in the pharmaceutical supply chain managers and hospitals 5.5 Harmonize and expand implementation of information systems to 5.5.7 Provide more rights at service provider level to know stock levels within the LMIS 1,2,3,4,5,6,7,8 improve end-to-end (e2e) visibility in the pharmaceutical supply chain system 5.5 Harmonize and expand implementation of information systems to 5.5.8 Support initiatives aimed at strengthening M&E and data management systems within 1 improve end-to-end (e2e) visibility in the pharmaceutical supply chain HTSS 5.5 Harmonize and expand implementation of information systems to 5.5.9 Support full development of the system for collecting and analysing of laboratory data 1,2,3,4,5,6,7,8 improve end-to-end (e2e) visibility in the pharmaceutical supply chain 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.1 Consider creation of a logistics management unit (LMU) to coordinate among parallel 1,2 supply chains and stakeholders. supply chains including vaccines, likely within HTSS, under the assumption that donors will continue to fund those systems 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.2 Lobby to include representation of CSOs within the CMST board to enhance supply chains and stakeholders. transparency and accountability during the awards of "public contracts" 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.3 Rationalize responsibilities among Ministries of Health, Finance, NLGFC, CMST, and 1,2,3 supply chains and stakeholders. District Councils over the supply chain management functions of medicines and related health products 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.4 Support and enhance district-level capacity to conduct supply chain management 1,3,7 supply chains and stakeholders. functions in light of the decentralization of these services, including Drug and Therapeutic Committees among others 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.5 Enhance supportive supervision and training for supply chain management personnel at 1,2,4 supply chains and stakeholders. all levels of the healthcare levels 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.6 Support strengthening of administrative and technical management functioning of the 1,2,3,4,5,6,7,8 supply chains and stakeholders. medical diagnostics and public health laboratory (PHL) services 5.6 Improve capacity to oversee, supervise, and coordinate across all 5.6.7 Include CHAM and its MOU across all areas and explore options for MOUs with 1,2 supply chains and stakeholders. additional partners 97 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 5.7 Develop procedures and establishment of temporary mechanisms that 5.7.1 Link supply chain efforts with the Public Health Institute of Malawi to assist in 3 adapt to predict, detect, and respond to emergencies responding to emergencies 5.7 Develop procedures and establishment of temporary mechanisms that 5.7.2 Consider the value of onshoring local manufacturing of some essential commodities, 1,2 adapt to predict, detect, and respond to emergencies e.g., PPE 5.7 Develop procedures and establishment of temporary mechanisms that 5.7.3 Develop plan for ensuring excess/surge spacing in warehousing and distribution 1 adapt to predict, detect, and respond to emergencies 5.7 Develop procedures and establishment of temporary mechanisms that 5.7.4 Implement the Emergency Supply Chain Playbook process 1,2,3,4,5 adapt to predict, detect, and respond to emergencies 5.7 Develop procedures and establishment of temporary mechanisms that 5.7.5 Identify the major institutions involved in the supply chain response, including district- 1 adapt to predict, detect, and respond to emergencies level public health emergency committees Objective 6: To develop a sustainable and harmonized country led digital health system that covers all areas of service provision and enables efficient delivery of health services at all levels of the health system 6.1 Improve coordination of digital health investments to increase 6.1.1 Strengthen leadership and governance structures for management of digital health 1,2,3,4,5,6,7,8 efficiency interventions 6.1 Improve coordination of digital health investments to increase 6.1.2 Create an enabling environment for effective implementation of digital health solutions 1,2,3,4,5,6,7,8 efficiency through appropriate legislation, policies and compliance mechanism 6.1 Improve coordination of digital health investments to increase 6.1.3 Strengthen Sustainability mechanism for digital health solutions 1,2,3,4,5,6,7,8 efficiency 6.2 Establish a reliable ICT infrastructure that enables utilization of digital 6.2.1 Improve capability of connectivity in poorly covered areas (i.e., areas with no or 2,3 health systems intermittent connectivity 6.2 Establish a reliable ICT infrastructure that enables utilization of digital 6.2.2 Extend coverage of renewable and hybrid power solutions 2,3,4,5,8 health systems 6.2 Establish a reliable ICT infrastructure that enables utilization of digital 6.2.3 Improve availability of computing infrastructure and devices 1,2,3,4,5,6,7,8 health systems 6.3 Build the capacity of clients, communities, health care workers, and IT 6.3.1 Increase capacity of health workforce and IT personnel to implement and utilize digital 1,2,3,4,5,6,7,8 personnel to participate in and benefit from digital health interventions health interventions 6.3 Build the capacity of clients, communities, health care workers, and IT 6.3.2 Increase awareness and capacity of clients and communities to utilize digital health 1,2,3,4,5,6,7,8 personnel to participate in and benefit from digital health interventions interventions 6.4 Leverage technology to increase access to and quality of service 6.4.1 Use innovative digital health technologies to increase access and quality of health (Also 1,2,3,4,5,6,7,8 delivery refer to MEHIS Activity 3.6) 98 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 6.4 Leverage technology to increase access to and quality of service 6.4.2 Leverage use of predictive analytics and big data to improve health service delivery 1,2,3,4,5,6,7,8 