This review responds to an NAO request for further work to assess the impact of the health Sector-Wide Approach (SWAp) in Malawi. Malawi has been a relatively strong performer in terms of health outcomes for many years. Since the early part of the decade, key health indicators such as infant and under five mortality rates have been better than average for least developed countries. This raises the question as to whether the SWAp is sustaining or even accelerating those gains or whether such progress is being made in spite of the SWAp. There are some suggestions that the rate of improvement is declining (suggesting that perhaps easier gains have been made, that the SWAp is performing less than ideally or that external factors are responsible).
Good progress has certainly been made during the SWAp period, although Malawi is unlikely to achieve the Millennium Development Goals health targets; it may achieve the U5MR but is well off-track to achieve the Maternal Mortality Ratio target. This is perhaps not surprising as it was recognised at the outset that the Programme of Work was resource-based rather than needs-based and provided for too few resources to achieve the MDGs. In practice, more resources have been made available than was anticipated.
The SWAp process has undoubtedly had serious weaknesses, which largely reflect the low level of national capacity, but also declining commitment (according to a recent World Bank review) which means that the process is less developed than in many other SWAp countries. This might suggest that the question “Has a SWAp been tried?” may be just as relevant as Has the SWAp worked?