Assessment of the service delivery for adults living with multimorbidity in Malawi

Abstract

Background
The presence of multiple chronic conditions in an individual, multimorbidity, is associated with higher mortality, longer hospital stays, and adverse socioeconomic impacts on families. Integrated disease management is suggested as the best approach, emphasising patient-centred care for managing multimorbidity. This thesis, organised as a series of potential papers for publication, is set in Malawi, where there is limited evidence regarding the public health sector's readiness to provide proper diagnosis and management of multimorbidity. The study aimed to examine how healthcare services are organised for adults living with multimorbidity through the lens of chronic kidney disease, diabetes, HIV, and hypertension.

Objectives
• To describe the policy environment and policy decisions relevant to the delivery of services for adults living with multimorbidity
• To understand the perspectives of healthcare workers on how services are organised for patients presenting to hospitals
• To explore the potential for multimorbidity patients who do not require hospitalisation to be managed and followed up at community and primary care.

Methods
This cross-sectional study was conducted in the districts of Blantyre and Chiradzulu, Malawi, from October 2022 to February 2024. The study included fourteen healthcare facilities representing primary (n=12), secondary (n=1), and tertiary (n=1) levels. Data collection involved multiple methods: reviewing 11 policy documents, conducting 13 indepth interviews with policymakers from local government (n=3), the Ministry of Health (n=7), and funding organisations (n=3), as well as with various healthcare worker cadres at Chiradzulu district hospital (n=10), Queen Elizabeth Central Hospital (n=12), and primary facilities (n=12). The modified WHO Service Availability and Readiness Assessment tool, comprising 44 tracer items, was used to assess the readiness of primary healthcare facilities.

Findings
Policy environment and policy decision: Malawi advocates for the integrated management of chronic conditions across key policies. Among other factors, policy implementation was hindered by a lack of resources, vertical disease funding, and an inadequate number and training of healthcare workers to manage multimorbidity. Healthcare workers may also be unwilling to take on new roles in the bid to integrate HIV and NCD services.
Healthcare workers’ perspectives: Neither study site integrated HIV and NCD care beyond disease screening. Clinicians held mixed opinions on the value of specialised versus integrated care. Some healthcare workers reported a lack of knowledge, skills, or guidelines for managing multimorbidity.
Facility readiness: Overall, 16.7% (2/12) of facilities had a readiness score of ≥70%, indicating that they met minimum requirements for providing services for multimorbidity. Barriers to service readiness included frequent drug stockouts, inadequate staffing and supervision, and a lack of clinical guidelines or protocols.

Conclusion and recommendations
The policy and clinical challenges discussed in this thesis require systems thinking to enhance the delivery of patient-centred care. The equitable and timely provision of resources; the development of guidelines for managing multimorbidity, training clinicians to screen and manage multimorbidity, and harmonising donor-government goals in setting the health agenda should accompany policy implementation for integrated multimorbidity management. Further research is needed to evaluate the feasibility and cost-effectiveness of various integration models and patient pathways.

Date of Award	31 Mar 2026
Original language	English
Awarding Institution	Liverpool School of Tropical Medicine
Supervisor	Miriam Taegtmeyer (Supervisor), Rhona Mijumbi (Supervisor) & Felix Limbani (Supervisor)