On 11th February, my colleague and good friend Prof Lorna Macpherson and I set off for Malawi to participate in the National Oral Health Policy Workshop that was scheduled for Thursday 13th and Friday 14th February in Lilongwe. The component of the MalDent Project that is focusing on policy development and the establishment of a caries prevention programme for children is critical to success. We had been working for a number of months to plan the workshop, in partnership with the Malawi Government Ministry of Health, University of Malawi College of Medicine and the World Health Organisation.
We had a trouble-free journey and landed in Lilongwe in the early afternoon of Wednesday 12th February. Dr Peter Chimimba met us at the airport and we were soon checked in at the Sunbird Capital Hotel, our home for the next three days and also the venue for the workshop.
After a short rest and freshen-up, we caught up with Peter again and were subsequently joined by Dr Yuka Makino, the WHO Africa Technical Officer for Oral Health and Dr James Mchenga, the Academic Lead for the BDS programme at the College of Medicine. Dr Makino had travelled from her office in Brazzaville, Republic of the Congo. We sat outside in the beautiful grounds of the hotel and worked through all the detail of the forthcoming workshop.
The following morning we were up early for breakfast and headed for the Viphya Suite where the workshop was being held. Many thanks are due to Annie Mwapasa and her colleagues for making all the arrangements and manning the reception desk.
The delegates soon began to arrive and we spent time making appropriate introductions between key players, as well as having opportunity to chat with colleagues.
It was a great honour that the Secretary for Health and Population, Dr Dan Namarika, attended the first part of the workshop.
Before the workshop commenced, Dr Namarika spent some time speaking with Yuka, Lorna, Peter and I, accompanied by Dr Nedson Fosiko, Deputy Director of Curative Services at the Ministry of Health.
Once the delegates were assembled, and following a prayer, the meeting began. The chairperson was Dr Kaponda Masiye, who is the Director of Planning and Policy Development at the Ministry of Health & Population. Dr Masiye trained initially as a dental therapist before studying medicine, so he has both a good understanding of, and interest in, oral health.
The first speaker was Dr Mwapatsa Mipando, Principal of the College of Medicine. He gave a brief overview of the recent developments and successes at the College before focusing on the MalDent Project and the subject matter of the workshop.
The World Health Organisation is a very important partner in the oral health policy development and we were delighted that Dr Kelias Msyamboza from the WHO Malawi Office attended the workshop. In his opening remarks he stressed the importance of implementation as well as development of policies.
We were next addressed by Dr Chithope-Mwale, the Director of Curative Services at the Ministry of Health & Population. He quoted the famous Bible passage from Ecclesiastes 3 – ‘A time for everything’ – and said that he felt that now was the time for progress to be made in the context of oral health in Malawi. He expressed his thanks to the College of Medicine for all that it does to support the Ministry of Health & Population.
Before we stopped for coffee it was the turn of the Secretary for Health & Population, Dr Dan Namarika, to address us. He stressed that a policy is ‘a document about people’ and how important it is to ensure that a policy, once created, actually impacts positively on the people for whom it is intended. The importance of embracing community health was highlighted and he announced that the President had determined that 9th October would become National Community Health Day. A key component of the National Health Policy is ‘prevention, prevention, prevention‘, and the Oral Health Policy must align with this principle. He spoke also of how data drives economies and how important it is to develop research within the area of oral health. The importance of cross-sectoral engagement involving, for example, education was a theme which also emerged in other presentations over the next two days.
There were many aspects of this presentation which fitted perfectly with the anticipated direction of travel for the forthcoming policy work.
There followed a coffee break during which a group photo was taken.
There were extensive discussions during the break, which provided an excellent opportunity for networking.
Dr Nedson Fosiko, Deputy Director of Curative Services, spoke next. He stressed that many of the Government Ministries are relevant to the health agenda. He also emphasised the point made previously, by Dr Namarika, that health information, ie data, is critical if healthcare services are to be planned effectively. Discussions later in the workshop demonstrated the need to enhance efficiency and accuracy of data collection procedures. Dr Fosiko also emphasised the importance of prevention of disease and of the ‘One Health’ concept.
Dr Yuka Makino, the WHO Africa Oral Health Technical Officer, delivered an excellent presentation on the WHO African Region Oral Health Strategy 2016-2025. She spoke of the severe dental workforce shortages in Africa and also the lack of data on oral health. Yuka pointed out that in the EU, 70% of dental care is funded by patients themselves – how could this work in lower income countries in Africa? A key theme was around Universal Health Coverage and the importance of community prevention initiatives, not just health service infrastructure. It is important to integrate oral health into general health coverage, including for example nutrition and smoking cessation. Similarly, oral health surveillance could be integrated into existing health information systems and ongoing NCD surveillance programmes. Importantly, people and communities, not just diseases, should be put at the centre of health systems.
