Journal Paper Review
CDI in Malawi 9
CDI in Malawi
The principles of Primary Health care (PHC) include universal access to healthcare, community and public participation, health promotion, intersectorial collaboration, and the appropriate use of technology in delivering healthcare. Many of these principles are reflected in the Community Direct Interventions (CDI) approach to primary healthcare in Malawi. However, some aspects of CDI also reflect poor alignment with some of the principles and values of PHC.
Accessibility is a principle of PHC that is concerned with the availability, affordability and equality of health service provision regardless of factors such as age, gender, location and ethnicity. CDI has assisted in improving access to primary care as the community is able to provide care, and consult with healthcare professional when need arises. In addition, the CDI involves many community volunteers who improve access to primary healthcare to some members of the community.
Public and community participation is the core pillar of both CDI and PHC. CDI involves the community in addressing common health problems. The use of CDI can allow the communities take charge of their own health and wellness. The community has been involved in CDI initiatives to distribute insecticide treated nets and in a program to manage malaria at home. CDI has been proposed as an effective approach to the community management of conditions such as Malaria, Diarrhoea, and malnutrition.
However, CDI is weak when it comes to the health promotion principle of PHC. CDI does little to impact the socioeconomic conditions of the community. However, socioeconomic factors such as shelter, education, peace, justice, income, food and equity impact the health of the community profoundly. CDI as described in the research article also makes poor use of technology. In addition, the intersectorial contribution to the CDI approach is almost non-existent as primary healthcare activities are carried out by health professional and there is little support for CDI from other sectors.
Malawi’s budget allocation for Essential Health Package (EHP) is far below the target set aside for towards the realization of the millennium development goals in health. Some countries that prioritize health in budgetary allocation have reached the desired 15 per cent of their national allocation for healthcare. As a result of the low budgetary allocation, the Malawi Primary health care system is underfunded and operates under significant resource constraints.
Malawi continues to face many health problems as there are inadequate resources to tackle them. Access to healthcare is still poor and communicable diseases such as malaria and Diarrhoea remain prevalent in most areas in Malawi. HIV/AIDS is also a considerable burden on the local health system while many Malawian children are malnourished. Good financing is needed in preventing and dealing in these problems within the health system.
Evidence of poor financing of the Malawian health system can be seen in the persistent shortage of essential drugs in the country’s healthcare facilities. Malawian health care system is also severely understaffed as remuneration for their staff has remained poor. Malawian health workers spend time attending training and workshops as they offer allowances that they use to supplement their salaries.
However, the inadequate allocation to the Essential Health Package is justifiable as the government has to take care of other aspects of development. The Malawian government allocates slightly more revenue to the education system in the country. Recently, the government funded projects to build new classroom, teachers’ houses, new teachers training college and for the rehabilitation of colleges and secondary schools. It is also important to appreciate that a permanent impact on the healthcare outcome of Malawian can only be achieved through a multi-sectorial approach. Funding for water and sanitation provision, education and the agricultural sector affects the socio-economic outcomes of Malawians.
The existence of some characteristics that can support CDI in the two districts is encouraging. The research found out that the two target districts had a PHC structure although it had not been optimally implemented. The authors also reported that Malawi’s PHC system is viable and active although it is faces many problems. The existence of the structure can provide a framework that can enhance the rollout of CDI in both districts. The willingness of the government to support the realization of the principles of PHC is another positive discovery.
The government of Malawi has shown willingness in supporting any initiative that will enhance its PHC system. It is clear that the government would be ready to fund the CDI rollout and implementation in the country. The government already supports existing community-based health initiatives as it feels they can improve access to healthcare in the country. In addition, the Malawian population also expressed their enthusiasm in participating in the CDI program. The population feels that they should be more involved in planning and implementing the PHC system.
Malawi also has many community health workers and volunteers who deliver different health service to the community. Most villages in Malawi have a Village Health Committee that takes charge of health issues in the community. Most volunteers and community workers expressed their enthusiasm at the possibility of being involved in the CDI program. The volunteers and the community argued that the Malawian PHC could be enhanced by allowing for greater community participation in health issues that affect them. The community health workers and volunteers asserted that they would be willing to participate in CDI initiatives that focusing on malarial home care, ante-natal mothers, management and diarrhoeal deseases, HIV counseling and testing and prevention of Mother to Child transmissions.
