Executive Summary
The Government of Malawi (GoM) aims to have the highest possible level of health and quality of life for its citizens. The provision of equitable and quality healthcare is largely dependent on the availability of adequate resources. However, planning and coordination of health activities have been challenging in the country, considering that there is substantial off-budget donor funding. According to resource mapping (RM) projections, in fiscal year (FY) 2017/18, 75 percent of funding for the health sector came from 189 external donors, each with separate budgets, priorities, decision-making processes and implementers; the GoM finances the remaining 25 percent of the health sector.
To address these challenges, the Ministry of Health (MOH) has adopted an annual RM exercise to track health sector resources and to inform planning and budgeting decisions both for the MOH and its development partners (DPs). Health sector RM provides detailed, forward-looking budget data, complementing other surveys like the National Health Accounts (NHA) and the National AIDS Spending Assessment (NASA) that collect historical expenditure data. This report presents the key findings of RM Round 5, which includes health sector budget data collected for FY 2017/18 through FY 2019/20.
In FY 2017/18, the total resource envelope for the sector is estimated at US$639 million, representing 9.5 percent of overall gross domestic product (GDP). Of that total, US$477 million (75%) comes from DPs, while the remaining US$162 million (25%) comes from the government. Compared to the last round of RM data from FY 2015/16, when the sector had a resource envelope of US$607 million, overall resources have nominally increased by US$32 million in nominal US dollar (USD) terms.
In FY 2017/18, the top four financing sources for health include the Global Fund (28%), GoM/MOH (25%), United States (16%), and the Health Sector Joint Fund (6%), which collectively provide 75 percent of all resources. If the subsequent six top financing sources are considered as well, the top 10 financing sources for health account for 92 percent of all health sector resources captured for FY 2017/18. This means that the remaining 181 financing sources contribute to just 8 percent of the overall resource envelope.
Within the US$639 million budgeted for 2017/18, HIV/AIDS is the programmatic area receiving the most funding at US$197 million (31%). This is followed by reproductive, maternal, newborn, and child health (RMNCH) at US$50 million (8%), malaria at US$43 million (7%), nutrition at US$32 million (5%), vaccines at US$19 million (3%), tuberculosis (TB) excluding HIV at US$13 million (2%), and environmental health and diarrheal diseases at US$6 million (1%). Mental health, eye, ear, and skin diseases, and noncommunicable diseases (NCDs) each receive less than US$2 million. On the extreme low end, neglected tropical diseases and respiratory infections receive less than US$0.5 million each. Additionally, a significant portion of funding was considered cross-cutting across disease areas, representing US$275 million (43%).
A separate analysis of all cost categories (which includes parameters such as administration, capital equipment, drugs, infrastructure and technical assistance) reveals that for FY 2017/18, drugs and medical supplies account for the largest area of anticipated spending at US$229 million, of which US$123 million is sourced from the Global Fund, largely for the procurement of antiretroviral (ARV) drugs. Health worker salaries and benefits is the second-largest cost category, at 12 percent of projected funds, followed by construction of infrastructure (8%) and community outreach activities (7%).
Funding within the total resource envelope earmarked for specific districts (as opposed to national-level programs or funding for central hospitals) amounts to US$338 million for FY 2017/18 but varies dramatically across districts. Total funding per district ranges from US$5 million in Likoma to US$44 million in Lilongwe, with a median of US$12 million. Districts also range in their level of donor 8
dependency; Phalombe has the greatest percentage of health funding from external sources (88%), while Dowa has the lowest (70%). Variations in donor funding across districts are partly due to district-specific projects, which are typically not integrated into the District Development Plans (DDPs). Increased transparency and coordination could lead to better management and execution of district funds.
Of the total funds made available to the health sector in FY 2017/18, 70 percent are dedicated to service delivery costs, while the other 30 percent are budgeted towards non-service delivery costs. Service delivery costs include items such as capital equipment, drugs, and salaries, while non-service delivery costs include items such as administration, research, and technical assistance. While a crude estimate, these figures indicate that, on average for every dollar budgeted, roughly US$0.70 will be given to health care facilities to provide health services. Improved efficiency in non-service delivery costs could dramatically improve facility-level resources.
The ultimate objective of RM is to equip all stakeholders in the health sector with increased knowledge and understanding of the flow of resources in the coming three years. It provides an understanding of the available resources for the sector and indicates the flow of funds from financer to implementer; across different programs, geographic regions, fiscal years, and cost categories. RM can be a powerful tool in resource mobilization; operationalization of strategic plans; coordination of implementation; identification of inefficiencies; and informing policy change.
The complete dataset is available on request from the MOH’s Department of Planning and Policy Development (DPPD) and should be adopted and analyzed proactively by stakeholders for their various health financing needs.
For more information and access to the full database, please contact the resource mapping email account at: resourcemappingmalawi@gmail.com.