What is new in the HSSP? The Health Sector Strategic Plan 2011-2016 is different from the Program of Work (PoW) 2004-2010 because it: ?

A written report for a plan review
Assignment 1 has a word limit of 3300 words and it is worth 50%. For submission date, please refer to the unit outline.

As an international consultant in Health Planning, you have been assignment by the Government of Australia to review the Health Sector Strategic Plan (HSSP) for the year 2011-2016 for the country of Muteu or (Theu). The Government of Australia has agreed to provide technical and financial support for developing a new Health sector Plan for the country of Muteu. Before the Ministry of Health in Muteu can develop the new strategic plan, The Australian Government in collaboration with Government of Muteu would like the current HSSP to be reviewed and evaluated as a basis for the next HSSP.

The first part of your assignment in this role, is to critically analyse the current HSSP (see the document as provided) and identify areas that need to be improved in the next planning process and the final plan document. You are asked to write a report of this plan review which should address the following areas;

Using frameworks for population’s health approach to health planning; strategic planning and health services planning;

? Using a SWOTT and PEST analysis tools, analyse the planning context and identify three major health system capacity concerns for developing and implementing the next HSSP. Discuss their potential implication on the next HSSP and provide suggestions of how these might be addressed
? Does the current plan address the core principles of health planning? Justify your position.
? What should be the three key priority health issues to be addressed in the next plan? Provide evidence and rationale for your recommendations in this regard
? What should be the main goals and objectives for the next plan based on the three main priority health issues as recommended?
? Using a decision tree, identify strategies which are most likely to help the Ministry of Health in Theu to reach its goals and objectives for the key priority areas?
? Present a stakeholder analysis matrix of the key stakeholders that the Ministry of Muteu needs to engage with and involve in the next planning process and discuss why

Note: Please, completely ignore implementation, budget implications and evaluation for now. When you get to read the provided health sector plan, you will realise that I have cut the sections that cover budgets, implementation, monitoring and evaluation as well as the preamble stuff (preface, table of contents, and list of abbreviations). I have left the sections on the context, situation analysis, mission, goals, objectives and strategies intact for you to appreciate the messiness of the real world. Be warned that the provided health sector plan is a big document (close to 38 pages with lots of tables and some empty pages), start getting to understand its context and main issues as soon as you can, do not wait until the last minute! At the same time, do not be overwhelmed with the size of the document, for purposes of the assignment, you will only get to read bits and pieces of information and not the whole document

The trick to getting this assignment right is to have a good grip of the ideal health planning which we are learning in this Unit. Only then, you can be able to see the flaws in the provided health sector plan and think of ways of how it can be improved.

All the best!

Your report should at least include the following information and headings:

Cover page
Title for the report, information about the author, to whom the report is being submitted

? Briefly describe the basis or background of this report
? Present and explain the framework which you are using for analysing Theu’s HSSP
? Provide the structure of your report

The body
Present and discuss your key findings using subtitles that reflect the requested areas to be addressed in the report.

Provide summary of your key findings and recommendations

? Include a list of references cited in the report e.g. for the Rationale or Program Activities.
Reference any existing resources that will be used to implement the program.

Marking Guide-Essay
OBJECTIVE 0% 20% 50% 70% 100% Weight Mark Awarded
Introduction: clearly defines the topic and purpose No introduction provided Poor formation of introduction. Poor academic language or use of casual language Topic discussed or aims stated. Good language used Topic discussed or aims stated. Good language used Topic & purpose clearly defined. Aims outlined. Clear academic language used 2
The introduction identifies the framework and structure (these can be informed by guidelines for the assignment or relevant theories for the topic being considered No framework for framing the plan
No structure outlined Framework and structure outlined in the introduction but;
1. do not relate with the main discussion and arguments or
2. are not used for framing the main discussion/body Framework and structure outlined in the introduction and are related with the main discussion but do not frame the structure of the discussion or vice versa Framework and structure outlined in the introduction; are related with the main discussion and used for framing the structure of the discussion Uses creativity in framing and structuring of the essay i.e. use of a work based scenarios as examples and conceptual frameworks 7
The student demonstrates a clear understanding of the topic area, context and issues being analyzed
No evidence of knowledge of the topic and context Minimal evidence of knowledge of the topic area and context of issues being analyzed Considerable evidence of knowledge of the topic and context of issues being analyzed Significant evidence of knowledge of the topic and context of issues being analyzed Demonstrates an outstanding level of knowledge for the topic area and context of issues being analyzed 10
Appropriate and clear use of relevant concepts and theories
relevant theory and concepts are explained clearly and applied critically in analysis of an experience in a specific context No theoretical concepts used Theoretical concepts mentioned but not explained or used Theoretical concepts clearly explained but not used appropriately Theoretical concepts and conceptual frameworks explained and used appropriately Theoretical concepts and conceptual frameworks explained and used appropriately
Exceptional application of theories in the analysis with clear examples 20
Argument development: Idea development is logical and orderly, presenting a cohesive argument The argument is not clear and not presented in a logical order Has provided limited argument development with significant sections which are incoherent The argument is clear/coherent but not in logical order Has addressed the purpose of the assignment coherently and with some attempt to demonstrate imagination Has addressed the purpose of the assignment comprehensively and imaginatively in an academic manner 20
There is evidence of critical thinking, indicating an ability in analysis and interpretation Critical Thought Either no evidence of literature being consulted or irrelevant to the assignment set Literature is presented uncritically, in a purely descriptive way and indicates limitations of understanding Clear evidence and application of readings relevant to the subject; uses indicative texts identified Able to critically appraise the literature and theory gained from variety of sources, developing own ideas in the process Has developed and justified using own ideas based on a wide range of sources which have been thoroughly analyzed, applied and discussed 15
Academic Writing Meaning unclear and/or grammar and/or spelling contain frequent errors Meaning apparent, but language not always fluent (i.e. casual). Grammar and/or spelling contain errors Language mainly fluent Grammar and spelling mainly accurate Language fluent. Grammar and spelling accurate High academic writing style appropriate to document. Grammar and spelling accurate. 10
Conclusion: A rational conclusion is offered and supported. Unsubstantiated/invalid conclusions based on anecdote and generalization only, or no conclusions at all Limited evidence of findings and conclusions supported by theory/literature Evidence of findings and conclusions grounded in theory/literature Good development shown in summary of arguments based in theory/literature Analytical and clear conclusions well-grounded in theory and literature showing development of new concept 5
In text referencing ? all text and diagrams are correctly referenced using appropriate referencing style. Problems with more than 4 citation requirements Problems with 3-4 citation requirement. Problems with 2 citation requirement. Problems with 1 citation requirement. All citation requirements met 2
Reference List ? current references (no more than 5 yrs old unless justified). Referenced using an appropriate referencing style. Problems with more than 4 referencing requirements Problems with 3-4 referencing requirement
Problems with 2 referencing requirement. Problems with 1 referencing requirement
All referencing requirements met 2
The presentation of the paper is of an appropriate academic standard Problems with more than 4 formatting requirements Problems with 3-4 formatting requirement
Problems with 2 formatting requirement. Problems with 1 formatting requirement
All formatting requirements met 2
Out of 30%

Note: A mark over 50% does not automatically mean that you have passed the paper if you have plagiarised

? Cover page as per Guide to Assignment Presentation (GAP) (Appendix A) including student declaration
? Clearly stated title on cover page
? Contents page as per GAP (with correct footer, as per Appendix B of GAP)
? All pages numbered correctly (starting with page 1 on Introduction page)
? Appropriate footer (Group Number, due date & page number)
? Short, appropriate headings and subheadings, correctly numbered and formatted

? Correct citation style has been consistently used, use APA 6th Edition as the recommended referencing style. Visit the Curtin Library homepage for guidelines on referencing
? All facts that are not original thought have a citation provided
? All components of citation are present
? All components are in the correct order
? Capitals are correct
? Punctuation is correct
? All direct quotes contain page number
? All tables and graphs correctly cited
? All citations are referenced in the reference list

? Correct citation style has been consistently used
? References appropriate age and where more than 5 years old are justified
? Credible sources of information used
? All components of references are present (inc electronic source & access date)
? All components are in the correct order
? Punctuation is correct
? Capitals & italics are correct
? Alphabetical order & hanging indent is correct
? All references are cited in the report

2011- 2016
Government of Muteu
Ministry of Health
Muteu Health Sector Strategic Plan 2011 – 2016
Moving towards equity and quality
Ministry of Health PO Box 3077 Lirome 3 Muteu

