• Reference: P-MW-IB0-005
• Approval date: 24/11/2005
• Start date: 04/09/2006
• Appraisal Date: 13/07/2005
• Status: OngoingOnGo
• Implementing Agency: MINISTRY OF HEALTH & POPULATION
• Location: THROUGHOUT THE COUNTRY

The Road Map for Accelerating Reduction of Maternal and Newborn Mortality includes the following activities across the six programmes of the POW.

Human Resources: This programme aims at ensuring adequate staffing at health facilities to provide essential health care package for maternal and neonatal health and building the capacity of training institutions to provide competency based training. This will involve training of tutors and lectures to be able to train more midwives and clinical officers. Training institutions will also be provided with teaching and learning materials to provide competency based training.

Pharmaceutical and Medical Supplies:This programme aims at procuring pharmaceuticals, medical and laboratory supplies to cover essential health care package for maternal and neonatal health.

Essential Basic Equipment: This programme will aim at procurement and maintenance of essential basic equipment to provide emergency obstetric care services.

Infrastructure and Facilities Development: This programme aims at upgrading and rehabilitating existing health facilities to provide adequate geographic coverage of emergency obstetric care services. This will involve establishing or strengthening communication system between health centres and hospitals through installation or repairing radio communication and telephones.

Routine Operations at Service Delivery Level: This programme aims at establishing and strengthening referral system through provision of motorized ambulances, providing supportive supervision to enhance quality of care, training village health committees in maternal health issues including birth preparedness, danger signs and collection of maternal death data. It will also include developing and distribution of IEC materials on birth preparedness and danger signs.

Central Operations, Policy Development and Systems Development: This programme involves reviewing and updating HMIS in line with the Road Map; reviewing, defining and adopting minimum standards and protocols of care for maternal and newborn health. Advocacy packages on maternal and newborn including family planning services will also be developed. Attention will be paid on exploring more active involvement of the private sector in maternal newborn health issues.

The above activities will be defined in Annual Work Plans and will be submitted to the Fund for approval.

The objective of ADF's contribution is to support activities of the programme that are aimed at accelerating reduction of maternal and newborn morbidity and mortality rates.

ADF Support to the health sector programme will focus on addressing issues contributing to the high maternal mortality in Malawi. The Support was designed within the context of SWAp in collaboration with other development partners and stakeholders to enable the Government of Malawi to achieve the MDGs related to maternal and newborn health. Over the years, the Ministry of Health with support from various development partners, notably DFID, UNICEF, UNFPA, WHO, USAID, EU, JICA and the World Bank has implemented several safe motherhood programmes. In spite of all these efforts Malawi's maternal mortality rate has continued to worsen from 620 per 100,000 live births in 1996 to 1,120 per 100,000 in 2000. According to the UNDP Human Development Report (2004), the adjusted rate for maternal mortality in Malawi is 1,800 for the year 2003, which is the second worst rate in the world.

In an effort to reverse the increasing trend of high maternal mortality rate, a multisectoral group consisting of government, stakeholders and development partners developed the Road Map for accelerating the attainment of MDGs related to the maternal and newborn health. The Road Map provides within a SWAp arrangement, a framework for building strategic partnership for increased investments on two levels where the health sector can make a difference, namely, the health service delivery and the community. Focusing investments on health service delivery will enhance availability of emergency obstetric and neonatal care, skilled attendance during pregnancy and childbirth, and essential equipment and supplies that will save the lives of women and newborns at all levels. Whereas, focusing on the community level will empower communities to ensure a continuum of care between the household and health care facility.

The design of ADF Support has addressed government's concerns for improving the overall efficiency of investment in the health sector, by moving away from the traditional project approach to a SWAp with the view to harmonizing donor support and ensuring a more targeted and equitable delivery of health services. This approach is intended to improve efficiency and equity in available resources. Furthermore, the Local Government Act, which was recently passed, provides the necessary legal framework for the decentralization policy, which will facilitate community participation in health planning and decision making i.e. democratic structures for poor people to participate in their own development.

The proposed intervention conforms with the Guidelines for Bank Group Operations using Sector-Wide Approaches (2004), the Bank Group's Health Sector Policy which seeks to improve access to quality health care and the Bank Group's harmonization efforts to reduce transaction costs of development assistance, improve the effectiveness, and efficiency of aid delivery and management. It is also in line with the lending strategy for Malawi, which seeks to alleviate poverty through strong and more equitable growth and improved health status of the population. The poorest and those living in the most remote areas contribute disproportionately to the burden of disease. Consequently, to reduce the burden of disease the programme is designed to strengthen the provision of health care to benefit the poorest and most marginalized people.

