Malawi Health Sector Strategic Plan III 2023-2030

Objectives

Malawi’s Health Sector Strategic Plan III (HSSP III), covering 2023 to 2030, seeks to advance universal health coverage so that all people can attain health that enables productive, high-quality lives. Its goal is to improve health status, client satisfaction and financial risk protection through equitable, accessible, affordable, sustainable, high-quality and evidence-based care.[1][2]The results framework links this goal to improved access, quality and efficiency of services.[3]

• Strengthen integrated service delivery by moving from fragmented vertical programmes towards comprehensive platforms of care across community, primary, secondary and tertiary levels, supported by defined service standards, referral systems, client safety and client-centred care.[4][5][6]
• Prioritise the Health Benefits Package as an evidence-based mechanism for maximising population health within limited resources, while transitioning from a list-based package towards integrated platforms of care.[7][8]
• Address social and environmental determinants of health through wellness promotion, safe food and water, sanitation and hygiene, healthy housing and workplaces, occupational health, climate adaptation, violence and injury prevention, and multisectoral preparedness for outbreaks and disasters.[6][9][10]
• Expand infrastructure, medical equipment, transport and referral capacity, including facilities in underserved areas, reliable water and power, equipment maintenance, trauma services and technology-enabled transport.[11][12][13]
• Develop a competent, motivated and equitably distributed health workforce through needs-based pre-service education, recruitment, deployment, professional regulation, supervision, performance management, career pathways and retention measures.[14][15]
• Improve availability, quality and rational use of medicines, medical supplies and technologies through strengthened forecasting, procurement, warehousing, distribution, regulation, pharmacovigilance and supply-chain digitalisation.[16][17][18]
• Build a sustainable, harmonised and country-led digital health system, alongside stronger locally led research, evidence generation, data sharing and translation of evidence into policy and service delivery.[18][19][20]
• Strengthen leadership, governance and health financing through accountability, decentralisation, community empowerment, strategic purchasing, equitable allocation and more sustainable resource mobilisation.[2][21][22]

Implementation

Implementation is organised around a systems-and-reforms approach, using the World Health Organization health-system building blocks and bottleneck analysis to combine routine service continuity with catalytic institutional and policy reforms.[23]HSSP III is operationalised through annual plans that jointly prioritise activities and costs within the available resource envelope, under the principle of “One Plan, One Budget, One Monitoring and Evaluation Report”.[24][25]

• Lead sector implementation through the Ministry of Health, with the Secretary for Health providing sector-wide oversight, directors leading thematic areas, and District Directors of Health and Social Services coordinating delivery within council governance arrangements.[26]
• Coordinate annual planning through the Health Sector Working Group, involving Ministry directorates, central hospitals, districts, the Health Donors Group, implementing partners and non-state actors; use technical working groups for specialist input and escalation of decisions.[27]
• Align Government, donor and implementing-partner activities through annual operational plans, memoranda of understanding, partner entry requirements and a code of conduct.[28][29]
• Decentralise service delivery, planning, financing and accountability through District Councils, district stakeholder forums, health facilities and communities, while strengthening facility-level oversight and community governance.[30][21][31]
• Use integrated platforms of care rather than disease-specific programmes as the basis for prioritising interventions across primary, secondary and tertiary levels, with annual updates reflecting emerging evidence, diagnostic capacity and quality-improvement priorities.[25][27]
• Strengthen financing through resource mapping, pooled and aligned funding, decentralised budgeting, direct facility financing pilots, strategic purchasing and provider-payment reforms.[32][33][34]
• Prioritise investments iteratively by comparing the cost of identified needs with projected resources. The full pre-prioritisation requirement for the intervention matrix over eight years is estimated at US$31.2 billion, equivalent to 32 trillion Malawi Kwacha, while a financial-year resource need of US$4.0 billion was prioritised to a US$537.1 million fungible resource envelope.[35][36]
• Strengthen health information and monitoring by decentralising interoperable systems, using the integrated Community Health Information System at community level, linking data through district and national platforms, and harmonising partner reporting systems.[37][38]
• Monitor results through a framework that tracks ultimate impacts in health status, financial risk protection and client satisfaction, alongside intermediate impacts in access, quality and efficiency.[29][3]Performance data are to draw on routine health, workforce, logistics, laboratory, surveillance and civil-registration systems, supplemented by facility and household surveys.[39]
• Apply annual, zonal and district reviews, data validation, performance contracts, financial controls, audits and community oversight to support accountability.[40][38]The monitoring matrix includes baselines and targets for 2024, 2027 and 2030, although some indicators retain targets or baselines to be determined.[41][42][43]

