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Comprehensive Analytical Profile: Malawi

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This analytical profile provides a health situation analysis of the Malawi and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to country context
2. Health status and trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context
Malawi map.jpg
Malawi is a small, narrow, landlocked country in sub-Saharan Africa. It shares boundaries with Zambia in the west, Mozambique in the east, south and south-west and Tanzania in the north. It has an area of 118 484 square kilometres, of which 94 276 square kilometres is land and the remainder is water. The major water body in the country is Lake Malawi, which is to the southernmost of the Rift Valley and has a total surface area of more than 30 000 km square kilometres.


The country is divided into three administrative regions, namely the Northern, Central and Southern Regions. There are 28 districts: six in the Northern Region, nine in the Central Region and 13 in the Southern Region.

Health Status and Trends

Life expectancy at birth depicts the overall mortality level of a population and summarizes the mortality pattern that prevails across all ages and by gender. The life expectancy at birth in Malawi is estimated at 48.3 years for males and 51.4 years for females. In 1977, the life expectancy for men was 39.2 years and for women was 42.4 years. This increased to 41.4 years and 44.6 years for men and women, respectively, in 1987. There has been a drop in life expectancy in Malawi, especially in the 1990s, mostly due to the HIV/AIDS epidemic.

Mortality rates are used to monitor progress of a population's health status. Infant and child mortality rates measure child survival and reflect the social, economic and environmental conditions in which children live.

Progress
Progress on SDGs
The Health System
Health system outcomes

In collaboration with its development partners and other stakeholders, Malawi developed the Programme of Work, covering the period from 2004 to 2010. The Programme of Work guided the implementation of interventions aimed at improving the health status of the people of Malawi. The overall goal was to improve the quality of life of all the people of Malawi by reducing the risk of ill health and occurrence of premature deaths, thereby contributing to the social and economic development of the country.

The implementation of the Programme of Work has contributed to strengthening the health systems and there has been increased funding to the health sector. Between 2004 and 2009 there has been increased output from the health-training institutions due to increased capacity.

Leadership and governance

The health sector was one of the earliest sectors to start the process of decentralization in line with the Decentralization Policy of 1997. In 2004, health devolution guidelines were formulated taking into consideration the prevailing legislation, the policy framework and available local capacity for implementation of the decentralization process. The guidelines further identified the functions and activities to be devolved to district assemblies and defined:

  • the role of the central Ministry of Health in policy development;
  • standards setting;
  • monitoring and evaluating how the devolved functions are executed in line with the Ministry’s overall goals, overarching sectoral plans and policies.

Some of the key challenges with regard to decentralization, including weak coordination of decentralization at national level, underfunding of district implementation plans and high staff turnover within the health sector, tend to affect health services delivery at district level.

Community ownership and participation

In the context of decentralization, the Ministry of Health in Malawi has put in place structures to facilitate community ownership and participation. Village health committees have been established to ensure individuals participate in activities that promote good health. Health facility advisory committees have also been instituted at health facility level to facilitate user and provider interaction.

Through these structures, communities are involved in monitoring delivery and usage of drugs from the central medical stores, participating in identifying health priorities, as well as in the delivery of the community component of the Essential Health Package. One of the challenges is that these committees have not been effective because the elected members have not been oriented on their functions.

In addition, the committees lack resources to conduct their business. Appropriate local by-laws at district and community levels should be developed and enforced to empower communities to perform certain actions on their own and demand the services that they need. Multisectoral structures for coordinating health service planning and implementation at community level should be established and sustained.

Partnerships for health development

The Government of Malawi has put in place sector working groups in all ministries in recognition that better coordination of aid and alignment to Government systems enhances efficiency and effectiveness, reduces duplication and ultimately improves health outcomes.

At national level, the Health Sector Review Group is mandated as the coordinating body for the sector to enhance partnership for health development. The administrative and operational responsibility for health at the district level has been delegated to local government with its governance structures.

These structures have the potential to better engage communities in health sector planning and implementation. However, the full potential of a decentralized system will not be achieved without clearer governance structures between all levels (centre, zone, district, health facility and village).

Health information, research, evidence and knowledge

The Malawi Ministry of Health is implementing a comprehensive and decentralized health management information system. It has developed policies, guidelines and procedures for implementing both its facility-based and population-based information systems.

Achievements of the health information system include:

  • the availability of data at all levels for planning and decision-making
  • availability of policy to provide guidance on the implementation of the system
  • implemented capacity-building activities for key health to ensure all health sector staff have the necessary skills.

