Atupele Muluzi: Can we do more with what we already have in Malawi health service?

Assuming the role of Minister of Health and Population has been my greatest challenge in government. It has seen me travel across the country to get a better understanding of the challenges our health sector is facing.

Malawi is extremely fortunate to be served by a highly committed and professional healthcare community. Recent developments in science and technology mean we are more effective in treating a wider range of medical issues than ever before, but they are working in a system where resources are stretched ever tighter.

Our population growth has increased significantly in the last 10 years meaning that the cost of healthcare has increased significantly as well, and our economy has failed to keep up with this growth. Financing the additional costs means we need to work much harder at making the resources we have, stretch further.

Despite these challenges our health service has delivered some real progress in recent years that include:
a. Reduction of the mortality rate of under 5s from 112/1000 live births in 2010 to 63 in 2015/16
b. Reduction in Infant mortality from 66/1000 live births in 2010 to 42 in 2016
c. Maternal mortality has fallen from 675/100,000 population in 2010 to 439 in 2016.
d. With the support of our development partners including UNAIDS, The Global Fund, PEPFAR/USAID, and others, we have seen the prevalence of HIV drop to 8.8% of our population from 15.3% in 1999, noting that our population has also grown significantly over this period. Malawi has also recorded significant progress towards the UNAIDS 90/90/90 targets with a recent assessment of 88/86/90.8.
e. We are now able to manage tuberculosis such that we are seeing only 334 cases per 100,000 individuals with new infections of just 159 per 100,000.
f. The death rate because of Malaria has reduced from 38% in 2014 to 24% in 2016.

Now as we seek to deliver Universal Health Coverage we must look to address some real levers of change to increase the effectiveness across our health sector, while managing the existing challenges that we face from cholera and other diseases.

Lever 1: Doing more with what we already have

Following ‘Cashgate’, many donors retreated from direct budgetary support, we are now slowly rebuilding confidence in our governance; which in turn is having an impact on how much we can then invest in our health service.

Unfortunately, as the cost of delivering our health strategy rises our national budget struggles to keep up with the rising population and its healthcare needs, even with the generous support of our development partners. The result is that we need to look at being more efficient with what we have, driving more value from each Kwacha invested.

My Ministry team is looking at how we can be more efficient, whether this is looking at how condoms purchased under family planning programmes can be incorporated within HIV Prevention activity or streamlining medical commodity supply chains to reduce overhead cost. Additionally, we are also improving dialogue across the healthcare sector to gain more value for the money invested.

The Malawi Government has committed to providing Universal Health Care to all Malawians, but I am not sure that we have done enough to explain what we mean by universal health coverage.

According to the World Health Organisation (WHO), ‘Universal Health Coverage’ means having access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services. The Government of Malawi seeks to achieve this at little or no cost to patients. With healthcare resources being as stretched as we see it today, it is now time to explore different options to cover the increasing costs of healthcare, particularly for those of us who can afford to pay.

This means we need to review the way in which we partner private with public healthcare in Malawi so that we can draw best value from the relationship for everyone. This means we need to look at how we support our civil servants, and make suitable provision for employers to better look after their employees. Government has committed to solving this problem of which a solution could be an insurance scheme. At this stage, my team and I are working with international experts who have real experience across Africa in developing successful and lasting solutions to our healthcare dilemma, looking at what works and does not work – we hope to have something tangible very soon.

Lever 2: Dealing with the theft of drugs and supplies

Apart from being efficient and stretching out our current healthcare resources, is the challenge of eradicating the loss of drugs and medical supplies from our health services through theft. There has been much in the news over the last few months over the theft that has occurred across the medical supply chain. We have used words like leakage when we discuss the issue, but let us be honest, it is clear theft and not from a fat system, but from sick Malawians who are dependent on these resources. The theft ranges from the odd bottle of 250 paracetamol stolen from a hospital ward, to large-scale theft of thousands of commodities from storage facilities.

We think that there are currently up to 13 independent supply chains covering the medical sector. I say ‘think’ as in truth we don’t actually know, but whatever the number it is too many. It means 13 sets of administrative fees, 13 logistics chains and 13 separate reporting and audit structures. This is paid for by the donors and reduces the available investment into valued commodities. Much of this is because of the loss of trust in the central medical stores and our associated systems.

Over the last 2 years the Central Medical Stores Trust has gone through much change to include the opening of a new warehouse that includes chilled storage and new management technology to improve storage of pharmaceutical drugs. A recent audit from DFID and the Global Fund has highlighted systemic issues that have weakened the system. We now need to focus on improving the management systems and the human resources to provide not just external confidence but a credible solution to ensure the people of Malawi receive the drugs they need when they need them.

