Differentiated Service Delivery in Malawi
Malawi’s ability to scale-up differentiated service delivery (DSD) is reinforced by strong governance, a national technical working group, and a national DSD coordinator. The country’s national policies and guidelines are supportive of ART decentralization and selected DSD models, such as multi-month scripting and teen clubs for adolescents. To date, more than 9,300 adolescents living with HIV have been enrolled in 135 teen clubs located in 26 of Malawi’s 28 districts.
Malawi’s efforts are backed by scientific evidence and research. In 2016, together with the Clinton Health Access Initiative, Malawi’s Ministry of Health conducted a process evaluation to understand the extent to which ART patients are differentiated based on their clinical stability, and the characteristics and costs of three models of DSD. The country continues to pilot DSD and conduct research that can inform policy, while investing in education and training for health care workers, monitoring and evaluation, and community engagement. Other models in early stages of piloting and evaluation include community ART groups, drop-in centers linked to health facilities for key populations (e.g., female sex workers, injection drug users), evening clinic hours, and weekend clinics for adolescents.
In Malawi, people living with HIV, as well as community members and leaders are involved in DSD activities, including participation in the national technical working group and programs. Barriers to the scale up of DSD include a lack of human resources and infrastructure in health systems, and regulatory frameworks prohibiting unlicensed health care workers from delivering care – lessening community-based efforts for stable, adherent patients.
Next steps and priorities for scale-up of DSD include the development of training and guidance materials, including new ART guidelines; integrating endorsed DSD models into existing frameworks and guidelines; rolling out coverage and diversity of differentiated services; and expanding existing community support groups.