Despite several achievements, the health management information system still has some weaknesses, including:

  • low quality of data in terms of completeness, reliability and timeliness;
  • weak linkage between various data sources;
  • some vertical programmes continuing to collect and use their own indicators, which are different from those articulated in the health management information system;
  • limited data analysis and use of information in the management of health services.
Health financing system

The Government of Malawi and its development partners signed a Memorandum of Understanding to finance and support the sector-wide approach Programme of Work. The Memorandum of Understanding provides a common framework for health sector planning, budgeting, financing, financial management, reporting and monitoring and evaluation. Other donors operate by providing discrete funding through project support, but are still signatories under the sector-wide approach Programme of Work.

In 2004–2005, the total health expenditure was 12.8% of gross domestic product and in 2008–2009 this decreased to 9.7%. The Government's expenditure on health as a percentage of total expenditure falls short of the Abuja Declaration target of 15%.

Service delivery

In Malawi, the Ministry of Health is responsible for:

  • the development, review and enforcement of health and related policies for the health sector
  • spearheading sector reforms
  • regulating the health sector, including the private sector
  • developing and reviewing standards, norms and management protocols for service delivery
  • planning and mobilizing health resources for the health sector, including allocation and management
  • advising other ministries, departments and agencies on health-related issues
  • providing technical support supervision
  • coordinating research
  • monitoring and evaluation.

Since 2004, the Ministry of Health in collaboration with development partners has been implementing a health service delivery strategy based on the delivery of the Essential Health Package. The implementing framework is guided by the National Health Policy, the Public Health Act (1948) (which is being reviewed), the Decentralization Policy, the Malawi Growth and Development Strategy II 2011–2016 and Vision 2020, among others.

Health workforce

In Malawi, public health workers are public servants and their management is under the Department of Public Service Management, which formulates and articulates all strategic public human resources policy. In the case of the Ministry of Health, the Public Service Commission has delegated some of its responsibilities to the Health Service Commission.

The Health Services Commission was established in 2003 and is responsible for:

  • recruiting, appointing and promoting health workers
  • disciplinary control of health workers
  • setting salaries for health workers
  • setting working conditions for health workers.

However, there is a lack of clarity regarding the Act that established the Health Services Commission and the powers invested in the Commission. This has resulted in some confusion regarding the respective roles of the Ministry of Health and the Commission in addressing human resource for health issues in Malawi.

Medical products, vaccines, infrastructures and equipment

The Pharmaceutical Section within the Ministry of Health is the central point for the organization, management and administration of pharmaceutical services in Malawi. It plays an advisory role to the Ministry of Health on pharmaceutical issues. The National Medicine Policy ensures the efficient and effective management and administration of pharmaceutical services in both the public and private sectors.

The Pharmacy, Medicines and Poison Act and the Dangerous Medicines Act ensure compliance with laws related to medicine handling and use in the country. Structures and processes have been established to ensure that all medicines imported into the country are checked for quality. However, lack of handling procedures for counterfeit medicines and no regulations for advertising of medicines are some of the challenges in regulating the pharmaceutical sector.

General country health policies

In Malawi, the Ministry of Health is implementing public health policies that are guided by a number of documents, including the Constitution of the Republic of Malawi, the Public Health Act and To the year 2020: a vision for the health sector in Malawi.[1]

A number of health sector reforms have been initiated by the Ministry of Health with a view to improving efficiency and providing quality health services. The major policy reforms include:

Universal coverage

One of the core objectives of the health sector in Malawi is to ensure that all Malawians have access to basic health services, especially in the rural areas. The Ministry of Health has made a policy commitment to institute service-level agreements with other service providers such as the Christian Health Association of Malawi and Banja la Mtsogolo, a nongovernmental organization, as one of the strategies to improve access to health services, especially by the rural poor.

Specific regulator frameworks have been put in place to ensure that all Malawians have access to basic health services, especially in rural areas. A Memorandum of Understanding has been signed between the Government of Malawi, represented by the Ministry of Health, and the Christian Health Association of Malawi secretariat while a service-level agreement has been signed between district health officers and proprietors of health facilities.

Specific Programmes and Services
HIV/AIDS

HIV/AIDS is a leading cause of mortality in Malawi. The prevalence among people aged 15–49 years is 10.6%. Over the years, HIV prevalence has decreased by 25%, mainly due to the natural evolution of the epidemic and prevention interventions being implemented.

HIV testing and counselling is a key strategic intervention as well as a significant preventive measure. It is an entry point for other interventions such as prevention of mother-to-child transmission and antiretroviral therapy. In 2004, there were 167 000 individuals counselled and tested and by 2010 this number had increased to 1 700 000, surpassing targets for universal access. The proportion of health facilities with at least a minimum package of prevention of mother-to-child transmission was 7% and this proportion was 100% in 2010, thus achieving the target as set in 2004.

