A few years ago, missing medicine and drugs was a major crisis in Malawi. The press was full of articles about stolen drugs being sold on for profit, and a 2015 report from the Officer of the Inspector General at the World Fund suggested that up to 35% of private clinics in Malawi were selling donated anti-malaria tablets, which should have been available to patients free of charge. The scandal sparked campaigns in Malawi and within the international community to promote whistleblowing and ensure greater accountability throughout the supply chain.
The UKAid funded Malawi Health Sector Programme -Technical Assistance (MHSP-TA) expanded a pre-existing community-based scheme to increase accountability and prevent this kind of corruption. The scheme was centred on the work of the Health Centre Advisory Committees (HCACs). These are small groups comprising community members and health service providers and were set up to increase community involvement with delivering health services and improving facilities-. However, the make-up of the groups had become male-dominated and elitist, with most members selected by community leaders and receiving no formal training. The MHSP-TA saw several opportunities in strengthening the HCACs, which would not only lead to their increased efficiency, but would also expand their role to create a local body capable of combatting malpractice in drug procurement.
Using methods which had previously been successful in other Options-led programmes, the MHSP-TA implemented steps to improve the HCACs. They created a training manual, which was piloted alongside courses led by civil society organisations on the guidelines and Terms of Reference for the HCACs, which had been supplied and updated by the MHSP-TA. At these training sessions, further sub-groups were formed from within each of the HCACs, with these smaller groups - known as Drug Management Sub-Committees (DMSCs) - taking responsibility for drug monitoring and oversight duties. The DMSCs introduced simple systems at a local level to increase accountability, such as taking monthly stock checks, signing off on deliveries, and creating inventory cards to monitor and verify supply levels. All of this made it harder for stocks to be stolen.
Thanks to their improved record keeping techniques, the DMSCs have been able to investigate irregularities and assess whether drugs have been wrongly taken. In Rumphi district, oversight of stock levels and records meant that the local DMSC could quickly identify the loss of 280 antimalarial tablets. They investigated the case and after comparing records and their enquiries at the facility, they could deduce that the missing tablets were, in fact, due to an error in the pharmacy records, which could then be corrected.
Aside from reducing cases of malpractice, strengthening the HCACs has also empowered them to demand better facilities. HCACs now assess the functionality of healthcare centres using a scorecard system to grade different aspects of the facility. These criteria include drug supplies and security, but also areas such as utilities and staff members. The scorecard ratings have given HCACs legitimacy when lobbying for improved services from local and national politicians and business leaders, making them more persuasive.
The HCAC at the Thuchila Health Centre has been able to use this scorecard evidence to improve their facilities. They have built two pit latrines, secured piped water for patients and staff, and restored the storm-damaged roof of their drug store, thanks to their engagement with community leaders and figures from the worlds of business and politics.
As the MHSP-TA programme comes to an end, provisions have been put in place to ensure initiatives established by the programme will continue. There have been calls for further investment in the HCACs, including scaling up of MHSP-TA’s small grants initiative. Most importantly, the HCACs have found an institutional home, falling under the jurisdiction of the Directorate of Preventive Health Services. By fully involving the community, the reformed HCACs have ensured efficiency and accountability, ensuring that the legacy of the MHSP-TA programme should continue to benefit the Malawi health service for years to come.