The Secretary of Health is currently leading a Tiger Team to review our management processes and the people who lead this management. We have included independent subject matter experts who have the depth of understanding and experience to be able to identify where we can have the largest impact on change. Many of the problems we face are not because of a lack of equipment or technology, but simply of poor management and a lack of dedicated technicians to support our already over stretched medical officers. The team are committed to making real change such that it will be with a much more robust structure to improve the situation for the people in Malawi.

Lever 3: Retaining and motivating our professional healthcare staff
As we reduce wastage, and establish more strategic plans to maximise the way we use our limited resources, we are able to free up more finances to invest in our people. Effective healthcare depends on committed and capable healthcare workers, whether they are doctors, midwives, cleaners or administrators. We are now reviewing how we train and then retain the people who serve our health service. We have lost too many good people to posts abroad, or jobs outside of their training simply because of the poor conditions we ask our people to work within. I have met some incredibly dedicated professionals within our health sector, in talking to them, they have offered a number of ideas on how we can make simple changes that will really improve their working conditions.

For example, we have learnt that our young doctors face a terrible choice. Some are offered the opportunity to receive further specialist training outside of the Malawi health service; if they do so, they are then unable to then return to work within our health service. Of course, we need to ensure that our people are trained to the highest standards, but we also need to offer some flexibility, particularly as this is not a unique problem to Malawi. We are now in discussion with the Medical Council of Malawi who govern the medical standards of doctors and nursing staff, to look at how we maintain standards while meeting the needs of our health service.

Our intent is to establish better working conditions across both the public and private healthcare sectors. That means we can both incentivise our healthcare personnel and reduce the number of people that we train then lose.

Lever 4: Engaging with our citizens to improve outcomes
My final lever seeks to establish a more direct line of communications with the people we serve. Having met with patient community groups and volunteer networks across the country, we have observed that, yes, they have complaints about the services they receive, but they also have insights on what can be done to improve them. The Secretary of Health and I are working with a range of community-based organisations, NGOs and other government ministries to look at how we can increase the dialogue between our patients and management of services. This is not just to increase accountability but to also increase the nature of the investment we all have in our healthcare; our collective responsibility to each other

There is much we can all do as individuals to reduce the cost of healthcare. Making sure we all wash our hands with soap after we go to the toilet and before we cook or eat food will dramatically reduce the number of cases of diarrhoea and other gastrointestinal related illnesses in the country. Using a toilet or latrine rather than openly defecating in random, undesignated areas and managing rubbish will not only improve how Malawi looks but reduce the spread of diseases such as cholera which is currently killing people across the country.

We recently hosted a symposium to look at the prevention of HIV/AIDS. Through this discussion we learnt about how behaviour change campaigns have achieved real change in public health issues across the region and indeed the world.
The accountability that we hope to gain from better engaging with our communities, I hope will transact in better influence in changing how we look after ourselves and those we love at home.

As we move forward, I hope to lead a Ministry of Health and Population that asks greater questions of itself and engages more directly with the people we serve. In return, I hope that the people of Malawi will understand the responsibility that we all have to each other. There is always more we can do to improve our health service, but there is also much we can do to reduce the stress on the health system through our own personal health and hygiene practices.

Malawi’s recent past has established an over-reliance on Government to provide; this in turn has weakened our health economy, reduced any self-reliance and established little or no long-term strategy. We must as a nation change. Yes, Government needs to evolve the policies of governance and we need to hold our civil service to a higher standard of delivery, but we, as Malawians must also change what we expect of each other. I am not shirking any responsibility as a Minister, but simply hope to change how we live together as a nation.

By looking to achieve more with the resources we have and reducing the loss through theft, we can deliver better impact across the health sector. This in turn will increase the investment we can make in our staff and by engaging more proactively with the people who use our health service we can better target where and how these investments are made.

The key deliverables for the next six months are:
1. Enactment of the revised Pharmacy, Medicine & Poisons Bill to provide stiffer penalties and fines for drugs theft offenders.
2. New health policies that deal with emerging issues such as health financing and mental health.
3. Finalisation of the Adolescent Girls & Young Women Strategy.

These are whole of government issues that need to be supported. As we start 2018, please can I ask that we take some time to reflect on what we want of a better Malawi, and what we can all do to help as a unified nation to get there. It is time that we stop the petty political squabbling and instead work closer together – the stakes are simply too high.

• The author is Ministry of Health and Population

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