Executive summary Muteu Health Sector Strategic Plan (HSSP) (2011-2016) is the successor to the Program of Work (PoW) which covered the period 2004-2010 and guided the implementation of interventions aimed at improving the health status of the people of Muteu. The Ministry of Health (MoH), other government ministries and departments, Health Development Partners (HDP), Civil Society Organisations (CSO), the private sector and other stakeholders in the health sector were involved in the development and implementation of the PoW which was extended to June 2011 to allow for the final evaluation. The Mid-Term Review and the final evaluation of the PoW informed the development of the HSSP, whose overall goal is to improve the quality of life of all the people of Muteu by reducing the risk of ill health and the occurrence of premature deaths, thereby contributing to the social and economic development of the country.
Among the achievements during the period of the PoW, according to the 2010 Demographic and Health Survey has been the reduction in infant and child mortality rates from 76/1000 in 2004 to 66/1000 in 2010 and from 133/1000 to 112/1000, respectively. The maternal mortality rate reduced from 984/100,000 in 2004 to 675/100,000 in 2010 with an increase in women delivering at health centres from 57.2% in 2004 to 73% in 2010. There has also been a reduction in pneumonia case fatality from 18.7% in 2000 to 5.7% in 2008 and an increase in the proportion of children with acute respiratory infections taken to health facilities for treatment from 19.6% in 2004 to 70.3% in 2010. Immunization coverage is high: 81% of the children aged 12-23 months old were fully vaccinated in 2010. This is an increase in coverage of 26% since the 2004 DHS. There has also been an increase in coverage of the estimated population in need of ART from 3% in 2004 to 67% in 20111.
While sustaining the gains made under PoW, the HSSP has taken further measures to address the burden of disease by putting more emphasis on public health interventions, including but not limited to health promotion, disease prevention and increasing community participation. The Essential Health Package (EHP) has been expanded after taking cognizance of the increasing burden of disease arising from non-communicable diseases (some of them ?lifestyle? diseases), such as mental illness, hypertension, diabetes and cancers. As the EHP is being implemented, the main priority will be interventions that are cost effective, and expansion of services to the under-served. Despite the gains made there are still a number of factors that need to be addressed that negatively impact on the health of Muteuans, namely the availability and quality of health services, access to health services and environmental and behavioural issues. The HSSP intends to achieve the following key outcomes and outputs:
Outcome 1: Increased coverage of high quality EHP services ? Health facilities including staff houses constructed and rehabilitated especially in under- served communities. ? Service Level Agreements implemented in identified areas. ? Emergency transport provided.
Muteu ART Programme Quarterly Report June 2011

2011- 2016
Outcome 2: Strengthened performance of the health system to support delivery of EHP services
? Sufficient skilled human resources for health trained, recruited and retained in the health sector. ? Quality medical equipment provided and maintained. Essential medicines and supplies made available all the time. ? Monitoring, evaluation and research activities strengthened. ? Appropriate standards, guidelines, Standard Operating Procedures, protocols and legislative frameworks developed.
Outcome 3: Reduced risk factors to health ? Public policies that impact on health advocated for. ? Healthy settings programs (workplaces, schools and communities) and water, sanitation and food safety interventions implemented. ? Vector control strategies strengthened and implemented. ? Advocating for healthy lifestyles and behaviours. ? Disaster risk management strengthened.
Outcome 4: Improved equity and efficiency in the delivery of quality EHP services ? Health financing strategy developed. ? Resource allocation formula reviewed. ? Increased harmonisation and alignment of partners.
The successful implementation of the HSSP will be dependent on a number of assumptions. These are: availability of adequate financial and human resources; conducive policy and legislative environment; transparent and accountable financial management and procurement systems; effective coordination and partnerships; adherence to international agreements such as the Paris Declaration for Aid Effectiveness, and improved literacy levels. The health systems strengthening approach, as recommended by WHO and other international agencies, will be used to effectively monitor the performance of the health system.
The ideal total cost of implementing this strategic plan is estimated at $ 3.2 billion over five years, while the plan based on projected resources costs $ 2.48 billion with an estimated gap over the five years of the HSSP of $ 754 million.
The overall implementation of the HSSP will be monitoring using an agreed performance framework2, as shown in Table 1.
Targets for some indicators will be set once baselines have been established. 13

No Indicator Baseline (2010-11)
Target (2015-16) Health impact 1 Maternal Mortality Ratio (MMR) 675/ 100000 155/ 100000 2 Neonatal Mortality Rate (NMR) 31/1000 12/1000 3 Infant Mortality Rate (IMR) 66/1000 45/1000 4 Under five Mortality Rate (U5MR) 112/1000 78/1000 Coverage of health Services 5 EHP coverage(% Facilities able to deliver EHP services) 74% 90% 6 % of pregnant women starting antenatal care during the first trimester 9% 20% 7 % of pregnant women completing 4 ANC visits 46% 65% 8 % of eligible pregnant women receiving at least two doses of intermittent preventive therapy 60% 90% 9 Proportion of births attended by skilled health personnel 58% (HMIS) 75% (WMS) 80% 80% 10 Penta III coverage 89% 94% 11 Proportion of 1 year-old children immunized against measles 88% 90% 12 Proportion of 1 year-old children fully immunized 80.9% 86% 13 % of pregnant women who slept under an insecticide treated net (ITN) the previous night 49.4% 80% 14 % of under 5 children who slept under an insecticide treated net (ITN) the previous night 55.4% 80% 15 Neonatal postnatal care (PNC) within 48 hours for deliveries outside the health facility Baseline to be established 16 % of women who received postpartum care after delivery by skilled health worker within seven days 10% 30% 17 Prevalence of HIV among 15-24 year old pregnant women attending ANC 12% 6% 18 % of HIV+ pregnant women who were on ART at the end of their pregnancy (to reduce mother to child transmission and for their own health) 35% 82% 19 % of health facilities satisfying health centre waste management standards 35% 55% 20 % surveyed population satisfied with health services (by gender and rural/urban) 83.6% (urban) 76.4% (rural) 90% (urban) 90% (rural) Coverage of Health Determinants 21 % of households with an improved toilet 46% 60% 22 % of households with access to safe water supply 79.7% (DHS 2010) TBA 23 % of children that are stunted 47.1% (DHS 2010) TBA 24 % of children that are wasted 4.0% (DHS 2010) 3 TBA Coverage of Risk factors 25 Contraceptive Prevalence Rate (modern methods) 42% (DHS 2010) 60% Health systems Outputs (availability, access, quality, safety) 26 OPD service utilization (OPD visits per 1000 population) 1316/1000 pop >1000/1000 pop 27 % of fully functional health centres offering basic EmOC services 98 90% 134 100% 28 % of non public providers in hard to staff/serve areas signed SLAs with DHOs Indicator Baseline Target
2011- 2016
Table 1 Core performance indicators
Others sectors have influence over food security and water and sanitation, notably Agriculture, Irrigation and Water Development 14

Indicator Baseline (2010-11)
Target (2015-16) 29 % of monthly drug deliveries monitored by health facility committees 85% 95% 30 % of health facilities with stock outs of tracer medicines in last 7 days (TT vaccine, LA, Oxytocin(oxy), ORS, Cotrimoxazole,(cotrim) Diazepam Inj., All Rapid HIV Test kits, TB drugs Magnesium Sulphate, (Mag sulph)Gentamicin, Metronidazole, Ampicillin, Benzyl penicillin, Safe Blood, RDTs) TT vaccine= 98% LA=98% Oxy= 95% ORS= 97% Cotrim = 99% Diaz Inj.= 94% All Rapid HIV Test kits=89% TB drugs= 99% Mag Sulph = Gent= Metro= Ampicillin= Benzyl penicillin= Safe Blood= RDTs= All tracer drugs 100% 31 % of health facilities supervised and written feedback provided 63% 100% 32 % facilities reporting data (according to national guidelines) 96% 99% 33 % districts reporting timely data 52% 90% 34 Bed occupancy rate 50% 80% Health Investment 35 % health facilities with functioning equipment in line with standard equipment list at time of visit Baseline to be established 36 % health facilities with functioning water, electricity & communication at time of visit 79% w 81% e 90% c 100% w 100% e 100% c 37 % health centres with minimum staff norms to offer EHP services Clinician=30% Nurses/Mws=50% EHO/HA=48% Composite=19% Clinician= 80% Nurses/Mws =75% EHO/HA= 70% Composite=4 5% 38 % GoM budget allocated to health sector 12.4% 15% WHO Rx success
2011- 2016

2011- 2016
1.1 Geographical location and administrative system Muteu is a small, narrow, landlocked country that shares boundaries with Zambia in the west, Mozambique in the east, south and southwest, and Tanzania in the north. Muteu has an area of 118,484 km2 of which 94,276 km2 is landlocked. The country is divided into three administrative regions, namely the northern, central and southern regions. Muteu has 28 districts, which are further divided into traditional authorities (TAs) ruled by chiefs. The village is the smallest administrative unit and each village is under a TA. A Group Village Headman (GVH) oversees several villages. There is a Village Development Committee (VDC) at GVH level which is responsible for development activities. Development activities at TA level are coordinated by the Area Development Committee (ADC). Politically, each district is further divided into constituencies which are represented by Members of Parliament (MPs) and in some cases these constituencies can combine more than one TA.
1.2 Population In 2011 Muteu?s population was estimated at 14.4 million.4 Since the population stood at eight million in 1987, this means that it has almost doubled over a 20-year period. At this growth rate it is estimated that by 2016, the population will be at 16.3 million and the health sector will be required to cater for an extra three million people5. With this population increase, there will be need for a corresponding increase in funding for the health sector. The proportion of Muteu?s population residing in urban areas is estimated at 15.3%. Muteu is one of the most densely populated countries in Africa: the population density was estimated at 105 persons per km2 in 1998 and increased to 139 persons per km2 in 2008 with the Southern Region having the highest population density at 184 persons per km2. Muteu?s population growth rate is estimated at 2.3%, predominantly due to the high total fertility rate (TFR), which is now estimated at 5.7, and the low contraceptive prevalence rate (CPR) of 35% among all women using any method 6. Almost half of the population is under 15 years of age and the dependency ratio rose from 0.92 in 1966 to 1.04 in 2008. About 7% of the population are infants aged less than 1 year, 22% are children under five years of age and about 46% are aged 18 years and above. Muteu is predominantly a Christian country (83%), while 13% are Muslim, 2% of other religions and 2% of no religion7.
1.3 Literacy status Low literacy levels, especially among women, and negative cultural practices that impact on health, affect the health of Muteuans. The 2006 Multiple Indicator Cluster Survey (MICS)
4 5 6
NSO (2009) Muteu housing and population census 2008 Zomba: NSO NSO (2009) Muteu housing and population census 2008 Zomba: NSO NSO (2010) Muteu Demographic and Health Survey 2010 Zomba: NSO. The rate among all women using any modern method is 33% 7 NSO (2009) Muteu housing and population census 2008 Zomba: NSO