Just before lunch, an additional presentation was added that had not been on the programme. The speaker was the Honourable Enock Phale, who is now a member of the Malawian Parliament but is a qualified dental therapist and former Oral Health Lead in the Ministry. I had met him in his former role during my first visit to Malawi in 2017 and it was lovely to meet up with him again. It transpires that he sits on the Parliamentary Health Committee, which is highly relevant to his dental background.
The Honorable Phale had already begun work on an Oral Health Policy document before he left the Ministry, and he took us quickly through the early draft. This document will be very helpful to us as we progress the strategy writing.
Before heading off to lunch I enjoyed a quick catch-up with the Honourable Phale. It was an immense honour and privilege to have a Member of Parliament at the workshop and we were very lucky to have been provided with a draft policy to kick-start our work.
Discussions continued over lunch before we headed back into the main conference room for the afternoon’s work.
Immediately after lunch we were given a very useful overview of the policy development process and public policy framework used by the ministries and Government in Malawi. This will provide a blueprint for the structure of the Oral Health Policy.
Dr Wiston Mukiwa then delivered a fascinating history of the evolution of dental health services in Malawi, as seen through the lens of his own experiences. This context for our work to develop an Oral Health Policy was extremely helpful.
The WHO NCD MAP Toolkit will be used in our work to develop the Oral Health Policy and move through to implementation. The toolkit was presented by Dr Kelias Msyamboza. He discussed the main steps of assessment, engagement, formulation, implementation and monitoring / evaluation.
Day 1 closed with small group discussions around two questions:
- What are the opportunities for embedding oral health within the broader NCD and UHC agendas?
- Who would be key partners in a multi-sectoral approach for developing an oral health policy in Malawi?
Each group fed back and the outcomes are being collated by Annie Mwapasa to inform the policy work moving forward:
Day 2 of the workshop was very colourful. Whilst I had turned up in my regulation business suit and tie, many of my Malawian friends were dressed in bright, colourful shirts – Friday is a ‘dress-down’ day! The Principal, Dr Mipando, has now offered to take me to meet his tailor so that I can enhance my wardrobe for future working Fridays!
The session began with a reflection on the proceedings of Day 1, delivered by Dr Janet Guta, Deputy Director for Clinical Services at the Ministry of Health & Population.
It was then the turn of Dr Masiye, who had been the workshop chair on Day 1, to talk about the NCD agenda in Malawi and how oral health could fit into the ongoing activities. In an excellent presentation he stressed the importance of community partnership and community empowerment, which are essential in any new policy. Dr Masiye also commented on the relatively small amount of funding available for the NCD agenda, despite the fact that these diseases now account for 30% of the disease burden in Malawi.
After Dr Masiye’s talk and a discussion led by Dr Fosiko, we broke again for coffee. We were delighted that on Day 2 of the workshop, Natasha Mwenda was able to join us from WaterAid Malawi. I had met Natasha in Edinburgh last year when she presented at a Malawi Cross Party Parliamentary Group meeting at Holyrood. Having embraced the importance of a cross-sectoral approach to improving oral health, it is critical that we consider water and sanitation. We look forward to collaborating with WaterAid as we develop the policy.
The morning session finished with an excellent presentation from Prof Lorna Macpherson, demonstrating how all the principles we had been talking about, including the WHO NCD MAP toolkit, had been applied in Scotland to establish the highly successful Childsmile model for prevention of dental caries in children. The high quality monitoring and evaluation that has been part of the overall process in Scotland has proven beyond doubt the effectiveness of the approach, which is now being introduced in multiple countries following completion of situational analyses to create models that are effective in each specific environment. The potential applicability in Malawi was plain to see.
The morning’s presentations stimulated additional discussion before we broke for lunch.
One of the novelties of this visit for me was the timing – I had never previously experienced Malawi in the rainy season. Whilst there were many bright periods, and it was constantly warm, the downpours of rain were impressive, even by Scottish standards! Here’s a short video-clip from lunch-time on Day 2:
After lunch, Lorna and I did a double act to update the delegates on overall progress with the MalDent Project and to show how the activities of this workshop were informing the policy and prevention aspects of the programme.
We then came to the climax of the workshop, which was to agree on the next steps. First, having agreed on the need for a task-force, we discussed the composition of that group. This was a lengthy debate, but finally agreement was reached, as follows (numbers in parentheses represent number of members):
- Ministry of Health & Population (Clinical, Nutrition, Planning Nursing (1)
- UoM College of Medicine (2)
- Kamuzu College of Nursing (1)
- University of Glasgow (2)
- Regulatory bodies ((MCM, NCM, MPB) (1)
- World Health Organisation (1)
- Dental Association of Malawi (1)
It was further agreed that the Ministry would provide the Terms of Reference for the task-force, after which its work could begin.
