POLICY BRIEF: Malawi November 2020 Closing the gap: Why achieving universal health coverage in Malawi now requires targeted investment in underperforming and underserved districts Key messages: 01 While governments 02 Leveraging data from 03 While Malawi’s overall 04 Low levels of around the world the 2018/19 Malawi availability of essential provider competency, are keen to achieve Harmonised Health health services especially for child universal health Assessment, this policy could be improved, health conditions, coverage, limited brief explores health in the short term the was the most notable barrier to service resources for health system gaps across government may want readiness. Almost means that they must the three dimensions to focus on making a third of districts prioritize areas of of health service existing facilities and had serious gaps in investments where availability, service providers more ‘ready’ clinical knowledge. needs and benefits readiness, and clinical to provide effective Monitoring knowledge are greatest. This knowledge at district care, especially in and competencies requires developing a level. It also proposes underperforming is an integral part of deep understanding priority areas of districts. As more the universal health of the barriers to investments to make resources become coverage agenda and health service access, progress on universal available, it could should be integrated including at the health coverage and gradually expand in routine information subnational level. enhance equity. availability of essential systems. services more widely. 02 POLICY BRIEF: Malawi November 2020 Closing the gap M ost countries now coverage, financial protection, and a way to close the gap in agree that striving access to quality health services. achieving UHC in Malawi. It draws for universal health on Malawi’s 2018/19 Harmonised coverage (UHC) To overcome inequities and Health Facility Assessment is important as it helps ensure improve health outcomes, quality (HHFA), which provides critical health for all, while enhancing service coverage to all people evidence on key issues affecting health security nationally, must be expanded. But resources service delivery. The 2018/19 regionally and globally. What is for health are limited, which HHFA offers one of the most more, UHC – defined as ensuring means that governments need comprehensive assessments “access to key promotive, to prioritize areas of investments of the health sector in Malawi preventive, curative and where needs and benefits are because it includes information rehabilitative health interventions greatest. This requires developing about service availability and for all at an affordable cost”[1] a deep understanding of the readiness; providers’ presence – also contributes towards barriers to health service access, and clinical knowledge; and reducing poverty and promoting including at the subnational level. patient-perceived quality of care gender equality. The Government Only with this information can drawn from the Service Availability of Malawi is no exception and is decision makers effectively target and Readiness Assessment* and actively working towards UHC resources and policies to advance the Service Delivery Indicators†. following an explicit constitutional UHC, ensuring access for all people, These were combined into a commitment “to provide adequate regardless of where they live. single tool with five modules: health care, commensurate with facility inventory, health worker the health needs of Malawian This policy brief explores roster, clinical vignettes, facility society and international standards Malawi’s health system gaps and finances and governance and of health care”[2]. The country’s geographic variations across the client exit interviews. Data was Health Sector Strategic Plan II also three key dimensions of service collected from all health facilities refers to the desire to achieve UHC availability, service readiness, in the country (1,106 health by ensuring that everyone has and clinical knowledge of facilities) including government, access to Malawi’s Essential providers. It also offers faith-based, CHAM (Christian Health Package (EHP)[3]. recommendations for prioritized Health Association of Malawi) and investments that tackle inequities private for-profit facilities between Launched in 2004, the EHP has in access to effective care as November 2018 and