2011- 2016
and 2010 DHS report show that the prevalence of diseases such as malaria, diarrhoea and acute respiratory infections decreases the higher the educational qualifications. Knowledge about diseases such as HIV and AIDS increases the higher the educational level attained, and educated people are more likely to access modern health care services compared to those who have little or no education. Education is therefore an important determinant of health. The Government of Muteu (GoM) introduced free primary education in 1994 and enrolment increased from 1.9 million to about three million. Although enrolment increased, government data reveals that only 30% of the children who start Standard 1 actually reach Standard 8 in primary school. This implies that 70% of the children drop out of primary school before reaching Standard 8. The literacy rate is estimated at 62% and it is higher among men (69%) than women (59%)8.
1.4 Poverty and health Muteu?s Gross Domestic Product (GDP) per capita grew from less than $250 in 2004 to $313 in 20089. During the implementation of PoW there was a remarkable economic growth rate ranging between 6% and 9%. This contributed to a reduction in the proportion of Muteuans living below the poverty line from 52% in 2004 to 39%10 in 2009. The proportion of people living below the poverty line was higher among rural residents (43%) in 2004 compared to urban residents (14%)11 in 2009. The prevalence of diseases such as malaria, ARIs and diarrhoea is higher among poor people compared to those who are rich12. Therefore, the successful implementation of the HSSP will depend to a large extent on the reduction of poverty. Muteu is predominantly an agricultural country: this sector accounts for 35% of the GDP and more than 80% of export earnings (primarily from tobacco sales) and it supports more than 85% of the population13. The DHS 2010 found that 58% of women and 49% of men work in agriculture. The sources of revenue for funding public services are taxes on personal income and company profits, trade taxes and grants from donors. In the event of insufficient revenue to cover the budgeted expenditure, the financing of the deficit is met either from domestic bank and non-bank sources, or from foreign financing in the form of loans from donor and overseas banks. In such a scenario, the financing of public services in Muteu is inextricably linked to the aggregate of each of these revenue sources. For instance, in the 2008/09 financial year, the major public sector sources of finance contributed in the following proportions: domestic taxes had a share of 77.9% and trade taxes had a share of 10.1%, while non-tax revenue was 12.0%. These revenues represented 24.5% of GDP. In terms of recurrent expenditures, health was the third at 10.2% after General Administration (33.9%), Agriculture (18.9%) and Education (13.7%)14.
8 9 NSO (2009) Muteu housing and population census 2008 Zomba: NSO IMF Article IV Consultation Report 10/87 of March 2010 10 11 12 13 14 NSO (2009) Welfare monitoring survey 2009 Zomba: NSO NSO (2009) Welfare monitoring survey 2009 Zomba: NSO NSO (2010) Muteu Demographic and Health Survey 2010 Zomba: NSO World Bank Country Brief: Muteu 2005-2010 Mwase, T. (2010) Health Financing Profile for Muteu. Lilongwe: MoH 17

DTP3 Mwi
2011- 2016
In 2004 the Ministry of Health (MoH) in conjunction with other government ministries, the private sector, Civil Society Organisations (CSOs) and HDPs developed the Sector Wide Approach (SWAp) Program of Work for the period 2004-2010 to guide the implementation of interventions in the health sector. The PoW was completed in 2010 but was extended to June 2011 to allow for the final evaluation of the Program. Substantial progress was made during the implementation of the PoW as demonstrated in improved health indicators, such as the maternal mortality ratio (MMR), infant mortality rate (IMR) and contraceptive prevalence rate (CPR). An Essential Health Package (EHP) was agreed upon, covering diseases and conditions affecting the majority of the population and especially the poor. This package has been delivered free of charge to Muteuans and most of the interventions for EHP conditions have been cost effective. The conditions in this package are: vaccine preventable diseases; acute respiratory infections (ARIs); malaria; tuberculosis; sexually transmitted infections (STIs) including HIV/AIDS; diarrhoeal diseases; Schistosomiasis; malnutrition; ear, nose and skin infections; perinatal conditions; and common injuries. The section below describes the progress that has been made so far in the fight against these conditions/diseases including progress in attaining the health-related Millennium Development Goals (MDGs).
2.1 Maternal, neonatal and child health
2.1.1 Vaccine preventable conditions
Immunisation coverage Muteu and Africa 1980 -2010 ? percentage

year –
Measles Mwi
Measles Africa DTP3 Africa
0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Source: WHO Global Observatory Data Repository 2011
Figure 1 Immunisation coverage Muteu and Africa 1980-2010 ? percentage

2011- 2016
Muteu has had a robust and enviable immunization programme for many years (Figure 1) and recent high coverage is confirmed in the 2010 DHS report which shows that 81% of children aged 12-23 months were fully immunized. This is an increase in coverage of 26% since the 2004 DHS. However, in 2010 the country experienced an outbreak of measles with an estimated 43,000 children requiring treatment. High coverage, particularly of measles is required to maintain herd immunity and additional resources will therefore be required to sustain a vaccine coverage of 90 per cent and above for all antigens.
2.1.2 Acute respiratory infections Acute respiratory infection is one of the most significant causes of morbidity and mortality amongst children worldwide. In Muteu, between 2004 and 2010 the proportion of children with ARIs taken to a health facility for treatment increased from 19.6% to 70.3%. Also, there was a reduction of pneumonia case fatality from 18.7% in 2000 to 5.7% in 200815. Evidence has shown that populations, especially children, that are heavily exposed to wood smoke from cooking are at much higher risk from severe pneumonia and higher risk of mortality16 . Prevention though hand-washing, immunisation with pneumococcal vaccine, early diagnosis and treatment with antibiotics are all highly effective. Along with malaria treatment and oral rehydration of diarrhoeal disease ARI is addressed through an Integrated Management of Childhood Illnesses (IMCI) approach. The successful implementation of pneumonia interventions in the PoW is likely to have contributed to the dramatic fall in infant and child mortality. Continuation of these interventions will help to achieve the two MDG targets dealing with child mortality by 2015.
2.1.3 Malaria Malaria is endemic throughout Muteu and continues to be a major public health problem with an estimated 6 million cases occurring annually. It is the leading cause of morbidity and mortality in children under five years of age and pregnant women. The use of Insecticide Treated Nets (ITN) when sleeping is the primary control strategy for preventing malaria. The Muteu National Malaria Indicator Survey 201017 showed a parasite prevalence rate by slide microscopy of 43.3% nationally, and severe anaemia prevalence (HB concentration >8g/dl) was 12.3% among children under five. Malaria parasite prevalence increased with age whilst severe anaemia showed the opposite trend; both malaria parasite and severe anaemia prevalence rates were higher among children who did not sleep under an ITN the previous night. The prevalence of severe anaemia in children under two years of age who did sleep under an ITN the night before 25.7% compared to a rate of 13.6% among those who did sleep under a net the previous night. This was found to be higher in the poorer wealth quintiles.
15 16 ARI programme data 2009 Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial : The Lancet, Volume 378, Issue 9804, 12 November 2011 17 Muteu National Malaria Indicator Survey 2010 NMCP MoH 2010. 19

2011- 2016
At present 60.4% of pregnant women are reported to have taken two or more doses of the recommended intermittent preventive treatment (IPT) as compared to 48% in 2006.
Currently coverage of Insecticide Residual Spraying (IRS) is low, with poor diagnostic capacity, abuse of ITNs, low coverage of second dose of SP in pregnancy, unavailability of quality ACT in the private sector, and poor adherence to treatment guidelines and policies all affecting the implementation of malaria interventions.
Prevention and treatment of malaria in Muteu
MDG ITN target 80%
MDG Rx target 80%
PoW 1 2004 – 2011
ITN projection 57% Rx projection 57%
Under 5 children sleeping under ITN last night
Pregnant women sleeping under ITN last night
Under 5 children receiving prompt
0 1995
antimalarial treatment
Figure 2 Prevention and treatment of malaria in Muteu ? trend and projection
2.1.4 Acute Diarrhoeal Diseases Dehydration from diarrhoea is one of the major causes of death in young children worldwide. The prevalence of diarrhoea overall in Muteu is estimated at 17.5 % with 38 % in children 6- 12 months. The 2010 DHS shows a higher percentage of reported cases without access to improved drinking water and sanitation. In 60% of cases treatment was sought from a formal health provider, and 24.2% of children under six months reportedly did not receive any treatment at all18. The BoD19 assessment calculates that the number of episodes of acute diarrhoea in children under five years of age is over 13 million per year, and yet the health service treated only 324,000 in 2010.
2.1.5 Malnutrition Although there has been some reduction, malnutrition remains high, with 47% of children under five stunted and 20% severely stunted. The prevalence of diarrhoea and disease outbreaks such as measles have a significant influence on nutritional status, particularly acute malnutrition, and have to be taken into account when interpreting nutrition surveillance results. Despite the expectation that the MDG target related to nutrition will be reached, high levels of underweight persist. Thirteen per cent of children under five are underweight and
Muteu DHS 2010
19 http://www.medcol.mw/commhealth/publications/national%20research/Burden%20of%20BOD%20and%20EH P7.docx 20

Deaths per 1000 live births
2011- 2016
3% are severely underweight (DHS 2010).
Children under 5 underweight – trend and projection
35 30 25 20 15
MDG target 14%
10 5 0
PoW 1 2004 – 2011
projection 12%
1990 1995 2000 2005 2010 2015 2020
Figure 3 Underweight children under five years of age ? trend and projection
Investments in child survival interventions such as vaccines for various diseases, effective treatment of pneumonia at community level, and effective prevention and treatment of malaria and diarrhoeal diseases have contributed significantly to the remarkable decline in infant and under five mortality rates as can be seen in Figures 4 and 5 below:
Infant mortality rate in Muteu – trend and projection
160 140 120 100 80 60 40
MDG target 45
20 0
PoW 1 2004 – 2011
projection 34 1985 1990 1995 2000 2005 2010 2015 2020 Year Figure 4 Infant mortality rate in Muteu – trend and projection

