By Nyasa Times

Published: June 24, 2009

Let me congratulate you on your appointment as minister of health.  

As you take on what is arguably one of the most important leadership in the ministry of health, you have an opportunity for a moment of reflection: Is the ministry of health on the right track? Given the many health problems in Malawi, what should be the priority for the ministry of health? Can the ministry continue to direct and coordinate the health services? What substance can your leadership bring to the ministry and at what cost to our health system? As a new leader, can you be cynical and strategic in pursuing the importance of realizing health for all Malawians?   

I do not know the definite right answer that you may hold for any of my questions but surely what I know, you as politicians claim completely opposite statements to what should be clear answers. The simple questions I have raised are intertwined perhaps directly linked to how you will manage the health service.  

For most politicians who have had the opportunity to run the health service in the past have given lame answers to what could be objective questions while intuitively justifying their failures of running the health system. For one former health minister, underfunding in the health budget was constant reference points for poor performance and dissatisfactory progress of the health service in providing population health. For sure, the budget is not discursively a defence, perhaps not intuitively good enough reason.  

For you the new minister, I sorely wish you do not give us the same common excuses if asked why you didn’t progress when your tenure in office came to an end.  

Malawians are now fully aware that our health sector expenditure has continuously suffered years of underfunding. Whatever the case, believe me not, everyone in the country will still expect some health returns. I think there are very good reasons to these expectations. The fact that funding to ministry of health is underfunded, it doesn’t mean it can’t reproduce health benefits. Also the fact that funding will not improve for many years to come does not mean Malawians will continue to experience poor health.   

As minister, I think you have great responsibility at hand. Rethink for a moment what you will do to improve the health of Malawians. Just think what you can do even in worse circumstances were economies are crashing and everyone is forced to experience hard times. The point here is that we need to devise strategies and perhaps adapt to cost effective policies. Strategies that deploys less costing yet designed to yield reasonable quality health or longer life.  

The central challenge of your new job shouldn’t be constrained on issues of money or costs. This is just a precautionary warning and it is not to diminish neither your capabilities in the eyes of the reader nor to advocate for certain health policies. It is worth remembering that tasks you undertake determine the success or failure of your tenure in office. It’s up to you to decide while remaining accountable to needs of many people in the country. What is peculiar about your office is that you have the political will that can mobilizes efforts to improve quality life for Malawians. 

While political stamina is not adequate to challenge differential health problems, your agendum of running the health business will require extra aspects of leadership. Most interesting is the forecast of getting things done even if they can’t get done. This vision for population health requires mapping out specific health goals while prioritizing them within the time frame and costs. It doesn’t stop there, it also require vision that directs the entire ministry of health to refocus on public health problems generally affecting the country.  

In broad sense, the ministry of health should not just rely on figures endorsed in the budgets but concentrate on feasible operational strategies. Arguably, any one can dispute or claim that everything or activity in any strategy require a bit of money. That is very true. The reasons are embedded, on one hand that we don’t plan well and on other hand we plan unrealistic targets.

As a minister, you now have a role of acquiring trained public health experts and other trained personnel to help provide cost-effective interventions. This can help national public health systems adhere to proper and effective use of resources while saving costs in subsequent programme strategies. To get there, you will have to institute recruitment, hiring, and firing policies based on merit. All those corrupt experts should go to give room to new blood with new ideas.  I might sound a bit unrealistic but your future ministry needs these expertises that can skilfully support and sustain the ministry in a more adequate and secure manner.  

These expertises will indeed foster a spirit of common purpose across the ministry. You can see for yourself that your ministry needs a major rethink. All around your health systems are problems of poor services either because the hospital has no trained nurses, no surgeons and no health economists. The global health initiatives come and go without concrete achievements. The vertical health programming have sprung up (Global Fund to Fight AIDS, Tuberculosis and Malaria; UNAIDS; the Global Alliance for Vaccines and Immunization) and very soon you and me will witness the millennium development goals go beyond 2015. 

There are very good reasons why there is slow progress in the MDGs and other programmes which your ministry coordinates. I will bring to your attention a few hiccups including problems with overlapping initiatives in global partnerships. 

From the outside, we have seen ministry of health struggle to keep up with the progress of improving health for Malawians. While, the ministry has a well organized primary health care system, its roles to provide  universal health care have evolved while becoming neglected in emerging themes of globalisation, trade and foreign policy. Yet this assigned priority of primary health care is important to unlock barriers to medicines and other health services. In great depth, the role of Primary health care is to contribute towards determining collective health through promotion of universal basic health services.  

The primary health care which your ministry has often ignored is still the right place upon which people’s health can be improved. This system has the most sophisticated organised infrastructure, theories and political principles, within which it can deal adequately with issues of inequity, inequality and social injustice emerging from negative economic externalities and neo-economic policies including issues of underfunding.  