Mzimba and Mangochi district have significant socio-economic differences as revealed by the table on the socio-economic characteristics of the two districts. The research reports that socio-economic indicators influence the health priorities of residents in the two districts. For example, the people of Mangochi prioritized malaria over diarrhoeal diseases. The people of Mangochi are poorly educated and the table suggests they earn lesser than their Mzimba counterparts. The prioritization of malaria may be related to their inability to purchase insecticide treated nets on their own. On the other hand, the residents of Mzimba are better educated and may be able to buy insecticide treated nets.
The education levels in the two communities also influences the perception of the residents over health issues. The poorly educated women of Mangochi may not perceive diarrhoeal diseases as a serious health issues while the better educated women in Mzimba perceive health issues more objectively. Uneducated people are unlikely to question how health workers prioritize health issues and instead follow the guidelines of the health workers. In the case, the residents of Mzimba agree with the priorities established by the government as regard health issues.
The prioritization of malaria in Mangochi may also be related to the fact that it is the greatest threat to infant’s health and survival. In the research, Mangochi reports a much higher infant mortality rate than Mzimba. The infant mortality rate may be linked to higher levels of Malaria in Mangochi district. In addition, the residents of Mangochi are mainly engaged in fishing, this means they live near stagnant water bodies. The stagnant water provides fertile breeding ground for mosquitoes and thus the area is more prone to malaria than Mzimba. Socio-economic factors have consequences on the spread and control of health conditions, and the perception of the priority of a condition as a public health issue.
According to the authors, the management of Measles and HIV should remain in the hands of professional health workers. The authors point out that the management of the two conditions is complicated and needs qualified health professionals. I agree with the views of the authors that is would be hard to manage HIV and measles at the community level.
The two diseases are easily transmitted from one person to the other when poorly managed. The resources shortage also means that there is shortage of preventive equipment that can be used in the management of the two conditions. Patients have to make long journeys to health facilities where equipment and drugs for treating HIV and TB are available. Providing these drugs and equipment to the community and community health workers would simply be too expensive. It would be inappropriate to expect poorly trained individuals with inadequate medical training to handle the management of HIV and measles. According to the report the supply of medical resource is often inadequate and erratic. This means the little that each district receives should be economically managed, and this can only be achieved by using professional health workers.
Training the community and community health workers to a level where they are competent enough to handle the two conditions is an expensive undertaking. The government cannot afford to train the community as it is already struggling to provide trained medical facilities in its medical facilities. In contrast, conditions such as diarrhoeal diseases, malaria and malnutrition do not need much professional training and experience to control. Malaria and Malnutrition can be managed by community health workers with no risk of transmission from patient to carer. On the other hand, one can care for a patient suffering from diarrhoeal diseases without catching the condition provided hygiene is observed.
It is challenging to deliver nutrition supplementation in the absence of trained nutritionists. For food supplementation interventions through CDI to be effective they must be delivered by trained nutritionists. However, Malawi does not have adequately trained nutritionist at the community level. Even though the government could embark on an initiative to train communities as nutritionist such an initiative would be too expensive. Already, the health sector faces a shortage of funds to meet more critical health needs. Food supplementation for young children can be handled by a community initiative such as CDI provided that the necessary competencies, resources and support systems are available.
In addition, community level initiatives without well trained nutritionist may lead to a waste of resources. It is not easy to separate children suffering from malnutrition from those who are healthy. In many cases, the community level intervention may fail to reach or enrol all malnourished children. At the same time, the program may be wasting resources by delivering supplements to children who are healthy. If resources are abundant, the program may roll out for all children regardless of their health. In contrast, the resource scarcity forces the program to carefully target malnourished children only. The most effective way to reach affected children is at clinics, hospitals and other health settings where their growth can be monitored.
However, Malawi lacks the network of support infrastructure to enrol and treat malnourished children in community settings. The health workers in the few understaffed clinics and hospitals are preoccupied with other health problems within the system. For the community to assist in delivering food supplementation community based nutritionists have to be effectively trained on delivering the interventions. In such a situation, the wastage of resources that may occur in a CDI based food supplementation intervention many is minimized.
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