The Ministry of Health in Malawi have analyzed and evaluated the Programme of Work (POW) 1 that ran from 2004 to 2010 and introduced and launched the new Health Sector Strategic Plan (HSSP) 2011-2016. Some of the notable successes of the POW 1 include:
reduction in infant, under five and maternal mortality from 76/1000, 133/1000, 984/100,000, in 2004 to 66/1000, 122/1000 and 675/100,000 in 2010, respectively; increase in under one year children fully immunized, skilled attendance at birth, contraceptive prevalence rate (CPR), HIV infected persons accessing ARVs, primary health centres providing full range of essential health package (EHP) and tuberculosis (TB) cure rate from 75%, 56%, 28%, 3%, 9% and 76% in 2004 to 81%, 75%, 42%, 65%, 78% and 89% in 2010, respectively; and improvement in nurse/patient and doctor/patient ratios from 1/4,000 and 1/62,000 in 2004 to 1/2634 and 1/32,000 in 2010, respectively.
It is against this successful implementation of the POW 1 that the Ministry of Health in Malawi together with it’s Health Sector Stakeholders went further to produce the new HSSP 2011-2016 with higher expectations. Two areas of emphasis in the HSSP are Health Promotion of EHP and Health System Strengthening. The latter involves three-fold pillars that are development & management of HRH; improving supply chain management of drugs & medical supplies; and improving health infrastructure in the country. However, in Health Promotion as a component of the prevention and public health service, is where this article is dwelling upon to expound on the expected challenges and proposition of some tangible remedies.
The current Malawi Public Health Act in use for the first Financial Year of implementing the HSSP 2011-2016 was enacted in 1948. Therefore, it does NOT need one to be a lawyer or a policy maker to visiolize the anticipated (possible) gaps at policy level to implement health promotion effectively. The Malawi Public Health Act 1948 has no clauses specific to non communicable diseases (NCDs), environment health social injustice, consumption of alcohol and smoking just to mention a few. Therefore, the HSSP implementation is likely to hit a fortress snag. The MOH in the country has been pressing for the review of the act document but our honourable (august) house has not prioritized it as it has been left at the law commission for a decade. With the current positive political will in the country where the Minister of Health is the Right Honourable Vice President for the first time, it is my humble hope that the MOH officials need to press even further this time around for the law commission to proceed with this act in the parliament.
The Malawi Health Education Services (HES) Department or Unit is under the Preventive Health Services Directorate in the Ministry of Health (MOH). As such, HES is more obliged for health promotion (HP) activities to do with preventive health services and administratively, sidelining curative and rehabilitative health promotion services which are equally important to clients, acute patients and chronic patients as the unit or department does NOT report directly to other directorates involved in curative and rehabilitative services (Clinical and Nursing Services Directorates). In principle, HES is expected to apply its services to both preventive, curative and rehabilitative clients, such that the HES services are cross cutting in nature. Health Promotion (HP) is defined by WHO as the process of enabling people to increase control over the determinants of health and thereby improve their health ( Adapted from WHO 1998, Health Promotion Glossary, WHO/HPR/HEP/98.1) p.1. The emphasis is on “people to increase control over the determinants of their health” which MUST be interpreted NOT only at primary preventive stage BUT also at both secondary and tertiary preventive stages. Clients/patients with the disease condition already are NOT left out in HP!
Some preliminary studies of the “golden hour” management in trauma and NCDs accidents (comatose clients/patients) in Malawi are showing gaps by the public in how to position the comatose body in transit to the nearest health facilities to prevent further worsening of the condition etc. Such gaps could be filled through effective HP at work place through occupation health. just to mention a few.
It is against this background that I have the opinion of recommending the HES in Malawi to be empowered to execute its duties comprehensively, such that it is better and logical in principle to be an independent directorate to coordinate diligently and effectively with, not only, Health Sector Directorates, but also, other related sectors including safe water supply, availability of healthy foods (agriculture and trade agreements), environmental affairs (climate change issue predisposing to emerging and re-emerging diseases) and education sectors for comprehensive approach to HP!. It is ONLY if this is achieved for HES to operate fully to fulfill its mandate of HP enshrined in WHO of : “HP is the comprehensive social and political process, which involves actions directed at strengthening the skills of individuals to improve their health. It also involves changing social, environmental and economic conditions so as to alleviate their impact on public and individual health”. WHO advocates HP to emphasize on the main prerequisites for health including peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity for total health to be achieved.
Health Expenditure Discrepancy in Malawi:
The Malawi National Health Accounts (NHA) 2010 results have clearly shown this discrepancy depicting the worsening of this phenomenon in the first NHA results that were conducted in 1998. The Malawi NHA 2010 focused on 2006/2007, 2007/2008 and 2008/2009 Financial Years and showed that the average expenditures were 24.7% and 46.0% for Preventive & Public Health Services and Curative Care Services, respectively. The remaining 27.3% was for health administration and other forms. Out of the 46% expenditures on curative health services, inpatient curative care services was 20.2%. The analysis of this results does NOT need one to be a chief accountant to note the discrepancy in health expenditure in resource constraint country like Malawi. Of course, curative care services costs are increasing spontaneously globally through highly advanced dynamic diagnostics, treatment and rehabilitation services.
Some of the leading challenges to this phenomenon include allocation of resources for HES or HP under one health sector directorate, preventive health services. I am of the opinion that if HP is comprehensively looked into in all major health sector directorates’ allocation to involve both secondary and tertiary preventive HP, this discrepancy might be reduced or eliminated for good. On the other hand, all stakeholders of health sector are encouraged to include specific allocation to HES in their programs to institutionalize HP in HES as a directorate of MOH.