While progress has been made in reducing child mortality in sub-Saharan Africa, maternal mortality continues to pose a persistent challenge. And to achieve the Millennium Development Goals by 2015, the public health community must continue to focus on ways to reduce these deaths—the vast majority of which are avoidable.
 
This Malawi Case Study illustrates how health system strengthening efforts have positively affected maternal health interventions and outcomes in the country. Drawing on an extensive review of both published and unpublished literature, data from large household surveys, and information obtained from interviews with key informants, it describes the health systems challenges faced by the Malawian government in the year 2000 and how the system evolved over the subsequent decade.
 
Malawi faced a severe crisis in human resources for health in the early 2000s, prompting a comprehensive initiative—the Emergency Human Resource Program —which increased the training capacity of institutions and provided financial and other incentives to retain and attract health workers. A Sector Wide Approach in health brought donors together to agree on a common government-led program of work centered around the Essential Health Package, and brought much needed funding to the health sector. A large number of additional Health Surveillance Assistants were deployed and their scope of work was expanded. Together with other health system strengthening initiatives, these three reforms drastically improved the availability, use and quality of key reproductive health services.
 
Major challenges remain, however, as suggested by the experiences of Gladys and Henderson. One example is the insufficient use of Health Management Information Systems data at all levels of the health system, leading to problems in planning and management and perpetuating the problem of poor data quality. And as a result of increased demand for facility-based maternal and neonatal health services, there is the challenge of an increased burden of work for nurses and midwives. Although this problem could be seen as an unintended consequence of some successful health system strengthening initiatives, slow progress in staffing health centers, lack of funds for infrastructure development, and continued problems with staff productivity mean that facilities are unprepared to absorb increases in demand.
 
The case study concludes with a number of strategies to address these challenges. While some involve the injection of additional resources, others aim at making better use of existing resources. The latter range from changes in the organization and management of the supply chain to changes aimed at making health facilities and health workers at all levels more accountable for the quantity and quality of the services they deliver.
 
The lessons learned are important to future efforts to improve maternal health in Malawi and throughout sub-Saharan Africa.

To read this case study, click here

Alex Ergo, Senior Health Economist at MCHIP