Setting Strategic Health Sector Priorities in Malawi

Authors: Ann Phoya, Trish Araru, Rabson Kachala, John Chizonga, Cameron Bowie


In 2010, the Malawian Ministry of Health began preparing a new Health Sector Strategic Programme (HSPP) with the goal of delivering health services more efficiently and cost-effectively. The Planning Department in the Ministry of Health in Malawi knew it needed to set priorities and concentrate on good value interventions because, notwithstanding very tight resources, it wanted to be responsive to the rapid increase in population, newly available interventions and the increasing health needs of noncommunicable diseases.  

The government had been spending an annual average of $14 per person on health care and knew that the likelihood of increasing the health budget beyond 11% of total government expenditure would be difficult. The Technical Working Groups devising the HSSP set about to systematically set priorities based on DCP2, particularly for the country’s Essential Health Package (EHP) which would account for the majority of HSSP spending. The Ministry hoped to expand the focus of the EHP to include interventions targeting cancers, noncommunicable diseases, and mental health.

The first step in constructing the new EHP was to update the burden of disease in Malawi with the latest available information from the WHO Burden of Disease. The Technical Working Groups then turned to the DCP2 which provided a comprehensive list of cost-effective interventions for improving health in Sub-Saharan Africa. Using this list, they were able to validate the inclusion of interventions already in the EHP. Further, Working Groups were able to justify new additions which were cost-effective in dealing with high burden diseases. For example, the mass treatment of neglected tropical diseases is now included in the EHP because it is cost-effective at under $10 per DALY while dealing with a disease burden of over 100,000 DALYs. Overall, the per annum cost of the EHP is estimated to be $33.4 per capita and will avert nearly 9.5 million DALYs during the 5-year run of the HSSP.

Ultimately DCP2 was helpful in allowing the Technical Working Groups to use evidence to inform their decisions. While the use of DALYs was new to many members on the team, they found them helpful in comparing the benefits of health interventions. Furthermore, using cost-effectiveness ratios allowed the Groups to systematically evaluate proposed additions to the EHP. By focusing on high-burden diseases and setting high and low bounds for acceptable cost-effectiveness ratios, the Groups forged a strategic program they knew would get them the highest value for their scarce resources. In the end, Malawi expects to avert nearly 350,000 deaths between 2011 and 2016 by following the practice and principles of disease control priority-setting.