Advancing accountability: Malawi’s strategic approach to health commitments
In a country where maternal mortality has decreased but still claims too many lives, where contraceptive access has improved but remains insufficient, and where adolescent health needs often go unaddressed, Malawi has developed a bold new blueprint for change.
The Collaborative Advocacy Action Plan (CAAP), unveiled in February 2025, represents a coordinated effort to improve accountability for women’s, children’s, and adolescents’ health through a structured approach that brings together multiple stakeholders under a common vision.
The initiative, led by Amref Health Africa under the stewardship of the Ministry of Health’s Reproductive Health Directorate, aims to transform how Malawi’s health commitments are implemented, monitored, and fulfilled.
With five ambitious advocacy goals addressing everything from health financing to youth representation, the CAAP establishes a framework that could significantly advance Malawi’s progress toward improved health outcomes for vulnerable populations.
This accountability-focused strategy comes at a critical juncture for Malawi’s health system. Despite notable achievements in reducing maternal mortality from 439 deaths per 100,000 live births in 2015 to 349 in 2019, and increasing access to modern contraception from 38.1% in 2012 to 48.3% in 2019, significant gaps persist in the healthcare landscape.
These improvements, while encouraging, fall short of what’s needed to achieve Universal Health Coverage targets as outlined in the country’s Health Sector Strategic Plan III (HSSP III) for 2023-2030.
The accountability imperative: Building on existing progress
Malawi’s health sector has demonstrated steady progress over the past decade, with life expectancy increasing significantly and mortality rates declining across several key indicators. According to the HSSP III, life expectancy rose from 55.6 years to 64.7 years between 2010 and 2020, driven largely by improvements in maternal and child health interventions and a robust HIV response.
The CAAP initiative builds upon this foundation while addressing persistent challenges in health system financing, inequitable access to services, and inadequate human resources. At its core, the plan establishes five key advocacy goals that align closely with national health priorities and international commitments:
- Increasing health financing – Committing to the Abuja declaration’s target of allocating 15% of the national budget towards health, with 30% of that dedicated to reproductive, maternal, neonatal, child, and adolescent health by 2030.
- Reducing maternal, newborn, and child mortality – Accelerating progress in line with the 2024 World Health Assembly MNCH resolution.
- Reducing unmet family planning needs – Working to reduce unmet needs for all women to below 11% by 2030.
- Reducing teen childbearing and ending child marriage – Decreasing teen childbearing from 29% to 20% and eliminating child marriages by 2030.
- Ensuring youth representation in decision-making – Including 30% representation of youth in decision-making bodies.
These accountability targets represent not merely aspirational goals but concrete measures against which progress can be systematically tracked and evaluated.
From commitment to accountability: The implementation mechanism
What distinguishes this accountability initiative from previous efforts is its robust implementation structure. The plan establishes a multi-stakeholder platform (MSP) that will conduct annual commitment implementation reviews, using a digital dashboard to track progress against each commitment.
“We have created this dashboard so we can track progress on each and every commitment. We have agreed that every year, we will review and assess where we are so that we can continue implementing and fulfill our commitments,” explained Madame Doreen Namagetsi Ali, Reproductive Health Services Director, during the launch of Malawi’s Digital Advocacy Hub in August 2024.
This accountability mechanism represents a significant shift in how health commitments are managed in Malawi. Rather than allowing commitments to fade into obscurity after they’re made, the digital tracking system ensures ongoing visibility and follow-through. The approach addresses a fundamental challenge identified by Parliamentary Committee Chairperson Dr. Matthews Ngwale: “Commitments have been made before in this country… But the problem is the knowledge of what commitments Malawi has made and how many commitments Malawi has made. That knowledge is very, very limited amongst us.”
Through the Digital Advocacy Hub, the CAAP initiative creates a shared space for collaboration and accountability that transcends sectoral boundaries. As Dr. Samson Mndolo, Secretary for Health, noted, “The Digital Advocacy Hub that we are launching today can be used as a shared space for collaboration among our diverse sectors.”
Accountability in context: The challenges of health system transformation
The accountability imperatives outlined in the CAAP initiative must be understood within the broader context of Malawi’s health system challenges. Despite impressive gains, the country’s health sector still faces significant hurdles in delivering equitable, high-quality care to all citizens.
