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Evaluation database

Evaluation report

2016 Malawi: District Health Performance Improvement Evaluation

Author: Gerald Manthalu

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report, and the executive feedback summary labelled as 'Part 3'.


As part of the process of improving the performance of the district heath system, UNICEF has been supporting the Ministry of Health (MoH) implement an approach called District Health Performance Improvement (DHPI) since 2012. DHPI, is a contextualised version of UNICEF’s District Health Systems Strengthening (DHSS) approach. DHPI is a systematic outcome-based approach to equitable programming and real-time monitoring that strengthens the district health system. It complements and builds on institutional planning and monitoring activities that already exist in a country. The DHPI approach helps strengthen performance and accountability for equitable health outcomes at the district level by identifying sub-populations or sub-geographical areas within the district that are not being adequately reached with essential health interventions and addressing the specific bottlenecks to the effective coverage of the interventions. Through the DHPI approach, District Health Management Teams (DHMTs) assess the root causes of identified bottlenecks and consultatively determine and prioritise bottleneck solutions that are included in district implementation plans (DIPs). The Ministry of Health, with support from UNICEF has been implementing DHPI since 2012. The approach was first piloted in 3 districts and later scaled up to an additional 18 districts.


The purpose of the evaluation was to conduct a retrospective process evaluation of DHPI activities in districts that began implementation of the approach in Phase II of the introduction of DHPI in MalawiThe objectives of the evaluation were to document the implementation of the DHPI approach in Malawi, describe the changes that resulted from the programme, document the enablers and barriers of implementation and describe resources needed to sustain/improve DHPI implementation. The evaluation criteria that this study considered were relevance, effectiveness and sustainability.


Primary and secondary data were used to assess the performance of the DHPI approach. Primary data were collected through key informant interviews at district level (District Health Office and local Non-Governmental Organisations (NGOs) working in the health sector) and health partners and MoH officials at central level. Secondary data included 2014/15 fiscal year (FY) District Implementation Plans (DIPs) for the evaluation districts, 2014/15 FY DIP review reports, case studies of DHPI implementation for the evaluation districts, DHIS2 data and other relevant documents.

Findings and Conclusions:

The DHPI approach was relevant and added value to the DIP process. There was buy in for the approach and DHOs were motivated to implement it. DHPI was valued in terms of improved use of real time evidence, community engagement, and bottleneck and causality analysis. DHPI assisted districts identify solutions that would increase coverage of interventions and address inequities in health and health services utilization.

Enabling factors for the sustainability of DHPI included the buy-in and value that national level Government officials and health partners attached to the process, the decentralization process that placed greater value in strengthening the planning capacities of district councils and the designation of DHPI champions. Sustainability was, however, threatened by high staff turnover and by the perception that the DHPI process was a UNICEF initiative as opposed to MoH’s.


• MOH should fully integrate in Multi-year and DIP guidelines DHPI principles which added value to the DIP process to ensure that there is only one source of district planning guidance. The MoH should work with the Ministry of Local Government and Rural Development to strengthen the oversight roles of relevant community health structures. UNICEF should focus on supporting the multiyear and DIP processes and not have DHPI as a parallel process.
• UNICEF in collaboration with the Department of Planning and Policy Development in MoH should re-train DHMTs that have experienced high staff turnover in district health planning.
• UNICEF should ensure that the bottleneck analysis tool is fully localized and DHO capacity in using it is built.

Lessons Learned:

Although DHPI was deemed relevant, there was no prior assessment of the DIP process to inform any specific areas that DHPI had to strengthen. There were hence DHPI elements which duplicated the pre-existing DIP process. In addition, some of the critical assumptions of the DHPI theory of change did not hold.

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Report information






Ministry of Health


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