The Health Sector Strategic Plan II (HSSP II) 2017-2022 is the health sector’s medium term strategic plan outlining objectives, strategies and activities and guiding resources over the period 2017-2022. It succeeds the HSSP I (2011-2016). HSSP II builds on the successes achieved under the previous plan while addressing areas where targets were not met and progress was slow. Under the HSSP I Malawi made substantial health gains. HSSP I targets for Under-5 mortality and infant mortality were surpassed, 63/1000 live births against a target of 78/1000 livebirths for the former and 42/1000 livebirths against a target of 45/1000 for the latter. There was also a steady decline in the maternal mortality ratio (MMR), which was estimated at 439/100,000 live births in 2016, down from 675/100,000 in 2010. Neonatal Mortality Rate was estimated at 27/1000 live births in 2016, down from 31/1000 live births in 2010. Despite the progress, Malawi’s MMR and neonatal mortality rate (NMR) are among the highest in Sub-Saharan Africa. The HIV prevalence among women and men age 15-49 age decreased between 2010 and 2015-16 from 10.6% to 8.8%.
The gains in health outcomes could partially be attributed to increased utilisation of some key services such as skilled attendance at birth which was estimated at 90% in 2016 and the percentage of pregnant women making at least one ANC visit during pregnancy was 95%. On the other hand, only 24% of pregnant women had their first ANC visit in the first trimester; only 51% had four or more ANC visits and only 42% of women and 60% of new-borns received a postnatal check 48 hours of birth. Median coverage of basic vaccinations reached as high as 95% although there was a decline in the percentage of children aged 12-23 months were fully immunized from 81% in 2010 to 71.3% in 2016. There was mixed progress with regard to development of health systems. The MoH promoted a total of 2,438 staff to more senior positions in the 2014/2015 fiscal year (FY), across many cadres. These promotions however did not extend to health staff working in CHAM facilities, which has created inequities across the workforce. There is still a vacancy rate of 45%, however. During the HSSP I period, a total of 12 new health facilities (1 district hospital and 11 health centres) were constructed. The proportion of the population living within 8 km radius of health facility, however, declined from 81% in 2011 to 76% in 2016. This indicates that there is still a significant proportion of the population that is underserved, especially those residing in the rural and hard to reach areas.
The health care system experienced shortages of essential medical products and technologies. This was due to many factors including inadequate funding, weak supply chain management and irrational use of medicines, leakage and pilferage. For health information systems, critical milestones were achieved at policy level including development of an eHealth strategy, an approved HIS Policy (October 2015), an updated handbook of national indicators and a HIS operational plan. Challenges still remain, the key one being the existence of parallel reporting systems which has created structural challenges and weakened the mainstream monitoring and evaluation system. There was mixed progress with respect to governance of the health sector over the past five years. Weak governance structures resulted in poor coordination. Health care financing in Malawi remains a challenge. During the period 2012/13-2014/15, development partners’ contributions accounted for an average 61.6% of total health expenditure (THE), Government accounted for an average of 25.5% and households 12.9% of the THE. In the HIV/AIDS subsector, donor contributions average 95% of total financing. Health care financing reforms were hence explored such as feasibility of a national health insurance scheme and establishment of a health fund.
Inequalities in health outcomes and health care access persisted during HSSP I; there were differences by wealth status, education, gender and geographical location. The 2016 MDHS shows, for example, that the prevalence of stunting in children under five years is 46% among children in the lowest wealth quintile, 37% among those in the middle wealth quintile and 24% for children in the highest wealth quintile. The goal of the HSSP II is to move towards Universal Health Coverage (UHC) of quality, equitable and affordable quality health care with the aim of improving health status, financial risk protection and client satisfaction.
The HSSP II aims to further improve health outcomes through the provision of a revised essential health package (EHP) and health systems strengthening for efficient delivery of the EHP. Specifically, the HSSP II sets eight strategic objectives for Malawi’s health sector – each with strategies and targets to implement by 2022:
1. Health Service Delivery: Increase equitable access to and improve quality of health care Services.
Objective 1 builds on the successes of the Essential Health Package (EHP), which has outlined the health care interventions available to all Malawians, free at the point of access, since 2004. The aim is to achieve universal free access to a quality revised Essential Health Package (EHP), irrespective of ability-to-pay, to all Malawians.
2. Socio-Economic Determinants: Reduce environmental and social risk factors that have a direct impact on health.
Objective 2 focuses on strategies that address the environmental and social risk factors that impact on health care requirements and health outcomes. Specifically, the objective focuses on behaviours and life styles, water and sanitation, food and nutrition services, housing, living and working conditions. This objective will be largely implemented at the community level.
3. Infrastructure & Medical Equipment: Improve the availability and quality of health infrastructure and medical equipment.
Objective 3 attempts to ensure existing health facilities are of sufficient quality and properly equipped to address their specified health care requirements and to increase the proportion of the population of Malawi living within 8km of a health facility.
4. Human Resources: Improve availability, retention, performance and motivation of human resources for health for effective, efficient and equitable health service delivery.
Objective 4 focuses on improving the absorption and retention rate of health workers in the public health sector while also achieving an equitable distribution.
5. Medicines & Medical Supplies: Improve the availability, quality and utilization of medicines and medical supplies.
Objective 5 focuses on improving the efficiency of the supply chain for medicines and medical supplies to ensure the availability of the EHP.
6. Health Information Systems: Generate quality information and make it accessible to all intended users for evidence-based decision-making, through standardized and harmonized tools across all programmes.
Objective 6 focuses on improving and harmonising data collection and management at all levels of the health system, through improving ICT capacity, data protocols and linkages between levels.
7. Governance: Improve leadership and governance across the health sector and at all levels of the health care system.
Objective 7 focuses on improving communication and strengthening coordination in the health sector particularly with the goal of reducing duplication and fragmentation in the health sector.
8. Health Financing: Increase health sector financial resources and improve efficiency in resource allocation and utilization.
Objective 8 focuses on attempts to increase the sustainable finances available to the health sector through both revenue raising and efficiency savings.
A primary concept of the HSSP II has been the rationalisation of the health sector’s objectives and activities. The design of the HSSP II has been more realistic than ambitious to ensure all objectives are actually achieved. A number of strategic choices were made with the focus of the HSSP II being on strengthening health sector governance structures and linkages, increasing equitable access and quality of EHP services, focusing infrastructure investments on rehabilitations and increasing medical equipment investments and improving use of health information at all levels.
The five-year cost of the HSSP II is estimated to be USD2,613 million. Costs increase from USD504 million in 2017/18 fiscal year (FY) to USD540 million in 2021/22. The total cost per capita each year remains constant at about USD30.
The HSSP II will be implemented by DHOs, central hospitals, development partners, civil Society organisations, Non-Governmental Organisations (NGOs) and other health stakeholders. It will be monitored and evaluated using a set of National Health Indicators. Routine and survey data will be used to measure progress through a harmonized country-led M&E framework.
The HSSP II is structured as follows: Chapter 1 introduces Malawi’s health care system and outlines the HSSP II development process. Chapter 2 provides an in-depth situation analysis providing a synthesis of both the health status and health care system. Chapter 3 puts forward the HSSP II vision, mission and goal as well as outlining the objectives set to achieve these. Chapter 4 introduces the revised Essential Health Package (EHP) outlining its detail and objectives. Chapter 5 provides detail of the strategies in the HSSP II by objective. Chapter 6 provides information about the strategic choices made in the plan outlining the priorities and implementation arrangements while also presenting a risk analysis with mitigation strategies. Chapter 7 presents the cost of implementing the HSSP II and Chapter 8 outlines the M&E Framework.