Assessing the use of an essential health package in a sector wide approach in Malawi

Abstract

Background: The sector wide approach (SWAp) used in many developing countries is difficult to assess. One way is to consider the essential health package (EHP) which is commonly the vehicle for a SWAp's policies and plans. It is not possible to measure the impact of an EHP by measuring health outcomes in countries such as Malawi. But it is possible to assess the choice of interventions and their delivery in terms of coverage. This paper describes an attempt to assess the Malawi SWAp through its EHP using these available measures of technical efficiency.

Methods: A burden of disease model was used to identify the priority diseases and their estimated incidence. Data from the health management information system (HMIS) were used to measure the coverage of these interventions. A review of the cost-effectiveness of the chosen and potential interventions was undertaken to assess the appropriateness of each intervention used in the EHP. Expenditure data were used to assess the level of funding of the EHP.

Results: 33 of the 55 EHP interventions were found to be potentially cost-effective (<$150/DALY), 12 were not so cost-effective (>$150/DALY) and cost-effective estimates were not available for ten. 15 potential interventions, which were cost-effective and tackling one of the top 20 ranked diseases, were identified.Provision had increased in nearly all EHP services over the period of the SWAp. The rates of out patient attendances and inpatient days per 1000 population had both increased from 929 attendances in 2002/3 to 1135 in 2007/08 and from 124 inpatient days in 2002/03 to 179 in 2007/08.However, by 2007/08 the mean gap between what was required and what was provided was 0.68 of the estimated need. Two services involving the treatment of malaria were overprovided, but the majority were underprovided, with some such as maternity care providing less than half of what was required.The EHP was under-funded throughout the period covering on average 57% of necessary costs. By 2007/08 the funding paid by SWAp partners including the government of Malawi to fund the EHP was at US$13.5 per capita per annum, which was almost half of the revised EHP estimated required expenditure per capita per annum.

Discussion: The SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two thirds of the services required. This was despite serious under-funding of the EHP, an increase in the population and shortage of staff.

Conclusions: The identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.

Figure 1

General activity health sector - Malawi 2002 - 2008.

Figure 2

The cost-effectiveness of and relationship to disease burden of actual and potential EHP interventions - Malawi 2008. 1 IMCI, 2 HIV Testing & Counselling (HTC), 3 Management of OIs, 4 Prevention of MTC transmission, 5 CBHBC, 6 ARV, 7 ARI in under-5s, 8 Malaria - bednets, 9 Treatment of Dehydration in U5s using Tanzi, 10 Malaria - under 5 using ACT, 11 Treatment of Wounds, fractures and dislocations, 12 Maternal care, 13 Family planning, 14 Treatment -smear negative and extra-pulmonary TB, 15 Treatment -smear positive TB, 16 Treatment - relapsed cases, 17 Growth Monitoring of U5 Children, 18 Testing and Treatment of Other Sexually Transmitted Infections (STIs), 19 Malaria - 5 and over using ACT, 20 Schistosomiasis mass treatment, 21 Full immunization with Penta vaccine, 22 Intermittent preventive treatment in pregnancy with SP, 23 Measles, 24 DPT, 25 Intermittent preventive treatment in children with SP, 26 Rapid diagnostic tests to improve malaria treatment, 27 Indoor residual spraying (two rounds per year), 28 Home made ORS, 29 Onchocerciasis, 30 Mass treatment filariasis, 31 Case finding and treatment of Trypanosomiasis, 32 Supplementary Feeding, 33 Mass treatment of Trachoma, 34 Trachoma surgery, 35 Prevention of Road Traffic Accidents, 36 Improved water supply, 37 Improved sanitation, 38 Cholera or rotavirus immunisation, 39 School health, 40 Emergency medical care - first aid training of volunteers, 41 Emergency medical care - ambulance service, 42 Bipolar disorders, 43 Depression, 44 Schizophrenia, 45 Epilepsy, 46 Cataract extraction, 47 ACE inhibitors, b-blockers and diuretics for CCF, 48 Aspirin, b-blockers and ACE inhibitors for IHD, 49 Aspirin for stroke, 50 Cancer

Figure 3

Cost of Essential Health Package-Malawi. Per capita national expenditure on health (excluding research, training, environment and nutrition) for 2002/3 to 2005/6 (left hand column of each year), per capita expenditure on EHP by government and SWAp donors for 2002/3 and 2004/5 to 2007/8 (right hand column of each year)