1 CHAPTER 1.

1.1 Introduction: Mission and Strategic Interventions of the Ministry of Health

The Ministry of Health in collaboration with its cooperating Partners have since been implementing a six year Program of Work under the framework of Sector Wide Approach. The POW identifies strategic interventions that would assist the Ministry of Health realise its Mission which is to ‘ stabilize and improve the health status of Malawians by ensuring availability of an effective health care delivery system that is capable of promoting health, preventing disease, protecting life and fostering well-being’. The major strategic intervention in the POW is to ensure access of an essential health package to all Malawians especially the rural poor and vulnerable groups such as women and children. The essential health package comprises of high impact health interventions that address disease conditions that contribute to high burden of morbidity and mortality in the population. Other strategic interventions that support delivery of the essential health package are as in Figure 1

1.2 Implementers of the Program of Work

The Ministry of health is the major implementer of the POW intervention especially delivery of the essential health package through its chain of central hospitals , district hospitals, rural and community hospitals, health centers, dispensaries and health posts. Other players in the sector who work in partnership with the Ministry include CHAM, Banja la Mtsogolo (BLM) and the private hospitals and clinics. Health Training institutions also play their part by training health workers both at pre-service and post basic level, while other members of civil society play advocacy role as well as monitoring satisfaction of beneficiaries Figure 1: Strategic Interventions of the Health program of Work

Increase availability of health workers in the public health sectorDevelopment; recruitment and retention of Human resources a amanagement of f Human Resources

Develop, review and monitor implementation of health related policies, gguidelines & standardsguidelines and standards Monitoring and Evaluation

Development and rehabilitation of health Infrastructure

Ensure access to quality essential health services

Increased availability of essential drugs and medical supplies suppliesSupply of drugs and medical supplies

Continuous availability & maintenance of medical equipmentuProvision and maintenance of equipment

Strengthening operations at district level

1.3 Financing of the Program of Work.

Financial resources for the POW are from government and cooperating partners who provide financial resources either as pool donors or discrete donors. During the reporting period, funding from some pool partners such as the World Bank and Sweden expired and has not been renewed. The Flemish Government is expected to join the pool fund in the coming financial year The Current financial resources are therefore form:

Malawi Government British Government through DFID Government of Norway Global Fund German Government (KFW & GTZ))

UNFPA UNICEF World Health Organization Iceida African Development Bank USAID

1.4 . Monitoring Implementation of the Program of Work

2 Progress of implementation of POW is monitored through a numbers of modalities which include continuous supervision by different levels of the Ministry of health; joint annual and midyear reviews, technical working group meetings, collection and analysis of data on agreed upon indicators of the POW.

CHAPTER 2: PROGRESS OF IMPLEMENTATION

o 2. 2. 1 Achievement of SWAP POW Indicators

Good progress has been observed in most of the targets set for the 2008/009 financial year. Among the achievements recorded include continued increase in EHP coverage ( (number for facilities able to deliver general OPD services; immunizations, family planning and maternity services) from 74% to85%; utilization of OPD services in health facilities from 1170 to1235 per 1000 population, proportion of one year children immunized against measles from 84% to 89%;and proportion of births attended by skilled attendance from 48% to 52% and increase in percentage ( 80 % t0 88%) of HIV pregnant women who receive complete ARP prophylaxis to reduce mother to child transmission. Little or no progress was observed in some indicators such as number of pregnant women and under-five children who slept under an ITN and number of pregnant women who start antenatal care within the first trimester. Annex1 provides details on progress made on each indicator

2.2.2 Progress on Strategic Intervention 1. Increasing Availability of Human Resources for Health

Development and management of human resources for health continues to be a priority intervention in the health sector to ensure appropriate staffing levels at all levels of health services delivery points. Activities carried out during the 2008/009 financial year included, support for pre-service and post basic

training, recruitment from training schools and the labor market, provision of incentives and in-service or continuous short term training. Implementation of these activities took into consideration recommendations and milestone agreed upon during the 2007/008 Joint Annual Review (Annex 2).

2.2.2.1. Pre-service Training

Pre-service and upgrading programs for professional health workers were given priority. All training institutions maintained their high enrollment figures, a total number of 1021 joined the various training school to train either as medical doctors medical scientists, pharmacists, nurses, clinical officers etc. Similarly the number of graduates is also on a steady increase as shown on as shown on Table 2. In addition to pre-service training, support was also given to those health workers interested in specializing or upgrading their basic qualification. The specialized courses included Masters degrees in paediatrics and internal medicine for medical doctors, masters degree in public health for clinical and non clinical personnel; midwifery for nurses and upgrading for diploma nurses and nurse technicians. Tables 1 and 2 provide details of the students enrolled for and graduating from the different training programs. As can be observed on tables 1 and 2, priority was given to training of professional health workers over management and development programs. Only 15 officers from the Finance department went for training in EPICOR in Tanzania.

Table 1: Number of Students Entering and Graduating from health training Institutions ( 2008/009 Academic year

No Category of Health Worker New Enrollment: 2008/009

Continuing Students

2008/009 Graduate

1 Medical Doctors 61 277 452 BSN 106 257 643 BMedSc ( Lab) 26 66 144 B.Pharma 20 45 05 Dip Clinical Med 91 1206 Dip RN 65 16 317 Dip NMT 452 698 3628 Cert. Clinical Med 120 281 1509 Lab Tech 20 45 3410 Pharmacy Tech 20 40 1911 Radiology Tech 20 38 2412 Dental Tech 20 15 8

Table 2. Number of Students Enrolled and Graduating from Post Basic Training Programs

No Type of Training

New Enrollment: 2008/009

Continuing students

Graduating Students

1 Master of Public Health

6 24 17

2 Mmed ( Paeds)

- - 1

3 Mmed ( Internal medicine)

- - 1

4 Mmed 8 - -5 MSN

( Midwifery) 10 - -

6 BSc ( Nursing Educ.)

29 22 26

7 Unv. Cert. Midwifery

35 - 30

8 RN upgrading 22 22 159 Psychiatry

Nursing 8 - 12

10 Community Nursing

1 5 - 15

11 MSc ( RH 2 - -12 TOTAL 135 68 11913

2.2.2.2. Short- Term Training

To assist health workers keep abreast of new knowledge and developments in health services a number of short trainings were conducted either by central or district level. Training targeted all categories of health workers as well as extension workers who support implementation of preventive health programs. Details of the trainings and the number of people trained are as in Table 3 below.

Table3: Category of Health Workers who participated in short term Trainings in 2008/2009

No Type of Training Category of Health Workers Number Trained1 HIV Testing & Counseling Clinical & Non Clinical staff 7312 HTC Supervision Clinicians 343 Update on HIV & AIDS Clinical & Nursing Educators/Tutors 254 ART & OI Management Clinicians & Nursing Personnel 4505 STI Trainers Update Clinicians 806 STI Syndromic management Clinical & Nursing Personnel 257 TOT WBRT Lab Technicians8 STI M&E tools Clinical, Nursing & Lab Techs 1109 Oncocerciasis prevention Extension workers 10,49310 Oncocerciasis mass treatment Clinical, nursing, environmental staff 2,83011 IDSR Lab personnel 140

12 ARI case management ( ETAT) Clinical & Nursing Personnel 32013 Community IMCI HSAs 47314 Food safety & Water quality

monitoringExtension workers 88

15 Professionalism & Ethics Registered Nurse- Midwives 9116 Cholera case management Mixed categories of health workers & extension

workers10,190

2.2.2.3. Recruitment and Deployment.

In addition to supporting training of professional health workers, the Ministry in collaboration with the health Service Commission conducted recruitment exercise for the public health sector. The recruitment exercise focused on students who were about to complete their training as well as those health workers who were outside the public health sector or were out of employment. Through these efforts 871 graduates were recruited and deployed to various government health facilities including CHAM. The gala exercise which focused on the open labor market identified 500 health workers comprising Clinical Officers, Nurses Medical Assistants and Environmental health Officers who will be offered employment in the coming financial year (2009/2010).

2.2.2.4. Retention and attrition of Health Workers in MOH Facilities.

Recruitment of health workers into the public health sectors need to be supported by retention strategies if the goal of increasing staffing levels is to be achieved. The incentive package which was developed and adopted last year was not implemented due to financial constraints. However two interventions which were included in the 2008/009 budget were implemented. These included continued payment of 52% salary top up for professional health workers and promotions. Most promotions were effected to fill vacancies created through the 2007/008 Functional review; through interview procedures, the Health Service Commissions recommended for promotion 171 health workers of various categories. Despite the recruitment and retention efforts, the public health sector still experiences attrition of health workers. During the period under review, 331 exited the public health sector either through death resignations and retirement. As shown on Figure 2 below, death accounted for

the highest (55%) cause of attrition followed by resignations. A few people retired from the service.

FIGURE 2: Causes of Attrition

169110

31

DeathResignationsRetirement

Due to the high numbers of attrition the net gain from the recruitment exercise is high not enough to make a significant reduction on the vacancy rate which is still high for medical doctors (58%) and 76% for nursing personnel. Figure 3 provides details on the vacancy rate for the different cadres in the Ministry of Health FIGURE 3: VACANCY RATES

Vacancy Analysis as of June, 2009

49

1522

63

86

5866

73 74 76

3242

88

00

102030405060708090

100

Admini

strati

on

Human

Resou

rce

Accou

nting

Audit

Specia

list

Doctor

s

Clinica

l

Techn

ical

Pharm

acy

Nursing

Preven

tive

Attend

ants

Plannin

g

HIV &

AID

S

Cadre

Rat

e

Vac

2.3. Strategy/ Pillar 2 – Provision of Pharmaceuticals and Medical Supplies

The target for pharmaceuticals and medical supplies in the period under review was to make sure that essential drugs, medical supplies and laboratory reagents are readily available in all facilities in the country. In order to do this the ministry allocated 15% of its total budget for procurement of drugs, medical supplies and laboratory reagents.

2.3.2. Drug Availability

Activities implemented to achieve the stated target involved among other things strengthening the logistics supply chain which included national drug quantification exercise in order to quantify national drug needs; issuance of tenders and procurement of drugs at Central Medical Stores (CMS), timely completion and submission of LMIS by DHMTs to inform CMS on monthly drug orders; timely distribution by CMS and active security measures for drugs both at CMS, RMS and service delivery points. Other activities carried out included capacity building of Zonal and District teams on monitoring drug usage, training of pharmacy technicians in LMIS and supportive supervision, production and circulation of monthly stock status report of Tracer Drugs.

