Assessing the use of an essential health package in a sector wide approach in Malawi.
BACKGROUND
The sector wide approach (SWAp) used in many developing countries is difficult to assess. One way is to consider the essential health package (EHP) which is commonly the vehicle for a SWAp's policies and plans. It is not possible to measure the impact of an EHP by measuring health outcomes in countries such as Malawi. But it is possible to assess the choice of interventions and their delivery in terms of coverage. This paper describes an attempt to assess the Malawi SWAp through its EHP using these available measures of technical efficiency.


METHODS
A burden of disease model was used to identify the priority diseases and their estimated incidence. Data from the health management information system (HMIS) were used to measure the coverage of these interventions. A review of the cost-effectiveness of the chosen and potential interventions was undertaken to assess the appropriateness of each intervention used in the EHP. Expenditure data were used to assess the level of funding of the EHP.


RESULTS
33 of the 55 EHP interventions were found to be potentially cost-effective (<$150/DALY), 12 were not so cost-effective (>$150/DALY) and cost-effective estimates were not available for ten. 15 potential interventions, which were cost-effective and tackling one of the top 20 ranked diseases, were identified.Provision had increased in nearly all EHP services over the period of the SWAp. The rates of out patient attendances and inpatient days per 1000 population had both increased from 929 attendances in 2002/3 to 1135 in 2007/08 and from 124 inpatient days in 2002/03 to 179 in 2007/08.However, by 2007/08 the mean gap between what was required and what was provided was 0.68 of the estimated need. Two services involving the treatment of malaria were overprovided, but the majority were underprovided, with some such as maternity care providing less than half of what was required.The EHP was under-funded throughout the period covering on average 57% of necessary costs. By 2007/08 the funding paid by SWAp partners including the government of Malawi to fund the EHP was at US$13.5 per capita per annum, which was almost half of the revised EHP estimated required expenditure per capita per annum.


CONCLUSIONS
The SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two thirds of the services required. This was despite serious under-funding of the EHP, an increase in the population and shortage of staff.


CONCLUSIONS
The identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.
Department of Community Health, College of Medicine, University of Malawi, Blantyre, 3, Malawi. cam.bowie1@gmail.com.
Cameron
C
Bowie
Takondwa
T
Mwase
Bull World Health Organ. 2008 Feb;86(2):101-10
18297164
Malawi Med J. 2006 Sep;18(3):103-10
27529005
Health Policy Plan. 2008 Jul;23(4):244-51
18562459
Bull World Health Organ. 2004 Dec;82(12):893
15654401
Lancet. 2010 Nov 20;376(9754):1775-84
21074255
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD005039
16235389
Health Policy. 2006 May;76(3):277-87
16039002
Health Res Policy Syst. 2006 May 16;4:5
16704726
Int J Health Plann Manage. 1998 Apr-Jun;13(2):177-90
10185508
Hum Resour Health. 2007 Jun 14;5:17
17570847