Deaths per 1000 live births
Maternal mortality per 100,000 live births
projection 435
2011- 2016
Under 5 child mortality rate in Muteu – trend and projection
MDG target 78
PoW 1 2004 – 2011
projection 57 1985 1990 1995 2000 2005 2010 2015 2020 Year
Figure 5 Under five child mortality rate in Muteu ? trend and projection
These trends demonstrate that there is a possibility that Muteu can reach the MDG targets for these two indicators. This will be possible if significant investments are made in child survival interventions.
2.1.6 Maternity and Neonatal Care The maternal mortality rate decreased from 984 per 100,000 live births in 2004 to 675 per 100,000 in 2010, with an increase in women delivering at health centres from 57.2% in 2004 to 73% in 2010.
Maternal mortality in Muteu – trend and projection 1600 1400 1200 1000 800 600 400 200 0 MDG target 155 PoW 1 2004 – 2011
projection 435
1990 1995 2000 2005 2010 2015 2020 Year of survey
Figure 6 Maternal mortality in Muteu ? trend and projection
According to the zonal reports, data from district maternal death audits shows that sepsis and post partum haemorrhage are the most likely causes of death in the majority of mortality cases based at health facilities. Unlike the MDGs relating to child health, the maternity MDG 22

2011- 2016
targets are unlikely to be met without significant additional investment to increase access to Emergency Obstetric Care (EmOC) for many more pregnant women (Figure 6), and a similar investment in family planning to reduce the total fertility rate. Using data from the 2010 EmOC survey, it is estimated that only half of the births requiring emergency care are receiving such care. Currently, the neonatal mortality rate (NMR) is estimated at 33 deaths per 1,000 live births and it is higher in rural areas (34/1,000) compared to urban areas (30/1,000). It is also higher among male children (38/1,000) compared to female children (30/1,000)20. About 69 per cent of women were protected against tetanus at their last birth. Figure 7 (below) shows the proportions of births attended by skilled attendants over time.
Births attended by skilled attendant
100 90 80 70 60 50 40
66 62 57
MDG target 80%
projection 72%
30 20 10 0
PoW 1 2004 – 2011
1990 1995 2000 2005 2010 2015 2020
Figure 7 Births attended by skilled attendant ? trend and projection
2.2 Family planning The population projections using the 2008 census data reinforce the importance of scaling up interventions to meet the family planning MDG targets. The TFR is expected to remain high and only fall slowly in the next five years if substantial investment is put into additional family planning services (Figure 8). The 2010 DHS report confirms the slow increase in contraceptive use. The projected percentage of women aged 15-49 years who will be using any form of contraceptive in 2015 it is anticipated to be 55%, while the MDG target for 2015 is 65% using modern methods (Figure 9). The Muteu Reproductive Health Strategy (2010-2015) echoes this target of 65% for the CPR.
DHS 2010

projection 5.5%
2011- 2016
Total fertility rate
9 8 7 6
Projection 5.5
5 4 3 2 1

PoW 2004- 2011
0 1970 1980 1990 2000 2010 2020
Figure 8 Total Fertility Rate
Contraceptive prevalence rate – all forms of contraception used by married women aged 15-49 years of age in Muteu
70 60 MDG 50 40 30 20 10 0 target 65%
PoW 1 2004 – 2011
projection 55%
1990 1995 2000 2005 2010 2015 2020
Figure 9 Contraceptive Prevalence Rate ? trend and projection
The 2010 DHS report further showed a significant unmet need for contraception, with 73% of women wanting to delay pregnancy or have no more children. Therefore there is need to increase the availability of family planning services to reach the 65% modern methods target (using the services of the MoH, the Christian Health Association in Muteu (CHAM) and Banja La Mtsogolo (BLM)).
2.3 Major Communicable Diseases Apart from malaria, the major communicable diseases are tuberculosis, HIV/AIDS and STIs.
2.3.1 Tuberculosis With regard to tuberculosis, the effort to collaborate and support the HIV/AIDS programme is paying off. More cases of tuberculosis are being detected and treatment failure is

WHO Rx success rate target ? 85%
WHO Detection rate target ? 70%
Case detection rate for all forms of tuberculosis (%) Smear positive tuberculosis treatment ? success rate (%) Incidence of tuberculosis (per 100 000 population per year) Deaths due to tuberculosis among HIV negative people (per 100 000 population) – Prevalence Data sources

2011- 2016
diminishing. There is some success in reaching the MDG targets for tuberculosis (Figure 10).
Tuberculosis MDG Indicators – Muteu
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 45
90 80 70
40 35 30
60 50 40 30 20 10 0
25 20 15 10 5 0
Source: WHO Global Observatory Data Repository 2011
Figure 10 Tuberculosis MDG Indicators
The treatment success rate at 86% is slightly above the World Health Organization (WHO) target of 85%. However, the case detection rate (46%) is still below the WHO target (70%).
2.3.2 Sexually Transmitted Infections including HIV/AIDS This component of the EHP consumes the greatest resources with direct costs in the order of an estimated 16% of the direct costs for the first year of the EHP programme. Moreover, this is expected to increase as the country moves towards universal coverage for the new ART regime. As part of the HIV prevention strategy, the health sector provides 25 million male and 1 million female condoms each year. HIV testing and counselling (HTC) is an integral part of the HIV prevention strategy and approximately 1.8 million people were counselled and tested for HIV in 2009/2010, representing 28% of the sexually active population. HIV testing among couples is limited, and the high level of HIV discordant couples has prompted the inclusion in the HSSP of strategies to promote couple testing (Figure 11). Another key prevention component is Prevention of Mother to Child Transmission (PMTCT). In 2009/10, 37% of HIV positive mothers received appropriate drugs and counselling. The HSSP provides strategies for increasing this by 10% annually over the five year period. Testing and treatment of other STIs is an important HIV prevention activity. About half the number of cases estimated in the BoD study were treated in 2010.

2011- 2016
HIV Incident cases per year – Muteu 2007
No risk Partners IDU Injecting Drug Use (IDU) Female partners of MSM Sex workers Men who have Sex with Men (MSM) Blood transfusions Medical injections Clients of sex workers Multiple partner and pre-marital (higher risk) sex Partners of clients of sex workers Partners of higher risk heterosexual sex Single stable heterosexual partner
0 0 0 14 38 113 139 368 1,695
12,414 16,978
34,673 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000
Figure 11 HIV cases 2007
Source : Muteu Antiretroviral Treatment Programme Quarterly Report June 2011 Figure 12 ARV coverage by zone
ARVs are the mainstay of treatment. The criteria governing who benefits from ARVs change as and when advice from WHO is updated. So far the implications are that more people will benefit from them. In June 2011 with the criteria for starting ARVs based on a CD4 count of less than 250 cells per mm3, there were 251,790 adults on ARVs, equivalent to 76% of eligible cases, and 25,197 children on ARVs equivalent to only 32% of eligible children, as shown by zone in Figure 12. Strategies have been put in place to increase adult coverage to 80% in 2011/2 and by 20% each year in children, in order to reach the MDG target of 80% ahead of time (Figure 13). If additional resources are mobilized to fund the increase in