Major achievement during the reporting period was reduction in stock out days for most essential drugs except for HIV test Kits. Figure 4 provides details on availability of some

tracer drugs. In addition to HIV test Kits, there are other essential items that were perpetually out of Stock at CMS. For example drug such as

Tetracyclines Sulbutanol Nebuliser Hydrocortizone injection Heppatitis vaccine Salbutanol tabletsAminophylline tablets Skin codition creams/ointments Quinine tablets Suture Umbilical cord cramp

Due to this perpetual stock out of these items DHMTs were forced to procure the items from commercial pharmaceutical stores at higher prices. This may probably be one of the reasons why DHMTS have accumulated a high debt at CMS. HIV Kits were also out of

FIGURE 4: Drug Availability by Zone

NZ

CEZ

CWZ

SEZ

SWZ

0 20 40 60 80 100 120

LA4x6LA 1x6SPTB drugsDiazepamTTVOyctocinORSH/Test Kits70

2.3.3. Interventions to improve availability of HIV Test kits

Following the wide spread stock out of HIV test kits an assessment of the HIV test kits logistics system was done which revealed systemic supply chain challenges such as1. Wide variations in the distribution of test kits across the supply chain2. Wide variations in the ordering of the test kits3. Inconsistent reporting on consumption and stock on hand4. Inconsistencies in the use of LMIS forms5. No standard system for storage and delivery of kits

To address these problems the following were recommended

1. Management of test kits to be fully integrated into MOH commodities logistics management system (MHCLMS). This is the system used for managing essential drugs and medical supplies.

2. Health Centres and HTC sites will pull test kits from RMS through their districts by completing LMIS forms and then submitting them to district pharmacy technicians.

3. Re-supply quantities will be generated by the supply chain manager (SCM), based on past month consumption.

4. RMS will be the central storage facility for HIV test kits. 5. District pharmacy and drug stores at Health Centres will be the storage facilities for Test

kits.6. High consumption sites, like MACRO and Lighthouse Trust, and other NGOs/CBOs that

do not have a pharmacy will be required to have a storage room with restricted access for storage of kits.

7. HTC counselors will be responsible for proper storage of tests in their custody in a lockable cabinet.

8. RMS will be responsible for direct delivery of kits, together with other essential drugs and health commodities to all hospitals, HCs including CHAM facilities.

9. High consumption sites will pay for and collect their kits from RMS10. NGOs/CBOs will collect from district pharmacies.

Other achievements in ensuring drug availability included:

1. Improved record keeping that has assisted in better forecasting and quantification of national drug requirement

2. Circulation of stock Status of Tracer drugs has provided opportunity for DHMTs to predict drugs available and prepare for requesting authority to procure outside CMS system

3. Quantification exercise has assisted CMS to estimate appropriate drug budget to meet national drug demand

2.3.4. Transformation of Central Medical Stores

Other interventions carried out on this strategy were efforts towards transformation of CMS from a Treasury Fund to Public trust Status. Major achievements in this area are the deregistering of CMS as Treasury Fund and the development of a Trust Deed which has been forwarded to the Minister of Justice for legal advice. Other support activities for this transformation are development of a draft organizational chart for the proposed Public Trust and the progressive recapitalization of the CMS through provision of funds necessary for establishment of letters of credit for procurement of drugs.

2.4. Strategy / Pillar 3: Continuous Availability and maintenance of Basic medical equipment

Availability of basic equipment is an essential component of health service delivery. Interventions planned during the year to ensure availability of such equipment included the following:

Standardization of equipment list for district/community hospitals and health centers Procurement of medical and hospital equipment Planned Preventive Maintenance Finalization of Standard List for medical equipment Equipment survey to determine the gap Specialist technician training in the maintenance training in dialysis machines and x-ray machines.

Implementation of these activities was however hampered during the period under review due to limited budget as out of the requested budget of MK1.1bn only MK66 million was provided for. Similarly, out of MK66 requested for operations only MK19m for operations was approved. Due to this financial handicap, only Kamuzu Central hospital received new laundry and opthamology equipment procured at MK98 million. Contracts for the supply of medical equipment for the various hospitals worth MK305m have been signed with various suppliers, and delivery is expected in the next financial year. The planned preventive maintenance of equipment in facilities was not carried out du to budgetary constraints Likewise, no spare parts were procured because of the same reason. Facilities, therefore relied on their old equipment to provide services. Most of the available equipment functioned optimally through out the year as shown on Figure 5 . However functionality of some equipment was not at 100% as shown Figures 5 and 6.

FIGURE 5: Percent of functional days for Basic Equipment

B/bank Oxy.Conc.

X-ray75

80

85

90

95

100

B/babankOX.Conce.Xray

The standard list for medical equipment for district and community hospitals, and health centres was formulated and published in March 2009 with joint funding from SWAp and JICA. .

Equipment survey was conducted to establish what equipment is available against the expected figures as prescribed by the Standard List of equipment. Currently, analysis is being carried out to determine the gap in district and community hospitals and health centres. Similar analysis for central hospitals awaits the determination of a Standard List for Central Hospitals.

FIGURE 6:Percent Functional Days for Basic

M/Cold Room

Ultra-sound

gen-erator

74767880828486889092

M/Cold RoomUltrasoundGenerator

2.5. Strategy/ Pillar 4: Development and Rehabilitation of Health Infrastructure

2.5.2. Funding for Infrastructure Activities

The 08/09 development budget was funded up to 6.8billion for both part I (6,757,970,000)

and part II (113,000,000). The targeted projects were as follows:, construction of Umoyo

staff houses, Construction of Basic Obstetric Care, expansion of training institutions,

construction of laboratories, Construction of Orthopaedic Centre at Kamuzu Central

Hospital, Rehabilitation of Zomba Central and Balaka District Hospitals, reconstruction of

Mzuzu Central Hospital sewerage, and preparatory work for the New Nkhata, Phalombe

District Hospital and Dowa District Hospitals. Apart from this budget districts and partners

had set aside funds to improve infrastructure in many facilities in the districts

2.5.3. Construction of Umoyo Staff Houses

The project aimed at improving the delivery through proper accommodation for medical

personnel. It involved the construction of new 250 houses that have been built across the

country and also rehabilitation the 250 existing staff houses. The initial plan was to construct

300 new staff houses but it was later revised considering the need for rehabilitating some

existing ones to avoid imbalances at the health facility.

The project is funded from the SWAp pool funds. The total budget for 08/09 was around

MK3.5 billion. The project has so far disbursed MK2 billion, an amount which was funded

but less than what was provided for in the budget. Currently, almost 95% of the new houses

is complete and 80% of the houses under rehabilitations are also complete. The challenge so

far is utilities connection by Electricity Supply Commission (ESCOM) and Water Boards,

which has prevented most of the houses be handed over.. The Ministry has since

communicated to the concerned authorities so as to have all connections done by end October

2009.

Completed Umoyo in NgabuRrural Hospital Chikwawa awaiting electricity

connection.

2.5.4. Construction of Basic Emergency Obstetric Care units (BEmOC)

The project aims at rehabilitating 54 health centres and make them BEmOC sites where

maternal services are being provided, provision of houses and functional utilities. The project

is being funded by a grant from the African Development Bank amounting to US$15million

(MK1.9) across the country and also includes support to the reproductive health programmes

mainly training. The Ministry has so far disbursed MK800million and is expected to

disbursed the rest before the grants expires in June 2010. The 44 BEmOC sites are expected

to be completed by October 2009 and the remaining 12 which were re-tendered due to no

proper bidders, by June 2010. Below is one of the BEmOC sites in Chisoka, Thyolo:

Chisoka BEmOC site showing part of the houses, the OPD and Martenity ward.

Expansion of Training Institutions.

With an aim of increasing intake to Health Training Institutions, the Ministry supports

Training Institutions in their Capital Investment. These are Malawi College of Medicine,

Malawi College of Health Sciences (Blantyre, Zomba and Lilongwe), Kamuzu College of

Nursing and CHAM. In 08/09, the total support was about MK888million and 09/10 is about

MK683million. Malawi College of Medicine resource centre captured below which is

expected to be completed by November 2009, is among the structures benefiting from the

pool funds.

Resource Centre at Malawi College of Medicine, Blantyre Campus.

Malawi College of Medicine Lilongwe Campus awaits the awarding of contract and is

expected to start in the 09/10 financial year. However, Malawi College of Healh Science

expansion in Lilongwe started as well as Blantyre campus for Kamuzu College of Nursing in

Kameza..

2.5.5. Laboratories Refurbishments

The project aimed at refurbishing laboratories as a way of improving diagnostic services both

at district and health centre levels. The budget provision was MK300 million. The phase one

considered the refurbishment of 7 laboratories and these included: Mangochi and Mwanza in

the southern region, Lilongwe (Bwaila), Mchinji, Kasungu in the central, and Rumphi,

Nkhata Bay in the north. Mchinji laboratory was completed and is now in use, Bwaila,

Mangochi and Mwaza are also completed and are about to be handed over. Poor

workmanship in Kasungu, Rumphi, and slow progress by the contractor in Nkhata Bay, has

had a negative effect on the completion of these laboratories. This project is overdue and has

had a very poor disbursement record. The Ministry is therefore planning to engage a

consultant who will supervise the remaining works in Kasungu, Rumpi and Nkhata Bay and

also help in supervising the 09/10 budgeted 23 laboratories refurbishment in various district

and health centre facilities.

2.5.6. Construction of Orthopaedic Centre at Kamuzu Central Hospital

The project involved the construction of an Orthopaedic Centre at Kamuzu Central Hospital.

The 08/09 provision was MK10, 500,000 and the work is completed

2.5.7. Rehabilitation of Balaka District Hospital

The project involved the construction of an administration block, paediatric ward, isolation

ward, kitchen and a VCT centre. The project aims at upgrading the hospital to be a fully

fledged District Hospital and it is being financed from the pool funds with a 08/09 budget

provision of MK40 million. This however had fallen short to the estimated scope of work

which was pegged at MK136 million. This project was expected to be completed by June 09,

however, due to late signing of the contract and the extension of the scope of work mainly for

the VCT centre, all works are expected to be completed by December 2009. The project has

so far disbursed MK119 million. However, from the revised estimates from the Ministry of

works experts, largely due to the inclusion of a VCT centre, the project is expected to cost

MK179 million.

2.5.8. Rehabilitation of Zomba Central Hospital

The project is funded under SWAp pool funds comprising of TB wards, dental clinic and

administration block (lot 1) and also staff houses (lot 2). The budget 08/09 provision was

MK548 million. Lot 1 commenced in September 2008 and is expected to be completed in

August 2011. So far, 30% of the work has been completed. The construction of houses is

expected to be completed November 2009 and is currently at 40% completion. There is also

an eye clinic under construction being funded by Lions AID Norway.

2.5.9. Preparatory work for Phalombe, Dowa and Nkhata Bay District Hospitals

The new Phalombe District Hospital project has not yet started due to lack of potential donor.

This also applies to new Dowa District Hospital. However, 2009/10 will allocated funds for

designing and the Environmental Impact Assessment as part of preparatory works. Clearing

the site for new Nkhata Bay District Hospital is finished and award of contract is expected to

be by December 2009. The hospital is expected to be completed by November 2011. The

total cost including equipment, is estimated at $10.7million.