delivery 6.4 Leverage technology to increase access to and quality of service 6.4.3 Align digital health interventions with comprehensive digital health architecture 1,2,3,4,5,6,7,8 delivery 6.5 Improve security of information and ICT Systems 6.5.1 Ensure continuity of service delivery in all service delivery points in cases of disasters 1,2,3,4,5,6,7,8 and loss of property 6.5 Improve security of information and ICT Systems 6.5.2 Develop and deploy standardized security management process in health sector to 1,2,3,4,5,6,7,8 promote acceptable use of data and related tools, including hardware and software 6.5 Improve security of information and ICT Systems 6.5.3 Address ethical issues in digital health in order to promote privacy and security of 1 clients’ data 6.5 Improve security of information and ICT Systems 6.5.4 Ensure that digital health information and users are protected from undesirable threats 1,2,3,4,5,6,7,8 including physical threats (fraud and theft), malwares, breach of privacy, misuse of information 6.6 Promote continuity of care through the shared health record 6.6.1 Lead efforts to ensure that longitudinal and cross-sectional patient health records are 1,2,3,4,5,6,7,8 accessible at the point of service delivery 6.6 Promote continuity of care through the shared health record 6.6.2 Strengthen the identification of clients and staff across the health system 1,2,3,4,5,6,7,8 6.7 Strengthen the sharing and accessibility of data across systems to 6.7.1 Implement a standard framework as a national standard for interoperability 1,2,3 enable use. 6.7 Strengthen the sharing and accessibility of data across systems to 6.7.2 Implement interoperability among priority systems 1,2,3,4,5,6,7,8 enable use. 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.1 Rationalize and harmonize routine data collection and reporting systems 1,2,3,4,5,6,7,8 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.2 Finalize configuration and expand functionality of DHIS2 (GIS, climate change, DHIS 2 1,2,3,4,5,6,7,8 tracker and CRVS) 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.3 Strengthen implementation of a national civil registration system and the generation of 1,2,3,4,5,6,7,8 vital statistics 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.4 Strengthen the implementation of key health related surveys 1,2,3,4,5,6,7,8 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.5 Strengthen disease surveillance through identification and reporting of notifiable 1,2,3,4,5,6,7,8 diseases 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.6 Ensure timely tracking of priority HSSP3 Indicators 1,2,3,4,5,6,7,8 99 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.7 Implement coordinated approach to routine data validation 1,2,3,4,5,6,7,8 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.8 Promote the use of data for decision-making at health facility level 1,2,3,4,5,6,7,8 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.9 Institutionalize the systematic use of data in regular review meetings at all levels 1,2,3,4,5,6,7,8 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.10 Build capacity of actors across all levels on data analysis, interpretation, and use 1,2,3,4,5,6,7,8 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.11 Strengthen process monitoring of HSSP3 implementation and annual implementation 1,2,3,4,5,6,7,8 plans 6.8 Effectively monitor and evaluate HSSP III implementation 6.8.12 Ensure alignment of partner activities to the MoH HIS/M&E strategies and annual 1,2,3,4,5,6,7,8 implementation plans Objective 7 To promote and coordinate the conduct of health research in order to generate high quality evidence required to inform the development of health and health care delivery 7.1 To build health research capacity in public, private, research and 7.1.1 Improve health research leadership, management and governance capacity 1,2,3,4,5 academic institutions 7.1 To build health research capacity in public, private, research and 7.1.2 Enhance health research coordination mechanisms by strengthening relevant research 1,2,3,4,5,6,7,8 academic institutions ethics committees (RECs) 7.1 To build health research capacity in public, private, research and 7.1.3 Enhance health research coordination mechanisms through increasing monitoring and 1,2,3,4,5,6,7,8 academic institutions inspection of adherence to National Health Sciences Research Committee (NHSRC) Standard Operating Procedures (SOPs) 7.1 To build health research capacity in public, private, research and 7.1.4 Enhance health research coordination mechanisms through developing and 1,3,5,7 academic institutions implementing guidelines for enforcing ethical standards on the conduct of health research 7.1 To build health research capacity in public, private, research and 7.1.5 Enhance health research coordination mechanisms through legislation and policy on 1,2,3,4,5,6,7,8 academic institutions intellectual property rights 7.1 To build health research capacity in public, private, research and 7.1.6 Enhance Institutional Capacity of health and related researchers to enhance 1,2,3,4,5,6,7,8 academic institutions organizational efficiency and effectiveness 7.2 To achieve the development of evidence-based policies in health 7.2.1 Strengthen coordination of health research knowledge generation, research knowledge 1,2,3,4,5,6,7,8 through intensification of knowledge generation, translation and utilization translation, knowledge sharing and knowledge utilization of research 7.2 To achieve the development of evidence-based policies in health 7.2.2 Include analysis of routinely collected and survey data, compilation and analysis of 1,2,3,4,5,6,7,8 through intensification of knowledge generation, translation and utilization disease & events surveillance data to support detection of outbreaks and implementation of of research international health regulations (IHR) as part of knowledge generation 100 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 7.2 To achieve the development of evidence-based policies in health 7.2.3 Strengthen research transparency and accessibility