These key decisions comprise just the outcome that was required to allow the policy development component of the MalDent Project to proceed.
Fittingly, it was Dr Fosiko, who has shown such great enthusiasm for the MalDent Project over recent months, who closed the workshop. This is what he said:
There was significant interest in the workshop from many of the national newspapers and broadcasters. You can read an article in the Nyasa Times here
This next photo, captured during one of the coffee breaks, is of two gentlemen who have worked tirelessly for over thirty years to enhance oral healthcare and, indeed, broader areas of healthcare in Malawi. Drs Wiston Mukiwa and Peter Chimimba have both held many senior roles in the Malawian health service, Ministry of Health, regulatory bodies and higher education institutions. One might think that by now they would be tired and their enthusiasm dulled, but not at all. They have amazing energy, commitment and a positivity which is remarkable and seemingly in endless supply – they are both an inspiration. The policy workshop that had just passed and been such a success was under-pinned in so many ways by these two outstanding professionals. We are so lucky to have them closely involved in the MalDent Project.
In the evening, following the end of the workshop, Lorna, Peter, James, Wiston and I enjoyed a celebratory meal with the Honourable Phale and two of the Dental School Assistant Lecturers, Drs Tasneem Chikwatu and Mirriam Chipinga. It was an excellent opportunity for me to speak at length with Tasneem and Mirriam, both of whom are very excited about their new roles.
We set out from the hotel in Lilongwe at 07.45 on the Saturday morning to drive to Blantyre. We stopped off en route at the famous Chikondi Stopover for a short rest and to buy some refreshments.
We reached Lilongwe by midday and after a quick bowl of soup we headed across to the College of Medicine campus, where we met a large number of the BDS 1 students and some of those on the Foundation Course. We enjoyed an interactive two hour session on dental public health, incorporating a lot of the material that had been covered during the workshop over the preceding two days. It is important that these pioneer dental students also feel part of the ongoing policy development, much of which will shape the oral healthcare environment into which they will emerge at the end of the BDS course.
We had a good rest on the Saturday evening. After breakfast on Sunday Lorna and I went for a walk around the city centre close to the hotel.
At 11am, Dr Chris Moxon came across to the hotel for a chat. Chris is a Clinical Senior Lecturer at the Wellcome Centre for Integrative Parasitology, University of Glasgow and an Honorary Consultant in Paediatric Infectious Diseases at the Royal Hospital for Children. His research focus is on cerebral malaria and he spends several months a year working in Malawi. We had a very enjoyable and wide-ranging discussion covering topics relevant to both our areas of interest.
Peter Chimimba’s wife, Frider, is a Lecturer in Pharmacology at the UoM College of Medicine. One of her young colleagues, Nelson Nyoloka, had applied to join the MSc in Clinical Pharmacology at the University of Glasgow and has been accepted. He will start the course in September 2020 and I had suggested that he should join Lorna and I for lunch at 12.30pm. We met in the hotel foyer and enjoyed a great time together for about an hour and a half. We provided lots of information about Glasgow and told us a lot about regulation of medicines and products such as toothpastes in Malawi – mutually useful! We look forward very much to welcoming Nelson to Glasgow in the Autumn.
Our visit was nearing an end but we had one more activity to look forward to – afternoon tea with the Principal at his home. Dr Mipando picked us up from the hotel at about 3.30pm and before driving to his house took us on a beautiful drive to the tea and coffee plantations just outside Blantyre. The undulating hills were covered in a sea of green tea plants, interspersed with trees – it was stunningly beautiful.
On reaching his house, Mwapatsa took us on a tour of the extensive garden that he and his wife, Linda, have established and continue to develop. They grow a myriad of fruits, vegetables and herbs, as well as flowers. We then retired to the patio for tea and to enjoy some avocado (known locally as ‘pear’) that had just been picked from the garden – it tasted fantastic. We are grateful to Mwapatsa and Linda for their kind hospitality – it was a lovely way to end our short visit to Malawi.
Mwapatsa drove us back to our hotel and we then had dinner with Peter Chimimba, before turning in early, ready for our journey home the next day.
The journey home was long (27 hours) and entailed four flights, but all were on time and there were no problems with connections or baggage.
Although this had been a short visit to Malawi, it had been immensely successful. The blue touch paper has now been lit to forge ahead with the policy work stream. Dr Fosiko finished his presentation on Day 1 with a slide that read “Let the game start”! I can’t think of a better way to close this post!
Acknowledgement: Many thanks to Gift Kayuni, UoM College of Medicine, for providing many of the photos in this post