% Coverage based on Spectrum model using CD4 count of <250 cells/mm3 2011- 2016 cases derived from the CD4 count change to 350 and the increase in maternity cases, numbers will have to be revised upwards in the course of the implementation of the HSSP. ART coverage in Muteu 120 100 projection 80 60 40 20 0 MDG target 80% 100% by 2014 2002 2004 2006 2008 2010 2012 2014 2016 Figure 13 Adult and child ART coverage in Muteu ART is complemented by the treatment of Opportunistic Infections (OIs) and community- based home care for AIDS patients. Currently, the coverage of OI treatment is about 20% of need and there are plans to increase coverage by 10% annually. The coverage of home- based care is adequate given the resources available, but the quality of care and the availability of drugs are important and need improvement. 2.4 Disability including Mental Illness The prevalence of disability in Muteu, as defined by the ICF model, is 4.18%. This is higher than earlier estimates of 2% in 1983 and 2.9% in 1993. Ntchisi District has the highest prevalence of disability at 7.79% and the lowest is Mchinji at 1.20%. The most common types of disabilities are physical disabilities (43%) followed by seeing (23%), hearing (16%) and intellectual/emotional disabilities (11%), communication disabilities (3%) and old age (1%). Other types of disabilities constituted 3% of the sample population. Nearly half of these disabilities were due to physical illness. The other major causes of disability were natural/from birth (17%) and accidents (10.6%). In a survey conducted by SINTEF21, nearly 7 in 10 respondents had become disabled at less than 20 years of age. In terms of health services, even though respondents mentioned that they needed the services, a significant proportion of respondents did not receive the services. For example, while 84% of the respondents were aware of health services and about the same proportion expressed the need for such a service, only 61% received health services. These results generally demonstrate that even though services may be available and the Constitution and the MGDS call for provision of services to all Muteuans, Persons With Disabilities (PWDs) do face barriers to accessing health services because of their disability. 21 SINTEF, CSR and FEDOMA. (2004). Living conditions of persons with activity limitations in Muteu. Oslo: SINTEF. 27 2011- 2016 Interventions to address mental illness were not part of the EHP under the PoW 1. It is estimated that 14% of the global burden of disease can be attributed to neuropsychiatric disorders, with around 20% of the world?s children and adolescents estimated to have mental disorders or problems, with similar types of disorders being reported across cultures. In Muteu the majority of patients with common mental health problems present in primary health centers, and one study involving 22 health centers with outpatient facilities in Machinga district and 3,487 patients attending those health centers, found that 28.8% of patients had a common mental health problem and 19% had depression. None of them had been detected or treated at baseline before primary health workers had received the relevant training. The availability of skilled mental health workers is minimal, and there is a 100% vacancy rates for clinical psychologist positions. There is one consultant psychiatrist in post. The country has a graduate psychiatric nursing course in Mzuzu graduating 10-12 nurses each year, and training in clinical psychology is currently under development. Service level agreements exist with St John of God Hospital in Mzuzu in the North. 2.5 Non-Communicable Diseases (NCDs) Muteu is currently faced with a double burden of both communicable and non- communicable diseases. The STEPS survey conducted in 2009 identified a high level of high blood pressure (see Annex 8) and diabetes22. The level of hypertension is higher in Muteu (35% of adults) than in the United States of America and the United Kingdom (27%). District and central hospitals have been treating such patients for a number of years outside the EHP. At present a strategy is being developed by the MoH on treatment regimes and outcome measures to deal with both conditions. The first phase is a pilot site opportunistic screening and treatment using effective but cheap drugs. NCDs account for approximately 12% of the Total Disability Adjusted Life Years (DALYs)23 which is fourth behind HIV/AIDS, other infections, parasitic and respiratory diseases. NCDs are thought to be the second leading cause of deaths in adults after HIV/AIDS. The HSSP has therefore incorporated NCDs in the EHP, and interventions include screening for cervical cancer, hypertension and diabetes and providing treatment. Cervical cancer is the most common cancer in women in Muteu and accounts for 9,000 DALYs per year. The chosen intervention of one VIA visit using colposcopy with acetic acid and cryotherapy is the best value for money at $74/DALY and it has already been successfully piloted in a number of districts in the country. 2.6 Social Determinants of health The Commission on Social Determinants of Health in their final report acknowledged the fact that misdistribution and poor quality of health care delivery systems are one of the social 22 Msyamboza KP, Ngwira B, Dzowela T, Mvula C, Kathyola D, et al. (2011) The Burden of Selected Chronic Non-Communicable Diseases and Their Risk Factors in Muteu: Nationwide STEPS Survey. PLoS ONE 6(5): e20316. doi:10.1371/journal.pone.0020316 23 One DALY can be thought of as one lost year of ?healthy? life. The sum of these DALYS across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. (WHO) 28 2011- 2016 determinants of health, ?however the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work and age?. 24 Annex 1 highlights some of the underlying risk factors for the major diseases in Muteu that are preventable. The factors influencing health status can be divided into: ? environmental, including safe water, sanitation and vector control, safe housing and work environments; ? physical, including lifestyles and behaviours that adversely affect health status such as alcohol and drug abuse, lack of exercise, unsafe sex; ? access to health and social services; ? mental and spiritual health, including gender based violence and child sexual abuse; ? access to education, and ? socio-cultural factors. One of the leading determinants of health is the level of education. National surveys show that health indicators are worse among people who have no or little education than those who have received secondary education or higher. For example, underweight and the prevalence of diarrhoea and malaria among children under five both decreased the higher the educational level of the mother. Health indicators are also better among higher income groups, so improving income and educational levels would therefore help to bring improvements in health status. In terms of living conditions in 2004, 64% of Muteuan households had access to clean water and this ratio slightly increased to 79.7%25. In 2004 16.1% of households in the rural areas did not have a toilet facility, and by 2008 the proportion in rural areas with no toilet facility decreased slightly to 13.5%26. The proportion of households with soap to use at critical times was quite low at 45%27. Only 2% of the population were using electricity for cooking. The majority of households in 2008 were using solid fuels (approximately 98%), which puts children at higher risk of respiratory infection if the rooms are not well ventilated. Nearly a third of women aged 15-49 years have experienced domestic violence since the age of 1528 with poor uneducated women in urban areas more likely to experience this. It was mostly the husbands who perpetrated violence against married women. The percentage of ever married women who sought help from the formal health system, social services, their employer or a lawyer after experiencing physical violence was low, at 3.3%. The causes of gender based violence (GBV) are complex and often deeply rooted in cultural beliefs, power relations, and the idea of male dominance exacerbated by alcohol and drug abuse resulting in or as a result of mental instability. During community consultations as part of the development of the HSSP, community members mentioned a number of diseases common in their areas. These were cholera, malaria, HIV/AIDS, tuberculosis, pneumonia and malnutrition. Even though there were some misperceptions about the causes of these diseases, in most cases community members were aware of the causes and they did mention that they sought treatment from health facilities 24 2008 Commission on Social Determinants of Health: Closing the gap in a generation: Health equity through action on the social determinants of health 25 26 27 28 DHS 2010 NSO (2009) Muteu Population and Housing Census 2008 Zomba:NSO Social Cash Transfer Evaluation 2010 NSO (2010) Demographic and Health Survey 2010 Zomba: NSO 29 2011- 2016 during illness episodes. Community members also consult traditional healers on issues relating to witchcraft. Prevailing cultural beliefs influence health, for example, in the way people seek health care and prevent illness. Beliefs in witchcraft, ancestors and taboos as causes of ill health still prevail. Some cultural norms and practices have also been shown to contribute to unsafe behaviour causing risks to sexual and reproductive health, as well as affecting access to timely health services and key commodities. 2.7 Health Systems Challenges 2.7.1 Drugs and Medical Supplies While the overall availability of tracer drugs improved over the PoW period, the shortage of drugs and other medical supplies continues to be a major challenge in health facilities. Factors such as lengthy procurement processes, poor specifications, weak logistical information systems, inadequate and unpredictable funding for medicines and inadequate infrastructure contribute to shortages of drugs. A significant proportion of districts overspend on drugs through buying at higher prices from the private sector. In some cases the health sector is subjected to inappropriate donations of medicines and other medical supplies. Also, there is a shortage of pharmaceutical staff, which is exacerbated by low output from health training institutions. 2.7.2 Human Resources for Health (HRH) Since the implementation of a six-year Emergency Human Resource Plan (EHRP) under the PoW, the human resource situation within the health sector has improved significantly. The total number of professional Health Care Workers (HCWs) increased by 53% from 5,453 in 2004 to 8,369 in 2010; the capacity of health training institutions increased across a range of programs and staff retention improved, among other things. However, only four of the 11 priority cadres (namely clinical officer, environmental health officers, radiology and laboratory technicians) met or exceeded their targets as set in the original EHRP design. Despite an investment of $53 million during the EHRP on pre-service training capacity, annual output of nurses only increased by 22%. An expanded staff establishment among priority HCW cadres (nurses, physicians, clinical officers, environmental health officers, laboratory and pharmacy technicians), has led to significant vacancies (see Annex 2). The human resource challenges remain both acute and complex and HR projections show that at current output levels it will take many years to come anywhere near the numbers of health staff needed to provide minimum standards of service delivery. 2.7.3 Laboratory and Radiology Services The delivery of laboratory and medical imaging services to support delivery of the EHP has been affected by the shortage of human resources. This is mainly due to low outputs from health training institutions, high attrition of personnel (especially from the public sector), inadequate funding and insufficient and inappropriate equipment. Furthermore, the National Reference Laboratory is lacking in capacity to provide reference laboratory services and the number of voluntary and non-remunerated blood donors for blood safety programs is low. 30 2011- 2016 Radiology also faces challenges, including a shortage of human resources, inadequate supervision and a lack of appropriate infrastructure to comply with the minimum space requirements stipulated in RSOG. Other challenges include the donation of equipment without accompanying guidance on procedures, and the absence of provision for the disposal of radiological waste, which poses a serious threat to the environment and to health. Currently, there are no laws governing the disposal of radiological waste, protective materials are inadequate, no site has been designated for the disposal of radiological waste and equipment for monitoring radiation is not available. 2.7.4 Quality Assurance Despite intentions stated in the PoW and the National Quality Assurance Policy, only a limited number of interventions have been implemented. These include the filling of the posts of a national QA Manager and central hospital and district level QA managers, operationalisation of Action Teams at ZHSO, and the establishment of QA committees. To date the Standard Based Management and Recognition (SBM-R) initiative in Infection Prevention (IP) has been rolled out to all district and central hospitals and some CHAM hospitals have also achieved recognition. Evaluations show that the perception of risks of hospital acquired infections has reduced among both hospital staff and guardians. While knowledge on IP has improved, compliance with IP practice according to recommended norms and standards still needs to be strengthened. Another SBM-R program covering Reproductive Health (RH) has since been rolled out to all district and central hospitals and the MoH is in the process of developing standards for IP and RH for health centres. Many stakeholders, however, are already implementing QA measures and are ready to harmonise their approaches with national guidelines and standards, aiming at continuous quality improvement at systems level. This constitutes the potential for the development of a sustainable QA/QM system with significant impact on outcomes during the HSSP period29. 2.7.5 Essential Medical Devices (Medical Equipment) At the time of developing the HSSP, the status of medical equipment in health facilities was unknown, as the last such exercise was carried out in 2007. The only available study of equipment in health facilities is the 2010 EmONC Needs Assessment which was conducted in 309 health facilities. This study showed that generally all instrument kits were incomplete; there was no resuscitation equipment for babies; and other vital pieces of equipment needed for newborn care were in short supply in both hospitals and health centres. The study also found a shortage of some basic diagnostic equipment and supplies; for example, only 29% of the hospitals and 7% of health centres had blood sugar testing sticks, and uristix for measuring protein were found in only 52% of hospitals and 13% of health centres30. During annual and semi-annual reviews of health facilities the Zonal Offices report on the status of equipment, but these are incomplete as not all districts submit data. 29 EPOS Health Management. (2010). Quality improvement of health care services in Muteu:Mission report. Lilongwe: MoH and GTZ. 30 MoH (2010) Muteu 2010 EmONC needs assessment draft report. Lilongwe: Ministry of Health.. 