The HSSP III identifies several critical bottlenecks that undermine service delivery, including:
- Lack of well-defined integration and streamlining in healthcare services across primary, secondary, and tertiary levels
- Weak referral systems across levels of care
- Poor quality and lack of client safety in healthcare service delivery
- Weak client-centred approaches and limited client trust in service delivery
These systemic challenges are compounded by financial constraints. Malawi’s total health expenditure remains at approximately $40 per capita per year, far below the WHO-recommended $86 needed for basic healthcare coverage. The HSSP III projects this will rise to only about $50 by 2030, still insufficient for comprehensive service provision.
Amref Health Africa’s leadership of the CAAP initiative is particularly significant in this context. As Hester Mkwinda Nyasulu, Amref Country Director, observed: “The journey towards strengthening advocacy for women, children and adolescents has just begun. We will support the Government of Malawi in convening the multi-stakeholder platform, advancing accountability and ensuring that all constituencies are represented.”
Accountability through multi-stakeholder engagement: A new governance paradigm
One of the most distinctive features of the CAAP initiative is its emphasis on multi-stakeholder engagement as a core accountability mechanism. The multi-stakeholder platform brings together government agencies, development partners, civil society organizations, and community representatives to collectively monitor and advance the implementation of health commitments.
This collaborative governance model represents a significant departure from conventional top-down approaches to policy implementation. By fostering shared accountability across diverse stakeholders, the initiative creates multiple accountability pathways and reduces the risk of implementation failure due to isolated bottlenecks.
During the Digital Advocacy Hub launch in August 2024, the multi-sectoral and multi-constituency audience of over 70 participants demonstrated the breadth of engagement the platform has already achieved. This wide-ranging participation creates an environment where accountability can flourish through mutual oversight and support.
“Today is a big day because we are looking at commitments that the government has made for the people it serves,” said Amref Country Director Hester Nyasulu at the launch event, as quoted by the PMNCH Communication team.
“We are here to launch the Malawi Digital Advocacy Hub but also to invite all of you to take part in this Multistakeholder platform where all of us are going to combine our efforts and support the government, specifically the Ministry of Health, to ensure commitments are fulfilled.”
Accountability through data: The digital transformation of health governance
Central to the CAAP initiative’s accountability approach is the digital dashboard that consolidates commitments and tracks implementation progress. This represents a significant advancement in how health governance is conducted in Malawi, bringing transparency and real-time monitoring to previously opaque processes.
The dashboard consolidates over 60 national, regional, and global commitments made by the Government of Malawi since 2014, creating a comprehensive view of the country’s health promises. This visibility is crucial for accountability, as stakeholders can easily identify which commitments are on track and which require additional attention.
This digital accountability tool aligns with broader digital health transformation efforts outlined in the HSSP III, which emphasizes “sustainable and harmonized country led digital health system that covers all areas of service provision and enables efficient delivery of health services at all levels of the health system.”
The integration of digital accountability tools in health governance promises to enhance implementation tracking and data-informed decision-making. Providing accessible, up-to-date information on commitment status, the dashboard would empower stakeholders at all levels to make better-informed advocacy and programmatic decisions.
The accountability balance sheet: Financing the future of women’s and children’s health
Perhaps the most ambitious element of the CAAP initiative is its financial accountability target: increasing health financing to meet the Abuja declaration’s benchmark of 15% of the national budget. This financial commitment is fundamental to achieving all other health goals outlined in the plan.
The financial accountability dimension is particularly challenging given Malawi’s economic constraints. As noted in the HSSP III, the country’s health financing has remained stagnant at around $40 per capita for the past decade, with projections suggesting only modest increases to about $50 by 2030 – still well below the WHO-recommended $86 needed for basic healthcare coverage.
This financial reality creates a significant accountability tension: how to achieve ambitious health targets with limited resources. The CAAP initiative addresses this challenge by emphasizing strategic prioritization within available resources and by advocating for increased domestic and international funding for health.
The focus on increasing the proportion of health budget dedicated to reproductive, maternal, neonatal, child, and adolescent health to 30% by 2030 represents a significant shift in financial accountability. Rather than simply advocating for more resources, the initiative calls for more strategic allocation of existing and future funding toward the most vulnerable populations.
Youth accountability: Bringing the next generation to the decision-making table
Among the most progressive elements of the CAAP initiative is its commitment to ensuring 30% representation of youth in decision-making bodies. This accountability target recognizes that meaningful health system transformation requires the active participation of those most affected by health policies – including adolescents and young people.
The emphasis on youth representation addresses a significant gap in Malawi’s health governance. Although young people constitute approximately 24% of the population according to the HSSP III, they have historically been underrepresented in health decision-making processes.
