Mulanje Mission Hospital

At its Local Meeting for Church Affairs in January 2017, Colchester Quaker Meeting agreed to support the work of Mulanje Mission Hospital in Malawi where Ruth Shakespeare, a Quaker doctor, is the medical director.  It was also agreed to refer the appeal to the Area Meeting.

A working group of Friends prepared a report and proposal to Colchester Meeting Malawi Hospital report to LM, which agreed to support the proposal for a project to alleviate malnutrition.

Dr Isabel King describes some of the heartbreaking situations she meets daily at Mulanje Mission Hospital: Mulanje Hospital letter from Dr King

Here are two papers in support of the appeal to the Meeting about the work of the hospital and proposals for the future:

Support for Mulanje Mission Hospital

The hospital; was founded in 1896 and is now a 200 bed general hospital serving 80,000 people from 72 villages. It is supported by the World Mission Council through the Church of Scotland and the Government of Malawi pays for many services including HIV treatment and prevention. Other missionary societies and private donors add to the funds which in 2015 were in excess of £120,000. The hospital has reserves but the running costs are very high and local inflation is 21%. It is notable that there is a high level of transparency with their detailed audited accounts available on line.

Some of the projects initially suggested are set out below. However a key project which looks very interesting is their Sustainable Livelihoods Project that looks at combating the severe and acute malnutrition amongst vulnerable rural households. This looks at all the factors including irrigation and also developmental training to but also to improve the limited range of enterprises they pursue, low productivity levels, high input costs due to reliance on imported fertilisers, seed and chemicals, lack of access to capital/credit for investment, and poor market access. There is a separate paper giving more detail below.

Their initial request was:

We need a new Haematology auto analyser. This is the machine that gives us full blood counts, telling us the haemoglobin, white cells and platelets, allowing us to diagnose anaemia, infection, malaria and cancers. It is one of our most essential laboratory tools (along with a microscope). So far this year, we have already spent £600 trying to fix our current one. We need to bite the bullet and buy a new one rather than throwing money at a failing machine. The quote we have is for MK 10,800,000, which by today’s rates is £10,285. If you were interested in a one-off donation for a piece of kit which would be used daily to diagnose common conditions and inform treatment, this would be an incredibly generous and useful way to do that.
£10,000 would provide essential medications for all hospital inpatient care and care for our palliative (end of life) patients for a whole 2 month period. This would be a huge contribution to our work and allow us to continue to treat everyone regardless of ability to pay. Though our hospital charges “user fees”, these are merely contributions to patients’ care and do not cover the cost of treatment – most of this is paid by the hospital.
We are responsible for the health of prisoners in Mulanje Prison. As you can imagine, many people here are incarcerated for insignificant crimes and the justice system is in an even more fragile state than health and education. If your friends are interested in the well-being of those within the criminal justice system, £1,000 per month would allow us to provide supplementary feeding to prisoners. >10% of those in our prison have severe acute malnutrition and a further 20% have moderate malnutrition. Prisoners are fed by their families – it is not the responsibility of the state to ensure adequate nutrition. Many are too poor for this so succumb to malnutrition and all its consequences, including increased susceptibility to infections like TB and pneumonia. We feed all prisoners and all prison staff once a week and run an in-prison clinic. £1,000 a month would fund the care to all those incarcerated.
Since then, after correspondence, the following schedule of amounts to support has been provided:

Bed sponsorship is always a great way to support MMH – £650 meets the costs of one bed for a year – probably about 30 patients would benefit from the bed sponsorship in a year.

For Sustainable Livelihoods, here are some indicative figures:

£200 will establish an orchard at a primary school
£300 will equip a new bee-keeping enterprise with three hives, bee suits, smoker and training.
£400 would enable the purchase and maintenance of a ‘walking tractor’ – a rotavator for loan to community garden schemes
£6000 would enable the development of a rural centre at Namisase as a resource centre for training the community in conservation agriculture and other income generating activities
£16,000 will pay for one new borehole and solar pump to provide irrigation for community agriculture – enabling two cropping cycles in the year.
Here is the second paper mentioned above:

Sustainable Livelihoods in Mulanje – scaling up our efforts

Mulanje Mission Primary Healthcare team August 2016

‘A livelihood is sustainable when it can cope with and recover from stresses and shocks, maintain or enhance its capabilities and assets, while not undermining the natural resource base.’ DFID 2011


More than 80% of the population of Malawi are dependent on agriculture for food and livelihoods. About 2 million of the 2.7 million hectares of cultivated land in the country are cultivated by smallholder farmers, mostly women, and mostly by hand. (World Bank 2010) They tend to cultivate small and fragmented landholdings, averaging less than one hectare per household, under customary land tenure. Maize, the food staple, is grown on almost 85% of the smallholder land area, together with a few other food crops such as cassava and sweet potatoes, to meet subsistence requirements.

