COUNTRY ACCOUNTABILITY FRAMEWORK: Assessment*, Dar-es-Salaam, Tanzania, February 13-15, 2012 Policy Context Global strategy on women and children/ commitment National Health policy/national Health Plan/Strategies M&E platform Malawi will strengthen human resources for health, including accelerating training and recruitment of health professionals to fill all available positions in the health sector; expand infrastructures for maternal, newborn and child health; increase basic emergency obstetric and neonatal care coverage to reach World Health Organization standards; and provide free care through partnerships with private institutions. The goal of Malawi's National Health Policy is to improve the health status of all the people of Malawi by reducing the risk of ill health and occurrence of premature deaths. This overall goal will be achieved by implementing strategies and interventions that address critical areas in health services delivery such as management, hospital reform, quality assurance, public private partnerships, human resources for health, drugs and medical supplies, blood safety, infrastructure and health financing. The national health policy also redefines the essential health package (EHP) based on the burden of disease study and the STEPS survey and it further puts emphasis on the need for an effective monitoring, evaluation and research system that will address the data needs of the sector. The Sector Wide Approach (SWAp) Program of Work (PoW) for Malawi covered the period 2004-2010 and it guided the implementation of interventions aimed at improving the health status of the people of Malawi. The MoH, Health Development Partners (HDPs) and other stakeholders in the health sector were involved in the development and implementation of the PoW. In addition to program monitoring and evaluation (M & E) data routinely collected using the Health Management Information System (HMIS), the PoW also provided for Joint Annual Reviews (JAR) for the health sector, the mid-term review (MTR) and the final evaluation as ways of measuring progress towards achieving the targets set in 2004. The PoW expired in June 2010 but was extended for one year partly to allow for the final evaluation to be completed. The results from both the MTR and the final evaluation informed the development of the Health Sector Strategic Plan (HSSP) 2011-2016. Over the period of the HSSP the MoH and stakeholders will ensure that monitoring and evaluation is strengthened including making the HMIS functional. Some of the key strategies to strengthen M&E are: 1) Strengthen the HIS policy and legislative environment; 2) Build the capacity of the health sector to effectively generate, manage, disseminate and utilise health information at all levels of the sector for programme management and development; 3) Strengthen the monitoring and evaluation system for Malawi s health sector. The development of a comprehensive M&E strategic plan is one of the intervention to strengthen M&E.
COUNTRY ACCOUNTABILITY FRAMEWORK: Assessment*, Dar-es-Salaam, Tanzania, February 13-15, 2012 Country team present at the Tanzania Accountability Workshop, Feb 13-15, 2012 GOVERNMENT John CHIZONGA Economist Ministry of Health Email: cchizonga@yahoo.com Diana KHONJE Acting Chief Reproductive Health Officer Ministry of Health Email: dianakhonje90@yahoo.co.uk Deric ZANERA Chief Statistician Ministry of Health WHO COUNTRY OFFICE Francis MAGOMBO, NPO/MPN Email: magombof@mw.afro.who.int HEALTH EQUITY NETWORK Martha KWATAINE Executive Director UNICEF Ellubey MAGANGA Emal: ermaganga@unicef.org USAID Chimwemwe CHITSULO Email: cchitsulo@usaid.gov