The youth accountability commitment aligns with broader concerns about adolescent health in Malawi. The HSSP III notes that approximately 30.8% of adolescent females begin childbearing, with complications from pregnancy and childbirth among the leading causes of death for girls aged 15-19 years, constituting 20% of maternal mortality in the country.
By bringing youth voices into decision-making processes, the CAAP initiative creates accountability mechanisms that can better respond to the specific needs and challenges faced by young people. This represents a significant shift toward more inclusive and responsive health governance.
From national to local: The cascade of accountability
A critical feature of the CAAP initiative is how it cascades accountability from national to local levels. By establishing a digital platform accessible to stakeholders at various levels, the initiative creates multiple nodes of accountability throughout the health system.
This multi-level accountability approach aligns with the decentralization principles outlined in the HSSP III, which emphasizes that “health service provision and management shall be in line with the Local Government Act 1998, which entails devolving health service delivery at all levels to community health governance structures and alignment with Local Government structures.”
The accountability cascade is reinforced through the commitment to annual reviews led by the multi-stakeholder platform. These regular assessment points ensure that implementation progress is monitored not just at the national level but across the health system, identifying bottlenecks and successes at various points in the service delivery chain.
This cascading accountability model represents a significant advancement in health governance in Malawi, creating multiple feedback loops that can drive continuous improvement in commitment implementation.
The international accountability context: Malawi’s commitments in global perspective
The CAAP initiative positions Malawi’s health commitments within a broader international accountability framework. The initiative explicitly references the 2024 World Health Assembly MNCH resolution as a guiding document for accelerating progress in reducing maternal, newborn, and child mortality.
This international framing is significant for accountability purposes, as it connects Malawi’s national efforts to global standards and commitments. By aligning domestic accountability mechanisms with international frameworks, the initiative creates multiple layers of accountability pressure – both internal and external – to drive implementation progress.
The international dimension also opens opportunities for comparative accountability assessments, benchmarking Malawi’s progress against similarly situated countries. Such comparisons can provide valuable insights into what is possible and practical within resource constraints, reinforcing the accountability imperative with evidence-based assessments of achievable targets.
Accountability in action: The path forward
As the CAAP initiative moves from launch to implementation, several factors will determine its effectiveness as an accountability mechanism for women’s, children’s, and adolescents’ health.
First, the initiative’s success will depend significantly on sustained political commitment from the highest levels of government. The participation of the Secretary for Health and the Parliamentary Committee Chairperson on Health in the launch events suggests strong initial support, but maintaining this commitment through political transitions and competing priorities will be crucial.
Second, the multi-stakeholder platform must establish itself as a credible, independent accountability mechanism capable of objective assessment and, when necessary, constructive criticism of implementation shortfalls. Balancing collaborative support with accountability demands will require skillful leadership and clear governance structures.
Third, the digital dashboard must evolve from a data repository to an active management tool that informs real-time decision-making and resource allocation. This will require not only robust technical infrastructure but also capacity building across the health system to ensure data-informed governance becomes standard practice.
Finally, the initiative must translate national-level accountability mechanisms into tangible improvements in service delivery at the community level. The ultimate measure of accountability is not documentation of commitments but improved health outcomes for women, children, and adolescents across Malawi.
Final Thoughts: Accountability as the cornerstone
The Collaborative Advocacy Action Plan represents a significant advancement in how Malawi approaches accountability for women’s, children’s, and adolescents’ health.
By establishing clear targets, creating robust monitoring mechanisms, and fostering multi-stakeholder engagement, the initiative lays the groundwork for more effective implementation of health commitments.
In a context of limited resources and significant health challenges, this accountability-focused approach offers a promising pathway toward improved health outcomes. By concentrating on strategic priorities, leveraging digital tools, and fostering broad-based participation, the CAAP initiative addresses not just what needs to be done but how to ensure it happens.
As Madame Doreen Namagetsi Ali emphasized, “We have agreed that every year, we will review and assess where we are so that we can continue implementing and fulfill our commitments.” This regular rhythm of assessment and adjustment creates a dynamic accountability ecosystem that can adapt to emerging challenges and opportunities.
The journey toward accountability for women’s, children’s, and adolescents’ health in Malawi has just begun, but the foundation laid by the CAAP initiative provides reason for cautious optimism. If successfully implemented, this accountability-centered approach could serve as a model not just for Malawi but for countries throughout the region facing similar health system challenges.