of evidence generated from clinical 1,2,3,4,5,6,7,8 through intensification of knowledge generation, translation and utilization trials and implementation science through mechanisms such as an open research repository of research 7.3 To ensure that portals for research funding are accessed and that 7.3.1 Build capacity to write health research grant proposals and market them to prospective 1,2,3,4,5,6,7,8 there are adequate funds to finance health research in Malawi funders to help make research self-sustaining and build research careers thereby positioning the health sector to provide local solutions to health care challenges Objective 8: To enhance effectiveness of leadership and governance at all levels of the health sector 8.1 Develop and implement a “One Plan, One Budget and One M&E” 8.1.1 Develop annual HSSP III Operational Plans that consolidate prioritized activities from 1,2,3,4,5,6,7,8 system in order to strengthen alignment and harmonization of donor and Government and partners and from the national, central hospital, and district levels Government funds towards health sector priorities 8.1 Develop and implement a “One Plan, One Budget and One M&E” 8.1.2 Enforce alignment and harmonization of Government and donor funding towards 1,2,3,4,5,6,7,8 system in order to strengthen alignment and harmonization of donor and priorities in the annual HSSP III Operational Plan, in line with the principles of aid Government funds towards health sector priorities effectiveness and development cooperation 8.1 Develop and implement a “One Plan, One Budget and One M&E” 8.1.3 Conduct Joint Annual Reviews, zonal reviews, and district reviews as an integrated 1,2,3,4,5,6,7,8 system in order to strengthen alignment and harmonization of donor and system with a common set of integrated indicators (e.g., tracking progress on DIP Government funds towards health sector priorities implementation and the National Health Indicators Handbook) in order to monitor annual HSSP III implementation 8.2 Strengthen policies, guidelines, and frameworks including at the multi- 8.2.1 Ensure health sector representation in the development, implementation, and sectoral level monitoring of other national sectoral plans that are closely linked to health, including education, agriculture, gender, WASH, etc. 8.2 Strengthen policies, guidelines, and frameworks including at the multi- 8.2.2 Facilitate development and inclusion of social determinants of health during the 1,2,3,4,5,6,7,8 sectoral level formulation of District Development Plans, Village Action Plans, and other multi-sectoral planning at the district and community levels 8.2 Strengthen policies, guidelines, and frameworks including at the multi- 8.2.3 Update and review regulatory laws and guidelines every five years 1,2,3,4,5,6,7,8 sectoral level 8.2 Strengthen policies, guidelines, and frameworks including at the multi- 8.2.4 Strengthen policy think tanks and policy engagement 2 sectoral level 8.3 Enhance financial management to strengthen accountability of funds 8.3.1 Conduct routine audits to strengthen accountability and transparency of Government 1,2,3 funds 8.3 Enhance financial management to strengthen accountability of funds 8.3.2 Build financial management capacity across the health system 1,2,3,4,5,6,7,8 8.3 Enhance financial management to strengthen accountability of funds 8.3.3 Conduct routine financial management activities 1,2,3,4,5,6,7,8 101 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 8.4 Improve governance, including stakeholder oversight, coordination 8.4.1 Enhance functionality of sector-wide governance structures such as the Health Sector 1,2,3,4,5,6,7,8 and implementation at all levels of the health service delivery system Working Group and TWGs 8.4 Improve governance, including stakeholder oversight, coordination 8.4.2 Increase provider autonomy and fiscal decentralization across primary, secondary, and 1,2,3,4,5,6,7,8 and implementation at all levels of the health service delivery system tertiary levels 8.4 Improve governance, including stakeholder oversight, coordination 8.4.3 Update the functional review of the MOH in alignment with integrated planning for the and implementation at all levels of the health service delivery system health system 8.4 Improve governance, including stakeholder oversight, coordination 8.4.4 Strengthen oversight of central and district hospitals, including building capacity of the 1,2,3,4,5,6,7,8 and implementation at all levels of the health service delivery system hospital ombudsman, finalizing guidelines for Boards of Trustees for central hospitals, and other oversight mechanisms 8.4 Improve governance, including stakeholder oversight, coordination 8.4.5 Build oversight capacity of the members of the Health and Environmental Committees 1,2,3,4,5,6,7,8 and implementation at all levels of the health service delivery system 8.4 Improve governance, including stakeholder oversight, coordination 8.4.6 Strengthen community oversight structures across planning, execution and evaluation 1,2,3,4,5,6,7,8 and implementation at all levels of the health service delivery system of the health sector, including forming, training, performance contracting, and supervising HCMCs, CHAGS and VHCs, and strengthening linkages among community health structures Objective 9: To set a health financing architecture that is able to mobilize adequate resources, distribute the resources in an efficient and equitable way, and strategically purchase services based on a well-defined benefit package in pursuit of UHC goals 9.1 To mobilize adequate, sustainable, and predictable funds for the 9.1.1 Improve efficiency across all health system functions at all levels of the healthcare 1,2,3,4,5,6,7,8 health sector to optimally delivery essential health services delivery system 9.1 To mobilize adequate, sustainable, and predictable funds for the 9.1.2 Enhance participation of communities in financing of public health services 1,2,3,4,5,6,7,8 health sector to optimally delivery essential health services 9.1 To mobilize adequate, sustainable, and predictable funds for the 9.1.3 