Réseau Pharmaceutique Œcuménique (EPN)

Executive summary of baseline survey research in Malawi

In Malawi, in May 2005, researchers from five countries were trained in the use of the baseline survey tools for the EPN Access to Medicines project (in order to carry out work in Cameroon, Ghana, Malawi, Togo, and Tanzania), and undertook fieldwork to complete the baseline survey for Malawi.

Please download:

• Full EPN Access baseline survey research in Malawi [.doc 579KB] [.pdf 310KB]
• Summary EPN Access baseline survey research in Malawi [.doc 76KB] [.pdf 67KB]

The EPN Guidelines project is part of the EPN programme entitled ‘Maximizing access to essential medicines for church health services and their clients’. The first phase of the project identifies the baseline in each EPN guideline area and feeds this information back to an in-country group that can then decide which EPN guidelines should be prioritized and what further work should be undertaken.

This summary of results provides the baseline for compliance with EPN guidelines in Malawi, and is drawn from the results of the tools used. Wherever possible, results are simply scaled up to cover all church health services (CHSs) in Malawi—this means that the compliance indicator is not a quantifiable certainty but is simply an indication of the level of compliance. A zero value shows that no facility was found that complied with that EPN guideline—it is possible that a facility does exist, but was not surveyed. Thus, a zero value only indicates a very low number of compliant facilities. A ‘no’ value indicates that something on a national scale does not exist.

The guided self-assessment workshops provided an indication of the priorities perceived by CHSs, in terms of which aspects of their challenges were perceived as having the greatest impact on increasing access. These priorities are indicated with an ‘X’ to the far left of Figure 1 (below).

Figure 1. Baseline EPN guideline compliance in Malawi

Overall conclusions

Based on the results of the guided self-assessment workshops, it is clear that the dominant trend for church health facilities is a worsening of their situation or, at best, little change. Informal discussions indicate that the departure of missionary health staff, the continuing brain drain, and the increasing poverty of a population frequently facing famine, all contribute to this situation.

However, the workshops also produced indications that there was a willingness to change, as well as recognition of the need to change. There were also important examples of success and improvement, in particular areas, in particular facilities. However, while one facility might be able to implement a particular SOP, a different facility would fail to implement in that particular area but succeed in another. These examples indicate that many solutions to church health service problems in Malawi do indeed lie within Malawi, and that the capturing of these experiences and the passing on of these approaches within the country could itself successfully increase access to health care through church health services.

Church health services (CHS) in Malawi provide approximately 37% of the available health care. All CHS hospitals and a proportion of clinics were given the opportunity to respond to the survey, with a total of 60 facilities contacted. A 58% response rate (35 facilities responded) was achieved for the survey. It is believed that the results are valid for general trends, but it is recognized that a higher response rate would provide a more accurate picture, particularly for clinics. Such problems were considered during the analysis of the results. All 10 planned guided self-assessment workshops were carried out, as were the 10 focus groups. Common results across these activities have been scaled up to inform the overall analysis.

The Christian Health Association of Malawi (CHAM) reports that the church health care facilities in Malawi number 33 hospitals and 132 clinics at the time of research. The government pays all health personnel salaries in CHSs and some allowances such as housing and transport. Government health facilities offer free health care (including consultation and medications), while the CHSs charge. In many areas, the CHS is the sole provider of health care.

Three issues emerged relating to the methodology.

• First, straightforward questions such as ‘do you implement rational use of medicines guidelines’ often provoked a positive response (taken literally, what ‘rational’ person would say no?) However, on examination of responses to further ‘test questions’ in the survey, it became clear that the answer was actually ‘no’.
• Second, despite a request to complete the survey during a management committee meeting or to have the most senior staff member complete it, this often did not happen—as indicated by the high number of ‘don’t know’ or incomplete responses.
• Third, the institutions responded very positively to the EPN visits (despite some organizational problems). The workshop and focus group participants were all excited about being asked and also about the process of asking. The survey process, on the other hand, indicates the need for training on teamwork for the institutions.

