December 13th, 2011
As a professional working and living in Malawi, I have seen firsthand the country’s health challenges. Landlocked with poor health indicators, Malawi suffers from a high maternal mortality: 637 mothers die for every 100,000 live births. And there are fears that this number may be even higher: public health facilities face frequent and prolonged drug stock outs, and fuel scarcity is hampering smooth referrals of serious cases to higher level health care facilities.
Amidst such challenges, the role of civil society, especially advocates, cannot be overemphasized. Civil society organizations are the “watchdogs” of government. Historically, they have played a critical role, not just by influencing policy formulation, but also by providing checks and balances to government power.
The Malawi System
Just like any development agenda, the delivery of health care services also takes place within a system. In Malawi, this happens on three tiers: primary, secondary and tertiary. And there are three ways in which primary health care can be offered in Malawi. The first is at health centers by health care workers with diplomas or certificates, the second is in village clinics by health surveillance assistants, and the third is in dispensaries at the local level.
Secondary care is provided at the district level by a health officer–often a doctor–and supported by other management team members. Tertiary care happens at the central hospital, a designated teaching facility, established to offer specialized treatment for serious cases. However, there are no district hospitals in districts where central hospitals are operating; thus, central hospitals are finding themselves congested with primary and secondary health care cases. The inefficiencies at both the primary and secondary levels filter up, hindering the tertiary level.
Where Advocates Come In
As a health rights activist working at a local non-governmental organization (NGO), my role has been to link policymakers with the reality on the ground, to ensure that national development policies and the national budget — a critical tool in fostering equitable development — translate into improved health service delivery. For instance, working side-by-side with other partners, the organization I represent was able to influence budgetary allocation increases to the health sector. As a result of our advocacy work, allocation to health has been increasing over time, from about 8 percent in 2006/07 to about 14.5 percent in 2009/10.
Advocacy in Action: The Emergency Human Resources for Health Plan
Coupled with HIV and AIDS, Malawi over the years has been suffering from severe shortages in health care service delivery due to the brain drain. In response to this human capital crisis, the Malawian government and development partners responded in 2004 by creating an Emergency Human Resources for Health Plan (EHRP), a stop-gap arrangment. Included in these measures were a 52 percent salary top-up for frontline health workers provided by DFID (UK’s development agency) and scholarships for paramedics to train through institutions like the Malawi College of Health Sciences and the Christian Health Association of Malawi (CHAM), among others.
EHRP was largely funded by donors such as Norway, DFID, and the World Bank. But as of 2009, the number of primary health care facilities with the minimum requirements of 2:2:1 (2 medical assistants, 2 nurses and 1 environmental health officer) moved from 13 percent to only 33 percent. That 33 percent demonstrates the crisis-level starting point for health workers in the country.
In 2010, the Malawian government withdrew the scholarships it had been providing to CHAM and MCHS, saying that the EHRP was being evaluated and there was no new arrangement with development partners yet on the best way of continuing the program. This angered the general public as students had to pay MK335,000/per academic year, a fee far too high for an ordinary subsistence household in Malawi. (100 Malawian Kwachas equals approximately 61 cents.) As members of civil society, we formed the Human Resources for Health coalition and launched the “fee hike campaign” to lobby policymakers.
The reaction to this campaign from DFID in particular was upsetting; it made me, as a civil society advocate, question whether development partners have ulterior motives in their support. The then-health advisor for DFID tried very hard to lobby the Minister of Health to discipline one particular civil society group: a nurses/midwives trade union organization. The trade union was behind an article in the media about the high vacancy rates that still existed even after the EHRP project.
Ideally, development partners from the US, the UK, Norway and others tend to work with government very closely when everything is okay, leaving out civil society. But at the moment that government fails to meet its obligations, donors then rush to civil society to strengthen their oversight functions. I find this behavior unacceptable, since it is based on frustration rather than trust. DFID wanted to prove to its host country that their aid had worked wonders in Malawi, so they wanted to avoid any contrary view from the civil society. As civil society, we appreciate the role that donors play. But it is our obligation not to twist reality to please a donor or any development country. If we make such a mistake, we lose credibility in the sight of the Malawians that we represent.
However, looking back, we did manage to convince the Minister of Finance and his team to allocate MK198 million for tuition scholarships for 1,200 medical students for CHAM and MCHS in the 2010/2011 budget. We picked medical students to remedy the government’s emphasis on paramedics over university graduates.
The MCHS and CHAM are the only two institutions that produce a cadre of health care workers at Certificate and Diploma levels. These are the ones deployed to work in the rural areas, where there is the greatest need for Human Resources for Health. Because of hard living conditions, these posts are not an attraction to most health care workers with a degree and above. Since rural Malawians should not be punished for living where they do, I lobbied hard for the re-introduction of these scholarships, so that the poor and marginalized would have access to qualified health care workers even at the primary health care levels.
On the Role of Donors
The other major challenge that we face in strengthening health systems and achieving equitable access in health care services is the overemphasis by development partners on the international non-governmental organizations (INGOs) at the expense of the local civil society organizations. Local civil society organizations are often accused of lacking capacity, and yet nobody seems willing to build that capacity. How do you expect an organization with six staff members to work wonders, compared to an INGO with 50 staff? I find myself wondering if donor countries are mainly interested in creating employment for their people under the guise of aid to recipient countries.
I was struck by the findings of a 2010 OECD report that out of every one dollar that the UK sends to developing countries in aid, 80 cents goes back to UK contractors; although the US has improved in recent years, 70 cents of every US aid dollar goes back to US contractors. This to me is a shameful reflection of the reality of donor politics. How are we to make long-term improvements if we have to depend on high-priced consultants and imported commodities?
Local NGOs and the Future of Malawi
The role of donor aid should not be understated in catalyzing positive change, but there needs to be a way to improve aid modalities so that they strengthen local NGOs on the ground. In the long run, it is Malawians who can best address Malawian problems. But the challenge of being an advocate in Africa is that we have to deal with forces that are both internal and external, as Malawi continues to suffer from political and economic instability. Advocates now have to live with castigations on state controlled radio and TV, and threats to our personal safety.
At times like this, it becomes clear that donors need pushy local NGOs to deliver on their long-term goals of increasing access to health care. In return, local NGOs need donors to support them and advocate for their right to push their governments without fear of reprisal. More than medicines and more even than health care workers, this is the best way I know to save lives in Malawi.Email This Post Print This Post