A study of stakeholders’ perception of Médecins Sans Frontières support to Thyolo district in Malawi

Background:
MSF Belgium has been working in Thyolo since 1997 supporting the Ministry of
Health (MoH) in the provision of STI and HIV-TB care & treatment in the district. Universal access to ART was attained in 2007 demonstrating that it is possible to scale up quality ART services in resource poor settings.
As the capacity of the national program has grown and strengthened, the nature of the support provided by MSF in the district has reduced and changed. Since 2008 HIV services have been increasingly integrated into general health care and thus MSF support into the MoH system.
This scaling down and integration of MSF support continues, with the aim being that the MoH increasingly assumes responsibility for HIV services in the district. A handover strategy is currently being planned together with the MoH to
ensure that this transfer of responsibility occurs in a transparent, responsible and sustainable way. This evaluation was commissioned as part of this process - the aim being to gain a better understanding of partner and stakeholder perceptions of MSF support in Thyolo and elicit recommendations to guide the handover process.

Purpose/objective:
To study the perception of other stakeholders in Thyolo District (community - MOH - other (I)-NGO) on the MSF support to Thyolo Health services in order to provide MSF with clear recommendations to guide the exit phase planning..

Methodology:
Qualitative methodology was used to collect primary data, mostly through semistructured interviews with key informants representing a wide range of MSF
stakeholders

Key findings:
After fourteen years in Thyolo district MSF has left its mark by proving universal coverage is possible in a high HIV prevalence, high TB caseload context. But the way MSF has gone about doing it, by putting in place their own systems, has created dependency on several levels in Thyolo district. In the community, MSF is perceived, rightly, as a life-saving organization without which the population feel they will not survive. As described, a very strong relationship has been created between MSF and the community, where there are expressions of great worry and fear now that MSF have announced they will hand over the activities. Although MSF and the MOH have been working in partnership for some time, the MOH is not perceived by the community as capable of taking over the activities implemented by MSF.

By the District Health Management Team (DHMT), MSF is seen very much as an outside force that has not been working in real partnership with the MOH, instead MSF is seen as being in the driving seat enforcing their own decisions and point of views without enough input and buy-in from the DHMT. Even if most stakeholders speak of excellent collaboration with MSF, MSF is, especially on district level and particularly by local NGO’s, largely seen as a provider – of technical, material and financial support – and not as an equal partner.

Recommendations:
In view of MSF’s upcoming withdrawal from Thyolo, issues of sustainability and
empowerment will become crucial for a successful handover with hopes of services being maintained at a reasonable level. But as sustainability is not MSF strongest suit, the next few years are going to be key in how MSF manages to balance its usual direct implementation approach and the challenges of empowering partners in Thyolo to take over activities, empowerment in this case, as in most others, entailing real and equal partnership. Indeed, for some stakeholders on national level, real success of MSF’s intervention in Thyolo will only be achieved with a successful handover, and thus with real long-term gains for Thyolo health district.
Looking at the recommendations given by the MSF stakeholders, there is a heavy emphasis on having a multi-partner approach in the exit strategy. The DHMT is of course seen as crucial for the success of the handover but quite a few stakeholders also brought up the role that the community could play, not only as beneficiaries of the programs but also as ‘watch-dogs’ and contributors.
On national level there was a strong demand for documentation on lessons learned in Thyolo. On lessons learned up until now, on the implementation of current and past activities, but also on the lessons that will be learned over the next few years. Because of the Malawian development type context, stakeholders have a specific interest in processes where local partners are empowered to achieve on their own providing long term gains for the country impossible to achieve with a direct service delivery approach.

Comments from the organisation, if any:
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