March 2019. already gone some way towards increasing access to health Health system performance services and improving health outcomes[4]. However, critical health system gaps, including inadequate numbers and by district distribution of health facilities, and severe shortages of health and on average, facilities offered workers, are commonly identified How available were about 70% of what they were as barriers to the implementation essential health services supposed to be delivering. of the EHP[5]. For example, a recent There was also considerable study looking at gaps in UHC across districts in variation across districts in in rural Malawi found that there is Malawi? terms of service availability. a significant geographical disparity The 2018/19 HHFA found that in the distribution of health The goal of the EHP is to offer an only about half of districts facilities[6]. This has resulted in essential package of health (16 out of 29), offered between inequities in effective population services to everyone in Malawi 50% and 75% of the essential POLICY BRIEF: Malawi November 2020 Closing the gap 03 health services they are expected to offer, while the remaining 13 offered more than 75% of these Chitipa services (see Figure 1, where Karonga districts are marked in yellow and green respectively). This leaves Figure 1: significant room for improvement Service availability score by district with regards to service availability throughout the country and Rumphi suggests that an overall lack of health services exists. On the Mzimba North positive side, the survey did not identify any districts with Nkhatabay significantly lower service Likoma availability than the others Mzimba (negative outliers). The service South availability score was calculated using the average number of essential health services offered at health facilities (see Box 1). Nkhotakota Kasungu Ntchisi Dowa Box 1: Service Mchinji Salima Availability Score Lilongwe Definition Dedza Mangochi The service availability score was defined as the average Ntcheu number of health services Balaka Machinga offered at health facilities. Service availablity score Services included in this <50% Serious gap Neno Zomba calculation are as follows: Mwanza 50% - 75% Room Blantyre Phalombe family planning; antenatal for improvment Chiradzulu care; delivery; immunization; Mulanje > 75% Progressing Thyolo child preventative and towards target Chikwawa curative care; malnutrition diagnosis and treatment; Lakes malaria; tuberculosis; and Source: 2018/19 Harmonised Health Nsanje HIV/AIDS. Facility Assessment, 2019 These services were selected to align with the Malawi EHP and the data collected in the 2018/19 HHFA survey. 04 POLICY BRIEF: Malawi November 2020 Closing the gap How ready were districts Chitipa Karonga to offer essential services in terms of key Figure 2: health system inputs? Service readiness score by district Rumphi On average, facilities had just Source: 2018/19 Harmonised over 60% of the critical health Health Facility Assessment, Mzimba 2019 North system inputs needed to deliver high quality EHP services, with all Nkhatabay Likoma districts in Malawi scoring within the 50-75% range. ‘Readiness’ to Mzimba South offer services was calculated based on whether health facilities had a standard set of trained staff and guidelines, equipment, Nkhotakota Kasungu essential medicines and commodities and diagnostics Ntchisi required to deliver EHP services, Dowa among those that were offering the Mchinji Salima service (see Box 2). An average Lilongwe readiness score of just over 60% Dedza suggests there is overall room for improvement in terms of service Mangochi readiness. In Chitipa, facilities Ntcheu had only half of the inputs Balaka Machinga required to deliver EHP services. Higher performing districts such Service readiness score Neno Zomba as Ntchisi and Salima did better <50% Serious gap Mwanza Blantyre and had around two-thirds of 50% - 75% Room Phalombe Chiradzulu essential inputs available for improvment Mulanje Thyolo (see Figure 2). > 75% Progressing Chikwawa towards target What is more, while there was Lakes Nsanje some variability in facility readiness by district, no district had more than three-quarters of the critical inputs required to deliver EHP services, Box 2: Service Readiness Score Definition demonstrating significant gaps in the availability of essential The service readiness score was defined