Improve and scale up optional paying services in public facilities 1,2,3,4,5,6,7,8 health sector to optimally delivery essential health services 9.1 To mobilize adequate, sustainable, and predictable funds for the 9.1.4 Increase external funding to the health sector2 2,3,4,5,6,7,8 health sector to optimally delivery essential health services 9.1 To mobilize adequate, sustainable, and predictable funds for the 9.1.5 Improve financing of family planning using domestic resources 1,2,3,4,5,6,7,8 health sector to optimally delivery essential health services 9.1 To mobilize adequate, sustainable, and predictable funds for the 9.1.6 Introduce innovative health financing mechanisms 1,2,3,4,5,6,7,8 health sector to optimally delivery essential health services 9.2 Improvement of efficiency and equity in pooling and management of 9.2.1 Reduce fragmentation of health sector funding 1,2,3,4,5,6,7,8 resources for the health sector 102 | Malawi Health Sector Strategic Plan III 2023-2030 STRATEGY DESCRIPTION ACTIVITY DESCRIPTION IMPLEMENTATIO N YEARS 9.2 Improvement of efficiency and equity in pooling and management of 9.2.2 Strengthen leadership, governance, and accountability mechanisms to ensure 1,2,3,5,6,7,8 resources for the health sector harmonization of health financing decision-making across all levels of the health system 9.2 Improvement of efficiency and equity in pooling and management of 9.2.3 Improve management and accountability of Government and donor funds 1,2,3,4,5,6,7,8 resources for the health sector 9.3 Development and implementation of strategic purchasing measures 9.3.1 Define and implement benefit packages for all levels of care 1,2,4,5,6,8 across the healthcare service delivery continuum 9.3 Development and implementation of strategic purchasing measures 9.3.2 Develop and implement effective strategic resource allocation and use measures 1,2,3,4,5,6,7,8 across the healthcare service delivery continuum across the healthcare delivery 9.3 Development and implementation of strategic purchasing measures 9.3.3 Develop and implement effective provider payment mechanisms 1,2,3,4,5,6,7,8 across the healthcare service delivery continuum 9.4 To establish and strengthen institutional arrangements and systems 9.4.1 Strengthen institutional capacity in health financing and PFM to effectively implement 1,2,3,4,5,6,7,8 for effective health financing at all levels of the health system the Health Financing Strategy 9.4 To establish and strengthen institutional arrangements and systems 9.4.2 Strengthen generation and use of evidence in health financing decision making at all 1,2,3,4,5,6,7,8 for effective health financing at all levels of the health system levels 9.4 To establish and strengthen institutional arrangements and systems 9.4.3 Strengthen the advocacy capacity for the Health Financing Strategy 1,2,3,4,5,6,7,8 for effective health financing at all levels of the health system 9.4 To establish and strengthen institutional arrangements and systems 9.4.4 Strengthen the legal, regulatory and policy frameworks for health financing 1,2,3,4,5,6,7,8 for effective health financing at all levels of the health system 103 | Malawi Health Sector Strategic Plan III 2023-2030

Annex 2: HSSP III M&E Matrix Ultimate Impacts 1. Health Status: 2. Financial Risk Protection: 3. Client Satisfaction (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic area programme Means of Verification 2024 2027 2030 HSSP III Impact: Improved health status, financial risk protection and client satisfaction. Mortality by age and sex Life expectancy at 64.7 (World Bank, 2020) 67 68 70 Annual National/TA Age, Sex, SES, Health Status birth projections (NSO) District Adult mortality rate 18 per 1000 (World 14 8 3 Annual National/TA Age, Sex, SES, Health Status between 15 and 60 Bank 2021) (NSO)2wASzx District years of age Under-five mortality 56/1000 live birth 50 35 15 NSO District/TA Age, Sex, SES, RHD Health Status rate (MICS,2019/2020) District Infant mortality rate 40 per 1000 live births 20 13 7 DHS & MICS District Age, Sex, SES, RHD Health Status (2019/2020, MICS) District Neonatal mortality 26 per 1,000 live birth 19 18 17 DHS & MICS District Age, Sex, SES, RHD Health Status rate (MICS, 2020) District Perinatal Mortality 35 deaths per 1,000 30 25 20 Annual District Gestation age, Type RHD Health Status (MDHS 2016) of SB Mortality by cause Maternal mortality 349 per 100,000 live 304 258 213 DHS & MICS District Age, Sex, SES, RHD Health Status ratio births (World Bank, District 2017) 104 | Malawi Health Sector Strategic Plan III 2023-2030 Ultimate Impacts 1. Health Status: 2. Financial Risk Protection: 3. Client Satisfaction (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic area programme Means of Verification 2024 2027 2030 AIDS related 70.3 per 1,000 49 41 34 SPECTRUM National Sex HIV Health Status mortality rate population (MoH, 2020) Mortality rate from 22.6% (World Bank, 21 19 17 Annual (DHIS 2 Facility Sex NCD Health Status CV diseases, 2019) Diabetes, cancer, chronic respiratory diseases between ages 30 and 70 Malaria mortality rate 37.45 deaths per 33 29 24 Annual (DHIS2) Facility Sex NMCP Health Status 100,000 population (WHO, 2020) Suicide mortality rate 5.4 per 100,000 5 4 4 Annual (DHIS 2) Facility Sex Police Health Status population (World Bank, 2019) Road traffic accident 33.4 per 100,000 29 25 20 Annual (DHIS 2) Facility Sex Traffic Police Health Status mortality rate population (World Bank, 2019) Fertility Adolescent fertility 136 births per woman 100 69 38 Monitored through National/District Sex RHD Health Status rate (age-specific aged 15-19 (MICS,2020) DHS and MICS fertility rate for women aged 10-14 and 15-19) Total Fertility Rate 4.2 births per woman 4 3 3 Monitored through National/District Age RHD Health Status (MICS,2020) DHS and MICS 105 | Malawi Health Sector Strategic Plan III 2023-2030 Ultimate Impacts 1. Health Status: 2. Financial Risk Protection: 3. Client Satisfaction (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic area programme Means of Verification 2024 2027 2030 Morbidity HIV prevalence rate 8.7% (MoH 2020) 