2.5.10. Maintenance of Mzuzu Sewerage System at Mzuzu Central Hospital

The project aims at rehabilitating the Mzuzu Central Hospital sewerage. The 08/09 budget

provisions were MK12 million. The work which is being supervised by the Ministry of

Works is yet to be implemented in the 09/10. The project did not take place due to capacity

problems by the supervisors. However, with the functional Infrastructure Unit in the Ministry

which will work hand in hand with experts from Ministry of Works, the project is expected to

be completed in the 09/10 financial year. The project involves designing and building of a

new sewer system.

2.5.11. Ethel Muthalika Maternity Wing at Kamuzu Central Hospital

The project is being funded by the Clinton Hunter Foundation. Malawi Government is

however purchasing all the equipment for the wing. Actual construction is completed and all

equipment is expected to be in the country by December 2009. The maternity wing is

expected to be opened in February 2010.

2.5.12. Bwaila Maternity wing

The project has been funded by the Rose Foundation. It has a bed capacity of 140 beds and is

expected to be opened in October 2009.

2.5.13. Status of Infrastructure at District level

DHMTs are continuing with their efforts in ensuring that health centers and staff houses

meets standard norm. All districts therefore supported the national infrastructure program by

maintaining staff houses and some health centers. Rehabilitations aims at installing running

water, communication system, electricity and making any necessary renovations. Currently

55% health centers satisfy the standard norm of running water, electricity, and

communication system and being fully renovated. This is an increase of 15% from last years

figure of 40%. Progress has also been made in providing same development in existing staff

houses whereby a total of 187 out of the target 450 houses were renovated.

2. 4. 13. Transport

District health offices have a total of 470 vehicles out of which 332 are runners. Of the vehicles that are runners 190 are ambulances. Distribution of bicycle ambulances has assisted referral of maternity. Progress made by districts in the reporting period consisted of procuring vehicles using ORT budget, boarding off non runners and implementing transport management. However the overall transport management is not good at district level. Only

seven districts have some documentation. on transport management. Of those that have some information none calculates or monitors transport performance

2.6. Strategy/Pillar 5: Ensure access to quality essential health services

There has been continued progress in ensuring access to quality essential health services as a result of progress made in the other pillars especially the human resources for health. Notable progress has been the sustained coverage of EPI antigens and continued progress in making sure that eligible Malawians access ARVs. Progress made in most areas of the EHP are summarized below.

2.6.2. Prevention of Vaccine Controllable Diseases:  Expanded Program of Immunization (EPI)

The EPI programme has continued to make progress in making sure that infants get fully immunized against childhood immunizable diseases before attaining the age of 12 months, all pregnant women get vaccinate with at least two doses of tetanus toxoid vaccine and women of childbearing age with 5 doses of TT.

Vaccination Clinic In Progress in Rumphi

At community level sensitisation on the importance of completing the immunization schedule and that surveillance activities for diseases of elimination and eradication remain effective

were key areas in which the programme made progress. A summary of progress in EPi is outlined in Table 4

Table4: Progress in immunization coverage

Progress Target Comment91% of EPI health facility reports were timely 95% Good84% of EPI district reports were timely 90% FairCompleteness of EPI reports was 100% 100% Very good4% of outreach under five clinics were cancelled <10% Very goodPenta 3 coverage was 95% 90% Very good86% of districts with penta 3 coverage of ≥80% 80% Good90% coverage for measles CABS indicator 80% Very good82% of districts with measles CABS indicator of ≥80% 80% GoodPenta1-Penta3 dropout rate was -0.6% (utilization of immunization services)

≤10% Very good

95% of districts with good utilization of services 80% Good94% of under one children had access to immunization services

90% Very good

96% of districts had good access to immunization services 100% GoodMeasles coverage for integrated measles campaign 100% 95% Very goodNon-polio AFP rate was 2.5 2.0 Good71% of districts had a non-polio rate of ≥2.0 100% PoorStool adequacy for AFP was 88% 80% Good79% of districts had stool adequacy of 80% 100% Fair93% of districts reported at least 1 AFP case 100% Good96% of the districts reported at least 1 measles case 100% Good

2.6.3. Acute respiratory infection

ARI programme has registered great success in the period under review despite problems in

accessing funds for programme activities. Progress made in acute respiratory infection has

been the achievement of hospital based case fatality rate for pneumonia of below 8% at the

National level with some districts such as Chitipa and Ntchisi district hospitals having

pneumonia case fatality rate of 1.4% and 2% respectively.

2.6.4. Malaria

Malaria control is one of the key Essential Health Care Package interventions in Malawi. During the period under review the malaria control program had mainly lined activities targeting case management, ITN distribution and indoor spraying. Progress made during the review period has been the mass distribution of 1.2 million ITNs to under-five children, conducting Indoor Residual Sprays at Ministry of Health, CHSU, HEU and Nkhotakota district. Other notable progress was the conducting of net retreatment campaign using 1, 2, 3 K-O tab, training of new health workers on Malaria Case Management and non increase in Malaria cases and related deaths as illustrated in the Table 5 and Figure 7 below

Table 5: Selected Indicators on Malaria Cases in Malawi, 2004/05 - 2008/09

Period

Population of

MalawiTotal Malaria New Cases

Total Malaria Inpatient Deaths

Malaria Incidence

(%)

In-patient Deaths

Per 1,000 Populatio

n

Total Malaria Cases as %

of Total OPD Attendance

2004 – 2005

12,341,170

3,481,684 6,444 28.2 0.52

35

2005 – 2006

12,757,883

4,204,468

7,216 33.0 0.57

30

2006 – 2007

13,187,632

4,442,197

6,566 33.7 0.50

35

2007 – 2008

13,630,164

5,208,241

8,558 38.2 0.63

34

2008 – 2009

13,066,340

5,781,126

8,452 44.2 0.65

34

Source: Central Monitoring & Evaluation Division (CMED)

FIGURE: 7

Selected Indicators on Malaria Cases, Malawi 2004/05 - 2008/09

28.233.0 33.7

38.2

44.2

0.52 0.57 0.50 0.63 0.65

3530

35 34 34

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

2004 - 2005 2005 - 2006 2006 - 2007 2007 - 2008 2008 - 2009Period

Malaria Incidence (%)

In-patient Deaths Per 1,000Population

Total Malaria Cases as % ofTotal OPD Attendance

2.6.5. Reproductive Health

Reproductive health unit continued to make progress in family planning, community-based maternal and newborn care services, institutionalization of condom use, skills training of service providers youth friendly health services and performance Quality Improvement (PQI.)Progress made by the unit includes:

Injectable contraceptive has now been introduced at community level in 9 districts, delivered by Health Surveillance Assistants.

A total of 437 HSAs and 18 supervisors have been trained in CMNH package. The three districts (Nkhotakota, Rumphi, Machinga) except Phalombe trained 120 HSAs on Community mobilization. Chitipa, Thyolo and Dowa trained 107, 100 and 70 HSAs on Community Mobilisation respectively.

Skills of service providers in male and female condom use and disposal were provided with updated information on the two products. From June 2008 a total of 330 service providers from all sectors were trained. (A total of 398 were trained in 2008). From January to June 2009:30 service providers from District hospitals including Likoma were trained in male and female condom use.

Training has been provided to DHOs, Deputy DHOs, DNOs, FP Coordinators and District Youth Officers (DYOs) all districts in the Southern Region namely. on Reproductive Health Commodity Security – Supply Chain.

12 participants were successfully trained and certified in repairing obstetric fistula. Refresher training was done in November 2008. Orientation of Community VHC was done in Mangochi in 2008. Orientation programme for Health care workers from Lilongwe District was conducted from 25th May -9th June 2009.

35 health workers were trained during the two sessions in VIA for the screening of cervical cancer and management of minor lesions. Refresher course took place for health workers from Ndirande, Chilomoni and other health facilities in the Southern region.

Basic Emergency Obstetric Care trainings (BEmOC) continued to be conducted through the zones with at least a minimum of one training per zone. Two supportive supervision visits were conducted to follow up on trained health workers in the health centres. Observation was that the BEmOC functions are being performed though several facilities lacked the manual vacuum aspirator for removal of products of conception in incomplete abortion and vacuum extractors.

The ten districts supported by Partnership in Maternal, Newborn and Child Health (PMNCH) implemented activities such as open days in the Community, Oientation of Traditional Birth Attendants on their new roles, integrated supervision and Community Case Management (Harmonised manual). A review meeting was conducted to share progress and best practices by the districts.

The female condom has also been integrated in a number of other programmes outside the health sector such as the Women, Girls and HIV programme under the Ministry of Women and Child Development, and the National Youth Council under the Ministry of Youth. This has increased access because more CBOs have requested training due to the demand and providing free female condoms. There are now 105 main service delivery points in the country with some having several other outlets in the community.

Malawi has now started the provision of DPMA at community level through HSAs hence guidelines and training manuals are in place.

Depo provera is now available at community level in at least 9 districts. Districts with active CBDA program show impact by increasing CPR

More BEmOC sites are being established at district level to provide wide coverage and access of Maternal and Newborn health

Three districts received funding from UNFPA through the Maternal Health Trust Funds in order to scale up the community RH activities. The districts have so far oriented Area Action Committees, Community safe motherhood task force, health workers and trained Village Health Committees.

PAC services have been scalled up to 28 new sites with support from ACCESS/USAID in November, 2008.

Services for young people are not available in most health facilities and where the services are available they are not adequately utilized by young people themselves. With the effort in training of health workers on Youth Friendly Health Services, provision of services has increased from 8% in 2006 to 50% of health facilities in 2009.

An expansion of 6 more facilities on Performance Quality and Improvement in Reproductive Health Standards (PQI-RH) was made bringing the districts oriented to RH standards to 20. All the 4 Central Hospitals have been incorporated in PQI-RH. Developing standards for RH has helped to set a yard stick by which the quality of RH services will be measured uniformly across the country.

Districts are also showing an interest in cervical cancer prevention by mobilising funds to train their health workers at district level.

More cases of obstetric fistula are being identified and operated in designated sites following a massive awareness campaign by RHU and partners.

The preliminary report of the strategic assessment is now available. The report indicates that most people interviewed admitted that deaths due to unsafe abortion occur in the communities and there are some deaths which are not reported to health facilities.

The report further indicates that more people are of the view that there should be some avenues to address such avoidable deaths due to unsafe abortion in Malawi so that Maternal Mortality Rate is reduced.

The effect of reducing unmet need in the districts where the DMPA is delivered at community level may not be captured in the DHS as it will be too early but can be inferred if the CPR has risen.

Enthusiasm of HSAs in delivering DMPA and the supervisory support provided by MSH who are implementing this project.