Mulanje Mission Hospital has for many years promoted and supported activities which underpin a broad approach to improving community health and nutrition. One such area is agricultural development, and the sustainable livelihoods approach – poverty reduction, reducing livelihood vulnerability, improving environmental sustainability, and participatory approaches – are key aspects of the work which has been carried out. Few would doubt the importance of these approaches.

Nutrition Rehabilitation Units, including the NRU at MMH, have been set up to reduce severe and acute malnutrition amongst vulnerable rural households, and have also promoted improved nutrition and diet diversification for people affected by HIV infection. MMH has supported village programmes with animal husbandry, pigs and dairy goats, vegetable growing, small scale fish farming and more recently has added bee keeping, mushroom growing and solar drying to the range of activities on offer.

However, in reality most smallholder farmers in the area are yet to generate meaningful incomes from farming – in part due to limited access to land, but also to the limited range of enterprises they pursue, low productivity levels, high input costs due to reliance on imported fertilisers, seed and chemicals, lack of access to capital/credit for investment, and poor market access. In recent years there has also been an increasing incidence of disasters such as flooding and drought, in large part brought about by climate change, high population growth and environmental degradation, which have contributed to chronic food insecurity in the area.

Irrigation schemes would seem to be an obvious part of the solution, with the possibility of increasing yields, multiple annual cropping cycles and larger scale production and marketing. However, recent local large scale ( >60 hectare) irrigation schemes in Mulanje show that this is not enough on its own. Such schemes typically have low utilization (20 – 40%) and traditional farming practices continue on the irrigated land, which is mostly used repeatedly for maize. Dependence on expensive inputs therefore continues. The potential benefits of irrigation can only be realized when farmers have opportunities to develop their knowledge and skills, and attention is paid to the transport and marketing of products in excess of local requirements.


MMH, working closely with local government and community partners, therefore proposes to scale up work on the promotion and support of sustainable livelihood approaches in its catchment area. The programme will be evidence-based, learning from national and international research, as well as from other organisations engaged in similar work in Malawi. Community participation is crucial at every stage.

The outcomes of the programme will be cross cutting, simultaneously addressing poverty reduction, improved health and nutrition, reduction in environmental degradation, and empowerment of vulnerable groups including women and children, orphans and others affected by HIV. These outcomes align closely with the objectives of the Malawi Agriculture Sector Wide Approach (ASWAp) and the Malawi Growth and Development Strategy (MGDS II)


Improved agricultural productivity
Adoption of evidence-based good agricultural practices, for example minimum tillage, cover crops and crop rotation to reduce dependence on costly inputs
Improve post-harvest management and storage to reduce losses
Implementation of wet land (gravity fed) and dry land (solar powered) irrigation schemes on communal lands
Diversification of small holder farming – cash crops and alternative staples
Increasing animal husbandry, including dairy cattle, to improve the asset base, nutrition and incomes of poor households
Increase small scale fish farming enterprises
Improved farming business management
Improved access to loans for agricultural investment
Map and improve supply of local processing facilities for crops and livestock
Increase resilience of rural communities to the impacts of climate change
Build capacity for small scale irrigation to scale up village level cereal production
Increase afforestation through agroforestry schemes – managed woodlots, fruit tree production, food forests, honey production, tree propagation
Scale up soil conservation practices, including catchment conservation and riverbank protection to increase and extend river flows
Increase number of households with food reserves in critical months
Support the development of village grain banks to avoid high prices during periods of scarcity
Reduce dependence of primary schools on external food distribution schemes
Improve opportunities for members of vulnerable communities to gain knowledge and skills
Use existing community, school and church-based networks to promote good practice
Integrate health and hygiene education, including HIV awareness, into all training programmes
Provide training in a range of smallholder techniques and enterprises
Support teaching of good agricultural practice at primary schools
Provide technical support and training for irrigation projects
Offer mentoring and ongoing business management support to smallholders embarking on new enterprises
Encourage innovation through demonstration projects, opportunities for skill sharing, evaluation and dissemination of results.
Identify influential farmers who will be trained to train other farmers in the community (farmer to farmer concept)

MMH, with the support of partners, will build on the successes of the NRU, and use its considerable experience of community development approaches across the catchment area to develop a newly invigorated Sustainable Livelihoods programme.