7.8 7.2 7 Annual District Sex HIV Health Status (15+yrs) (%) HIV incidence rate 0.22 per 1,000 HIV 0 0 0 Annual District Sex HIV Health Status (15-49 yrs) (%) negative population (MoH, 2020) TB incidence rate 141 per 100,000 people 106 71 36 Annual District Sex NTCP Health Status (World Bank, 2020) Transmission rate of 6.3 per 100 HIV infected 5.7 5.5 5.3 Annual National None HIV Health Status HIV from mother to mothers (Malawi child Spectrum file) TB Incidence 141 per 100,000 (WHO TBD TBD 36 Annual District sex NTbCP Health Status (notification) rate 2020) 106 | Malawi Health Sector Strategic Plan III 2023-2030 Ultimate Impacts 1. Health Status: 2. Financial Risk Protection: 3. Client Satisfaction (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic area programme Means of Verification 2024 2027 2030 Percentage of 4.4 % WHO (2017) TBD TBD 0.1 Annual District Sex DPPD (NHA) Financial Risk households making protection catastrophic payments for healthcare using the 10% of total consumption basket spent on healthcare Proportion of TBD TBD TBD TBD Annual District Sex DPPD (NHA) Financial Risk households with protection catastrophic Out of Pocket expenditure exceeding 40% of non-food expenditure Medical TBD TBD TBD TBD Annual District Sex DPPD (NHA) Financial Risk Impoverishment rate protection 107 | Malawi Health Sector Strategic Plan III 2023-2030 Ultimate Impacts 1. Health Status: 2. Financial Risk Protection: 3. Client Satisfaction (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic area programme Means of Verification 2024 2027 2030 Inequality adjusted TBD TBD TBD TBD Annual District Sex DPPD (NHA) Financial Risk Financial Risk protection Protection score Percentage of Client TBD TBD TBD 98 Annual District Sex DPPD (NHA) Client Satisfaction satisfied with the health service delivery 108 | Malawi Health Sector Strategic Plan III 2023-2030 Intermediate (Health Service Delivery) Impacts 1. Access 2. Quality 3 Efficiency (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic programme Means of area Verification 2024 2027 2030 HSSP III Intermediate Impact: Improved access to, quality and efficiency of health services ART coverage among known HIV- 98% 99% 99% 99% Annual District Sex HIV Access infected pregnant women Antiretroviral Therapy (ART) 86% 88% 90% 92% Annual District Sex HIV Access coverage HIV-positive TB patients on ART 99% 100% 100% 100% Annual District Sex HIV Access during TB treatment % of births attended by skilled 96.4% (2020, MICS) 98% 99% 100% 5 years District Sex RHD Access health personnel (MICS) Demand for family planning 79.9% (MICS,2020 TBD TBD 83.3% 5 years District Sex RHD Access satisfied with modern methods (all currently Married) FP2030 (MICS) women) for All women Intermittent preventive therapy for 36.22% 44% 52% 60% Annual District Sex NMCP Access malaria during pregnancy (IPTp) Penta III coverage 109 | Malawi Health Sector Strategic Plan III 2023-2030 Intermediate (Health Service Delivery) Impacts 1. Access 2. Quality 3 Efficiency (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic programme Means of area Verification 2024 2027 2030 HSSP III Intermediate Impact: Improved access to, quality and efficiency of health services Percentage of women with (5) or TBD TBD TBD TBD Annual District Sex RHD Access more doses of IPTp % of 1year-old children immunized 70% (MICS, 2020) TBD TBD TBD 5 years District Sex RHD Access against measles (MICS) % of 1year-old children fully 72.6% (MICS, 2020) TBD TBD TBD 5 years District Sex RHD Access immunized (survey based) (MICS) Use of Insecticide treated nets 76.8% (MICS, 2020) TBD TBD 91 5 years District Sex NMCP Access (ITN) (MICS) Antenatal care coverage − at least 51% (MICS, 2020) TBD TBD TBD 5 years District Sex RHD Access four visits (%) (MICS) Postpartum care coverage TBD TBD TBD TBD Annual District Sex RHD Access Modern contraceptive prevalence TBD TBD TBD 54.8% Annual District Sex RHD Access e rate (all women) FP2030) 110 | Malawi Health Sector Strategic Plan III 2023-2030 Intermediate (Health Service Delivery) Impacts 1. Access 2. Quality 3 Efficiency (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic programme Means of area Verification 2024 2027 2030 HSSP III Intermediate Impact: Improved access to, quality and efficiency of health services Children with diarrhea receiving TBD TBD TBD TBD Annual District Sex RHD Access oral rehydration solution (ORS) Vitamin A supplementation TBD TBD TBD TBD Annual District Sex RHD Access coverage (6-59 months) Cervical cancer screening 61% facilities are TBD TBD TBD Annual District Sex NCD Access providing Cervical cancer screening (EmONC, 2020) Percentage of CHAM catchment TBD TBD TBD TBD Annual District Sex Access population not covered by SLAs 111 | Malawi Health Sector Strategic Plan III 2023-2030 Intermediate (Health Service Delivery) Impacts 1. Access 2. Quality 3 Efficiency (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic programme Means of area Verification 2024 2027 2030 HSSP III Intermediate Impact: Improved access to, quality and efficiency of health services Percentage of health facilities 22% TBD TBD TBD Annual District Sex RHD Quality providing EmONC signal functions 3 months prior to assessment (disagg: BEmONC, CEmONC) OR: Availability of BEmONC and CEmON C services per 500,000 population Percentage of Health facilities with TBD TBD TBD TBD Annual District Sex QMD Quality full infrastructure requirements in line with respective level of care/% health facilities meeting minimum infrastructure norms 112 | Malawi Health Sector Strategic Plan III 2023-2030 Intermediate (Health Service Delivery) Impacts 1. Access 2. Quality 3 Efficiency (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic programme Means of area Verification 2024 2027 2030 HSSP III Intermediate Impact: Improved access to, quality and efficiency of health services Health worker density and TBD TBD TBD TBD Annual District Sex HRH Quality distribution Health worker density and TBD TBD TBD TBD Annual District Sex HRH Efficiency distribution (adjusted for workload) Current expenditure on health by 32.59% (World Bank, 