Secondly MSH has recruited CBDAs who are advocating for increased use of family planning and therefore increasing the number of clients who are available for DMPA and other methods.

Following the introduction of the non human condom dispenser in 2006 and the review exercise in September 2008, RHU embarked on a roll-out programme of the initiative to all the remaining 18 districts.

2.6.6. Tuberculosis

Tuberculosis continues to be one of the major public health problems in Malawi. The national TB response coordinated by the National TB Control Programme (NTP) continued with the approach of Directly Observed Therapy–Short course (DOTS) and progress is being made in many key result areas as outlined below:

1. 97% of diagnosed TB patients have been put on appropriate TB treatment (the target is 95%). There are still some hospitals that could not achieve the target.

2. TB case notification has reduced by 2% from 26,299 cases in 2007 to 25,684 cases in 2008

3. Cure rate among new smear positive cases has increased from 79 % in 2006 to 83% in 2007 (the WHO target is 85%). This has resulted in the treatment success rate reaching the WHO target of 85% for the first time in more than 15 years.

4. Death rate among the new smear positive cases has decreased from 11% in 2006% to 9% in 2007 .

5. Default rate has remained at around 3% (Target is below 5%)6. The percentage of TB cases accessing HTC services and accepting them has now

reached 84% throughout the country.7. The TB/HIV co-infection rate has decreased from 77% in 2000 to 63% in 2008 and

among them 57% accessed ART during their TB treatment 8. Districts continued to scale up establishment of community sputum collection points

to reduce distances that TB suspects travel to health facilities9. Government has now appointed a medical officer for prisons who will be responsible

for ensuring that TB control activities in prisons are monitored and reported

2.6.7. HIV/AIDS

Progress in the fight against HIV and AIDS pandemic continues to be registered in all districts. Recent reports indicate that there is a decline in HIV prevalence from 14 % to 12%. All the biomedical intervention areas namely HIV Testing and Counseling (HTC), management of HIV-related infections including provision of Antiretroviral Therapy (ART), Prevention of Mother to Child Transmission of HIV (PMTCT) and management of Sexually Transmitted Infections (STIs) continued to register significant achievements.

2.6.7.1. HIV Testing and counseling [HTC]

The number of people that were tested and counseled for HIV from July 2008 to June 2009 was 1.7 million against a target of 1.15 million. The National HTC Week Campaign was held in November 2008 and 186,217 people were tested for HIV during the week of which 7.2% tested positive. Out of 1.7 Million persons that received HTC services during the review period 10.8% were tested during the National HTC Week Campaign. This is the highest number of HIV tests performed in a single year, surpassing the target of 1.15 million by 562,170. The highest number of people tested was in the Southern Region which contributed 53.1% of all people tested, the Central Region contributed 34.2% and the Northern Region contributed 12.7 %. Among all people tested, 69.3% were females and 33.7% were males. Women that were pregnant at the time of testing constituted 28.1% of all persons tested. Of all persons tested, the proportion of people that tested positive was 11.6%. The proportion that tested positive in the Northern Region was 8.0%, Central Region was 9.35% and the highest positive proportion was from the Southern Region with 14.0%. A summary of progress in this area is in table

Table 6. Uptake of HIV Testing and Counselling July 2008 – June 2009

Indicator TotalTotal # tested and counseled 1,712,170% Tested in Northern Region 12.7%% Tested in Central region 34.2%% Tested in Southern Region 53.1%HIV + 11.6%% of Males 33.7%% of Females Non-Pregnant 38.2%% of Females Pregnant 28.1%% of First Time Testers 63.0%

% Testing as couples 11.2%% Tested 17months and below 1.3%% Tested between 18 months and 14 Years

6.4%

% Tested 14-24 years 37.6%% tested 25 years and above 49.6%# Referred for ART 144,900# Referred for PMTCT 61,091# Referred for TB 9,328

2.6.7.2. National HTC Week Campaign

The results of the HTC Week Campaign 2008 were as shown in Table 3 below.

Table 7. Results of the HTC Week Campaign 2008No Northern

RegionCentral Region

Southern Region

Malawi

1 Total Number of persons tested 35,873 70,726 79,618 186,2172 Males 16,515 32,703 33,963 81,1813 Females non-pregnant 16,850 30,490 37,365 84,7054 Females Pregnant 2,508 7,533 8,290 18,3315 HIV Positive 4.2% 5.4% 10.2% 7.2%

2.6.7.3. HIV care and treatment

Good progress in this key area has been the continued increase beyond set targets in number of people who are alive and on ARVs Progress in this area is summarized in table below:

Table 8: Patients Alive and on Treatment December 2006 – June 2009

No Year Target Achievement

1 December 2006 60,000 59,980 [ - ]

2 June 2007 70,000 79,398 [ + ]

3 December 2007 90,000 100,649 [ + ]

4 December 2008 130,000 147,479 [ + ]

5 June 2009 150,000 169,965 ( + )

2.6.7.4. Prevention of mother to child transmission of HIV Overall the performance of PMTCT programme is summarizes achievements in the table below. However due to lateness in reporting in three districts only outputs between July 2008 and March 2009 are presented.

Table 9: Achievements, July 2008 – March 2009

# of sites (cum)

New ANC

# women tested

# of pregnant women HIV+

Mother ARV prophylaxis

Mother CPT

Infant Prophylaxis

Infant CPT

518 335,300

327,400 33,255 25,822 26,256 (includes women with old HIV status identified in ANC)

15,407 19,069

Under-performing districts: Mzimba, Dedza, and Mulanje.

2.6.8. Onchocerciasis

Progress made in onchocerciasis has been the treating of 1,597,659 out of 1,936,129 people representing treatment coverage of 82.5%.The annual MDA is reducing the itching and skin problems in populations around onchocerciasis endemic districts.

2.6.9. Lymphatic filariasis

This year Malawi has started implementation of LF mass treatment in 8 districts. treatment. Over the review period, the major progress made is that LF was fully integrated in terms of training and mass treatment with Onchocerciasis programme and also with other programme campaigns such as Malaria/ITN, Primary Eye Care [PEC] and Vitamin A/Measles campaign.

Mass Drug Administration [MDA] conducted treated 2,704,323 out of a total of 3,358,816 at risk population representing 80.5% from districts of southern region of Malawi in Blantyre, Chikwawa, Chiradzulu, Mulanje, Mwanza, Neno, Phalombe and Thyolo.The exercise also identified 1,427 cases of Hydrocoele out of which 212 cases benefited from surgical operations..

2.6.10. Health education services

Progress in health education services has been made in the areas of creating public awareness, facilitating community involvement and participation and promoting activities which foster health behaviour and encouraging people to want to be healthy.A total of 94 film shows in hard to reach areas and 123 band performances were done during the review period The shows and band performances focused on social mobilization campaigns in the areas of HIV/AIDS, Malaria, TB, cholera SRH, water and sanitation and many more. Another area where progress has been made is in conducting nine separate world commemoration events for health to launch annual themes around specific health topics. While there was good progress at service delivery point, the Health Education Unit continued with the development of various IEC materials including print materials, material for radio, outdoor advertising, media coverage, and behaviour change interventions at district level to support delivery of behaviour change interventions. All material produced during the year have been pre-tested and most have been printed and are being distributed.

2.6.11. Environmental health services

The mission of Environmental Health Section is to develop criteria and prescribe health quality standards, enforce and monitor compliance with statutory standards and to establish and implement preventive and promotive intervention measures to protect human health.The main activities implemented last year were aimed at improving water quality and sanitation, promoting food hygiene and quality control, protecting human environment. raise public awareness on environmental health issues. Results from routine monitoring of water quality indicate that most of the water supplies in rural areas are contaminated. On port health progress has been made in deployment and training. The major activities carried out at ports of entry are travellers’ health checks, quarantine, surveillance and personal advice to travellers on health risks such as malaria, bilharzia and other prevailing illnesses and diseases.

On Avian influenza the Ministry made several press releases on press media and made investigation of suspected AI outbreaks in birds in Ntchisi and ZombaSwine flu sensitization of health personnel in boarder districts is another key progress made in this key area

2.7. Strategy/Pilla.r 6 : Strengthen Policy development standards setting supervision, monitoring and evaluation

A number of policy documents, guidelines and standards were developed during the year under review. Some of these documents have been finalized and are being used, whilst others are still in draft form awaiting input from a broad range of stakeholders. Details on the status of specific policy documents, standards and guide lines are outlined below:

2.7.2. Policy development

2.7.2.1. National Health Policy and Health Act

The national Health Policy is in its final stages of development. All technical consultations have been completed, what remains is input from Principal Secretaries Committee and Cabinet. Similarly, technical input into the proposed health act has been completed and legal experts are now working on the document.

2.7.2.2. Clinical management

Two key policy development documents have been developed:Traditional medicine policy and the Malawi Standard Treatment Guidelines (MSTG).Both policy documents have not yet been disseminated and its implementation has not yet started.

2. 6. 1. 3. PharmaceuticalNational Medicines and Medical Supplies Policy revised National Pharmaceutical Strategic Plan developed

2. 6. 1. 4. HTC Guidelines.

The Review of HTC Guidelines (2004 Edition) which began in 2007 was completed. The process involved consultation with various stakeholders and presentation to technical sub-groups and TWG meetings. The printing of the guidelines is awaiting release of RCC funding.

2. 6. 1. 5. Paediatric HTC Guidelines.

The Paediatric HTC guidelines of 2007 were reviewed in 2008-9. This review is now completed and UNICEF is assisting with printing of this document.

2. 6.1.6. Development of the Child HIV Counseling Guide

A draft Child HIV Counseling Guide has been completed. A workshop with a group of senior HTC counselors was held from 30th March to 4th April at Mt Soche Hotel in Blantyre to pre-test the draft guide. Comments and additional information were inserted into the guide. By the end of June the final draft of the Child HIV Counseling Guide had not been completed. When completed in the first quarter of 2009-10 year, the guide will be the basis for a five day MOH approved Child HIV Counseling Training Course.

PMTCT guidelines

PMTCT guidelines have been revised to incorporate combination ARV prophylaxis.National ANC and maternity registers, and women health passports have been printed .

TB/HIV guidelines

TB/HIV guidelines have been drafted and will be finalised before December 2009.

Pre ART programme

Minimum package for Pre-ART has been developed following a stakeholders meeting. This will form the basis for the guidelines for the Pre-ART programme.

ART guidelines

ART Guidelines 3rd Edition has been produced and OI guidelines have also been revised M & E tolls have also been revised and the new ART registers, New ART Master cards and new patient ID’s have been distributed to the Health Facilities

National condom strategy

The document has been reviewed and revised. All key stake holders were involved throughout the process. The final draft document is due for proof reading by experts. The documents is aimed at filling identified gaps and improve on the supply chain management. It ensures promotion of both male and female condoms with reflection on the HIV prevention strategy.