31 2011- 2016 2.7.6 Health Financing Significant resources have been invested in the health sector and by the end of the PoW a total of almost $US900 million had been spent, with GoM dramatically increasing its level of spending from an estimated $US46.3 million in 2004/05 to $US134 million in 2009/10. Equally, support from HDPs increased from $US21.3 million in 2004/05 to $US63.4 million in 2009/10. However, there was a significant decline from the $US103.2 million of DP pooled funds provided in 2008/09, down to $US56.2 million disbursed in 2009/10. Untimely disbursement of donor funds has forced GoM to borrow from the domestic market at high interest rates, which increases the cost of health service delivery. A significant amount of donor funds remain off budget, and without detailed analysis of interventions and activities per donor in relation to specific outcomes of the HSSP, it is difficult overall to attribute which resources have the highest impact on particular health service outcomes, or indeed on some outputs. In addition to this, administrative costs associated with contractors, including NGOs, have yet to be reviewed in detail. The number of projects funded by donors that fall outside the PoW increased over the period of the Program. Total health spending rose from $US5.3 per capita in 2004/5, peaked at $US16.3 per capita in 2008/09 and declined slightly to an estimated $US14.5 per capita in 2009/10. The GoM budget allocated to the health sector increased from 11.1% in 2005 to 13.6% in 2008/9 before falling back to 12.4% in 2009/10. Progress is being made by GoM towards achieving the Abuja Declaration (2001) target of 15% of government funding to be spent in health. A resource allocation formula, which is subject to review after three years, has been developed jointly by the MoH and Ministry of Local Government and Rural Development (MoLGRD). Despite public services being offered free of charge, household out-of-pocket payments increased rapidly during the PoW. The capacity to regularly track sources of health financing and their uses using internationally recognized tools such as National Health Accounts remains weak. 2.7.7 Financial Management Financial management has strengthened over the period of the PoW. The external audits commissioned each year have continually generated unqualified audit reports ? that is to say, they have certified that the financial statements have fairly recorded the income and expenditures of the health sector without any qualifying remarks. One challenge is that in real terms (after adjusting for inflation), funds managed in the health sector have more than doubled to reach 229.6% of their 2004 levels, resulting in a corresponding increase in transactions, however staffing levels have not changed. The ratio of staff to manage funds is especially poor at MoH headquarters compared to other levels. A review of the finance staff establishment will be undertaken in the course of implementing the HSSP to assess how to accommodate the increased workload. Financial management at district level is now the responsibility of MoLGRD31. At this level, harmonisation is underway so that the sector and the common service accounting staff will be brought together to form one unified team in order to increase efficiency. The capacity of health finance staff at district level was strengthened through the Financial Management Coaching of Cost Centres Programme which was active from March 2009 to March 2011. Building financial management capacity in the districts and central hospitals has also been strengthened 31 More detailed discussion on decentralisation is in Chapter 6. 32 2011- 2016 through the deployment of Financial Analysts in all districts under the auspices of National Local Government Finance Committee (NLGFC) of the MoLGRD. While financial management skills have been steadily improving, a significant proportion of common service personnel in MoH lack relevant accounting qualifications, and training of such staff has been infrequent. The Financial Management Implementation Plan (FMIP) includes training for non-financial managers and such training has yet to be carried out. Finance staff in MoH and central and district hospitals require better access to computers and internet services. Lack of office space for finance staff is evident throughout MoH and in many District Health Offices (DHOs). While the health sector recognizes the value of oversight and audit and welcomes both, the capacity of the Finance Section is continually challenged because of the poor alignment of HDPs with financial systems and the associated ad hoc organization of oversight arrangements and audits which are not only unharmonised, but also time wasting and often duplicative. A major effort during the implementation of the HSSP will be to minimize the oversight burden without compromising the quest for continuous system strengthening. There are other challenges in financial management. The flow of funds from central level to districts in some cases does not match cash flow forecasts; the flow of funds within districts is unreliable, especially to rural health facilities; the absorption of funds at MoH headquarters, especially in infrastructure, is low due to procurement bottlenecks; financial reporting is weak; donors? requirements for individual financial reports increases the workload of finance staff; uptake of internal audit findings is low; finally, there is a high number of external audits. Strategies will therefore be put in place to explore the possibility of the direct transfer of funds to rural facilities, and to strengthen collaborative efforts between the finance and procurement units at the central level. Notwithstanding the challenges highlighted above, the Finance Section, supported by the Department of Accountant General, has continued to make steady gains in key areas, including audit completion, financial reporting and upgrading of skills. 2.7.8 Procurement Like any government entity, the public health sector has continued to follow procedures for procuring goods, works and services as laid down in the Public Procurement Act (2002) and elaborated in the Public Procurement Regulations of 2004. During the implementation of the PoW, major challenges in procurement have included: lack of capacity, especially at the central level; poor coordination between the Procurement Unit and other departments, including districts; lack of well documented procurement procedures; unclear role of the central level in procurements undertaken at the district level, and excessive emergency procurements. Procurement capacity challenges in the public health sector have been exacerbated by the commissioning of multiple audits by different partners and the operation of a parallel system of oversight to provide reassurance to HDPs. In these areas the development partners have failed to align to country systems in accordance with the 2005 Paris Declaration on Aid Effectiveness and the 2008 Accra Agenda for Action. 2.7.9 Monitoring, Evaluation and Research The MoH has been implementing a comprehensive Health Management Information System (HMIS) countrywide since 2002. The draft HMIS Strategic Plan (2011) explains how data is managed at all levels. Routine data on age and sex is collected but reporting is not always 33 2011- 2016 disaggregated. The other sources of data are the DHS, MICS and other national surveys. While systems for monitoring and evaluation are in place, challenges exist which impact on the effective functioning of the HMIS. These challenges include: inadequate staffing; insufficient disaggregated data; inadequate funding; occasional stock-outs of HMIS forms, pencils and other supplies; inadequate support for ICT at district and lower levels: untimely submission of data to CMED by districts, and low data quality due to infrequent data validation exercises. Lack of trust in the data generated by the HMIS has resulted in donors supporting the creation of parallel data collection systems. The existence of parallel data collection systems for vertical programs such as HIV/AIDS and malaria puts a strain on already scarce HRH. Civil statistics are vital, yet Muteu still lacks a coherent system for registering births and deaths, although it would be possible for HSAs to collect such data effectively. The MoH has recruited Statistical Data Entry Clerks and 65% of them have already reported for duties, and will attend Training of Trainers courses at zonal level. The National Commission on Science and Technology (NCST) regulates the conduct of research in Muteu by the various institutions involved. Challenges are as follows: the absence of legal and policy frameworks to regulate research; weak coordination and monitoring of research being carried out within the country; limited multidisciplinary research, largely due to the lack of highly qualified and experienced indigenous researchers; and poor utilization of research findings for practice and policy formulation, due to limited interactions between researchers and those to whom the research findings may be of use. As a way of addressing some of the problems being faced in the area of research, the NCST is implementing a five-year Health Research Capacity Strengthening Initiative (HRCSI) with support from the Wellcome Trust, the Department for International Development (DFID) and the International Development Research Centre (IDRC). The HRCS initiative offers an opportunity for Muteu to improve the capacity of Muteuan researchers to conduct high- quality research. 2.7.10 Universal access The MoH is committed to ensuring that services in the EHP are available with universal coverage for all Muteuans. The signing of Service Level Agreements (SLAs) with CHAM facilities for the delivery of Maternal and Neonatal Health (MNH) services is one way of ensuring that the services are accessed by everyone regardless of their socio-economic status. Evidence shows that the removal of user fees in CHAM facilities has resulted in an increase in the number of patients seeking care in these facilities. Universal coverage also includes geographical coverage. An analysis of the proportion of Muteu?s population living within an 8km radius of a health facility (Annex 3) shows that there are certain districts that are better served than others. On Likoma Island, where there is no government facility, none of the population is served, and this district is followed by Chitipa where 51% of the population live more than 8km from a health facility, Kasungu (38%), Balaka (32%), Chikwawa and Mangochi (27%). On the other hand, in Chiradzulu, Blantyre, Mulanje and Zomba Districts less than 5% of the population reside more than 8km from a health facility. In some rural places, the health infrastructure is absent or dysfunctional. In others, the challenge is to provide health support to widely dispersed populations. In high density urban areas, health services can be physically within reach of the poor and other vulnerable populations, but provided by unregulated private providers who do not deliver EHP services. 34 2011- 2016 Annex 4 compares the number of health facilities in Muteu in 2003 and 2010: about half of the facilities in both 2003 and 2010 belonged to the MoH. Between 2003 and 2010 the number of health facilities in Muteu increased overall from 575 to 606, largely due to an increase in the number of health centres (from 219 to 258). The significant increase in MoH health centres is attributed to some public facilities, mainly maternity units and health posts, being upgraded to health centres in line with the aims of the Program of Work for the Health Sector (PoW) 2004-2006. While new health facilities have been constructed and some existing health facilities have been renovated or upgraded, challenges still exist. The construction of Umoyo Houses32 has not been completed and staff accommodation remains a challenge, especially in hard to staff/serve areas. Rehabilitation of infrastructure is rarely done, hence the need for refurbishment. Other challenges relating to infrastructure include the lack of ICT in most health facilities, inadequate staff in the Infrastructure Unit at MoH headquarters, and inadequate funding for construction and maintenance of infrastructure and equipment. 2.8 Policy Context 2.8.1 National Policy Context The Constitution of the Republic of Muteu states that the State is obliged ?to provide adequate health care, commensurate with the health needs of Muteuan society and international standards of health care?33. The Constitution therefore guarantees that all Muteuans will be provided with free health care and other social services of the highest quality within the limited resources available. It also guarantees equality to all people in access to health services. The Muteu Growth and Development Strategy (MGDS II) is an overall development plan for Muteu and aims at creating wealth through sustainable economic growth and infrastructure development as a means of achieving poverty reduction. The MGDS recognizes that a healthy and educated population is necessary if the country is to achieve sustainable economic growth, and achieve and sustain MDGs. The long-term goal of the MGDS with regard to health is to improve the health of the people of Muteu regardless of their socio-economic status, at all levels of care and in a sustainable manner with increased focus on public health and health promotion. The National Health Policy is in its final draft and the National Public Health Act is in the process of being reviewed. The HIV Bill is in draft form and is expected to be passed during the period of the HSSP. The development of the Health Sector Strategic Plan took into consideration this and other existing legislation, namely the Prevention of Domestic Violence Act, the Wills and Inheritance Act and the Child (Care, Protection and Justice) Act. Other pieces of legislation, such as the Divorce, Marriage and Family Relations Bill and the Deceased Estates Bill (to replace the Wills and Inheritance Act) are being reviewed. In 1999 the GoM defined the MoH?s strategic vision for health care in Muteu into the 21st century under the title ?To the year 2020: A vision for the Health Sector in Muteu?, outlining the broad policy direction for the health sector at all levels. The document acknowledged that financial resources for health in Muteu are inadequate to address the increasing population, the disease burden and the awareness of rights for Muteuans. It was in this document that 32 33 Staff housing programme designed to improve availability of staff houses in remote, hard to reach areas Section 13 (c) of the Constitution of the Republic of Muteu 35 2011- 2016 GoM first defined the EHP for Muteu which would be made available to every Muteuan at his or her first contact with the formal health care system34. This EHP was revisited in 2004 during the development of the PoW and then again in 2010 during the development of the HSSP. It is the policy of GoM that the EHP should be provided free of charge to all Muteuans and hence contribute to reducing poverty, as it addresses the damaging social and environmental conditions that most poor people endure. The HSSP has also been informed by the draft National Health Policy (NHP) whose overall goal is to improve the health status of all the people of Muteu by reducing the risk of ill health and the occurrence of premature deaths. This overall goal will be achieved by implementing strategies and interventions that address critical areas in health services delivery, such as management, hospital reforms, quality assurance, Public and Private Partnerships (PPPs), HRH, Essential Medicines and Supplies (EMS), blood safety, infrastructure and health financing. The NHP also redefines the EHP based on the Burden of Disease assessment and the STEPS survey, and it lays emphasis on the need for an effective monitoring, evaluation and research system that will address the data needs of the sector. The HSSP takes on board all these issues. Highlighting the inadequate resources available for the health sector, the National Health Policy also defines the EHP, confirming that it will be available to all Muteuans free of charge. The provision of health services has been decentralised, so that the responsibility for service delivery has passed from MoH headquarters to the MoLGRD in accordance with the Decentralisation Policy and Decentralisation Act. Thus, districts have been given greater responsibility for managing health services at district and lower levels. 