A Malawian Health Official Explains How a Unique Partnership with the U.S. Government is Improving Health Outcomes

“This impact will live beyond the life of the project.”

Mangochi is one of two districts in Malawi participating in a government-to-government partnership with the U.S. government. The collaboration is strengthening Malawi’s district-level health facilities to address challenges in health system performance which lead to suboptimal health outcomes. / Thoko Chikondi, USAID

In Malawi, where district-level health facilities play a critical role in delivering health services, district councils face challenges with filling vacant health worker roles, persistent shortages of essential medicines and supplies, and inadequate health infrastructure. These issues have resulted in suboptimal health indicators, particularly in maternal and child health, and nutrition, as well as challenges in the management of HIV, malaria, and tuberculosis.

Recognizing that capable government systems are critical to sustainably deliver health services, USAID partners directly with the local governments in two Malawian districts through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. President’s Malaria Initiative (PMI). The partnerships with Mangochi and Zomba District Councils are helping local governments improve health outcomes as part of USAID’s government-to-government (G2G) model.

The G2G model works through national systems to support long-term sustainability of coordinated care that addresses all aspects of patient health.

We sat down with Dr. Henry Chibowa, director of Health and Social Welfare Services for Mangochi District, to discuss how this unique government-to-government partnership is improving health outcomes in one of the most highly populated districts in Malawi.

Dr. Henry Chibowa serves as the director of Health and Social Welfare Services for Mangochi District and oversees the government-to-government activities on behalf of the District Council. / Thoko Chikondi, USAID

What are some of the most critical health issues in Mangochi District?

Malawi as a whole suffers from a shortage of trained health care workers with vacancy rates around 50%. The country also has a high HIV prevalence and high maternal and child mortality.

Mangochi is a highly populated district. The district hospital has a catchment area population of 93,000 which it serves. In addition, there are 58 health facilities that refer patients to the district hospital. Our maternity ward delivers around 40 babies per day — that’s the second highest number of deliveries of any maternity ward in Malawi.

How does the government-to-government partnership between the U.S. government and Mangochi District Council work?

G2G is a very innovative type of development assistance. The U.S. government is providing funding assistance directly to the Government of Malawi, as opposed to channeling it through an implementing partner. This leads to the more seamless alignment of priorities because the funds are being allocated by us, the [district] government.

Since we are the ones planning how the funds will be used, we also feel responsible and accountable for the performance of activities being funded.

In the initial phase of this G2G collaboration, USAID worked closely with the Mangochi District Council to enhance their operational and managerial capacity in health services. This planning phase prioritized listening to and addressing the needs of the local districts rather than implementing USAID-driven solutions. / Thoko Chikondi, USAID

What health service improvements have you seen so far?

USAID G2G assistance provides salary support to increase the number of health care workers in district health facilities. These additional human resources have made a huge difference in the quality of care. The beauty of that is because there’s already a commitment by the government to take on those salaries after the assistance ends, all those facilities where we’ve sent health workers will still have those human resources.

Whether the G2G funding ends tomorrow or next year, this impact will live beyond the life of the project.

The improvements in health services speak for themselves. For example, the G2G funds 11 HIV program sites that conduct testing and provide treatment. In the first year of the G2G [partnership], 3,000 people were tested for HIV at those sites. Last year, (the second year of the project), over 20,000 people were tested.

In the maternity wards, there was previously one midwife for every four beds. Now, there is one midwife for every bed, we have equipment in the operating room, and we’ve seen an almost 20% decrease in maternal deaths.

Through the G2G assistance, USAID worked with the Mangochi District Government to integrate newly hired health workers into the district health workforce to ensure lasting impact. / Thoko Chikondi, USAID

What health system improvements have you seen so far?

We have seen great improvements in the managerial capacity of the district health office and District Council itself. In order to execute the partnership milestones, we needed to change the way we work. It was a challenge at first, but now it makes the partnership run more efficiently.

The culture that we’re creating… . We’re building a culture of performance.

Even if the leadership team that’s there now moves on, it’s hard for it to be reversed because it’s been ingrained in the system and that will make the work more sustainable in the years to come.

In 2023, Mangochi won an award for best performing neonatal care center in Malawi. Dr. Chibowa attributes this to work done through the G2G, including mentorship of staff. / Thoko Chikondi, USAID

Health care workers are the backbone of health systems. How have these efforts impacted the health care workers throughout Mangochi?

The G2G [model] has helped to greatly strengthen the work environment. A midwife now has the tools she needs to do her work thanks to procurement through the G2G program. Because those things are now available, it makes work enjoyable and easier for the health care workers.

Health workers no longer have to say: “If only I had a suturing set, I could have saved a life.”

We’ve also seen a change in the knowledge and skill level of health care workers resulting from frequent supervision and mentorship visits which are part of the G2G [model]. Staff say they feel more supported by their superiors. When you put these things together, work is more meaningful for the health workers.

Seeing and hearing the improvements over the past three years has also helped improve work satisfaction because health workers see that they are contributing to improving lives in the district.

USAID’s G2G model exemplifies how a comprehensive health approach, emphasizing locally-led solutions, not only empowers local health care providers and district council staff, but also enhances the national systems’ ability to meet standards and advance collective efforts. / Thoko Chikondi, USAID

How has direct USAID assistance helped promote local ownership and leadership of health programs in Mangochi?

The use of government systems strengthens the local government itself.

Normally, USAID projects that fund implementing partners will interface with the district health office. But now, because the money is being [implemented] through the District Council, we as a district health office need to cooperate with the District Council. It brings all of us together and forces us to cooperate.

It forces us to work like a team, and we’re already seeing these positive relationships extending to our other work. It’s building relationships that other projects are benefitting from.

About the Author

Cassie Vasiloff is a Communications Advisor for USAID’s Office of HIV/AIDS.