Health promotion policy

Health Promotion Policy which embraces current trends and emerging issues and challenges within the health promotion and communication field was developed .TheNational Health Promotion five year Strategic Plan (2009 – 2014) is in its final stages.

Participatory Hygiene 2nd Sanitation Transformation (PHAST) training manual

Development of PHAST training manual , PHAST training guide , and a zero draft PHAST tools kit was done during the period under review .This is aimed at helping training of health extension workers.

HSAs Training Curriculum and Job description

The HSA training curriculum and job description was reviewed. over the period under review. The process also resulted in the development of a trainer’s manual and facilitators guide for the same cadre. Currently the documents are being processed for printing with financial support from UNICE

National Sanitation Policy Development

The National Sanitation Policy for Malawi was sent to cabinet and the policy was approved early this year. This activity was done jointly with the Ministry of Irrigation and Water Development

Water Quality Monitoring

The development of a training manual on Water Quality Monitoring for the health extension workers was finalized in the same period under review

Food Safety and Hygiene

Three policy documents were developed in this key area namely1. Food Safety and Hygiene strategic Plan. 2. Food Safety and Hygiene training manual.3. Food Safety and Hygiene activities monitoring tools.

Avian influenza:

The following activities related to avian influenza were carried out during the period under review:

1. Development of AI Preparedness Plan 2. Development of the one year implementation plan3. Development of communication plan for AI4. Development of AI messages.

A task force and a technical committee have been instituted to provide guidance on the implementation of the plan and dissemination of messages

HINI Influenza ( Swine Flue)

Progress made in this area is:1. Formation of the National Task Force on Swine Flu2. Formation of National Technical Committee on Swine Flu3. Development of SF Preparedness Plan 4. Sensitization of health personnel in boarder districts

Hospital Care for Children

A WHO Pocket book for Hospital Care for Children in low resource countries to act as a reference material for the standards of hospital care for children in Malawi was reviewed and adapted .

Highly pathogenic type A influenza specimens

Standard Operating Procedures (SOPs) for collection, processing, storage, packaging, transportation and testing of Highly Pathogenic Type A Influenza (H5N1 and novel H1N1) specimens were developed by the public health laboratory section PHL

Laboratory based surveillance

National Laboratory Based Surveillance System for viral infectious diseases was developed and a draft framework developed and has been circulated for input and commenting to various stake holders.

Nursing and Midwifery related Policies

No Programme Type of policy document Status / remark1 Nursing Education Nursing midwifery strategy

‘committed to care’Draft waiting for stake holders meeting

In-service education guide Final draft2 Community Based

NursingPalliative care guidelines Draft, for stakeholders

consultative meetingsPalliative care training manual for Volunteers

First draft, for consultative meetings.

Integrated School Health Nutrition strategy

Developed in collaboration with the MOEST, Now final draft will be presented to both ministries (MOH & MOEST) for approval.

School Health Nutrition guideline

Community health nursing To be presented to

road map senior management for their input

School health in-service refresher manual for health workers

Final draft for pretesting

3 Quality Assurance Nurses and midwives standards.

Finalized , for printing & dissemination

Review of IP standards & guidelines

Finalized waiting for dissemination through zone meetings

Job descriptions Developed waiting for MOH official comments

Progress on Governance Structures

Most Technical working groups (TWGs) did not manage to meet for four times as scheduled. On average TWGs met twice with exception of the Quality Assurance TWG which never met. Failure to meet was attributed to busy schedule of Chairpersons. To address this problem, all TWGs have a now a co-chair who can conduct meetings if the chair person is busy with other duties. Proposed amendments to the SWAP MOU have now been agreed upon by most partners and signing of the amended version will take place any time in the next financial year.

Progress at activity level

Most activities outlined in workplans of all departments of the MoH have been implemented. Activities targeting milestones and recommendations made during the last reviews and the recommendations from the recent 2008/2009 Midyear Review were implemented at different degrees. Progress on milestones and recommendations from midyear reviews has been presented in various areas of this report

Financial Management

The main focus of this report is to provide the financial performance of Health Sector Wide

Approach for the year ended 30th June 2009.

The SWAP Program of Work continues to be financed by government and a number of

cooperating partners who are either - pool partners who provide funding through a common

bank account or discrete partners who finance specific items in the POW.

Total expenditures under the PoW in the first four years of the SWAp - 2004/05 through

2007/08 - have been MK 7.31, 13.23, 16.21 and 22.47 billions, respectively. The budget

approved for 2008/09 is MK31.18 Billion.

Accounting policies

The principal accounting policies adopted in the preparation of the consolidated statement of

receipts and payments are set out below: -

Basis of preparation

The consolidated statement of receipts and payments has been prepared in accordance

with Malawi Government accounting system under the cash basis accounting

convention.

(i) Receipts

Receipts represent actual funding received from GoM and from Development

partners, for both pooled funds and discrete funds.

Pooled funding comprises funding from donors and from Government of Malawi.

Most funds from pooled donors are paid to the Foreign Currency Denominated

Account (FCDA) held at the Reserve Bank of Malawi. From this account, some

payments are made directly to suppliers, with the balance being transferred when

required to the Malawi Kwacha SWAp account; or to the Malawi Government

Consolidated account (MG1). Other pooled donor funding is paid by donors directly

to suppliers. Apart from such direct payments to suppliers, funding of health sector

cost centres is done through the normal monthly Treasury funding from MG1.

Discrete funding comprises funds for specific development projects both from GOM

and from donors

(ii) Payments Payments are made in Malawi Kwacha through the various operating bank

accounts. The payments represent actual amounts derived from the respective cost

centres’ expenditure returns as submitted to the Ministry of Health for

consolidation.

(iii) Foreign currency transactions

Foreign currency transactions are translated into Malawi Kwacha using exchange

rates prevailing on the dates of the transactions. Any exchange gains or losses arising

from translation are included in the consolidated statement of receipts and payments.

FINANCIAL PERFORMANCE FOR THE QUARTER AND YEAR

Below is a combined statement of receipts and payments for the year ending 30th June 2009 in

Billions of Malawi Kwacha.

TOTAL FUNDING

Funding input consists of the following different elements:

a. Donor pooled funding to the MOH SWAp US dollar bank account.

b. GOM pooled funding to cost centres to meet their recurrent needs and also for pooled

development projects. This pooled funding is provided from GOM’s main MG1 bank

account, which is supplemented from sums drawn from the SWAp bank account. Thus

GOM’s pooled input is the net of these two.

c. Discrete funding, which is partly from Donors and partly from GOM. Discrete funding

from Donors includes funding of the donor share of most budgeted development projects,

but excludes those that are pooled. It also includes unbudgeted projects such as those

funded by NAC and UNICEF. GOM funding of discrete projects consists of GOM’s share

of budgeted development projects.

Donor pooled fundingDonor pooled funding (category a. above) is summarized in the Table 1 below:

Funding from each Donor

Amount pledged for 2008/09

Amount disbursed 4th

quarterUSD m USD m USD m %

DFID 33.7 11.5 31.8 94%Norway 19.8 8.5 16.1 81%Global Fund 31.1 3.7 47.9 154%KfW 7.8 3.6 6.8 87%UNFPA 0.3 0.2 0.3 110%UNICEF 0.3 0.0 0.3 100%World Bank 1.0 0.0 3.0 300%Grand Total USD m 94.1 27.5 103.2 110%MK B equivalent 3.93 14.39 Exchange gain/(loss) 0.00 -Grand Total MK B 3.93 14.39

Cumulative disbursed in year to date

The total sum pledged from donors for 2008/09 was $94.1million. During the fourth quarter,

donor pooled funding was received as shown in Table 1 above in the column labeled “amount

disbursed in 4th quarter”. As at end June 2009, total donor pledges for the year had reached

110%. It is notable that World Bank pledged US$1million but disbursed US$3million for a

project that ended in September 2008. Similarly, Global Fund had pledged US$31.1m but

actual disbursement was at 154%. This is a positive indication of the Development partner’s

commitment to support GoM to address major health issues through Health Sector Wide

Approach (SWAp).

GOM pooled fundingFunding by GOM to the pool (category b. above) is summarized in Table 2 below in MK

billions:

Pooled GOM funding

Approved budget for 2008/09

Amount disbursed 4th

quarterMK B MK B MK B %

From MG1 to cost centres (recurrent) 26.28 4.81 24.82 94%Pooled development funding 3.83 0.54 1.59 42%From SWAp a/cs to MG1 (1.05) (12.06) Sundry revenue 0.02 (0.06) Net Pooled GOM Funding 4.32 14.29

Cumulative disbursed in year to date

GoM recurrent funding to cost centres as at 30th June 2009 was cumulatively 94% of the

budget for the year. Meanwhile, pooled development funding from GOM was low at 42%.

Discrete fundingDiscrete funding, category c. above, is summarized in the following Table 3 in MK Billions:

Discrete projects fundingApproved budget for

2008/09

Amount disbursed 4th

quarterMK B MK B MK B %

Discrete development funding from donors:ADF/ADB (ADFB IV) 1.90 0.09 0.86 45%OPEC (Phalombe hospital construction) 0.27 0.00 0.00 0%OPEC (Nkhata Bay hospital construction) 0.27 0.00 0.00 0%Norway (Replacement of Zomba central) 0.50 0.00 0.00 0%

Total discrete development donor funds 2.93 0.09 0.86 29%Discrete development funding from GoM 0.06 0.30 0.36 588%Unbudgeted donor discrete funding

NAC - 0.04 UNICEF support 0.14 0.30 Unbudgeted donor discrete funding 0.01 0.70

Total Discrete Funding 2.99 0.54 2.27

Cumulative disbursed in year to date

As at end June 2009, ADB had disbursed MK0.86bn which is 45% of the annual pledge.

Meanwhile, it should be noted that OPEC confirmed that they were not disbursements in the

year.

In addition, at the end of June 2009, funding for unbudgeted projects was received from the

following discreet donors:

NAC disbursed MK0.4bn. Of course NAC also made some direct

disbursements to UNICEF, College of Medicine, and Ministry of Finance

amounting to MK6.04bn in respect of Health activities.

