Are policy formulations in Malawi open and consultative?
Policy analysis of Integrated Community Case Management of childhood illness :

A mother of three girls at some hospital in Chiradzulu District during child immunization campaign waiting for their turn

Malawi’s critical shortage in human resource for health (HRH) is a national concern. The HRH crisis affects health service delivery negatively with poor health indicators like neonatal, infant and child mortality rates. Upon observing lack of improvement in child mortality rates and the likelihood of not meeting MDGs 4 and 5 the need of task shifting became apparent and policies were developed to address the situation.

In 2013, REACH Trust conducted a study aimed to explore and analyse how factors, actors and events that led to the development of the Integrated Community Case Management of childhood illness ( ICCM) policy and programs in order to promote easy and timely access to essential  treatment for common conditions affecting the new born and the child.  Key actors in the process included different departments within Ministry of Health (MoH), funding agencies like the World Health Organisation (WHO) and UNICEF and other non-governmental organisations in the health sector. In addition some relevant documents were retrieved for the exercise.

The objectives of the study were to document and analyse the specific expressions of policy that support or inhibit iCCM implementation and identify facilitators and barriers to iCCM policy context, content and process of policy change and actors involved in policy making. The research aimed were pursued through a qualitative retrospective case study of iCCM policy in Malawi.

Results showed that respondents, including those from bilateral and multilateral agencies viewed the policy formulation process as open and consultative. However, some resistance to some aspects of the policy was evident concerning the use of health surveillance assistants to deliver a service that is clinical in nature. Furthermore, the findings show that there were some global critical events which influenced the process of iCCM policy development. It was also noted that research evidence and other scientific data  global, regional and local played a vital role in policy formulation although there were not many local studies conducted that could have been used to inform the policy process. However, health management information system and clinical IMCI utilization data were used as sources of local data while DHS and MIC Survey provided information trends on progress on mortality.

Perceived challenges in the implementation of iCCM policy were associated with inequities in coverage between districts; limited funding and iCCM activities not being a priority; shortage of staff; overburdening of non-professional cadre of community health workers, Health Surveillance Assistants (HSAs); and HSAs not residing in their catchment area. Monitoring and supervision is another challenge in the implementation of the iCCM policy because the HSAs’ line of command is not the clinical hierarchy. At the same time regulatory authorities are of the opinion that HSAs cannot administer drugs including the injectables.  Some challenges were related to policy formulation process like:  scope of iCCM work; financial sustainability and drug specifications.