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1 Malawi health care system Malawi is currently using a three tier health care delivery system: primary, secondary and tertiary levels of care. About 50% of the health facilities are owned by the Ministry of Health whilst 16% are under the Christian Health Association of Malawi. Private providers own 20%, while non-governmental organizations operate 7%. Statutory corporations and companies own 5% and 2% of the facilities respectively. Access to health services is limited. In 2004, the proportion of the population living within 5 kilometres of a health facility was only 46%.

The health system continues to face a critical shortage of human resources for health (HRH). The current doctor/population and nurse/population ratios are 1:53,176 and 1:2,964, respectively; far below the WHO recommended standards for developing countries; 1 doctor/5,000 population and 1 Nurse/1,000 population. While interventions have been put in place to address the shortage of staff, the health sector still faces challenges. These include the under-production of health personnel and staff attrition due to deaths, resignations and migration. To address these problems, a human resource for health strategic plan 2007-2011 was developed to harness human resource capacity development efforts. The strategic goal of the HRH strategic plan is to attract, develop and retain adequate numbers and well-distributed health workers with the requisite skills and experience for efficient and effective accomplishment of the strategic vision, mission, goals and objectives of the Ministry. There are a number of major challenges with regards to pharmaceuticals. The challenges include ineffective procurement, storage and distribution processes; and inadequate financial resources which negatively affect the supply chain management and result in frequent stockouts of essential drugs and medical supplies. The systems for monitoring of actual consumption of drugs and drug quality control are weak and grossly inadequate. The governments policy emphasises on the provision of health services within the context of health reforms. The reforms are aime d at improving efficiency and enhancing community participation in decision making and implementation of health programmes. Decentralization is one of the major reforms. A devolution plan was developed from the National Decentralization Policy and has guided the decentralization process in the sector. In the devolved state, primary and secondary levels of care are managed by Local Assemblies (LAs). Districts develop their own health plans using participatory structures and funding for health services is channelled directly to the Local Assemblies by the Treasury. At the central level, the main role is that of stewardship which includes, among other roles, provision of technical support to Local Assemblies in the efficient implementation of their health plans. In 2004, the Government of Malawi adopted the SWAp as a mechanism of coordinating the activities of all stakeholders in the health sector. The health SWAp provides for the government and all development partners to pool their resources to support a common plan and expenditure framework that ultimately contributes to the MGDS and the MDGs. The priorities revolve around the provision of the Essential Health Package (EHP), that is delivered free of charge at the point of delivery, and focuses on interventions against 11 major health problems. These include: vaccine preventable diseases; malaria; acute respiratory infections (ARI) including pneumonia; diarrhoeal diseases including cholera; Sexual and reproductive health including family planning; HIV/AIDS and sexually transmitted Infections; tuberculosis; schistosomiasis; nutritional deficiencies; common injuries; and ear, eye and skin infections. Currently the EHP is undergoing review to include non communicable diseases that contribute significantly to the burden of disease. The per capita total health expenditure is at US$20 which is below the US$34 recommended by the WHO Commission on Macroeconomics and Health. In addition, total expenditure on health accounts for about 9% of total government expenditure, which is far below the target of at least 15%, agreed in the Abuja Declaration.