as the average facility inputs required to deliver quality readiness score across EHP health services as defined in Box 1. health services across the Services that were not offered at a facility were excluded from the country. This highlights the need service readiness score for that facility. Individual items required to monitor service readiness along to be ‘ready’ for a service were defined by the WHO Service with service availability, if effective Availability and Readiness Assessment indicators and refined care is to be provided. based on country guidelines. POLICY BRIEF: Malawi November 2020 Closing the gap 05 Source: HHFA 2018/19 06 POLICY BRIEF: Malawi November 2020 Closing the gap Clinical competence: Chitipa Karonga What did healthcare providers know? Figure 3: Provider competency score by district The national provider Rumphi competency score, calculated Source: 2018/19 Harmonised Health Facility Assessment, by measuring health workers’ 2019 Mzimba North clinical knowledge across six conditions using patient Nkhatabay Likoma vignettes (see Box 3), was 58%. This means that, on average, Mzimba h South providers were able to identify the correct diagnosis and treatment for just over half of clinical cases presented. Nkhotakota Kasungu Additionally, only 6% of providers (less than one in ten) offered the Ntchisi correct diagnosis and treatment Dowa for all conditions. The 2018/19 Mchinji Salima HHFA found that clinical Lilongwe knowledge varied substantially Dedza by district, from a low of 45% in Neno district to a high of Mangochi 76% in Machinga district. Ntcheu Balaka Machinga Out of the 29 districts in Malawi, Provider competency score almost one-third (8 out of 29) Zomba <50% Serious gap Neno had serious gaps in terms of Mwanza Blantyre Phalombe clinical knowledge, with providers 50% - 75% Room Chiradzulu for improvment able to identify and treat less Thyolo Mulanje > 75% Progressing than half of the health conditions Chikwawa towards target (see Figure 3). The variability in provider competency was Lakes Nsanje revealed to be one of the most critical barriers to offering effective care as availability of inputs alone will not translate into better health outcomes Box 3: Provider Competency Score Definition unless providers also have the knowledge, skills, and The provider competency score was defined as the average competencies to clinically percentage of selected conditions for which a provider gave the care for patients[7]. correct diagnosis and correct treatment. A total of six tracer conditions were included in this indicator calculation: diarrhoea and dehydration, pneumonia, diabetes, tuberculosis, malaria with anaemia, and anaemia in pregnancy. Data was collected through the administration of patient vignettes. POLICY BRIEF: Malawi November 2020 Closing the gap 07 Table 1: District performance heat map District Service Availability Service Readiness Provider Knowledge Score Score Score 1 Balaka 74.7% 68.9% 59.9% 2 Blantyre 51.2% 52.6% 57.8% 3 Chikwawa 60.8% 55.3% 63.1% 4 Chiradzulu 81.9% 63.2% 48.2% 5 Chitipa 73.2% 50.6% 56.8% 6 Dedza 68.6% 62.6% 46.7% 7 Dowa 76.0% 65.7% 47.7% 8 Karonga 71.0% 60.7% 66.6% 9 Kasungu 68.4% 56.5% 59.7% 10 Likoma 69.4% 61.0% 59.3% 11 Lilongwe 67.4% 59.9% 62.1% 12 Machinga 77.0% 61.6% 75.9% 13 Mangochi 78.7% 66.3% 68.3% 14 Mchinji 65.9% 58.1% 63.7% 15 Mulanje 79.0% 67.3% 65.0% 16 Mwanza 71.6% 66.6% 46.9% 17 Mzimba North 72.9% 61.3% 53.6% 18 Mzimba South 85.7% 69.3% 48.9% 19 Neno 87.8% 71.6% 44.9% 20 Nkhata Bay 82.0% 69.1% 68.0% 21 Nkhotakota 66.9% 60.2% 52.3% 22 Nsanje 71.7% 62.0% 63.8% 23 Ntcheu 71.2% 60.6% 52.5% 24 Ntchisi 90.3% 73.2% 48.8% 25 Phalombe 86.9% 71.0% 46.6% 26 Rumphi 73.8% 61.3% 53.6% 27 Salima 84.1% 72.5% 54.6% 28 Thyolo 65.8% 55.6% 50.6% 29 Zomba 77.1% 69.7% 60.8% Key <50% 50%-75% >75% Room for Progressing Serious Gaps improvement towards target Source: 2018/19 Harmonised Health Facility Assessment, 2019 08 POLICY BRIEF: Malawi November 2020 Closing the gap Health providers at all levels of diagnosis and treatment of acute How and where should care need to be able to diarrhoea and severe dehydration, investments be appropriately assess, diagnose, as well as malaria and anaemia. prioritized to make and manage common childhood When looking at diagnosis and progress on UHC in and adult illnesses. This is critical treatment of malaria with anaemia, Malawi? to prevent complications, reduce it