Fact Finding Tour
Clinic Blog 25 September 2013
The Rev. Kenneth Alemekezeke Chikondi-Phiri, Lonjezo Kathawa, Sautso Chikapa and I left Makupo early in the morning, Monday 23 January. We were on the road for 6h30 and as we drove through Kasese and Madisi we stopped to arrange meetings with the medical staff later in the week as we return to Makupo/Chilanga. We were on our way to meet the coordinator of health services for the Nkhoma Synod CCAP Hospital, Mr Yoas Mvula at his office in Lilongwe.
He was our first stop and a good thing too. He really knew his stuff and has put us on the path we need to follow to get this clinic up and running. First he briefed us on the church's health infrastructure.
Nkhoma Synod Health consists of Nkhoma Hospital with 330 beds and10 health centres scattered across the Central region. The hospital is a major installation with full service while the clinics provide maternity care, voluntary counselling and testing for HIV, anti-retroviral treatment and outpatient service. There is a nursing college with an intake of 120 per year in two streams. Sixty are Unicef sponsored midwife technicians in an 18 month basic programme to replace traditional village birth attendants and the other 60 are full registered nurse midwives.
The Synod's Primary Health Care Department is in Lilongwe from where they coordinate preventative health awareness in the villages. He cited as an example the IRS Individual Residual Spray programme which ran from 2009 to 2012. It was so effective where it was implemented that it reduced the admission of under fives by 80% at the local hospitals during the rainy season. It was such a significant drop in admissions that it led to a reduction in workload with a consequent savings on drugs and more importantly a significant reduction in the death rate among children and pregnant women.
He dealt with issues of sustainability and the provision of staff and drugs. The health department of the synod is in partnership with the Malawi government and donors for the provision of drugs and staffing. The government provides medical and certain non-medical personnel. CHAM the Christian Health Association of Malawi mobilises resources for all health institutions of the member churches which also includes the provision of drugs and personnel. CHAM also carries out supervision visits to facilities to enforce Ministry of Health MoH and World Health Organisation WHO standards. The synod has an annual Health Day when all member churches make a special collection which goes towards drug procurement
As a result it is very rare that Nkhoma synod facilities run out of drugs.
Structure
The CCAP Synod has a Board of Trustees which governs all church activities including the Health Unit which is headed by a moderator as the chairman, the church's General-Secretary and others. The Health Department has its own board separate from the church's. The chairman is a church representative while other members are from different professions and include MoH and CHAM. The church has internal and external auditors who regularly verify bookkeeping in every facility.
Each facility has a Health Advisory Committee consisting of the chairman who is the local presiding minister; the head of the health facility who acts as the secretary; as well as local traditional leaders, and community members. The advisory committee's role is to provide a lik to the local community. These local Health Advisory Committees report by sending the minutes of its monthly meetings to the Health Management team in Nkhoma. This keeps them aware of issues and allows early problem solving.
In addition to these advisory committees, there is a Health Management Committee at each facility. These are composed of the facility's head Medical Officer, Nurse, and administrator.
Mvula's role as health department coordinator is to visit each facility to enforce the standards established by the 3 regulatory bodies. He ensures that available funds are channeled to the individual units of the Health Department and each unit is registered under Nkhoma.
Nkhoma also has a maintenance department to look after building infrastructure and oversee new construction.
Under the government guidelines Nkhoma provides some free medical services to pregnant women and children under 5 as well as HIV related services. Nkhoma and CHAM are lobbying the government for support to provide free primary health services to all citizens.
Accreditation: The Chilanga Community Clinic will fall under the Nkhoma accreditation not just because it sits on mission land but because it facilitates the necessary government accreditation. The process is as follows:
To reflect an expressed need of the community a request must be made to the Kasungu District Commissioner via the District Assembly. The District Health Officer (DHO) sits there and he and his staff undertake an assessment. The basic criteria are that there be no other facility within 5 kilometres and that the population in catchment basin warrants such a facility. The DHO documents his research which is forwarded to the MoH who will determine that they do not have the resources to satisfy the request. The request is then forwarded to Nkhoma's health unit synod for its support. The DC endorsement is the essential first step to get this process underway since it ensures that it falls within the local development plan and in order for the accreditation process to begin and which leads eventually to staffing arrangements and the provision of drugs, etc...
We have already jumped through some of these hoops but we have clearly not followed procedures in the required order and in most cases the groundwork has already been lain. There are some problems to deal with and after we get back to Kasungu and finish with this round of meetings we will be in a position to outline these and propose a strategy for dealing with them. On our way home, we are going to visit three facilities and try to learn from them. Thursday we have a meeting with St-Andrews. Next Monday, we will draft a more complete report to cover all the above after we get back to Kasungu.