The issue of direct and indirect EPN Guideline impact

A clear entry point is when a need for intervention meets the capacity to intervene. The issue of indirect, but still important, impacts needs to be part of the analysis of a response to CHS-identified needs and problems. For example, while EPN cannot do anything directly about increasing institutional resources, the implementation of some of the EPN guidelines would indirectly increase resource availability:

• EPN Guidelines
  • Pricing policies in place and operationalized.
  • Compliance with drug donations guidelines.
  • Implementation of standard operating procedures for procurement.
  • Access to credit (for some patients).
• Indirect impacts
  • Improved financial stability, income, and resource availability and efficiency in some areas.
  • Reduced likelihood of closure.
  • Reduced theft (of pharmaceuticals).

Indirect impacts would also contribute to the improvement of quality of care in relation to, for example:

• Improved skills—in a number of areas, particularly pharmaceutical-related.
• Reduced staff turnover and brain drain, through increased staff commitment and motivation, particularly in pharmaceutical-related areas.
• Improved training, MIS systems, and the simplification of a wide range of procedures.

As identified through force field analysis in the workshops, increased resources would produce the biggest lift, and improved management would reduce the biggest constraint. The force field analysis shows a direct relationship between these areas. However, while human resources provide the second biggest lift, only the staff training aspect was identified as a crucial constraint—these two areas are only partly linked and indicate that increased training would be the priority area of the human resource challenge.

Two further aspects were identified as constraints and had no matching lifting aspects—client poverty and government politics and policies. While both of these issues are important and EPN guidelines would indicate that the relationship with government could be improved, the issue of client poverty itself is beyond the bounds of the EPN guidelines and indeed the work of EPN.

An analysis of the problem tree exercise allows us to match EPN guidelines to problem solving. See the report for more details.

Potential priorities

There appears to be an issue of understanding of pharmaceutical terminology, particularly where certain terms that have particular pharmaceutical meanings are being interpreted literally, such as ‘rational use of medicines’. The survey showed that many people answered ‘yes’ to the question ‘does your facility comply with rational use of medicines practices’, when their answers to other ‘test questions’ showed the answer to be ‘no’.

In nearly all EPN guideline areas there is at least one hospital that indicates it has implemented the EPN guideline. This means that a significant impact could be achieved through networking efforts and sharing local examples, rather than only through external guidance.

The EPN guidelines can also be linked to leading problems through the force field analysis. Below are four issues identified as areas where greatest positive change could be achieved, partnered with a corresponding EPN guideline.

1. While it is extremely difficult to do anything directly about increasing institutional resources, the implementation of some of the EPN guidelines could indirectly increase resource availability.
• Pricing policies in place and operationalized.
• Compliance with drug donations guidelines.
• Implementation of standard operating procedures for procurement.
2. The inclusion of further EPN guidelines in the work would directly respond to the hospital-based recognition for improved management.
• Compliance with best practices for drug storage and management.
• Functioning Drug and Therapeutics Committees (DTC) in hospitals.
• All ‘owners’ with maximum understanding of roles, best practice, and management information, understanding of revolving fund concept and implementation of methods of increasing access for the poorest.
• Quality assurance policy in place and implemented.
• Transparency mechanisms in place in support of ‘Health for All’.
• Pharmaceutical function represented at all levels of discussion.
• Disaster preparedness procedures in place.
3. The particular importance of training of human resources would be reflected in the need to train staff as part of the above EPN guidelines and to support the implementation of other EPN guidelines, for example:
• Compliance with rational use of medicines ‘guidelines’.
• At least one pharmaceutically trained person per facility.
• Access to key pharmaceutical information.
• Regular assessment of pharmaceutical unit work.
4. The identification of government policies and politics could be addressed in part by the implementation of EPN guidelines, for example:
• Effective community involvement system in place.
• Cross-institutional information sharing, including provision of information to national drugs policy and national health management information systems.
• Mechanism in place to allow for representation at regional and national levels in relevant debates.
• Church leaders’ awareness of key messages.