is important to note that without disease progression and severity, accounting for the co-morbidity The findings of the 2018/19 HHFA improve neonatal and pregnancy of anaemia, provider competency point to areas where critical outcomes and, in the case of was substantially higher and in health system support is needed, communicable diseases, lower some districts on par with and highlight particular districts disease transmission. A recent knowledge for diagnosis and that are underperforming relative study estimated that in 2016 alone treatment of adult conditions. to others. The heatmap in Table 1 5 million people died due to poor However, the same was not found summarizes the scores across quality of care in LMICs[8] . for diagnosis and treatment three areas (service availability, of acute diarrhoea with severe service readiness, and provider To further investigate the clinical dehydration: even without clinical knowledge) for each performance of providers in accounting for the co-morbidity district and the colour scheme districts with the most serious of severe dehydration, identifies where serious gaps exist gaps, the 2018/19 HHFA gathered competency of acute diarrhoea (red); where there is room for data on competency to correctly was low. Malawi achieved MDG 4 improvement (yellow); and where diagnose and treat common for child survival through the districts are progressing towards conditions. Figure 5 summarizes scale-up of interventions that are the target (green). the findings for six conditions effective against the major causes separately. Across the lowest of child deaths including malaria, Districts performed best in terms performing districts, providers pneumonia, and diarrhoea[9]. of service availability, but their demonstrated the highest However, to build on this success, service readiness and provider knowledge for adult health sustain these gains, and make knowledge scores were weaker. conditions such as diagnosis progress on child survival, it is This suggests a need to focus and treatment of diabetes and paramount to ensure that on making existing facilities more tuberculosis. Provider knowledge providers have the clinical ‘ready’ to provide effective care was the lowest across districts knowledge to adequately and by ensuring that critical inputs for childhood illnesses such as effectively care for patients. are available and providers have the knowledge to adequately diagnose and treat health conditions. Provider knowledge strikes as the most critical and urgent gap to be filled, given that eight out of 29 districts have serious gaps (a score below 50%) in adequately diagnosing and treating patients for common health conditions (Chiradzulu, Dedza, Dowa, Mwanza, Mzimba South, Neno, Ntchisi, and Phalombe). POLICY BRIEF: Malawi November 2020 Closing the gap 09 8% 8% Chiradzulu Figure 5: 2% 39% Provider 63% competency 59% to correctly 76% 81% diagnose and treat common conditions 1% for under- 7% 22% Dedza performing 64% districts 67% 59% 54% Key: 76% Acute diarrhoea and severe 30% dehydration 33% 14% Dowa 72% Acute diarrhoea 64% only 27% 82% Malaria and 69% anaemia Malaria only 12% 31% Mwanza 12% Pneumonia 39% 69% Normal 27% pregnancy with 66% 97% anemia Diabetes 27% Mzimba South 32% Tuberculosis 5% 21% Source: 2018/19 54% Harmonised Health 48% Facility Assessment, 81% 2019 79% 1% 6% 18% Neno 38% 40% 72% 60% 78% 9% 13% 4% Ntchisi 33% 56% 42% 91% 91% 12% 12% Phalombe 0% 22% 64% 39% 81% 84% 10 POLICY BRIEF: Malawi November 2020 Closing the gap Policy implications While Malawi would benefit from South, Neno, Ntchisi and Phalombe. interventions needed for improving expanding the availability of Ensuring that patients seeking care the clinical quality of care to essential health services at existing facilities receive effective Malawians and therefore health throughout the country, the treatment is a critical step to outcomes. In particular, there is 2018/19 HHFA highlights the need maximize health outcomes, ensure urgent need to close the clinical to prioritize the use of limited value for money, and maintain trust knowledge gaps around child resources for health by making in public sector health care. illness and co-morbidities, in which existing facilities and providers providers showed the lowest levels ‘ready’ to provide effective care in Improving provider competency of clinical knowledge. districts with the most serious to diagnose, treat