Clinic Report 21Sep13

It appears that I have hit the ground running. Wednesday's arrival was the usual ritual of greeting and arranging accommodation. Thursday was supposed to be busier. Unfortunately, neither the reverend nor the headmaster were available in the morning, having been called to the Ministry of Education office in Kasungu to deal with urgent issues around the boarding facilities in the day schools. That gave me some time to go up to the site of the school Bishop's is building near Senior Chief Kaomba's court about 2 kilometres southeast of us. It is a very ambitious school set up and Ken Manda is acting as site manager. It is a school and does not appear to have a health facility included as had been rumoured.

We finally met the reverend to make begin making our plans in mid-afternoon. We were the folks at Makupo who represent the village on the clinic joint committee and myself. I explained the purpose of the visit and he was super agreeable with the purpose and the validity of the concerns that the Canadian clinic support folk had raised. We agreed to start our exploratory visits by going to St. Andrews and Kasungu District Hospital the next afternoon and begin to plan our trip to Lilongwe for next week.

I decided to travel with Lonjezo as Makupo's eyes and ears to this process. He was one of the 3 Makupo youth to begin health training at St Andrews earlier in the year and originally wanted to train as a nurse. Kenneth Alimekezeke Chikondi-Phiri is the minister in charge of the Chilanga CCAP mission. I wanted Kenneth to see what was happening at other church sites and how they function as compared to the Nkhoma method. Sautso will join me on Saturday and hopefully she will be our project management representative after I leave. She has worked with Nellie and I since the first well in 2004 and is a very trusted collaborator who is a competent administrator, and has completed a certificate in management including accounting

We arrived unannounced at St. Andrews to find Peter Minjale, the medical officer, on vacation and literally everyone else at lunch. Mrs Phyllis Bwanali, the Nursing matron graciously came to introduce us to the facility. I had not really visited the place since we went as group in 2008 and I was impressed at how much it has grown. In fact, it began as a small clinic, even smaller than what we are proposing. It is now a large sprawling facility with several wards, a surgery, delivery facilities and a dentist, ante-natal services, nutrition rehabilitation and outreach services. Most of what is there has been put in place over the last 10 years. A testament to its essential role in the health care system was the fact that the operating theatre was being used by a surgeon from Kasungu District Hospital while we were visiting, because of a problem with their facility. It was an essential orientation for we lay people.

We wanted to visit the District Health Officer at Kasungu District Hospital. We need to coordinate with him and his team around issues of government sanction, standards and support. Unfortunately, the vice-president had come to Kasungu on some specious mission to lay a cornerstone for a new maternity wing at the hospital, which was in fact an excuse for a political rally. The governing coalition of Joyce Banda is facing a real insurgence of the MCP especially in the heartland of Kamuzu Banda. The net result was that all people except essential medical staff were obliged to attend the rally as part of the protocol duties when the VP is in town. We therefore couldn't meet anyone at the hospital and a tour was not really necessary.

We still had some time together so we moved across the road to te Kasungu Inn and spent a couple of hours planning, discussing and sharing ideas. We have our first meeting set up with the Nkhoma Health Unit in Lilongwe for Monday morning and one with the contractor for that afternoon. On the way down to Lilongwe we will stop at Madisi and Lifeline to set up visits on Wednesday afternoon as we return from Lilongwe. So those 3 days are starting to look profitable and I am pleased with how things are shaping up.

Some brief background before I close off. Mission organisations still deliver well over half of Malawi's health care. So collaboration on issues of health care are with government and or the church. The Anglicans have set up St. Andrews as a satellite of their much larger facility in Nkotakota about 1.5 hours to the lakeshore to serve the much under-serviced region of eastern Kasungu. Despite the name Presbyterian as part of the CCAP moniker, Nkhoma Synod of the CCAP operates in the Central region in alliance with the old Dutch Reform Church now known as World Renewal, not the international Presbyterian church of Scottish heritage. Nkhoma is situated about an hour south of Lilongwe and has a rather elaborate set up including a large teaching hospital, training facilities for nurses and other health personnel. Their health unit is in Lilongwe so I will take the opportunity to pass by Nkhoma in a later phase of the trip when I go to the southern region.

The churches depend on outside help and are more than willing to collaborate with funding organisations even old non-believers like me. To that end Kenneth agrees that if it would help fund-raising efforts then we should create a local NGO to make the clinic structure arms length from the church and open to everyone in the community. Sautso is office manager for one of Malawi's preeminent law firms so we will explore the value of this option over the course of the visit with someone from there.