36.20% 39.90% 43.50% Annual District Sex DPPD Efficiency government as a % of total 2019) expenditure on health Disbursement rates for TBD TBD TBD TBD Annual District Sex DPPD Efficiency Government and Donor Fund Clean audit rates for Government TBD TBD TBD TBD Annual District Sex DPPD Efficiency and Donor Funds Share of budget Devolved to TBD TBD TBD TBD Annual District Sex DPPD Efficiency facility level 113 | Malawi Health Sector Strategic Plan III 2023-2030 Intermediate (Health Service Delivery) Impacts 1. Access 2. Quality 3 Efficiency (and Equity by socioeconomic status, gender, geographical location) Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting and geographic programme Means of area Verification 2024 2027 2030 HSSP III Intermediate Impact: Improved access to, quality and efficiency of health services Percent of donor funds and TBD TBD TBD TBD Annual District Sex DPPD Efficiency projects not fully aligned to HSSP III OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Outcome 1: improved Percentage of health 39 (Annual report for 45 60 75 Health care DISTRICT Central Hospitals, QMD Service access to and equity of facilities providing essential MoH under the quality reports, District Hospitals, Delivery quality health services health services that meets Directorate with Meeting Zones & National minimum quality of care reference to COHSASA minutes, Bi- standards introduced in 2019) annually Output 1.1: Integrated Percentage of services that TBD 25 45 65 Health care DISTRICT Central Hospitals, QMD Service health care systems are integrated at service reports, District Hospitals, Delivery developed delivery level Meeting Zones & National minutes, Bi- annually Output 1.2: Improved Percentage of health 8 22 40 55 Health care DISTRICT Central Hospitals, QMD Service quality of health care facilities meeting minimum reports, District Hospitals, Delivery standards Meeting Zones & National 114 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification quality of health care minutes, Bi- standards annually Output 1.3: Improved Percentage of facilities with TBD 61 72 80 Suggestion DISTRICT Central Hospitals, QMD Service client-centered care at functional system on client- Boxes, District Hospitals, Delivery all levels of the centered care Facility Zones & National healthcare system Advisory Meeting minutes Outcome 2: Improved Percentage of entities at all TBD 15 65 100 Annual DISTRICT Central Hospitals, QMD Social capacity in preventive, levels of care that have Reports District Hospitals, Determinants promotion, and functional multi-sectoral Zones & National for health rehabilitative health stakeholder committees on service in addressing social determinants of social determinants of health health Output 2.1: Increased Percentage of target TBD 30 85 100 Annual DISTRICT Central Hospitals, Preventive Social awareness of positive population reached with Reports District Hospitals, Health Determinants health behavior in the priority health behavior Zones & National for health community change messages Output 2.2: Increased Percentage of target TBD 25 75 100 Annual District Disaggregated by WASH Social awareness on water households reached with WASH, housing Determinants sanitation and hygiene information and and working for health (WASH), safe housing communication on water environments and working sanitation and hygiene environments (WASH), safe housing and working environments Output 2.3: Improved Percentage of institutions TBD 35 75 100 Health care DISTRICT Central Hospitals, QMD Social working environments adhering to minimum reports, District Hospitals, Determinants standards on occupational Meeting Zones & National for health health minutes, Bi- annually 115 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Output 2.4 Enhanced Percentage of target TBD 30 65 100 Annual DISTRICT Central Hospitals, Preventive Social capacity in vector and households reached with Reports District Hospitals, Health Determinants vermin control, priority interventions on Zones & National for health pandemic, disaster vector and vermin control, preparedness response pandemic, disaster and surveillance of preparedness response and diseases surveillance of diseases Output 2.5: Enhanced Percentage of service TBD 25 75 100 Health care DISTRICT Central Hospitals, QMD Social multi-sectoral capacity provision points with reports, District Hospitals, Determinants on prevention and capacity in preventions and Meeting Zones & National for health response to violence, response to violence, minutes, Bi- discrimination, discrimination, accidents, annually accidents, and injury and injuries Output 2.6: Improved Percentage of entities with TBD 25 65 100 Health care DISTRICT Central Hospitals, QMD Social response capacity in the capacity in the management reports, District Hospitals, Determinants management of the of the effects of the climate Meeting Zones & National for health effects of the climate and climate change minutes, Bi- and climate change at annually levels of service delivery Outcome 3: Improved Percentage of population TBD 10 50 100 Health care DISTRICT Central Hospitals, QMD Infrastructure availability of health within 5km-radius of a public reports, District Hospitals, and medical infrastructure and or contracted health facility Meeting Zones & National equipment medical equipment at all meeting the minimum minutes, Bi- levels of health care infrastructure and medical annually equipment requirements Output 3.1 Increased Percentage of planned TBD 10 60 100 Health care DISTRICT Central Hospitals, QMD Infrastructure number of health health infrastructure in the reports, District Hospitals, and medical facilities constructed CIP constructed Meeting Zones & National equipment following the Capital minutes, Bi- Investment Plan (CIP) annually 116 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Output 3.2 Increased Percent health TBD 10 65 100 Health care DISTRICT Central Hospitals, QMD Infrastructure number of health infrastructure, upgraded or reports, District Hospitals, and medical facilities upgraded or rehabilitated or maintained