UNICEF disbursed MK0.3bn

KfW disbursed MK513.9m (US$3.62m)

GTZ disbursed MK70.3m

Combined pooled funding

Table 4 below analyses the 2008/09 funding to cost centres between GOM and donors in

accordance with the proportions adopted when the SWAp PoW was originally costed:

Total GOM Donors Total GOM Donors GOMDon'MK B MK B MK B MK B MK B MK B % %

Total funding input (as above) 8.25 4.32 3.93 28.68 14.29 14.39 Funding to cost centres PE funded by MG1 1.73 1.37 0.36 6.77 5.35 1.42 79% 21%ORT (including drugs) funded from MG1 3.08 1.39 1.69 17.99 8.10 9.90 45% 55%Pooled development funding - - - 0.05 0.02 0.03 Total from MG1 4.81 2.75 2.06 24.82 13.47 11.35 ORT funded from SWAp FCDA a/c - - - 1.83 0.83 1.01 45% 55%Devel'mt funding from MG1 via deposit a/c 0.54 0.24 0.30 1.59 0.72 0.88 Total funding to cost centres (CCs) 5.35 3.00 2.35 28.24 15.01 13.23 Input over/(under) CC funding 2.90 1.32 1.58 0.44 (0.72) 1.16

4th Quarter Cumulative to 30 June 2009

Analyzing the cumulative position for the year, it can be seen that GOM has under-funded by

MK0.72bn this year, whereas donors’ over-funding is MK1.16bn.

The picture presented in Table 5 below combines the result for the current year to date with

that of previous financial years since the start of the SWAp, with figures taken from the

accounts to 30th June 2008, using the same ratios as above. The combined result is as follows:

Total GOM Donors

Input over CC funding in 2008/09 as above 0.44 (0.72) 1.16 Input over expenditures at the end of 2007/08 6.96 7.43 (0.47)

Cumulative input over CC expenditures 7.39 6.70 0.69

Reconciliation to SWAp accounts MK BSWAp account bank balances 6.66 Other pool bank balances 0.09 Balance with UNICEF -Closing commitment & accruals balanceSWAp account use for discrete 0.64

7.39

This analysis shows how cumulatively, the GoM funding has exceeded its share of spending

by MK6.70bn while donors funding have exceeded their share by MK0.69bn. On this basis,

all the balances in the SWAp accounts are attributed to GoM.

.POOLED FUNDING AND EXPENDITURE BY MOH LEVEL

Table 6 below analyses pooled funding to cost centres (recurrent plus funding of pooled

development projects). The funding is divided into PE, ORT excluding drugs, and Drugs.

Drugs relate to drug funding from Treasury for purchases by cost centres, mostly from

Central Medical Stores (CMS). The analysis is by level, i.e. Headquarters (HQ), Central

Hospitals (CH), District Health Offices (DHO), Health Service Commission (HSC), and

CHAM. Figures are for the quarter to end June 2009 and are in MK millions:

HQ CHs DHOs HSC CHAM TotalMK m MK m MK m MK m MK m MK m

PE 250 1,118 3,384 27 1,994 6,773ORT 10,866 1,419 8,051 55 0 20,391Drugs (CHs only) 0 1,078 0 0 0 1,078Total 11,116 3,616 11,435 82 1,994 28,242

PE 362 1,110 3,590 30 1,994 7,085ORT (excl drugs) 12,038 1,383 5,389 39 18,848All drugs 0 986 2,399 3,385Total 12,399 3,479 11,377 69 1,994 29,318

PE 205 956 2,839 31 2,810 6,841ORT (excl drugs) 12,710 1,417 5,286 55 0 19,469All drugs 0 1,081 2,715 0 3,795Total 12,915 3,454 10,840 86 2,810 30,105

Pooled budgets by funding category:

Pooled expenditures by funding category:

Recurrent & direct supplier funding from MG1 plus ORT payments from SWAp account:

Table 7 below shows percentages calculated from the table above:

HQ CHs DHOs HSC CHAM Total

PE 121.9% 117.0% 119.2% 86.7% 71.0% 99.0%ORT 85.5% 100.2% 100.6% 100.0% 0.0% 104.7%Drugs (CHs only) 0.0% 99.8% 0.0% 0.0% 0.0% 28.4%Total 86.1% 104.7% 105.5% 95.2% 71.0% 93.8%

PE 144.8% 99.3% 106.1% 111.2% 100.0% 104.6%ORT 110.8% 97.4% 96.7% 70.9% 0.0% 92.4%Drugs (CHs only) 0.0% 91.4% 0.0% 0.0% 0.0% 313.9%Total 111.5% 96.2% 99.5% 84.0% 100.0% 103.8%

PE 176.5% 116.1% 126.4% 96.4% 71.0% 103.6%ORT (excl drugs) 94.7% 97.6% 101.9% 70.9% 0.0% 96.8%All drugs 0.0% 91.3% 88.4% 0.0% 0.0% 89.2%Total 96.0% 100.7% 105.0% 80.0% 71.0% 97.4%

Proportions of budget funded:

Proportions of funding utilised:

Proportions of budget spent:

Significant features are:

Treasury is funding PE at a rate in excess of the original budget. This is shown by the

percentages that are higher than 100% - HQ with 121.9% of budget funded, CHs with

117.0%, and DHOs at 119.2%.

In the case of HQ, the PE figures differ from those in the financial statements due to

payments totaling MK833m in the year to date - for salaries of new HSAs, which had not

yet been charged to DHOs, and for UNV doctors – as this sum, which has been charged

to PE in the financial statements, was funded by ORT and so has been included under

ORT above to avoid distortion to the percentages.

The division of ORT funding from Treasury into ORT excluding drugs and drugs alone is

inconsistent between the various levels, as Treasury do not report DHOs’ drug funding

separately from non-drugs ORT.

HQ was funded 85.5% of the year’s ORT budget; CHs were funding 100.2% (excluding

drugs) and DHOs 100.6%. Meanwhile, CH’s drugs funding was 99.8% of budget.

On ORT utilization of funding received, HQ was at 110.8%, CHs (excluding drugs) at

97.4% and DHOs at 96.7%. Note that CH’s utilization of drugs funding was only 91.4%.

Meanwhile, the proportion of DHOs’ drugs budget spent was only 88.4% in the 12

months, compared to 101.9% for non-drugs ORT, an indication that some DHOs were

utilizing their drugs budget for non-drugs ORT spending.

POOLED DEVELOPMENT & DISCRETE FUNDING & EXPENDITURES

Table 8 below shows that the funding and implementation of discretely-funded projects at the

end of June 2009, reached 81.4% and 64.9% of budget respectively, while pooled

development projects expenditures were slow at 45.1%.

Budget Actual

Funding MWK

Millions MWK

Millions Use of budget

Pooled development funding 3,879 1,643 42.4%Discrete funding (as above) 2,992 2,437 81.4%Total funding 6,871 4,080 59.4%

ExpenditurePooled development projects 3,879 1,750 45.1%Discretely-funded projects 2,992 1,941 64.9%Total expenditure 6,871 3,691 53.7%

SUMMARY OF ALL EXPENDITURES

A summary analysis of total expenditure by pillar is detailed in Table 9 below, covering

recurrent expenditure, development expenditure and expenditure on unbudgeted discrete

projects:

2008/09

Approved

Budget Planned Actual Variance Use of

planned Use of budget

MWK Millions

MWK Millions

MWK Millions

MWK Millions % %

1.0 Human Resources 8,214 6,776 9,825 -3,049 145.0% 119.6%2.0 Pharm's, Med' and Lab' Supplies 4,885 4,885 6,532 -1,647 133.7% 133.7%3.0 Essential Medical Equipment 1,021 1,021 755 266 73.9% 73.9%4.0 Infrastructure 7,196 7,196 3,138 4,057 43.6% 43.6%5.0 Routine Operations (service level) 5,136 5,136 5,470 -334 106.5% 106.5%6.0 Support to Inst'ns and Sys Dev 6,645 6,645 5,538 1,107 83.3% 83.3%Total Use of Funds by POW PILLAR 33,097 31,659 31,259 400 98.7% 94.4%

Cumulative to 30 June 2009

This analysis shows total expenditure of MK31.3bn at end of June 2009, being 94.4% of the

year’s budget.

Pillar 1: Human Resources

HR expenditure was 119.6% of budget, mainly because Treasury was funding PE in excess of

the amount approved by parliament.

Pillar 2: Pharmaceuticals, Medical and Laboratory suppliers

Expenditure under this pillar in the 12 months was 133.7% of the budget for the year,

probably reflecting the fact that some cost centres were paying arrears to Central Medical

Stores.

Pillar 3: Essential Medical Equipment.

Expenditure under this pillar was slow at 73.9%. Pillar 4: Infrastructure

Expenditure on infrastructure was also slow at 43.6% on major projects, compared to budget,

such as on the construction of staff houses.

Pillar 5: Routine operations at Service Delivery level

Routine operations expenditure was 106.5% of budget for the year.

Pillar 6: Support to Central Operations, Policy and Systems Development

Expenditure of under this pillar was 83.3% of the year’s budget. The total includes two large

transactions which had not been fully reflected in the original budget. One is a payment to

UNICEF of MK1.8bn for malaria drugs, for which a virement was approved by Treasury.

The other was purchases for CMS of over MK1.8bn.

CONCLUSION

The overall implementation of 2008/2009 budget was good with only three pillars overspent.

As at end June 2009, 94.4% of the budget was used. The Ministry’s priority now is to begin

the audit for 2008/09 and to get up-to-date with collation of expenditure returns from cost

centres for the first quarter FMR of 2009/2010 financial year.

          

Procurement System

Implementation of the Procurement Improvement Plan.

Progress in the implementation of the procurement improvement plan has not been very satisfactory:

Fewer trainings and supervisions have been conducted due to lack of resources. Only one officer from the headquarters has been sent on a master’s degree programme

in procurement. Some officers have, using their own resources, enrolled for a master’s degree program at MIM.

While positions for procurement officers have now been created in all district and central hospitals, the staff vacancy rates remain high. All district hospitals do have qualified procurement officers in place. Not all positions have been filled for procurement officers in the central hospitals. Common Service for public procurement cadre now established.

Oversight Arrangements in Procurement. Following the pulling out of the World Bank from the health SWAp in September 2008, Pool Partners could not finalize oversight arrangements for all health SWAp procurements until November 2008 when it was agreed to recruit an interim procurement oversight firm for non health products. DFID had offered to facilitate the recruitment of the interim oversight firm. The contract for the interim oversight firm expired in January 2009 and it was expected that the intermediate oversight firm would be recruited with financing from DFID by February 2009. As at January 2009, expressions of interests for the intermediate oversight firm had been done. DFID extended contract with Charles Kendall to coincide with the recruitment of the intermediate oversight firm. Intermediate firm was expected to be in place by end April.

Recognizing that some medical supplies are so critical, pool partners and government agreed that UNICEF could be used in the procurement of health related supplies including drugs,

vaccines and other medical supplies. UNICEF however agreed to be responsible for procurement of the following under the new arrangement with government: Vaccines and ITNs, Nutrition supplies, GFAM funded supplies for AIDS, TB, and Malaria

Thus, the majority of the medicals supplies not to be procured through UNICEF would still have to be procured through Central Medical Stores. To date, the procurement unit has only facilitated the following GAVI funded procurements through UNICEF: BCG, OPV, Measles and TT vaccines, Immunization Devises and DTP-HepB-Hib vaccine totaling USD2,077,037.16 and nutrition supplies totaling USD748, 683.40. Funds in respect of the above procurements were transferred to UNICEF account. As at the time of compiling this report, deliveries for the above supplies had not yet taken place. Some Global Fund funded supplies for malaria have been submitted for procurement to UNICEF.