and manage gaps. These include Chiradzulu, common health conditions is one To inform a roadmap for action, Dedza, Dowa, Mwanza, Mzimba of the most critical human resource further analysis is needed to gain POLICY BRIEF: Malawi November 2020 Closing the gap 11 a deeper understanding of what the actual care delivered. As such, could offer an effective mechanism drives Malawi’s difference in further research to unpack the to do this. This would help identify performance. This includes ‘know-do’ gap will be needed. service quality gaps and inform understanding why some providers plans for ‘hands on’ training, perform better than others in terms Monitoring and improving provider refresher courses, and mentoring of clinical care, and what knowledge and competencies as needed. Implementing this interventions are the best fit to should be included as a core monitoring agenda would provide address the gaps. While the element of the UHC agenda. a critical accountability framework 2018/19 HHFA offers insights Investing in routine monitoring to ensure Malawians received on the level of clinical knowledge of of clinical knowledge and effective care and health financing healthcare providers, it does not go competencies as part of routine resources achieve the highest so far as to provide information on supervision and evaluation activities return on investment. 12 POLICY BRIEF: Malawi November 2020 Closing the gap Endnotes Contacts The Service Availability and Readiness Assessment is a health facility assessment tool designed to assess * and monitor the service availability and readiness of the health sector and to generate evidence to support For more information the planning and managing of a health system. It is designed as a systematic survey to generate a set of tracer indicators of service availability and readiness. on Malawi’s Harmonised Health The Service Delivery Indicators are sets of health and education indicators that examine health workers’ † Facility assessment, and teachers’ effort and ability, as well as the availability of key inputs and resources that contribute to the functioning of a health facility or school. please contact: sdi@worldbank.org References Image Credits 1. World Health Organization. Universal Health Coverage: Factsheet. Geneva; 2019. We are grateful to have been granted permission to use the 2. Government of the Republic of Malawi. Constitution of the Republic of Malawi. Lilongwe; 2017. range of illustrative photos in this brief. 3. Government of the Republic of Malawi. National Community Health Strategy (2017-2022). Cover © Direct Relief Lilongwe; 2017. Page 5 © Direct Relief 4. Ministry of Health and Population [Malawi]. The Essential Health Package (EHP). Available from: Page 8 © UN/OCHA https://www.health.gov.mw/index.php/essential-health-package. Page 10 © US Agency for International Development 5. Chansa C and Pattnaik A. Expanding health care provision in a low-income country: the experience of Malawi. Universal Health Coverage Study Series No.34. Washington, DC: World Bank; 2018. 6. Abiiro, GA, Mbera, GB, De Allegri, M. Gaps in universal health coverage in Malawi: a qualitative study in rural communities. BMC Health Serv Res. 2014;14(1):234. 7. 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;6(11):E1196-E1252. 8. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low- quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. The Lancet. 2018 Nov 17;392(10160):2203-12. 9. Kanyuka M, Ndawala J, Mleme T et al. Malawi and Millennium Development Goal 4: a countdown to 2015 country case study. Lancet Glob Health. 2016;4(3):E201-E214. The policy brief project was generously funded by the World Bank, the Government of Japan (through the Japan Policy and Human Resources Development Fund, administered by the World Bank), and the Global Financing Facility. Additional partners were engaged in supporting the Malawi HHFA survey technically and financially, including the Global Fund to fight AIDS, Tuberculosis, and Malaria, the World Health Organization, the Clinton Health Access Initiative, and the United States Agency for International Development. Disclaimer The World Bank does not guarantee the accuracy, Rights and Permissions © 2020 International Bank for Reconstruction and completeness or currency of the data included in this The material in this work is subject to copyright. 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