2.8.2 International and Regional Policies Muteu is a signatory to a number of international conventions, of which the most important is the 2000 Millennium Declaration with its eight Millennium Development Goals or MDGs, four of them relating directly to health. These are: Reduce extreme poverty and hunger (malnutrition – MDG 1), Reduce child mortality (MDG 4), Improve maternal health (MDG 5) and Combat AIDS, malaria and other diseases (MDG 6). The country is on course to achieving MDG 4, however, MDG 5 may be difficult to achieve before 2015, due to a number of factors. Therefore the HSSP has included strategies and interventions aimed at accelerating progress towards achieving the MDG targets by 2015. As a member state of the WHO, Muteu is also a signatory to the Ouagadougou Declaration on Primary Health Care (PHC) and Health Systems in Africa: Achieving better Health for Africa in the New Millennium in which African countries reaffirmed their commitment to PHC as a strategy for delivering health services, and as an approach to accelerate the achievement of the MDGs as advocated by the World Health Report of 2008. Other important international declarations to which Muteu is a signatory are: 1. The Abuja Declaration which calls on African Governments to increase their budgetary allocation to health to at least 15% 34 MoH (1999) To the year 2020: a vision for the health sector in Muteu. Lilongwe: MoH and Population 36 2011- 2016 2. The Paris Declaration on Aid Effectiveness, the Accra Agenda for Action and the Busan Partnership for Effective Development Cooperation35, which call for harmonization and alignment of aid in all sectors 3. The Africa Health Strategy 2007-2015 4. The 1986 Ottawa Charter on Health Promotion 5. Libreville Declaration on Environment and Health 6. AU Maputo Plan of Action on Sexual and Reproductive Health and Rights. Muteu is committed to these declarations and strategies but challenges still remain. For example, as mentioned above (2.7.6), the country has yet to achieve the target of 15% budgetary allocation for the health sector as detailed in the Abuja Declaration. This long-term goal is expected to be achieved, but within the context of the overall budgetary balance, recognizing other developmental priorities including education, water and sanitation, agricultural development, and infrastructure. Such areas of spending have their own developmental merits, while also contributing significantly to health outcomes. 2.9 Summary of the analysis As this chapter has demonstrated, the PoW (2004-2010) has registered overall progress in many spheres of the health sector. For example, there has been a decline in the maternal mortality rate (MMR); staffing levels have improved, although this has been offset by an expanded staff establishment, which has created more vacancies; there has been a general improvement in the availability of drugs and other medical supplies, and there have been many other successes. Annex 5 details the strengths, weaknesses, opportunities and threats that may affect the implementation of the HSSP. Some key risks might hinder the MoH and its stakeholders in the implementation of the Plan, and so Annex 6 provides a risk analysis outlining key risks and how they may be mitigated. 35 Fourth High Level Forum on Aid Effectiveness (HLF-4, 29 November ? 1 December 2011) 37 2011- 2016 3 INTRODUCING THE HEALTH SECTOR STRATEGIC PLAN 3.1 Development of the HSSP: Rationale and Process The HSSP (2011-2016) has been developed following the expiry of Sector Wide Approach (SWAp) Program of Work, a fore-runner strategic document for the health sector in Muteu which covered the period 2004-2010 and guided the implementation of interventions aimed at improving the health status of the nation. The MoH, HDPs and other stakeholders in the health sector collaborated in the development and implementation of the PoW. Progress towards achieving the targets set in 2004 was measured using program monitoring and evaluation (M&E) data routinely collected using the Health Management Information System (HMIS), and the PoW also provided for Joint Annual Reviews (JARs) for the health sector, a Mid-Term Review (MTR) and a final evaluation.. Although the PoW expired in June 2010, it was extended for one year partly to allow for the final evaluation. The results from both the MTR and the final evaluation therefore informed the development of the HSSP. The development of the HSSP also coincides with the development of the MGDS, the overall development agenda of the Government of Muteu. In mid-2010 the MoH formed a Core Group (CG) to coordinate the development of the HSSP. In order to ensure that the process was participatory the CG drew membership from all departments in the MoH, health workers? training institutions, the private sector, Civil Society Organizations (CSOs) and HDPs. The CG was chaired by the Director of the SWAp Secretariat in the MoH and members met regularly to discuss the progress made in the drafting of the HSSP as well as other emerging issues. Technical Working Groups (TWGs) were given the responsibility of contributing towards the development of the situation analysis for their thematic area, identifying objectives, strategies and key interventions and key indicators and also looking at implementation arrangements. The following TWGs participated in the development of the HSSP: Finance and Procurement, Hospital Reform, Human Resources (HR), Health Promotion, Public Private Partnerships (PPP), Health Infrastructure, Essential Medicines and Supplies (EMS), Laboratories, Essential Health Package, Quality Assurance and Monitoring, Evaluation and Research. Consultations were conducted with individual departments and disease programs. The development of the HSSP also benefited from technical assistance provided by both local and international experts and supported by HDPs, namely DFID, WHO, GTZ, FICA, USAID and UNFPA. A number of agreements were made during the 2010/2011 JAR meeting in October 2010 including: ? Revision of the Essential Health Package (EHP) based on the Burden of Disease (BoD) study conducted by the College of Medicine (CoM) and the STEPS study on NCDs conducted by the MoH and WHO. ? Discussion of some critical issues that should be addressed in the HSSP for example alternatives for sustainably financing the non-EHP conditions. Traditional authorities, religious leaders and MPs, among other interest groups, participated in this JAR workshop. As part of the development of the HSSP, literature was also reviewed including the Muteu MDG reports, the MGDS and specific disease strategic plans. The 38 2011- 2016 development of the HSSP also benefited from existing or draft strategic plans namely Malaria; Pharmaceuticals; Tuberculosis; Environmental Health; Nutrition and Food Security Policy and Strategic Plan; the Extended National AIDS Action Framework; Health Information Systems (HIS); the comprehensive Multi-year EPI Plan; and the Sexual and Reproductive Health and Rights Strategic Plan. The HSSP was also informed by the draft National Health Policy and the draft Health Bill. Focus Group Discussions (FGDs) were conducted with community members in six districts, two from each region, to get their inputs into the HSSP. The major outcome of this consultation was that community members also identified as important the diseases that have currently been included in the EHP. Thereafter, a national consultative workshop with participants from the Zonal Health Support Offices (ZHSOs), MoH headquarters, DHOs, chiefs, CSOs, HDPs and other government Ministries and Departments was held at Crossroads Hotel in Lilongwe on 2nd December 2010 to review the first draft of the HSSP. This workshop was also attended by Traditional Authorities, religious leaders and MPs. Comments were then incorporated into the document and a consultant was hired to cost the HSSP. As part of developing the HSSP two internal JANS36 assessments were done by the CG and stakeholders. The comments from these assessments were incorporated into the HSSP. In April-May an external team was invited to conduct the JANS with support from the HDPs. A further internal JANS was conducted at the end of June 2011. The comments from the external JANS were used to finalize the HSSP document. Annex 7 shows the roadmap for development of the HSSP and stakeholders who were involved, external JANS reports and response by MOH to the JANS. 3.2 Priorities for the HSSP 3.2.1 Major recommendations from evaluation of the PoW 1 The following are the major recommendations from the evaluation of the Program of Work: 1. Both MoH and HDPs are experiencing high staff turnover with great loss of institutional memory. Over the period of the HSSP mechanisms need to be put in place in order to retain staff as well as to address the critical staff shortages at all levels. 2. Monitoring and evaluation in the health sector focuses on the measurement of impact and outcomes, and so there is need to ensure that hospital statistics are added to the routine HMIS and made available. The M&E system needs be extended to monitor quality of care, and data should be disaggregated by gender, age and place of residence. The use of a broad baseline survey linked to impact evaluation is recommended to complement the DHS, and this survey should be carried out and the role of research should be made clear. 3. The EHP was defined in 2004 and disease patterns have changed since then. The evaluation recommended that the EHP should be revised to take into consideration the introduction of new technologies, changing disease patterns and available resources. There should also be gradual expansion of the EHP (e.g. by including cost-effective interventions for non-communicable diseases such as cardiovascular disease and 36 Joint Assessment of National Strategic Plans 39 2011- 2016 diabetes, mental health interventions, and a package of highly cost-effective surgical procedures to be provided in rural and district hospitals). 4. The drug supply system needs to be strengthened and dependence on emergency tenders has to be reduced. The logistics management information system needs to be improved to generate accurate data at facility level and departments have to provide accurate and complete specifications. There is also a need to recapitalise Central Medical Stores (CMS). 5. The HSSP should address issues of equity, including gender and geographical location. Preventive and curative health care should target hard to serve and vulnerable groups, e.g. adolescents seeking sexual and reproductive health care and antiretroviral treatment, orphans and other vulnerable children, women and girls seeking post- abortion care, the disabled, rural and traditional communities, and border and migrant populations. 6. Quality assurance approaches need to be strengthened and become systematic, as over the years QA has been implemented on a piecemeal basis. The implementation of interventions at district level should be based on need and public health priorities. 7. The HSSP should address issues of HRH management, coordination and oversight at all levels of implementation. 8. DIP guidelines should be revised to allow for better alignment of PoW planning and budgeting formats with those of MoLGRD/MoF. These recommendations have been taken into consideration during the development of this plan. 3.2.2 Burden of Disease (BoD) for Muteu In 2006 the College of Medicine (CoM) conducted a BoD study looking at the incidence and prevalence of all major diseases and disease-specific death rates, ranking the top ten conditions according to these rates. This study shows the top ten risk factors and diseases causing deaths in Muteu, as shown in Annex 8. HIV/AIDS is the major cause of mortality, followed by Lower Respiratory Infection (LRI), malaria, diarrhoeal diseases and conditions arising from perinatal conditions. The ranking of the top diseases and conditions was useful as it enabled an assessment of priority diseases for inclusion in EHP. Cost-effective interventions are available for most of these diseases and conditions. As has been mentioned earlier on, the STEPS survey clearly demonstrates that NCDs are also a significant public health problem, as can be seen in Table 2 below and this has led the MoH to establish an NCD Unit at headquarters. 40 – Prevalence Data sources Hypertension 32.9% NCD STEPS survey 2009 Cardiovascular diseases (using cholesterol as a marker) 8.9% NCD STEPS survey 2009 (N=3910, age 25-64 years) Injuries other than RTA 8.5% 37 WHS Muteu 2003 (N=5297, age >=18years)
Diabetes 5.6% NCD STEPS survey 2009 Asthma 5.1% WHS Muteu 2003 (N=5297, age >=18years)
Road Traffic Accidents (RTA) 3.5% WHS Muteu 2003 (N=5297, age >=18years)
2011- 2016
Table 2 Prevalence of Non- Communicable Diseases (NCDs) in Muteu
Since the diseases and conditions identified by the BoD study and the STEPS survey contribute to high levels of morbidity and mortality in Muteu, the national Technical Working Group on the EHP used the studies in identifying the 13 conditions to be prioritized within the EHP. After wide consultations, the original EHP as contained in the PoW 2004-2010 was modified to include new interventions, while maintaining the original set of interventions. The full list of conditions is as follows (with new ones marked with an asterisk): 1. 2. 3. 4. 5. HIV/AIDS ARI Malaria Diarrhoeal diseases Perinatal conditions 6. * NCDs including trauma 7. 8. Tuberculosis Malnutrition 9. * Cancers 10. Vaccine preventable diseases 11. * Mental illness and epilepsy 12. * Neglected Tropical Diseases (NTDs) 13. Eye, ear and skin infections During the FGD with community members, participants agreed with research findings, giving HIV/AIDS, ARIs, tuberculosis, malaria and diarrhoea as the most common diseases in their communities. The evidence used to assess each intervention is derived from core datasets comprising a revised Burden of Disease assessment for 201138, an assessment of the cost- effectiveness of past and potential interventions, the preliminary report of the Demographic Health Survey of 2010 (DHS 2010), ad hoc epidemiological surveys (such as the Malaria and EMOC surveys of 2010), projections of Millennium Development goals (MDGs) and published research evidence. The EHP TWG used the following criteria for prioritising interventions for inclusion and the setting of targets in the EHP:
37 38 World Health Survey Muteu (2006) http://www.who.int/healthinfo/survey/whsmwi-Muteu.pdf Burden of Disease estimates for 2011, College of Medicine 2011, at http://www.Muteu- mph.co.uk/data/bod%202011/Burden%20of%20BOD%20and%20EHP1.doc

