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The Office of the Auditor General's investigation of Norwegian development aid to the health sector in Malawi

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Background and objectives of the audit

Malawi is one of the world's poorest countries - and faces major challenges in the health field: a shortage of human resources and equipment combined with poor infrastructure. The country has high rates of child and maternal mortality, and has been hard hit by the HIV-AIDS epidemic. Norway is one of Malawi's main donors in the health sector, both bilaterally and through the GAVI Alliance and Global Fund to Fight AIDS, Tuberculosis and Malaria. A majority of the bilateral funds have been granted as budget support, and have consequently been relatively free funds.

The objective of the audit was to assess the attainment of targets for Norwegian health inputs in Malawi, and the public administration's follow-up and oversight of the use of the funds. Another objective was to take a look at the degree to which human resources, medicines, supplies and funds for equipment and infrastructure reach hospitals and health centres.

Findings and recommendations

While health services are improving, important goals remain

Malawi is moving forward with respect to child and maternal mortality and access to basic health services. Key goals for reducing child and maternal mortality and strengthening the health system have nevertheless not been met.

Supervision to ensure that funds are spent as intended has clear weaknesses

The Ministry of Foreign Affairs should

  • ensure that accounts from the recipient country's authorities and the contents of annual audit reports from external auditors are followed up
  • strengthen expertise and capacity for supervision of public financial management

Inefficient distribution of resources to hospitals and health centres - loss of medicines, lower availability of health personnel

The Embassy should

  • take steps in conjunction with other donors to achieve better utilisation of health personnel and higher availability of medicines, medical equipment and infrastructure.
  • take the initiative vis-à-vis the Ministry of Health in Malawi concerning measures that can strengthen the Ministry's expertise and capacity in public financial management
  • consider increased use of field visits to show presence and to collect necessary information about the situation in the country

While global health funds are important for combatting AIDS, malaria, tuberculosis and child mortality, Malawi is highly vulnerable to fluctuating support

The Ministry of Foreign Affairs should encourage the funds to collaborate better with the recipient countries on increased co-funding over time.

It is questionable whether the Ministry of Foreign Affairs' allocation of budget support to Malawi is in accordance with the Storting's intentions

The Ministry of Foreign Affairs should consider whether further budget support and sector budget support to Malawi must be contingent on substantial improvement of the management of the country's finances.

Guidelines are not in accordance with intentions

The guidelines for budget support should be clarified and updated so that they are in line with the Storting's intentions concerning when such support can be granted.


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Riksrevisjonen, Storgata 16, P.O. Box 6835 St. Olavs plass, 0130 Oslo, Norway

Phone: +47 22 24 10 00 974 760 843