Civil registration & vital statistics systems Assessment 1 Plan 1 Coordinating Mechanism 1.5 Commitment 2 Hospital reporting 1.5 Community reporting 1 Vital statistics 1.5 Local studies 3.00 The Government of Malawi is committed to civil registration and vital statistics (CRVS) strengthening. A CRVS plan was developed in 2003, however, implementation is slow and registration is not mandatory. Hospital reporting is not complete and ICD is not used. Community reporting systems are in pilot stage. There is only one health and demographic surveillance (HDSS) site in Karonga. 1. Conduct CRVS assessment, review plan and strengthen current plan 2. Strengthen hospital reporting and use of ICD for causes 3. Community reporting of birth and deaths (with cause): learn from pilots, roll out 4. Strengthen analytical capacity of vital statistics office 5. Establish more HDSS sites and ensure good reporting
Monitoring of results National M&E Plan 3 M&E Coordination 1.5 Health Surveys 1.5 Facility data (HMIS) 0.66666667 Data sharing 1 Analytical capacity 3 Equity 2 MNCH indicators There is a national monitoring and evaluation (M&E) plan and coordinating committee. Greater involvement of academia is needed. There is no coverage survey planned for 2012-13. HMIS has problems of completeness and data quality. There is a District Health Information System 2 (DHIS-2) pilot in 2 districts. Analytical capacity is limited and there is no specific focus on maternal, neonatal and child health (MNCH). Equity data are presented but can be done more effectively 1. Review and revise the M&E plan for the Malawi Health Sector Strategic Plan (HSSP) to be comprehensive and include maternal neonatal and child health (MNCH) indicators 2. Plan a MICS coverage survey for 2013 3. Conduct data quality analysis, with verification for key indicators 4. Expand DHIS 2, with data clearinghouse 5. Ensure one site for all information (e.g. Malawi Socio-economic Database (MASEDA)) 6. Analytical capacity strengthening at ministry of health (MOH) and other institutions 7. Improve equity analysis and presentation
Maternal death surveillance & response Notification 1 Capacity to review and act 1.5 Hospitals / facilities 2 Quality of care 2 Community reporting & feedback 0.5 Review of the system 3 The national level committee is not functional and has not produced any report since it was constituted. While reviews take place and most of the districts report on maternal deaths, there is no reporting at the national level. The capacity to do maternal death surveillance and response (MDSR) is limited. Reporting is timely but ICD is just being piloted. The private clinics sometimes are not willing to provide data/information. The competence of those doing the maternal death audits is not at the desired level in some cases. An emergency obstetric and neonatal care (EmONC) assessment was done in 2010. 1. Strengthen the national level committee. A technical advisor has taken up this issue. The sexual reproductive health technical working group (SRH TWG) has to take this issue as a key item during their meetings. The reproductive health unit (RHU)has to call for a meeting to discuss this issue. 2. Improve the capacity of those doing the maternal death reviews (MDR) 3. Expand the ICD reporting system. To be discussed at the meeting organized by the RHU. Private health facilities should be actively involved. Facilitate the enacting of regulations that could encourage the private providers to report/provide data. Strengthen hospital capacity to do MDSR. 4. Combine quality of care and service provision surveys. 5. Learn good practices with the aim of adopting those that are relevant. Harmonize tools. 6. Community midwives will assist in the reporting once they are in place (June 2012). However, there is need to scale up the numbers. Ministry of Local Government needs to construct structures for the community midwives to operate from. Enforce verbal autopsies at the district leveldistrict health management teams (DHMT) would actively lead the process. Community midwives should be actively involved in the analysis process. Link with births and deaths registration. 7. Revive the national committee to improve their oversight function.