Meeting Zones & National equipment rehabilitated or based on CIP minutes, Bi- maintained based on annually CIP Output 3.3 Increased Percent of health facilities TBD 10 65 100 Health care DISTRICT Central Hospitals, QMD Infrastructure number of health equipped to minimum reports, District Hospitals, and medical facilities with essential requirements Meeting Zones & National equipment equipment minutes, Bi- annually Output 3.4: Improved Percentage of health TBD 25 60 100 Health care DISTRICT Central Hospitals, QMD Infrastructure equipment management facilities with functional reports, District Hospitals, and medical systems at all levels Asset Management Unit Meeting Zones & National equipment (AMU) minutes, Bi- annually Output 3.5: Enhanced Percentage of health TBD 25 75 100 Health care DISTRICT Central Hospitals, QMD Infrastructure transport and facilities with functioning reports, District Hospitals, and medical communication systems transport and Meeting Zones & National equipment based on CIP communication systems minutes, Bi- annually Output 3.6: Improved Percentage of institutions TBD 25 75 100 Health care DISTRICT Central Hospitals, QMD Infrastructure infrastructure and adhering to minimum reports, District Hospitals, and medical medical equipment infrastructure management Meeting Zones & National equipment guidelines minutes, Bi- annually Outcome 4: Increased Percentage of health TBD TBD TBD 100 Annual District, Sex DHR Human number of service facilities meeting the National resources for delivery points with the minimum staffing norms health required competent and motivated staff 117 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Output 4.1: Reduced Percentage of vacant TBD 20 60 100 Annual District, Sex DHR Human vacancies at all levels of positions filled National resources for health system health Output 4.2: Increased Percentage of health cadres TBD 35 75 100 Annual District, Sex DHR Human number cadres that are produced in line with the National resources for produced at training HSSP III needs health institutions in line with the requirements of the HSSP III Output 4.3. Increased Percentage of staff that TBD 25 75 100 Annual District, Cadre DHR Human number of service enroll for staff development National resources for delivery point with opportunities health standard human resources Management norms Output 4.4: Increased Percentage of functional TBD 25 75 100 Annual District, Sex DHR Human number of service service delivery points with National resources for delivery points creating functional performance health a conducive working management policies and environment for effective systems career progression Output 4.5: Increased Percentage of staff TBD 25 65 100 Annual District, sex DHR Human staff morale and rewarded based on National resources for performance in the performance criteria health delivery of health care services Output 4.6: Increased Percentage of service TBD 25 75 100 Annual District, sex DHR Human access to quality data delivery utilizing own data National resources for for decision-making for decision-making health 118 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Outcome 5: Increased Percentage of health TBD 15 60 100 Monthly, District Central Hospitals, HTSS Medicines and quality, availability and facilities without stock-outs Annual District Hospitals, medical rational utilization of of tracer medicines and Zones & National supplies medicines related and related medical supplies. medical supplies Output 5.1 Increased Percentage of service TBD 25 60 100 Monthly, District Central Hospitals, HTSS Medicines and capacity in quantification delivery points accurately Annual District Hospitals, medical and forecasting to quantifying and forecasting Zones & National supplies deliver health services medicines and commodities Output 5.2 : Increased Percentage of health TBD 20 65 100 Monthly, District Central Hospitals, HTSS Medicines and capacity in logistics and facilities adhering to Annual District Hospitals, medical storage management in approved logistical cycle Zones & National supplies maintaining product management quality Output 5.3: Increased Percentage of prescriptions TBD 15 60 100 Monthly, District Central Hospitals, Clinical Medicines and availability of medication done according to standard Annual District Hospitals, Services medical for patient treatment treatment guidelines Zones & National supplies Output 5.4: Increased Percentage of targeted TBD 10 60 100 Monthly, District Central Hospitals, QMD Medicines and medicine quality through medicine quality Annual District Hospitals, medical improved capacity in assessments completed Zones & National supplies Quality Assessment. Output 5.5: Increased Percentage of health TBD TBD TBD 100 Annual District Central Hospitals, DHR Medicines and capacity in the personnel with capacity to District Hospitals, medical supervisory and conduct quality assessment Zones & National supplies coordination of supply including testing, auditing, chains and stakeholders and licensing. Output 5.6: Increased Percentage of institutions TBD 25 65 100 Annual District Central Hospitals, DHR Medicines and capacity in Emergency implementing a documented District Hospitals, medical preparedness and Emergency preparedness Zones & National supplies response and response plan. 119 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Outcome 6: Improved Percentage of health TBD 25 65 100 Annual District Disaggregate by Digital Health Digital health information and data facilities with a functional HSSP III pillars, management and facility wide management EHP priority sharing through digital system areas and health system decision-making unit Output 6.1: Increased Percentage of resources TBD 15 50 100 Annual District Central Hospitals, Digital Health Digital health coordination and available for in digital health District Hospitals, investment in digital investments in line with the Zones & National health in line with CIP CIP Output 6.2: Increased Percentage of health TBD 20 65 100 Annual District Central Hospitals, Digital Health Digital health investment