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4 6

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3.2.3 What is new in the HSSP? The Health Sector Strategic Plan 2011-2016 is different from the Program of Work (PoW) 2004-2010 because it: ? Places emphasis on health promotion and disease prevention, as the majority of the diseases affecting Muteuans are preventable;
? Focuses on community participation, in line with the Ouagadougou Declaration; ? Promotes integration of EHP services delivery at all levels; ? Redefines the EHP based on the Burden of Disease study and the STEPS survey, and as a result mental health and NCDs will constitute part of the new EHP;
? Promotes the expansion of SLAs; ? Defines EHP by level of service delivery; ? Encourages exploration and implementation of alternative sources of financing; ? Places emphasis on the reform of central hospitals; ? Promotes the implementation of quality assurance interventions; ? Promotes increased coordination and alignment, and the reduction of transaction costs.

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4.1 Vision and mission The Vision of the health sector is to achieve a state of health for all the people of Muteu that would enable them to lead a quality and productive life. The Mission of the health sector is to provide strategic leadership by the Ministry of Health for the delivery of a comprehensive range of quality, equitable and efficient health services to all people in Muteu by creating an enabling environment for health promoting activities.
4.2 Guiding principles The guiding principles for the HSSP are inspired by the primary health care approach contained in the international aid effectivness agreements signed in Paris, Accra and Busan. The principles are: 1.
National ownership and government leadership: In the interest of national development and self-reliance, all partners in the health sector will respect national ownership of this HSSP, and the extent to which this principle is reinforced will be measured.
Human rights based approach and equity: All the people of Muteu shall have access to health services without distinction by ethnicity, gender, disability, religion, political belief, economic and social condition or geographical location. The rights of health care users and their families, providers and support staff shall be respected and protected.
Gender sensitivity: Gender issues shall be mainstreamed in the planning and implementation of all health programs and tracked for impact.
Ethical considerations: The ethical requirement of confidentiality, safety and efficacy in both the provision of health care and health care research shall be adhered to.
Efficiency: All stakeholders shall use available health care resources efficiently to maximize health gains. Opportunities shall be identified to facilitate the integration of health service delivery where appropriate to address client needs efficiently and effectively.
Accountability: All stakeholders shall discharge their respective mandates in a manner that takes full responsibility for the decisions made in the course of providing health care. All health workers at all levels and all DPs shall be accountable to the people of Muteu.
Inter-sectoral collaboration: In addition to the MoH there are also other Government Ministries and Departments and CSOs that play an important role especially in

2011- 2016
addressing social determinants of health; hence inter-sectoral collaboration shall be promoted.
Community Participation: Community participation shall be encouraged in the planning, management and delivery of health services.
Evidence-based decision making: Interventions shall be based on proven and cost- effective national and international best practices.
10. Partnership: Public Private Partnership (PPP) shall be encouraged and strengthened to address the determinants of health, improve service provision, create resources (e.g. training of human resources) and share technologies among others.
11. Decentralization: Health services management and provision shall be in line with the Local Government Act of 1998 which entails devolving health service delivery to Local Assemblies.
12. Appropriate technology: All health care providers shall use health care technologies that are appropriate, relevant and cost effective.
4.3 Goal The Goal of the Health Sector Strategic Plan is to improve the quality of life of all the people of Muteu by reducing the risk of ill health and the occurrence of premature deaths, thereby contributing to the social and economic development of the country.
4.4 Objectives of the HSSP The broad objectives of the HSSP are: 1.
Increase coverage of the Essential Health Package interventions, paying attention to impact and quality.
Strengthen the performance of the health system to support delivery of EHP services.
Reduce risk factors to health.
Improve equity and efficiency in the delivery of quality EHP services.




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