Care should not depend on people reaching the health system.

Building Malawi’s
Last-Mile Maternal and
Child Health System

We build the systems that make continuous, skilled anticipatory care possible for smallholder farming families in communities that facility-centred health systems were never designed to reach. From before the first pregnancy to the child's fifth birthday.

1.5M+ 96% 4 7

People Reached Skilled Deliveries Active Districts Districts by 2030

EXPLORE THE MODEL

PARTNER WITH US

THE GAP THE SYSTEM HAS NOT YET CLOSED

A crisis of reach

For smallholder farming families in rural Malawi, last-mile maternal and child health care remains fragmented, facility-centred and doorstep blind. By the time a family reaches a facility, it is often already too late.

Women often face long distances to care, transport costs they cannot afford, limited health information and weak referral systems. During the rainy season, flooding and poor road networks can make access even more difficult.

Early childbearing, high fertility rates and inadequate access to maternal health services are the main contributing factors in the high number of maternal deaths among young women in Malawi. Girls aged 15-19 years are twice as likely to die during childbirth as women 20 years and above. Coupled with HIV, complications during pregnancy and childbirth are the leading cause of death for young women aged 15-19 years

Unsafe abortion because of unwanted pregnancy is also common among adolescents which is an indicator of girls’ and women’s unmet need for contraception.

For every woman who dies in pregnancy or childbirth, between 20 and 30 more survive with injuries, infections, or lasting disability, almost all of it preventable.

84% of the population living in rural areas

225/100,000 Maternal mortality ratio

27/1,000 - Neonatal mortality rate per 1,000 live births

42/1,000 - Under-five mortality rate per 1,000 live births

136/1,000 Adolescent fertility rate

BARRIER 1

Distance

The nearest facility can be two or more hours away on foot, across uneven terrain, through seasonal flooding, while heavily pregnant. Distance is a decision made against a woman every day the system does not come to her.

"She walked two hours in labour. She arrived alone. The facility was not expecting her."

BARRIER 2

Cost on a farming income

Transport to a facility can cost a day's income for a smallholder farming family. During planting or dry season, that income does not exist. A system that requires payment before access has already excluded her, without asking her to decide.

"The fare to the clinic was a week's income. She waited to see if it would pass."

BARRIER 3

Limited health
awareness

No one has visited to explain the danger signs of pregnancy. No one has taught her what to watch for in a newborn. The knowledge gap is what happens when a health system has never reached the household where she lives.

"She did not know the headache was a warning. No one had ever told her it could be."

BARRIER 4

A system built around a facility

The health system was designed around a building. It waits. It does not look for the smallholder farmer in her third trimester who cannot come. Her absence is treated as her failure, not the system's design flaw.

"The system was there. She just was not who it was built to find."

A system that requires all four conditions to be met by the smallholder farming family will only ever reach a fraction of the women who need it most. The failure belongs to the system's design not to the families it cannot reach.

"Care should not depend on people reaching the health system. The health system should reach people early, continuously and in time."

WANDIKWEZA'S RESPONSE

Proactive Doorstep Care

Proactive Doorstep Care (PDC) is Wandikweza's six-layer connected system and its answer to the reach crisis. It shifts preventive, routine and follow-up care from facilities to households: bringing skilled care to the farm, to the community, to the doorstep, before complications escalate into emergencies.

Most health systems wait at a building for a family to arrive and the families carrying the heaviest burden are the ones least able to make that journey. PDC inverts that relationship. Care moves toward the family, continuously, from before the first pregnancy to a child's fifth birthday, so that the moment a danger sign appears is the moment the system is already there, not the moment a journey begins.

Six connected layers carry that shift in practice

A household enrolled early, a Community Health Worker who returns again and again, a skilled midwife who reaches the home itself, a full clinic that comes to the community, a facility that receives a family it already expects, and an emergency response that closes the gap when every minute counts.

Each layer depends on the one before it and feeds the one after it, together, they form a single continuum, not six separate services.

And it is built to last. PDC rests on three things constructed together from Day 1: the physical Last-mile infrastructure to deliver care where it has not consistently reached, the Community Relationships that make care trusted and used, and the Government co-ownership that makes care sustainable long after Wandikweza steps back.

EXPLORE THE MODEL

THE ARCHITECTURE

What the System
is built from

Each of the six layers is a distinct operational component with its own workforce, protocols, supervision structure and connection to every other layer. Together they form one coordinated system, not six separate services running in parallel, but a single continuum in which each layer depends on and feeds into the next. That is what makes Proactive Doorstep Care a system, not a program.