Addressing these issues, especially the complex social and political influences that restrict health services, may require integration of the mainstream principles within primary health care approach.  Based on the current systems, primary health care remain the only conventional health delivery system that can deal adequately with resilient public health problems. However, to strengthen this approach, I propose that your ministry revitalize primary health care whilst incorporating your services with scholarship that tags human rights, partnerships, research and development, advocacy and national drug policies.  

The essence of primary health care approach although often portrayed as an old system, is a vital tool in Malawi since it seeks to address all problems while fighting incursions that perpetuate bureaucratically defined territories.  

As a minister, and supposedly indicated in your job description, you have the responsibility to coordinate efforts with other ministries. Primary health care approach is perfect strategy in beginning to address threads of health problems such as housing, water and food. This approach can also be used as avenue upon which it can assume the main product to raise money consequently improving the budget. This is not rocket science but health management system. I propose to you sir to take advantage of the existing fiscal policies other government are implementing. How about increasing taxes on alcohol and cigarettes to subsidize your health budget.  

These dominant fiscal policies not only increase the budget on health but also become some form of check list in regulating bad health behaviours that cost the government millions of kwacha in health costs.  In short, while you commit to real and measurable objectives, ensure you greatly reduce the dependence on grants and trust funds. If possible, make efforts to acquire funding for priority functions that could be fully protected to avoid the temptation to take on non-priority work simply because funding can be found for it.  

In sum, because maintaining ministry of health’s budget requires pleasing constituencies, and the fact that the agency’s main product such as impartial public health expertise is often undermined. It will be very difficult to implement any successful project especially if the ministry will be strongly influenced by bad politics. For this, a strong leader (like you if am correct) can use diplomatic skills to make sure that the politics is kept at a safe distance from the technical work. If that fails, strategic “naming and shaming” can draw attention to the problem and transfer the pressure of politics back to those who would distort the facts or the process.  I strongly hope you will not be such a leader otherwise that marks your down fall.  

If the ministry was to meaningfully generate, mobilize, and communicate technical guidance to those who are operating programmes on the ground. The ministry should provide the most desperately needed resources and highly valued services that people want. To do this the Ministry as I have proposed earlier requires having all the relevant technical expertise in-house. While it is important to take note of peoples needs, the notion about what works need to be investigated and this can be widely dispersed regarding their sources of knowledge. This can come in form of research or expert consensus. Here, again, the role of leadership is important to mitigate high profile health concerns, like AIDS and swine flu.  

While in office you may consider the following as priority actions.  

First, your action in office can address the public health act. This tool is vital one even though problems solving in public health may be clear. However, in many other cases, problems in public health may require legal considerations.

Here, this tool to any sensible minister will find it helpful in resolving extraordinary problems. The sad part of it all is that public health act for Malawi is outdated and lags behind in so many issues. The 1948 public health is such outdated to confronts or reflect contemporary public health problems. This can be one important job for you in the first few months of office. All you need to do is call for consultations and put through a petition to parliament for review and amendment of the act. The public health act of 1948 has strengths and benefits for improving population health. This act although ignored can also be used to enforce quality standards and disease notification.  

Second, your action can focus on fundamental policy considerations. Here, the Ministry of health should consider the economic and budgetary constraints and clearly map them in terms of importance.  While doing this exercise forget about money since it’s not the only limitation. In health services, they are other fundamental factors that can improve health outcomes that do not necessary depend on spending money to deliver goods and services.  

Third, your action maybe worth while if you continued in scaling up effective interventions. As minister, and since you are new to the office, it’s important that you review existing programmes and perhaps scale up interventions to proven their efficacy. In achieving the scale-up, you require the ambitious goals to implement these activities successfully. You also need to establish new goals and projects that may be associated with your new office.

Forth, your actions need to concentrate on the continued need for ongoing research. In Malawi, experts are not motivated to engage in research. Your office needs to provide necessary funding to these priorities. It’s not a waste but it pays in long terms. Malawi can not smoothly develop if it was to rely on external research. The government and the ministry of health need to pour funding into epidemiological and health systems research to improve the efficiency of available interventions, technological research to reduce their costs, and biomedical research to develop new tools for dealing with as yet unsolved and emerging health problems. 

Firth, your action can focus on opportunities and challenges of globalization. Just as globalization has greatest opportunities, it also has challenges for public health. These challenges require strict scrutiny. Here, the ministry has the responsibility of ensuring that health systems gets all the positive benefits while avoiding negatives such as risks of infectious diseases. We now live in an era when the explosion of trade, travel, and communications is spreading new cultural influences and lifestyles faster than ever before, and the division between domestic and international health problems is becoming increasingly obsolete.  

Sixth, your action can focus entirely on multidisciplinary orientations. Here, the ministry will have to continue and adapt to governance issues that entirely based on the multidisciplinary approach to disease control, which merges the best of the medical and economic sciences. While you are in charge of the ministry, you will to carryout assessments to every recommendation in light of evidence.

*Evanson Sambala, doctorate trainee-epidemiology and public health. University of Nottingham