Changing traditional practices and customs cannot be a short term effort – a sustained commitment of at least 5 years is required.

Key elements of the programme will be:

Redesign of the current NRU as a training and resource centre, providing a range of educational opportunities at low cost to local community members, together with access to learning materials such as books and DVDs, and access to computers for research and assistance with business administration
Re-utilising the rural centre at Namisase to work alongside the NRU, as a second training and resource centre for the area, with demonstration irrigated gardens, whilst maintaining and extending the current IGAs at Namisase – the nursery school, tailoring training and maize mill.
Providing an IEC (information, education, communication) approach throughout the local community to promote conservation agriculture and improved farming practices, together with health and hygiene education and HIV awareness.
Supporting implementation of agreed irrigation programmes in selected areas with appropriate technical support
Work with primary schools to improve the knowledge and skills of teachers, parents and pupils, and promote school gardens
Supporting a local network to develop business skills for small scale farmers
Assessment of the need for credit/loan facilities, shared plant and equipment such as tractors, processing facilities and market transport with a view to further proposal development.
Assess outcomes of different irrigation models with a view to increasing the number of schemes and expansion of acreage of initial schemes as evidence suggests is appropriate

Working with the Ministry of Irrigation, Mulanje Office, MMH proposes four irrigation schemes are implemented in the first year, to provide a range of opportunities and experience.

Nansomba Wetland Scheme
Nansomba dry land scheme
Two small scale irrigation schemes for existing community-run garden
Development of Knowledge and Skills

Implementation Plan

Phase One: 2016-17

Work with potential partners to establish support for MMH SL programme

Employ volunteer to work with existing MMH resources to:

Develop current NRU to become a training and resource centre for a range of agricultural learning opportunities

Establish baseline position in MMH catchment area:

assessment of existing community gardens and primary school gardens to agree next steps with community

consultation with local leaders and assessment of poorly utilized land with a view to implemetation of irrigation in Phase Two.

Phase Two: 2017-18

Implementation of programme as funding permits:

Seek and employ key local staff

Sustainable Livelihoods Programme Manager – overall responsibility for delivery of the outcomes

Conservation agriculture trainer – to work alongside MMH home gardening officer in the Training and Resource centre to deliver training programmes and facilitate learning networks

Secure technical support for implementation of Irrigation schemes – available from Ministry of Irrigation, Mulanje office, and contractors on an ad hoc basis

Tender for contractors to establish agreed irrigation schemes in two areas, at least one to be a solar powered scheme, plus two community garden irrigation schemes

Begin to train Farmer to Farmer trainers: a learning network for innovative farmers in the catchment area

Begin redesign of Namisase rural centre as an agricultural training and resource centre with a range of demonstration areas and study materials

Scaling up production: work with partners to implement and extend animal husbandry to at least two additional villages

Establish at least one further fish farming enterprise

Establish primary school gardening schemes at three more schools

Establish at least three small scale agroforestry schemes, including bee keeping, both for income generation and to increase community appreciation of the value of standing trees

Phase Three: 2018-19

Communicate programme of educational opportunities at the training and resource centre and begin to deliver courses

Establish a learning network for primary school teachers of agriculture

MMH staff work with Learning Networks to implement IEC activities in health, hygiene and HIV awareness

Initial assessment of Irrigation programme, necessary changes incorporated and extended as appropriate

Continue extension of animal husbandry, fish farming and agroforestry

Assess and evaluate activities with partners and plan for years 3-5

Governance and Accountability

Initially managed by MMH, this programme should develop a local Advisory Committee, and report to management via the Primary Healthcare Coordinator. MMH publishes annual audited accounts at

MMH has an excellent track record for the management of externally funded projects to budget and on time, for eg

DFID grant for palliative care service development 2015-6 £64,000

European Commission grant: extending essential health services at village level 2016 £ 26,000

DFATD Canada grant for maternal and child health 2016 – 2018 $107,000 pa

Further information

See , or contact Dr Ruth Shakespeare

The papers with fuller details may be downloaded by clicking on these links:

Support for Mulanje Mission Hospital

Sustainable Livelihoods in Mulanje v2