An Action to address cases of misprocurements raised in the 2006/2007 procurement audit report was developed and circulated to all SWAp Pool Partners. The action plan was executed accordingly

Implementation of the 2008/2009 Procurement Plan. Due to delays in agreeing on oversight arrangements on procurement and finalization of the procurement plan, the majority of the high value procurements requiring international competitive bidding procedures could not be implemented during the first half of the year as planned. The procuring unit was making efforts to float all such tenders in the second half of the financial year. However, due to budget overruns in the ministry, the majority of the high value procurements could not be undertaken during the financial year. See progress as per table below:

Name of Contractor/Suppliers/consultant and his address Nature of Contract

Date of tender/RFQ

Date of closure of tender

Approved method of procurement

Reasons for change of method

Date of Contract award

1Kingfisher Insurance Brokers

Provision of Motor Vehicle Insurance Services

01/04/2008

05/09/2008 NCB NA

07/01/20

2 Pasimalo Security ServiceProvision of security services

14/12/2006

15/01/2007 NCB NA

05/02/20

3 Pasimalo Security ServiceProvision of security services

14/04/2008

15/05/2008 NCB NA

01/07/20

4 Queen Margaret University

Consultanct services for District Expenditure Pattern NA NA SSS NA

25/11/20

5Dziko/Mkatha Building Contractors

Rehabilitation of Balaka distric Hospital Apr-08 22/05/08 NCB NA

09/09/20

6 MMSPKT Contractors

Rehabilitation of Zomba Central Hospital

02/06/2008

21/03/2008 ICB NA

23/07/2008

7 Hualong Contractors

Rehabilitation of Zomba Central Hospital

02/06/2008

21/03/2008 ICB NA

23/07/2008

8Computer Connections Limited

Consultancy for drawing up of inventory for IT Equipment in the ministry of Health

08/01/2008

08/07/2008 RFQ NA

26/08/20

9 Pabu Building Contractors

Rehabilitation of Mzuzu Central Hospital Sewage     NCB    

10 AMPROC

Consultancy for Procurement Audit for Ministry of Health SWAP

14/03/2008

06/01/2008 ICB NA

24/09/2008

11 Hub Media Group

Consultancy for TV Documentary

22/09/2008

24/09/2008 RFQ NA

16/10/20

12 Sungani Mtande

Installation of Access Software in Accounts

11/05/2008

11/12/2008 SSS NA

28/01/2009

13 Zingano and Associates

Design of the New Nkhatabay District Hospital May-07

31/05/2007 NCB NA

52 Months

14 Zingano and Associates

Supervision of the New Nkhatabay District Hospital May-07

31/05/2007 NCB NA

52 Months

15 Speedy General Dealers

Procurement of stationary on framewoek contracts

10/03/2006 30/11/06 NCB NA 27/02/07

16 A.J stationary

Procurement of stationary on framewoek contracts

10/03/2006 30/11/06 NCB NA 27/02/07

17 CFAO

Procurement of 6 Double Cabs

05/03/2008 13/07/08 ICB NA

18/08/2008

18 Toyota Malawi

Procurement of one Station Wagon

05/03/2008 13/07/08 ICB NA

18/08/2008

19 Xerographics Limited

Purchase of 125 computers and software

17/03/2008 30/04/08 ICB NA

23/07/2008

20 Gestetner Limited Office Equipment

17/03/2008 30/04/08 ICB NA

23/07/2008

21 Centre for Social Research

Procurement of Consultancy services to conduct HRM Census 15/08/07 30/08/07 ICB NA 18/10/07

22 Chancellor College

Procurement for Consultancy Services for Team Building 29/06/07

27/7/2007 NCB NA

30/10/2007

23 GITEC

Health Facility Assessment Survey

12/01/2007

29/02/2008 ICB NA

05/01/20

24 Roja Construction Company

Rehabilitation of Ministry Headquarters

06/01/2007

07/02/2007 NCB NA

07/03/20

25

Chikpnde Electrical Contractor

Rehabilitation of Ministry Headquarters-Electrical

06/01/2007

07/02/2007 NCB NA

07/03/20

25 MA-WI Tech

Printing of IEC Materials for World TB Day 15/01/08 19/01/08 RFQ NA 22/01/08

26 Agri-Visual Limited

Procurement of an Audio Visual Van 15/03/08 15/04/08 ICB NA 17/07/08

27

Computer Connections Limited

Supply and installation of an anti-virus 25/09/07

10/02/2007 RFQ NA

10/02/20

28 Parad Limited

Procurement of 40 Desk Computers and 40 Laser jet Printers

19/01/2008

26/01/2008 RFQ Urgent

03/02/20

29 Mercantile International

Printing of TB 2500 Strategic Plan

09/07/2008 15/10/08 RFQ NA

11/11/20

30 Winiko Theatre Company Drama Awareness 14/01/09 21/01/09 SS NA 22/01/09

31 Venus Printing

Printing of 25,000 5 Development Plan

09/11/2008 18/09/08 RFQ NA 19/09/08

32 Liu Construction

Rehabilitation and extension of BEmOC Health Centres ( Chisoka, Khonjeni, Chonde, Namitambo, Namadzi and Domasi Health Centres)

14/04/2008

15/05/2008 NCB NA

01/07/20

33 Tafika Building Contractors

Rehabilitation and extension of BEmOC Health Centres (Phimbi, Mbendera, Mtanja, Nainunji, Makhuwira, Monkey-bay, Phiri longwe and Nankuma)

14/04/2008

15/05/2008 NCB NA

01/07/20

34

Malaya Building Contractors

Rehabilitation and extension of BEmOC Health Centres (Kawamba, Kaluluma, Santhe, ChuluChankhungu and Chizolowondo)

14/04/2008

15/05/2008 NCB NA

01/07/20

35

Hualong Construction (PVT) Limited

Rehabilitation and extension of BEmOC Health Centres (Kochilira/ Nkhwazi, Chitedze, Ming'ongo,Nsalu, Nsalu, Chimbalanga and Mtenthera)

14/04/2008

15/05/2008 NCB NA

01/07/20

36

Nangaunozge Building Contractors

Rehabilitation and extension of BEmOC Health Centres (Lobi, Chikuse, Ganya, Kapeni, and Lizulu)

14/04/2008

15/05/2008 NCB NA

01/07/20

37

Fukumere Building Contractors

Rehabilitation and extension of BEmOC Health Centres (Ntharire, Misuku, Kapolo and Chilumba)

14/04/2008

15/05/2008 NCB NA

01/07/20

38 China Gansu Contractors

Rehabilitation and extension of BEmOC Health Centres (Enukweni, Mhuju and Bolero)

14/04/2008

15/05/2008 NCB NA

01/07/20

39

Hualong Contruction Pvt Limited

Rehabilitation and extension of BEmOC Health Centres (Mzuzu, Jenda, Bula, Chintheche and Liuzi)

14/04/2008

15/05/2008 NCB NA

01/07/20

40 Design Printers

Printing of Chronic Cough Registres

05/12/2007

12/12/2007 RFQ Urgent

13/12/20

41 Xerographics Limited

Purchase of IT Equipment Apr-08

16/05/2008 NCB NA

03/07/20

42 Gestetner

Purchase of Office Equipment Apr-08

16/05/2008 NCB NA

03/07/20

43 IT Centre

Purchase of IT Equipment Apr-08

16/05/2008 NCB NA

03/07/20

44 Gestetner

Purchase of Office Equipment Apr-08

16/05/2008 NCB NA

03/07/20

45

Fukumere Building Contractors

Umoyo Housing Project: Chitipa

14/04/2008

15/05/2008 NCB NA

01/07/20

46

Hualong Construction (PVT) Limited

Umoyo Housing Project: Karonga

14/04/2008

15/05/2008 NCB NA

01/07/20

47

Mwendayekha Building Contractors

Umoyo Housing Project: Rumphi

14/04/2008

15/05/2008 NCB NA

01/07/20

48

Tikhalenawo Building contractors

Umoyo Housing Project: Mzimba/Nkhatabay

14/04/2008

15/05/2008 NCB NA

01/07/20

49 Wahkong Construction

Umoyo Housing Project: Mzimba

14/04/2008

15/05/2008 NCB NA

01/07/20

50 Liu Construction

Umoyo Housing Project: Kasungu/Mchinji

14/04/2008

15/05/2008 NCB NA

01/07/20

51

Intercity Building Contractors

Umoyo Housing Project: Dowa/Ntchisi

14/04/2008

15/05/2008 NCB NA

01/07/20

52

Nangaunozge Building Contractors

Umoyo Housing Project: Nkhotakota/Salima

14/04/2008

15/05/2008 NCB NA

01/07/20

53

Hualong Construction (PVT) Limited

Umoyo Housing Project: Lilongwe

14/04/2008

15/05/2008 NCB NA

01/07/20

54 Delta Construction

Umoyo Housing Project: Dedza

14/04/2008

15/05/2008 NCB NA

01/07/20

55 Delta Construction

Umoyo Housing Project: Blantyre/Mwanza-Mneno

14/04/2008

15/05/2008 NCB NA

01/07/20

56 Delta Construction

Umoyo Housing Project: Balaka/Mangochi

14/04/2008

15/05/2008 NCB NA

01/07/20

57 Tafika Building Contractors

Umoyo Housing Project: Zomba

14/04/2008

15/05/2008 NCB NA

01/07/20

58 Project Building Contractors

Umoyo Housing Project: Balaka/Machinga

14/04/2008

15/05/2008 NCB NA

01/07/20

59 BM Contractors Limited

Umoyo Housing Project: Mangochi/Machinga

14/04/2008

15/05/2008 NCB NA

01/07/20

60

Malaya Building Contractors

Umoyo Housing Project: Machinga

14/04/2008

15/05/2008 NCB NA

01/07/20

61 Wahkong Construction

Umoyo Housing Project: Phalombe/Mulanje

14/04/2008

15/05/2008 NCB NA

01/07/20

62

Nangaunozge Building Contractors

Umoyo Housing Project: Chiradzulo/Mulanje

14/04/2008

15/05/2008 NCB NA

01/07/20

63

Computer Connections Limited

Supply and installation of an anti-virus

25/02/2008

04/03/2008 RFQ NA

05/03/20

64

Floatdene International Limited

Purchase of 4 Electrolyte Analyser Starter packs NA NA SSS NA

11/12/20

65 MOD Chartered Archtects

Consultancy services for the design, supervision and construction management for the expension of Malawi College of Health Sciencies-Blantyre Compus

01/08/2008

01/09/2008 NCB NA

03/10/20

66

Norman & Dawban (Mw) Limited

Consultancy services for the design, supervision and construction management for the expension of Malawi College of Health Sciencies-Zomba Compus

01/08/2008

01/09/2008 NCB NA

03/10/20

67 Zingano and Associates

Consultancy services for the design, supervision and construction management for the expension of Malawi College of Health Sciencies-Lilongwe Compus

01/08/2008

01/09/2008 NCB NA

01/10/20

68

Nangaunozge Building Contractors

construction of maintenance unit and rehabilitation/expansion of four health centres in Salima

14/04/2008

15/05/2008 NCB NA

01/07/20

69

Western Construction Company

construction of a pilot phase of two houses of Nsiyaludzu in Ntcheu District

14/04/2008

15/05/2008 NCB NA

01/07/20

70

Hualong Construction (PVT) Limited

construction of single, two and three storey pharmacology, physiology and biochemistry labolatory blocks, teaching block, day room, animal house.