The design of the proposed ADF Support has taken into account a number of major lessons learned from the previous five Bank Group interventions in the health sector. This includes delays in project implementation due to the low capacity of the executing agency, the lack of government ownership in the traditional project approach, the need to align expansion of health infrastructure with the required staffing levels and drugs, and lack of capacity to monitor and evaluate project outcomes. As indicated above, the design of the POW and SWAp is based on a government led strategy intended to strengthen local capacity at both central and district levels. GOM and the Development Partners acknowledge the need for clear leadership by the MOH in the provision of health services. The POW and SWAp will ensure availability of adequate drugs and staff in the health facilities. It will also enable the MOH to move away from the individual reviews by various donors to a more coordinated way of monitoring and evaluating performance based on an agreed set of indicators.

The development of SWAp for the health sector of Malaew is taking place against the background of a very poor population and a weak infrastructure. Malawi is one of the poorest countries, with a per capita income of USD 170.00 (2000). It is characterized by inequitable distribution of resources. Access to health services for the poor (majority of which are in rural areas) have been limited due to socioeconomic and geographical barriers. The poor are denied access to services for reasons related to either availability or affordability. One of the strategies the SWAp is the implementation of an Essential Health Package (EHP). This package takes into priority consideration the needs of the most vulnerable population in Malawi, namely rural population. The programme will enhance access of rural population to the Essential Health Package, by strengthened the network of primary health care and providing of quality care.

While there are a number of possible risks in the implementation of the POW, Malawi has the potential for making progress towards achieving the health MDGs with support from its Development Partners. Advances in health status will contribute towards poverty reduction, and therefore, the programme benefits outweigh potential risks. Implementation of the POW through a SWAp arrangement will stimulate participation of users and civil society in planning, decision-making and monitoring of health facilities. The SWAp offers the opportunity for strengthening institutions to improve targeting and focus of resource allocation and activities, accessibility and relevance of health services delivery to the needs of the vulnerable groups, the poor, women and children, a greater proportion of whom are in rural areas. The provision of targeted EHP will lead to an improved health status of the poor population, which in turn will improve their productivity.

Death and disability related to maternal causes account for a large percentage of the burden of disease among women of reproductive age in Malawi. The reduction of maternal and newborn morbidity and mortality requires effective and immediate access to skilled assistance in childbirth and easy access to referral facilities for complications, such as those requiring caesarean sections. In Malawi, it is estimated that about 45% of deliveries are taking place outside the health facilities. With improved access and utilization of these services by pregnant women, it is expected that this proportion would be reduced and infant and maternal mortality would be reduced as well. At least 40% of infant deaths are a result of poor care during pregnancy and delivery, these deaths will be avoided through improved maternal health. Utilization rate of contraception is likely to increase, thereby, improving child spacing and reducing fertility rates.

Ensuring that EHP interventions reach women will strengthen the possibility of meeting poverty reduction objectives and MDG targets. For example, HIV/AIDS has reversed decades of improvements in life expectancy to the current 39 years; left thousands of children orphaned and eroded the quality of health services by straining the limited resources in the MOH. However, sufficiently empowering women to improve their health through implementation of EHP will contribute in reversing this trend. The POW also covers provision of drugs and equipment, infrastructure development, and strengthening the health systems all of which are bound to have a positive social impact.

Furthermore, the EHP provides a limited but effective range of priority services that will be given to all individual Malawians free of charge at the point of delivery. Removal of financial barriers to the provision of health services will ensure accessibility to quality health care for all. This will also have a significant social impact on the health status of the disadvantaged population. Decentralization and community participation in planning and delivery of health interventions will also enhance the capacity of the health sector to reach the poor and vulnerable populations.

The programme is complementary to the Malawi Growth and Development Strategy, which gives utmost attention to needs of the poor. Provision of training and procurement of medical equipment and supplies under the programme will strengthen the skills of the staff, improve diagnostic procedures and treatment, and strengthen the IEC activities with respect to cost-effective interventions that will have major impact on the reduction of disability and absenteeism due to the major diseases in rural remote areas. Reduction of the high morbidity rate due to easily preventable diseases will result in higher productivity. The programme will have a positive impact on the economic well-being of families living in rural areas by lowering costs of treatment and demands on family members to provide support to the sick.

In Malawi women constitute a significant proportion of the work force particularly in the agricultural sector, where they are often major producers of both the subsistence and cash crops. The deaths of women therefore results in loss of to productive contribution to the workforce. The economic impact of women who are disabled due to pregnancy related problems is equally high. The death of mothers also has negative impact on children. The probability of children dying rises with the mother's death. The death of mothers also increases the probability of children's absenteeism from school.

KGOSIDINTSI Nana Beth Gokwadilwe - OSHD3

Finance source	Amount
ADF	UAC 15,000,000
Government	UAC 138,100,000
Co-financier	UAC 325,500,000
Delta	UAC 5,000,000
Total	UAC 483,600,000