The present study assessed PHC in two rural Malawian districts without CDTi experience and found that despite lack of a national policy on PHC, there is a PHC system in place which is being propelled by EHP programme. There is lack of awareness of PHC concept amongst health service providers at all levels. PHC services are implemented at all levels despite that the system has several challenges which affect the implementation of services. Some of the challenges are inadequacy of supplies, shortage of personnel, poor quality of infrastructures and unavailable transport and communication equipment.
The study has revealed that health providers and beneficiaries in the study districts to a greater extent share similar but not necessarily in same order priority health issues and health interventions as outlined in Table
4. Similarities in priority health issues and interventions were mostly observed amongst providers and communities in both study districts. However, while a similarity in priority health issues between providers and communities in Mangochi was observed this was not the case in Mzimba. The agreement on priorities among the providers in the two districts can be attributed to the adherence of the national priorities as set by the EHP. The difference by the communities in Mzimba to agree with the providers can be ascribed to the fact that the district has better socio-economic, demographic and health indicators than Mangochi (Table
1) which might have influenced their perceptions.
The study has also found that though some health implementation partners are present at district level, they are scarcely or unevenly distributed at health facility and community levels. Both the providers and beneficiaries perceived that PHC is not comprehensively delivered and need to be strengthened by more community participation and involvement. In both study districts, there are several socio-political groups which are actively involved in the delivery of PHC at community level.
Other previous studies have pointed out that Malawi has a viable and active PHC system in place, although not without problems
[16–18]. Observations in the study districts revealed inadequate population coverage of health services and care. System-related barriers to access to health services exist in the form of insufficient supplies or stock-outs of essential drugs, medical supplies and inadequate human resource for health, particularly in rural areas
. There are also geographical barriers to accessing health care services in that the few functional health facilities are situated far apart and many people travel long distances to access services. Consequently, stakeholders perceived serious unmet gaps in the provision of basic health services in both districts.
The study found that although there is a PHC system which spans from community, through health centre up to district levels in the study districts, it lacks proper and effective coordination. The general lack of awareness of the PHC and EHP concepts among health service providers and consumers, pointed to weak policy formulation and dissemination within the system, resulting in implementation disparities. Implementation and organisation of PHC interventions at community level suffered from inadequate resources, poor collaboration between partners and limited participation of the communities benefiting from the services. It is recognised that by the adoption of the EHP by the Ministry of Health has helped to revitalise the dormant PHC strategy in Malawi.
As one way of strengthening PHC at community level, other well tested strategies such as CDI could be explored
]. A wealth of literature shows that interventions against conditions such as malaria, diarrhoeal diseases and malnutrition can realistically be managed at community level, whereas others such as measles and HIV and AIDS require substantial medical training and experience to be properly managed
]. It is therefore necessary to distinguish health issues suitable for community directed management from those that should remain in the hands of professional workers at health facility level. This study has documented PHC resources, capacities and supportive systems that are assets in promoting and strengthening community participation in PHC related services at community level. Based on these assets, we propose intensified dialogue with communities and public health authorities in the districts on which interventions are suitable for implementation using the CDI approach and how to do it in practice. Special emphasis in this dialogue should be paid to interventions identified as promising by informants of this study, namely:
Home case management for malaria
Management of diarrhoeal diseases
Treatment of schistosomiasis
Provision of food supplements against malnutrition.
For those interventions that we do not consider suitable for the CDI approach, some further operational research studies that would assess their feasibility for the CDI approach or shed light on ways of making them suitable for the CDI approach need to be done.
It is noteworthy that despite the many challenges faced by the health sector in Malawi, the authorities remain committed to improving accessibility to community health services. There are ongoing community-based health initiatives actively engaging communities themselves
. There is also a network of volunteers and community health workers who are actively involved in the delivery of various health services at community level. However increasing community participation is likely to bring specific programme benefits, as shown with CDI
[13, 14]. Here we show that both providers and beneficiaries in the two study districts perceived community participation as vital for the strengthening of PHC. It is desirable that the interventions are defined on the basis of existing supportive capacity and engagement of the health system, its partners, and the communities themselves to increase the sense of ownership and to minimise conflicts or duplication of efforts
. This study shows that perspectives of stakeholders on the specific PHC interventions to be prioritized were similar. Thus, the minimum conditions for the early involvement of all stakeholders, including community members, in the planning phase of interventions are met. Stakeholders interviewed expressed their desire for the implementation of interventions such as provision of ITN to children under the age of five and ante-natal mothers, home case management of malaria, management of diarrhoeal diseases, treatment of schistosomiasis, HIV testing and counselling (HTC), prevention of mother to child transmission (PMTCT) of HIV services and provision of food supplements to malnourished children and mothers implemented at the community level. However, considering the limitations in available resources, competencies as well as supportive systems in the target districts it is more realistic to apply the CDI strategy for the provision of ITN, home case management of malaria, management of diarrhoeal diseases and treatment of schistosomiasis than for the provision of HTC and PMTCT services, and food supplementation.
Our study has some limitations. Firstly, qualitative data were collected from only two districts. Our results therefore may not represent the whole country, though interviews with national authorities and reviews of official documents suggest that our findings could be generalised. Secondly, although independent FGD were conducted with different age groups and genders, no different perceptions of PHC priorities were found between them, suggesting that the issues raised were prevalent in the areas such that the old and the young, male or female knew about them leading them to identify the same priorities. Further, results of the individual in-depth interviews reported similar observations, which support our findings. The use of multiple data sources is a major strength of this study. There is a need for intervention studies applying both qualitative and quantitative methods to assess the processes and effects of specific CDI interventions and for those interventions where CDI strategy has never been applied there is a need for further research to assess their feasibility or to shed light on ways of making them suitable for the CDI approach.