14/04/2008

15/05/2008 NCB NA

01/07/20

71 Delta Construction

construction of new labolatory with

14/04/2008

15/05/2008 NCB NA

01/07/20

associated site works and services at Kamuzu Central Hospital and extensions to the exisisting labolatory at QECH

72

Kamwaza Design Partnership

Supervision and construction management of Umoyo Housing Program South East Zone

14/07/2007

13/08/2007 NCB NA

28/09/20

73

Kamwaza Design Partnership

Supervision and construction management of Umoyo Housing Program South West Zone

14/07/2007

13/08/2007 NCB NA

28/09/20

74 DDC Designs

Supervision and construction management of Umoyo Housing Program Central East Zone

14/07/2007

13/08/2007 NCB NA

28/09/20

75 DDC Designs

Supervision and construction management of Umoyo Housing Program Central West Zone

14/07/2007

13/08/2007 NCB NA

28/09/20

76 DDC Designs

Supervision and construction management of Umoyo Housing Program Central West Zone

14/07/2007

13/08/2007 NCB NA

28/09/20

77 MD Initiative

Supervision and construction management of Umoyo Housing Program Northern Zone

14/07/2007

13/08/2007 NCB NA

28/09/20

78

Kamwaza Design Partnership

Supervision and construction management for BEmoaC health centres in the Southern Region

09/09/2007

08/10/2007 NCB NA

23/11/20

79 DDC Designs

Supervision and construction management for BEmoaC health centres in the Central Region

09/09/2007

08/10/2007 NCB NA

23/11/20

80 MD Initiative

Supervision and construction management for BEmoaC health centres in the Northern Region

09/09/2007

08/10/2007 NCB NA

23/11/20

81 Chanika Building Company

Construction & Painting works

17/07/2004

24/07/2007 RFQ NA

26/07/20

82 Plus Ten

Supply and delivery of Building materials.

17/07/2004

23/07/2007 RFQ NA

26/07/20

83 Vhaima Building Company Fitting tiles

17/07/2004

25/07/2007 RFQ NA

26/07/20

84 GlobeComputers

Purchase of Laptop computers

07/08/2007

14/08/2007 RFQ NA

16/08/20

85 MACS Agencies

Supply and fitting of carpets

18/08/2007

25/08/2007 RFQ NA

30/08/20

86 MACS Agencies

Supply and fitting of carpets for PAM offices

17/07/2008

24/07/2008 RFQ NA

04/08/20

87 Valentines Investment

Construction of Water Kiosks

16/08/2007

23/08/2007 RFQ NA

30/08/20

88 Design Printers

Printing of OPD Register

17/11/2008

24/11/2008 RFQ NA

25/11/20

89 Hub Media Group

TV/Radio documentries

17/11/2007

24/11/2007 RFQ NA

27/11/20

90 Hub Media Group Gingles production

21/10/2008

28/10/2008 RFQ NA

31/10/20

91 Venus Printing

Printing of Desk calenders

13/09/2007

20/09/2007 RFQ NA

21/09/20

92 Multiple Suppliers Vehicle tyres Various Various RFQ NA Various

93 Various dealers/garages Service of Vehicles Various Various RFQ NA Various

94 Various dealers/garages Service of Vehicles Various Various RFQ NA Various

95 HH Wholesalers

Procurement of hardware materials

01/10/2008

08/10/2008 RFQ NA

10/10/20

96 Far Distribution Company

Procurement of heavy duty bicycle

18/09/2007

17/10/2007 NCB NA

05/12/20

97 Toyota Malawi

Procurement of 15 Nos. Motor Vehicle Ambulance

23/06/2008

22/07/2008 NCB NA

07/09/20

  PARTEC LtdService contract for CD4 Count Machine     DC NA  

  Medical Consultants AfricaService contract for Phillips Machine     DC NA  

 Sitbec Construction Company

Construction of Perimeter Fence at CHSU     NCB NA  

 Sitbec Construction Company

Renovation and Extension of National TB Ware-house at Central Medical Stores     NCB NA  

  Hualong, City

Rehabilitation/replacement of Zomba Central Hospital     ICB NA  

  Winiko Theatre Co.Consultancy on cholera campaign     DC NA  

  Compubyte Electronics Ltd

Inventory for IT equipment in the Ministry of Health     RFQ NA  

  Pabu Building Construction

Rehabilitation of Mzuzu Central Hospital     NCB NA  

  AMPROC

Consultancy to undertake Procurement Audit     ICB NA  

  Hub Media GroupConsultancy for TV Documentary     RFQ NA  

 Lot 1. Tayub Lots 2 & 4 Blockbuster Lot 3. Shire Ltd

Procurement of Office Furniture & Equipment     NCB NA  

 Reticia, Marsy, Tregia & International Agencies

Procurement of various stationery items     NCB NA  

  Business Machines Ltd

Tender for Procurement of IT Equipment for Cost Centres     ICB NA  

 Lot 1. IT Centre Lot 2. Gestetner Ltd

Tender for Procurement of IT Equipment for EPI     NCB NA  

  EPOS Health Consultants

Consultancy on Financial Management Coaches     ICB NA  

  Skywaves Mw Ltd

Tender for procurement of eye equipment     DC NA  

 

1. Toyota Mw 15 ambulances 2. HTD Ltd 5 Trucks (7 ton) 3. Mike Appel & Gatto Ltd 3

Procurement of Ambulances, Double Cabs, Heavy Trucks and Station wagons     ICB NA  

D/Cabs and 4. HTD 10 Station Wagons

  Vital Signs Ltd

Procurement of spare parts for a Gambro AK 95 Dialysis Machine at Kamuzu Central Hospital     DC NA  

  Mike Appel & Gatto LtdSupply and Delivery of 3 No. D/Cabs.     LIB NA  

  HTD Ltd

Supply and Delivery of 10 4 x 4 Station Wagons     LIB NA  

  Toyota MalawiSupply and Delivery of 15 Amblances     LIB NA  

  HTD LtdSupply and Delivery of 7-5ton Trucks     LIB NA  

Action Plan to address cases of mis-procurements. An Action to address cases of misprocurements raised in the 2006/2007 procurement audit report was developed and circulated to all SWAp Pool Partners. The action plan was executed accordingly.

Key Undertakings to address challenges/way forward

Filling all vacancies for procurement officers with appropriately qualified officers

Increased provision of training in procurement management

Provision of adequate financial resources to the Procurement Unit in the Ministry of Health to intensify its training and supervision activities in all the cost centres in the health sector.

Controlling officers to identify focal points (procurement teams) from departments to act as liaison persons on preparation of procurement plans. Preparation and submission of procurement plans to become a management function. Procurement plans to be linked to the budget cycle, in particular to the cash flow.

All Pool Partners to align with the agreed SWAp procurement procedures in the implementation of procurement activities which they finance.

Need for the Ministry of Local Government to ensure that all districts submit their reports on their procurement activities. The Ministry does not have systematic information on the performance of district based contracts since reports from the districts are not available.

Development of a procurement data base system for management of procurement function.

CHAPTER 3. CHALLENGES AND WAY FORWARD

While the sector made remarkable progress in many key result areas of the POW, a number of challenges continued to hamper progress in other areas. The key challenges faced during the reporting period could broadly be grouped into four categoriesPolicy development The ministry faced some challenges in policy development partly as a result of capacity and partly as a result of circumstances beyond control of the MoH. Key policies that have not moved with at the anticipated pace are the National Health Policy and National Health Act, The transport policy, the SWAp MoU and Cham/MoH MoU. Other policy related documents that have not progressed as expected are the PPP guidelines,DHMT management manual and revision of costings for SLAs.While some policies delayed as a result of capacity problems many policies have been completed or were completed some time back but still remain un launched. Progress on reforms which depends much on new policies slowed down because decisions have to be made out side the domain of the MoH.Implementation of policyWhile recognizing the challenge of making policies, it is also noted that there were challenges related to full implementation of some policy decisions. A typical example is the failure to implement the locum guidelines and the consequent failure to control various practices at lower levels of the ministry. A number of policies have either not been fully implemented of are partly being implemented eg the capital investment plan which is not being followed. Reasons for the problems related to this are capacity and financial constraints. Monitoring policy implementationMany policies have been developed but monitoring framework for implementation of those policies are not in place as part from few departments most departments neither use HMIS nor have their own means of checking that policy is being implemented. The environmental section for example has not yet put a mechanism to check progress implementation of various policies developed in that department. This lack of monitoring created a two fold effect .The first one being that the departments do not have targets and therefore prepare plans that can not be linked with progress on the ground. The second one is that reporting has been a continuous challenge for most of them since they have no targets

Procurement Challenges

In adequate training and supervision of the procurement function in the health sector due to lack of resources.

Capacity constraints at all levels in procurement in the health sector. Established positions not filled at the DHO level.

Budget overruns affecting execution of the procurement plan during the 2008/09 financial year.

Delays in submission of specifications by user departments affecting implementation of the 2009/10 procurement plan and splitting of tenders

Numerous unplanned and urgent procurements not in the approved budget and procurement plan overloading the already overstretched procurement unit, leading to compromises on procurement procedures and overcrowding of the more important planned procurement activities.

Poor coordination amongst the players (user department, procurement unit and accounts department) involved in the procurement process leading to delays in procurements, delays in payment to suppliers and procurement of wrong items.

Lack of linkage between the procurement plan and cash flow delaying payment to suppliers.

Communication and coordination

The last challenge has been communication / coordination challenge. What mostly eats up most of the time of senior staff in the ministry are meetings, some of them scheduled others not. Beside this there are also a number of workshops happening within the ministry that require full participation of the same staff who are to drive key processes in the MoH. The zonal health support office has not yet been fully utilized to assist MoH in linking with the districts

Way forwardFinalise the policiesand lauch policiesAssist in Implementation of policiesMonitor policy implementation through various meansCoordinate activities of the health sectorStrengthen use of TWG to assist in identifying solutions to bottlenecks in implementation