Monitoring & Evaluation

HSSP III establishes an integrated monitoring, evaluation and accountability architecture centred on the ultimate impacts of improved health status, financial risk protection and client satisfaction, with equity assessed by socioeconomic status, gender and geographical location. Intermediate performance is assessed through access, quality and efficiency of health services.[3][41][44]

• Use a results framework that links inputs, activities and annually agreed milestones to outputs, pillar outcomes, intermediate impacts and ultimate impacts; each objective has an outcome and each strategy an output.[3]
• Implement the “One Plan, One Budget, One Monitoring and Evaluation Report” model through annual operational plans, joint planning and review platforms, partner codes of conduct, memoranda of understanding and feedback to the Joint Annual Review.[25][29]
• Track indicators at national, district, traditional authority and facility levels, using specified disaggregation including sex, age, socioeconomic status, geography and service setting where relevant.[41][42][43]
• Report most matrix indicators annually, while selected facility and infrastructure indicators are reported bi-annually, selected supply indicators monthly, and some population indicators through periodic household surveys.[44][45][46][47]
• Draw evidence from routine systems including the Health Management Information System, Human Resource Information System, Integrated Disease Surveillance and Response, logistics and laboratory information systems, civil registration and vital statistics, facility surveys and household surveys.[39]
• Strengthen decentralised, interoperable information systems through the integrated Community Health Information System, district systems, point-of-care digital records and a harmonised dashboard platform.[37][38]
• Assign national monitoring and evaluation coordination to CMED, digital oversight to the Digital Health Division, and technical coordination and service-data quality assurance to Quality Management.[38]
• Establish first-year baselines, integrate performance indicators into information systems, use performance contracts for senior management, central hospitals and District Councils, and align national surveys with evaluation cycles.[40][38]
• Strengthen accountability through audits, financial-management controls, provider performance management, community oversight, health-facility management structures and transparent monitoring of partner adherence to agreements.[40][21]
• Monitor major health outcomes against 2024, 2027 and 2030 milestones, including a reduction in households making catastrophic healthcare payments from 4.4% to 0.1% by 2030; some baselines and targets remain to be determined.[41][43]
• Target selected 2030 service outcomes including 92% antiretroviral therapy coverage, 100% skilled birth attendance, 91% insecticide-treated-net use and 98% client satisfaction with health-service delivery.[44][48]

Costing & Financing

HSSP III applies resource-envelope-based prioritisation: the full eight-year intervention matrix was costed before activities were iteratively reduced to fit available fungible resources. Financing reforms seek to mobilise sustainable domestic and external resources, improve pooling and allocation, decentralise fundholding, and strategically purchase services through the Health Benefits Package.[49][22][35]

• Estimate the unprioritised eight-year resource need at US$31.2 billion, equivalent to MWK32 trillion, for financial years 2023/2024 to 2030/2031.[35][36]
• Prioritise the financial year 2024/2025 resource need of US$4.0 billion to the estimated fungible envelope of US$537.1 million; available resources exclude non-fungible operational, payroll and programme-management costs.[36]
• Cost HSSP III at US$78.7 per capita in its first year and US$172.12 per capita on average over eight years.[35][36]
• Use an estimated US$65 cost-effectiveness threshold per disability-adjusted life year averted when prioritising Health Benefits Package interventions.[8][4]
• Recognise that total health expenditure has remained about US$40 per capita annually, against a benchmark of up to US$86 per capita for the minimum Health Benefits Package, with US$50 per capita by 2030 presented as the feasible ambition.[22][33]
• Increase government health allocations towards the Abuja target of 15% of the total government budget, from an approximate current allocation of 10%.[22]
• Mobilise revenue through government funding, donor financing, community contributions, optional paying services, private insurance, the Health Services Joint Fund and government-to-government arrangements.[22][33]
• Align government and partner resources through annual resource mapping, operational planning, pooled or harmonised funding, decentralised budgeting, commitment controls and routine audits.[40][21][25]
• Identify persistent fiscal-space constraints, donor dependence, fragmented funding and insufficient resources for optimal package delivery; the available material does not provide a comprehensive quantified funding-gap analysis by programme.[50][33][34]
• Allocate a FY2024/2025 workforce envelope of US$59.7 million, while reporting an over-US$400 million gap for staffing and delivering the prioritised access-constrained package at status-quo quality.[51][52]