in ICT facilities with minimum District Hospitals, infrastructure supporting required ICT infrastructure Zones & National digital health systems for digital health systems Output 6.3: Increased Percentage of targeted TBD 25 70 100 Annual District Sex Digital Health Digital health staff capacity in digital users trained in digital health systems health services Output 6.4: Increased Number of clients receiving TBD 25 65 100 Annual District Sex Digital Health Digital health health services services through tele health delivered on digital health platform Output 6.5: Improved Proportion of staff trained in TBD 15 60 100 Annual District Sex Digital Health Digital health security of information information and ICT and ICT Systems systems security Output 6.6: Increased Proportion of digital health TBD 20 65 100 Annual District Sex Digital Health Digital health integration and sub systems integrated interoperability of health through interoperability for systems at all service sharing of health data delivery levels across platforms 120 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification Outcome 7. Increased Completion rate for TBD 25 65 100 Annual District Central Hospitals, DPPD Health research knowledge generation research projects District Hospitals, and management for Zones & National health Output 7.1: Increased Percentage of health TBD 25 60 100 Annual District Central Hospitals, DPPD Health research health research capacity research conducted by MoH District Hospitals, across public, private, and CHAM staff Zones & National research and academic entities Output 7.2: Increased Percentage of health TBD 15 50 100 Annual District Central Hospitals, DPPD Health research capacity in knowledge policies informed by District Hospitals, management and research evidence Zones & National utilization for evidence based decision making by policy makers Output 7.3: Increased Percentage health TBD 4 8 10 Annual District Central Hospitals, DPPD Health research financing in health expenditure spent on District Hospitals, research research Zones & National Output 7.4: Increased Proportion of service TBD 25 60 100 Annual District Central Hospitals, DPPD Health research sharing and utilization of delivery points with District Hospitals, data for decision- information management Zones & National making systems that are integrated for data sharing Output 7.5: Increased Percentage of targeted M&E TBD 25 70 100 Annual District Central Hospitals, DPPD Health research HSSP III implementation activities completed District Hospitals, performance monitoring Zones & National and evaluation Outcome 8: Increased Percentage of service TBD 30 50 70 Quarterly Facility By levels of QMD Leadership and transparency and delivery points meeting service delivery governance minimum standards of 121 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification accountability in the transparency and health sector accountability Output 8.1:Iincreased Percentage of health TBD 25 60 100 annual District By health zones Planning Leadership and harmonization and institutions adhering to the Department governance alignment of donor and “One plan, One Budget and government funds One M&E” system towards health sector priorities Output 8.2: Increased Percentage of targeted TBD 15 65 100 annual District By Program Planning Leadership and coordination of policies, activities implemented Department governance guidelines, and through multisectoral frameworks at the multi- coordination completed sectoral level Output 8.3: Increased Percentage of service TBD 15 55 100 Quarterly District By facility, District Planning Leadership and accountability of budget delivery points meeting Zone, National Department governance utilization minimum accountability requirements Output 8.4 : Increased Percentage of service TBD 15 60 100 Quarterly District By facility, District QMD Leadership and performance in health delivery points with Zone, National, governance emanating from functional oversight or HAC, ADC functional governance governance structures structures Outcome 9: Increased Percentage of service TBD 15 45 100 Quarterly, District Central hospitals, DPPD Health effectiveness of the delivery points with Bi-annual, District Public financing health financial minimum health financial Annual facilities, Faith- management system management systems based Health requirements facilities, Health Zone Output 9.1: Increased Percentage of health TBD 15 50 100 Quarterly, District Central hospitals, DPPD Health financial sustainability in service delivery points with Bi-annual, District Public financing 122 | Malawi Health Sector Strategic Plan III 2023-2030 OUTCOMES AND OUTPUTS Impacts Indicators Baseline Targets Period of Smallest Disaggregation Responsible Domain reporting geographic programme and Means area of 2024 2027 2030 Verification the delivery of essential sustainable financial Annual facilities, Faith- health services mobilization strategies Financial based Health Reports facilities, Health Zone Output 9.2: Increased Percentage of service TBD 15 65 100 Quarterly, District Central hospitals, DPPD Health efficiency and equity in delivery points achieving Bi-annual, District Public financing management of pooled minimum efficiency and Annual facilities, Faith- health resources equity requirements in Financial based Health financial management Reports facilities, Health Zone Output 9.3: Increased Percentage of service TBD 20 65 100 Quarterly, District Central hospitals, HTSS Health efficiency in delivery points meeting Bi-annual, District Public financing procurement in health minimum requirements for Annual, facilities, Faith- strategic purchasing LMIS based Health facilities, Health Zone Output 9.4: Improved Percentage of health TBD 20 60 100 Quarterly, Facility Central hospitals, DPPD Health health financing at all service delivery points Bi-annual, District Public financing levels of health system adhering to health minimum Annual facilities, Faith- financing requirements Financial based Health Reports facilities, Health Zone 123 | Malawi Health Sector Strategic Plan III 2023-2030