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Stefan Leiderer et al. — Several health centres for the delivery of primary health services (maternal and child health, treatment of common diseases). Health centres are not separate cost centres but fall under the responsibility of district hospitals. As such, the Ministry of Health and Population (MoH) accounts for 64 % of the total number of formal health facilities (Hanson 2005, 1). Beside the public health care providers and some private clinics, non-governmental organisations play an important role in providing health care services in Malawi. The most important among these is the Christian Health Association of Malawi (CHAM), which provides 26 % of health care facilities (Hanson 2005, 1). 6 The most prominent government strategy in the Malawian health sector is the Essential Healthcare Package (EHP), which is also incorporated in the MPRSP. The EHP consists of a bundle of health services that are supposedly available for every Malawian throughout the country. It is intended to improve the quality and availability of essential healthcare inputs, to improve the access to essential healthcare and to strengthen the administration and financing of essential healthcare services (Republic of Malawi 2002, 60). Implementation of the EHP programme, however, is difficult, not least due to the poor staffing situation in the sector. The health sector is extremely donor dependent, with donors providing around 60–75 % of total expenditure over the period from 2000/01 to 2003/04 (Hanson 2005, 8). In October 2004 the government and a group of donors (DFID, NORAD, World Bank) launched a Sector Wide Approach (SWAp) for the health sector. The financing mechanism is viewed as an important instrument for implementing the EHP. Accordingly, the EHP Programme of Work provides an extensive list of activities that should be financed with SWAp resources (Republic of Malawi 2004). Although at the time of research, the SWAp was still in its very early stages, most stakeholders expected substantial improvements regarding the alignment of donor procedures to the Malawian budget cycle and donor coordination in general, 6 CHAM coordinates health units from different church denominations, including hospitals, health centres, and dispensaries. Together, these units provide roughly one third of health services in Malawi. CHAM receives funds from government, churches and private donations. In addition, it charges user fees for health services. 52 German Development Institute
Public Financial Management for PRSP Implementation in Malawi leading to reduced workload on all sides thanks to harmonised monitoring and reporting requirements. Most votes within the health budget (around 80–90 %) are classified as Poverty Priority Expenditures (PPEs) and thus cannot be cut back during the budget year in case of cash fluctuations (see Section 5.1.2). As a result, funding for salaries and drugs appear to be disbursed relatively regularly and without substantial fluctuations during the financial year. 7 This seems to apply less so to expenditures for administration at headquarters. Furthermore, operational costs are often cutback substantially during the fiscal year, because expenditure items such as fuel, electricity, water etc are not classified as PPEs. Similar to teachers in the education sector, one major problem in the health sector consists in the lack of qualified medical staff. Table 1 shows the population to health personnel ratios for doctors and nurses in Malawi. Approximately 50 % of key positions, such as doctors, clinical officers and nurses cannot be filled; this leads to a severe shortage of medical professionals in public hospitals and health centres. Although the government produces a number of qualified professionals in nursing schools and universities, a large share of these graduates are absorbed by private facilities offering better salaries or they emigrate to Europe and other countries where salaries are generally much higher than public sector pay in Malawi. 8 Among the reasons for the poor staffing situation are the cumbersome recruitment process and poor coordination between different departments in the MoH. For example, it is common for new staff to receive their first salary 3–4 months after taking up their job in the public health service. 7 However, this does not mean that drugs and supplies are readily available in all regions of the country, as explained below, 8 Especially the UK is blamed for luring urgently needed nurses and doctors away from Malawi. As a counter-measure, the British Department for International Development (DFID) has recently agreed to top up the salaries in Malawi’s public health sector. This measure should attenuate the brain drain and contribute to attracting and retaining more qualified medical professionals in the public sector. German Development Institute 53
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Public Financial Management for PRS
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Studies Deutsches Institut für Ent
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Preface The present study on ‘Pub
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4 The Case of Malawi 44 4.1 Why Mal
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Bibliography 151 Annexes 157 Tables
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Boxes and Tables in the Annexes Box
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DS EHP ESAF EU GBS GDP GoM GRF GTZ
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TOR UDF UNCDF UNDP UNV USAID VAP VD
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Discussion Paper 16/2007 Schirm, St
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