Strengthening Facility and Community Linkages for MNH in Five

Districts in Malawi

QI project journals

According to DHSS 2016 Malawi’s maternal mortality ratio (MMR) was estimated to be 439 maternal deaths per 100,000 live births whereas under five child mortality (U5MR), infant mortality, and neonatal mortality (NMR) were at; 63, 42, and 27 deaths per 1,000 live births respectively. Still birth rate was at 13 per 1000 pregnancies. These figures indicated that the SDG Goal 3 of 70/100,000 for maternal mortality ratio remained a challenge for Malawi to achieve by 2030, while the goals U5MR of 25 and NMR of 12 per 1000 livebirths were within reach.



With financial support from UNICEF, MaiKhanda Trust implemented a project that aimed to strengthen the facility and community linkages in five of its intervention districts of Blantyre, Thyolo, Dedza, Mangochi and NkhataBay. The project was implemented in two phases. The first phase of the project run from October 2017 to February 2020 and was implemented in partnership with CARE Malawi through its Community Score Card Consulting Group, while the second phase from June 2020 to December 2021 was in partnership with the Association of Medical Doctors in Malawi.

The Implementation


Implementation involved employing evidenced-based methodologies including quality improvement (QI) at health facility level which was complemented with community-based maternal and neonatal health care (CBMNC), and community score card (CSC) processes. 

  • The QI approach was utilized to enhance knowledge and skills of the frontline health workforce. This initiative was implemented in 36 quality of care (QoC) learning sites identified by Ministry of Health through its Quality Management Directorate (QMD).
  • CBMNC targeted at empowering household and communities to take responsibility and action for their own health whereas the CSC aimed at developing innovative and sustainable models, and also at improving accountability for MNH service delivery with greater community involvement. These initiatives were implemented across all the 5 districts. 

Other key strategies that facilitated awareness and creating demand for health services included jingles and panel discussions. Jingles which were aired through community radios; and panel discussions with subject experts particularly in the areas of Sexual Reproductive Maternal Newborn Child and Adolescent Health and Rights.

Project Outcomes


Over 80% of QoC learning sites were observed to have good knowledge on utilization of QI concepts as they have improved MNH service delivery through the completion of QI projects with at least one or more change ideas adopted into their systems. The change ideas which were tested and adopted include; keeping malaria test kits and LA at maternity, task allocations among team members on each shift, carrying out mentorship sessions, adhering to documentation tools (registers, forms, QI journal etc), documentation tool developments and many others.


CBMNC programme showed remarkable improvement in the percentage of HSAs who were practicing CBMNC. The percentage of HSAs practicing CBMNC and reporting increased from a median 19% in the first year of project to a median of 43% in final year of the project. This had resulted in an increase in the number of women reached by HSAs through door to door visits from a median of 232 women per months in the first year to 409 women per month in final year of the project.

Communities that were reached out through this initiative, tremendous improvements were observed in accessing MNH services from their nearest health facilities and having their delivery supported by skillful health workers. This observation was made specifically in Dedza district.



CSC processes contributed to the successful participation of communities in developmental works such as construction of bathrooms and toilets at nearby health facilities, mobilizing resources for guardian shelter project and in some instances, community members successfully negotiated on the reduction costs of maternity services.

Key learnings from the project


There is need to conduct follow-ups to monitor, and evaluate effectiveness and sustainability of the QI projects and mentorship processes. There is also need for adequate support on medical supplies, equipment and stationary to support the implementation of QI projects in health facilities.


Timely replenishment of CBMNC tools such as registers, reporting forms, thermometers, timers and many others to HSAs. As one way of getting more HSAs into practicing the programme, there is need for enhancing supportive supervisions. HSA supervisors should intensify mentorship sessions to HSAs observed with some difficulties on how to conduct proper home visits. The programme can further be strengthened if it is complimented with community empowering approaches such as CSC process, participatory learning action (PLA) and many others. 

5 implementing districts
Toilets constructed as a result of community score card process

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