27. A programme-based approach for maternal and child health at the district level in Malawi

Erla Hlín Hjálmarsdóttir
Ministry for Foreign Affairs, Iceland

After decentralisation, Malawi’s districts had to work on how to best deliver core public services to their communities

Development challenges remain enormous in Malawi, with the country ranking 171 in the United Nations Development Programme’s 2018 Human Development Index (UNDP, 2018[1]). Malawi records some of the highest poverty, child marriage and child-bearing rates in the world making these issues a core concern for development. Adolescent pregnancies represent a quarter of all pregnancies in Malawi, and 29% of youth aged 15-19 have had a baby. The associated health burden is substantial, as adolescent pregnancies account for 20% of maternal deaths, and the rate of obstetric fistula among this group is significant.

Malawi has been one of Iceland’s main development partners for almost 30 years (since 1989) where it had started out investing in the Lake Malawi fisheries sector. By the turn of the Millennium, Iceland’s approach shifted significantly as Malawi decentralised political powers and resources to subnational governments. Decentralisation in Malawi left its 28 districts with increased responsibilities in providing core services such as health, education, water and social services. In this new context, Iceland was faced with a dilemma of maximising its proportionally modest levels of development aid to combat extreme poverty and health challenges, while adhering to best practices for effective development co-operation. Iceland’s close co-operation with district authorities in Mangochi grew from fisheries to support in other sectors.

Supporting Mangochi District Council deliver public health services to its communities

Initially, Iceland, using a conventional project approach, ventured into the health sector in fishing communities in Mangochi District by building health infrastructure and offering outreach activities. It also provided training to medical staff, community-based distribution agents and health surveillance assistants. In addition to a number of fisheries projects, Iceland also participated in projects in the district, including water and sanitation, education, adult literacy and life-skills training for the rural poor.

In 2012, following the creation of Mangochi Basic Services Programme (MBSP)1 Iceland’s support evolved into a district level programme-based approach. A pro-poor focus and emphasis on marginalised groups, gender equality and human rights have long been Iceland’s primary development themes, and this has continued throughout the MBSP. With a focus on water and sanitation, public health and primary education, the MBSP closely follows the Mangochi District Development Plans, thus adhering to one of the key principles of the Busan Partnership for Effective Development Co-operation: ensuring that ownership of development priorities rests with the recipient country. The district’s institutions and systems are used, including its procurement system, which serves to strengthen the financial management capacity of the district government and public services locally. Moreover, through close co-operation with district authorities Iceland could help ensure that support reaches the poorest and most vulnerable people, aligning with the call of the Sustainable Development Goals (“SDGs”) to leave no one behind.

Focus on a single district with good co-ordination and understanding of the local context to maximise the impact of a small donor

This Mangochi Basic Services Programme has several advantages for development partners. Evaluations indicate that district level programme based approaches are suitable for Iceland as a small donor. Given the small size of Iceland’s development contribution, concentrating resources within one district facilitated project/programme co-ordination by a small team of staff, enhanced harmonisation with greater insights on the local context. Results achieved were more tangible while Iceland could maximise the development impact of its relatively modest overall development budget.

Iceland’s partnership in public health in Mangochi District has contributed to more expectant mothers attending prenatal and antenatal care and delivering their babies at health centres leading to a decline in maternal mortality and increased access to emergency obstetric care. And while the number of stillbirths has remained roughly constant over the past few years, a recent evaluation suggests that this is due to better recording.

What next?

In the Mangochi District, there is increasing focus on delivering SDG 17 (Partnerships for the goals) to streamline and enhance the overall efficiency of support of different partners within the district. There is scope for more donor harmonisation and for complementary public health contributions to have greater impact on sustainable development. As an example, Iceland is teaming up with the United Nations Population Fund (“UNFPA”) to offer family planning services, which includes addressing the physical and emotional consequences of gender-based violence. Furthermore, Iceland and UNFPA will have a joint obstetric fistula programme through UNFPA’s centre at the Mangochi District Hospital.


[1] UNDP (2018), Human Development Indices and Indicators, 2018 Statistical Update, http://hdr.undp.org/sites/default/files/2018_human_development_statistical_update.pdf.

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