LAYER 1

Households, Families & Caregivers

The origin of the system. Health-seeking behaviour starts at the household, with families and caregivers making decisions before any health worker has identified them. This is the foundation of PDC. Everything else the system does is built on what happens here first.

LAYER 4

Mobile Outreach Infrastructure

A scheduled, mapped outreach system that deploys clinical teams to fixed community points on a regular calendar, bringing ANC, postnatal care, nutrition assessment, family planning and general clinical care to where populations are concentrated.

LAYER 2

Community Health Worker Network

280 trained, supervised, and incentivised CHW, recruited from the communities they serve, operating to standardised protocols and supported by a tiered supervision structure that maintains quality at scale across all districts.

LAYER 5

Facility Integration & Referral

Government health facilities are integrated into the PDC system through active referral pathways, two-way communication protocols and shared patient records so facilities receive prepared patients and can communicate outcomes back to the community layer.

LAYER 3

Midwives on Wheels Programme

A cadre of skilled midwives deployed on motorbikes, equipped for community-based maternal assessment and care. Operationally distinct from outreach clinics, they go further, move faster, and respond directly to CHW escalations in real time.

LAYER 6

Maternity Rapid Response System

MRRS is a dedicated obstetric emergency coordination infrastructure, comprising equipped ambulances, trained first responders and facility pre-notification systems, designed to collapse the time between complication and care

THE BUILDING BLOCKS

The Three Building blocks of a System that outlasts us

The three building blocks are built simultaneously, because none of them works without the others. A system with infrastructure but no community trust goes unused. A system with trust but no government co-ownership collapses when the funding ends. The absence of any one of them is not a gap in the model. It is the end of it.

Each block fails without the other two. We build all three, together, in every district we enter. That is what makes it a system and not a program.

Proactive Doorstep Care rests on three building blocks, each representing a distinct and irreplaceable dimension of last-mile health system development.

Government Co-Ownership provides the mandate, the budget integration, and the institutional structures that give the system continuity beyond any external programme and beyond any single funding cycle.

Community Relationships provide the trust and social foundations that determine whether communities engage with what has been built.

Last-Mile Infrastructure provides the operational and physical capacity to deliver care where it has not consistently reached.

WHAT HAPPENS WHEN FAMILIES ARE
FOUND EARLY

Reach changes everything

When care reaches people at the household, before complications arise, before the journey to a facility becomes necessary, outcomes change. These numbers reflect what happens when a health system is built to find people where they are, before they need to find it.

of women of reproductive age (15-49
years) with access to modern
contraceptive method

of pregnant women register in their first trimester and receive syphilis testing

of births are attended by a skilled health professional

of children with symptoms of malaria, diarrhea, or pneumonia are assessed within 24 hours

When care reaches people early, continuously and in time, outcomes improve. The PDC model demonstrates this at district level, with results that are repeatable and scalable.

Outcomes tracked across Dowa, Mangochi, Salima and Mchinji districts through continuous data systems

Rooted in Malawi. Built with communities. Designed to stay. Since 2016.

ABOUT WANDIKWEZA

We build Health Systems

Wandikweza is a Malawian organisation building last-mile maternal and child health systems that reach smallholder farming families continuously, at the household and before complications arise, from before the first pregnancy to the child's fifth birthday.

We build the system that delivers care early, continuously, and in time. We scale it through government, so that what outlasts us is a health system the Government of Malawi owns and runs.

WE DO NOT BUILD ALONE

Building Systems
through Partnership

Proactive Doorstep Care does not work in isolation. The government co-owns it. Communities shape it. Funders make it possible. Researchers strengthen its evidence base. Frontline health leaders carry it forward. Each partnership is structural, one that is built into it. Without government co-management, the system has no mandate. Without community trust, it has no reach. Without sustained funding, it has no continuity.

Government Partnership

Integrated with Malawi's Ministry of Health at district level ensuring the system is sustainable, government-owned and aligned with national health strategy.

Global
Funders

Supported by global health funders committed to building last-mile systems that scale, endure and generate evidence that shifts how the sector thinks about rural health delivery.

Research Partners

Academic and research collaborators generating evidence that informs both practice and policy, building a global knowledge base for last-mile maternal and newborn care systems.

Community Leadership

Every district system is designed and operated with communities, from village leadership to CHW networks, because systems that do not belong to communities do not survive them.