Innovation and ehealth Policy Infrastructure Services Standards 3 Governance 2 Protection 1 Health management information system (HMIS) strategy is available and the e-health is part of the HMIS strategy. Use of information, communication and technology (ICT) for Reproduction, maternal, neonatal and child health (RMNCH) started in 2 districts. Cell phones are available but internet needs to be upgraded. The availability of electricity in all facilities also needs to be upgraded. Multiple ehealth pilots are being implemented. There are issues with compatibility of data from different systems 1. Evaluate the RMNCH project and then scale up ICT for MNCH 2. Upgrade the infrastructure for electronic communication 3. Strengthen the use of ehealth services to improve information sharing 4. Develop / strengthen a system of coordination of standards to ensure interoperability 5. Develop data protection, legislation and regulatory framework for sharing health information Monitoring of resources National health accounts 2 Compact and coordination 2 Production capacities 0 Data use 1 There is a national health account (NHA) framework and in 2004 and in 2010 MNCH subaccounts were done. There is no compact but resource mapping is done and there is a joint funding agreement for sector-wide approach (SWAp). However, the coordinating mechanism for NHAs and resource tracking is not functioning properly. NHA production capacity needs considerable strengthening 1. Facilitate process to develop a compact 2. Set up a steering committee, officially approved, with institutional support, and functioning using results-based management methods 3. Strengthen NHA capacity: analysis, use of ICT, focus on RMNCH and database improvement 4. Use subaccounts for RMNCH for budgeting
Accountability processes Annual reviews 2 Synthesis informs reviews 1.5 From review to planning 2.5 Compacts or equivalent 3 Annual multi-sector reviews and joint annual reviews (JAR) are conducted mid-year and annually. While key stakeholders are involved, follow-up of agreed upon action points is not done adequately. Civil society are involved but women s organizations are not adequately involved. M&E framework is available in the HSSP and is used for the reviews; however, the M&E plan is understood differently by different partners and there is a multiplicity of tools used to measure this. Data collection for the millennium development goals (MDG) monitoring is weak. Reproductive health (RH) indicators are not included in the Welfare Monitoring Surveys. While survey data are good, there is weakness in the way HMIS data is collected. More work is needed in data utilization. There are multiple reporting channels by different stakeholders that do not involve the MOH. Maternal death audits are conducted (by civil society) but it is not systematically done and it is not discussed at the national level. A maternal death audit committee was put in place but is not active. Mechanisms for M&E exist e.g. the new HSSP has been developed based on the review of the previous strategic plan (sector wide approach (SWAp) programme of work). While stakeholders are involved through technical working groups (TWG), in the zonal and district review meetings, challenges remain on how to translate the review milestones at the district level. No full compact exists - only those partners in the SWAp pool are involved. SWAp is midway to achieving this. While typically not the case, reprogramming can occur within an organization when an activity has already been done using other funds. Sector reviews do take place but not all partners are engaged and not all partners buy in. Synthesis of information is done but does not make full use of data available. 1. Need to conduct a reviews involving both SWAp and non-swap partners. Stakeholder mapping is required. A mapping of women's organization is required to determine who they are and evaluate their presence. These women's organizations need to be engaged. Integrate the monitoring tools and set definitions of indicators. Continue working on alignment of MDG monitoring with the national statistics office (NSO) 2. More work needed in data utilization and developing an integrated reporting system which involves MOH and the use of MOH information for reporting. Engagement of civil society is needed as well as the revamping the MDSR committee 3. Strengthen the zonal and district review processes e.g. meetings 4. Develop a compact. Advocate partners to have a flexible structure for budgeting e.g. during mid-year review
Advocacy & outreach Parliament active in RMNCH 1.5 Active RMNCH civil society 1.67 RMNCH progress report/review 2.6 Media role 0.75 National Countdown meeting 0 Parliament: Member of parliament (MP) involvement on public hearing is not strong. Civil society not active in RMNCH. While there is no coalition of civil society, there is strong engagement of community leaders on maternal health. RMNCH progress report and reviews are not prominent, but some reviews on the integrated management of childhood illness ( IMCI) and MNCH acceleration plan review have been done Media: There is a weekly column on RMNCH in newspapers and a community radio programmes on RMNCH issues. However, sustainability of these programmes could be a problem as it is a donor-funded initiative. 1. Meet MPs to advocate for RMNCH and National Countdown 2015 using the MDG report 2. Mapping of civil society; develop a combined integrated management of childhood illness (IMCI) and maternal child health manual for community mobilization 3. Produce consolidated report on RMNCH and disseminate widely. Design web pages for RMNCH 4. Develop media strategy, sensitize media owners on RMNCH issues, and have regular media briefings 5. Hold Countdown event during 2012-13: create a national committee for it, invite WHO/UNICEF/UNFPA support 6. Better integration of RMNCH in national health sector reviews KEY: Needs to be developed/done Needs a lot of strengthening Needs some strengthening Already present/no action neede