Tuberculosis

Tuberculosis (TB) is one of the public health problems in Malawi. It is a major cause of morbidity and mortality in the population. In 2011, there were 21 653 reported TB cases in Malawi. Of those, 19 331 (89%) were new; 865 (4%) were previously treated smear-positive pulmonary TB cases; and 1457 (7%) were previously smear-negative and extrapulmonary TB cases.

The national TB response, coordinated by the National TB Control Programme, continued with DOTS, the basic package that underpins the Stop TB Strategy approach. TB case notification has been steadily decreasing from around 29 000 cases in 2005 to around 26 000 in 2009. The treatment success rate for adults was 89% in 2011, surpassing the WHO target of 85%. The case detection rate in DOTS areas was 49%, compared with the target of 70%.

Malaria

Malaria remains a major cause of morbidity and mortality in Malawi, especially among pregnant women and children aged under 5 years. The Health management information system annual bulletin 2009[2] indicates that malaria accounts for 30% of all outpatient visits. In addition, 52% of all children aged under 5 years in inpatient departments are admitted due to malaria and anaemia and nearly 60% of all hospital deaths in children aged under 5 years are due to malaria and anaemia. The number of presumptive cases of malaria increased from 3.7 million in 2005 to 6.1 million in 2009. Death rates due to malaria have decreased from 5.6% to 3.4% in 2004 and 2009, respectively.[3]

The Malawi National Malaria Control Programme developed a Malaria Policy (2009) that covers the main intervention areas of malaria control and prevention, namely effective case management, use of long-lasting insecticide nets, indoor residual spraying as well as operational research and information, education and communication. The policy also addresses cross-cutting issues such as management, financing and human resources. Without improvement in these areas, enhanced malaria control and prevention efforts will not succeed. The policy was developed within the context of the Essential Health Care Package and the sector-wide approach.

Immunization and vaccines development

According to WHO guidelines, a child is considered fully immunized if he or she has received:

  • a vaccination against tuberculosis (Bacille Calmette-Guérin, BCG)
  • three doses of diphtheria, pertussis and tetanus (DPT) vaccine
  • three doses of pneumococcal conjugate vaccine (PCV)
  • at least three doses of polio vaccine
  • one dose of measles vaccine.

These vaccines should be received during the first year of life.

Since 2002, Malawi has replaced the DPT vaccine with pentavalent vaccine that protects against DPT, hepatitis B (HepB) and Haemophilus influenzae type B (Hib). In Malawi, BCG and polio vaccine should be given within the first 14 days after birth, and the DPT-HepB-Hib, PCV and polio vaccines should be given at approximately 6, 10 and 14 weeks of age. The measles vaccine should be given when, or soon after, the child reaches 9 months of age. It is recommended that children receive the complete schedule of vaccination before their first birthday.

Child and adolescent health

Acute respiratory infection, fever and diarrhoea are among the leading causes of childhood mortality and morbidity in Malawi. The prevalence of childhood diseases in Malawi is high, with 35% of children aged under 5 years reported to have fever, which is a symptom of malaria but may also accompany other childhood illnesses. Also, 18% of children aged under 5 years have diarrhoeal episodes and 7% of children aged under 5 years have acute respiratory infection.

The nutritional status of children in Malawi has improved, although it is still low. A total of 47% of children aged under 5 years are stunted, 4% are wasted and 13% are underweight.

Maternal and newborn health

The Government of Malawi is implementing a comprehensive and integrated sexual and reproductive health programme at all levels. The National Sexual and Reproductive Health and Rights Policy 2009 provides the framework for the implementation of the sexual and reproductive health programmes.

This Policy incorporates emerging issues in the various components of sexual and reproductive health in line with both national and international recommendations, including:

These emerging issues are in line with other policy guidelines, such as the:

Gender and women's health

Adolescent health is a public health issue in Malawi in a number of ways. Demographically, the adolescent group (aged 15–24 years) constitutes about 20% of the total population of the country.[4] These adolescents face many challenges due to harmful and cultural practices, premarital sex and lack of access to family planning education and services resulting in, among other things, unwanted pregnancies, unsafe abortions and early childbearing.

The Malawi demographic and health survey 2010[4] also indicates that people marry early, as the mean age at marriage is 17.8 years for females and 22.5 years for males. Sexual activity among adolescents in Malawian society starts early: 26% of young women aged 15–19 years had started childbearing, 20% were mothers and 6% were pregnant with their first child.[4] This early exposure to sexual activity exposes adolescents to pregnancy and sexually transmitted infections, including HIV/AIDS.

Epidemic and pandemic-prone diseases

Structures have been established in Malawi to respond to outbreaks of disease and epidemics. A multisectoral District Epidemic Management Committee has been constituted at national and district levels and is responsible for epidemic management, including:

  • reviewing and approving the epidemic preparedness and response plan
  • mobilizing resources for epidemic prevention and control
  • coordinating and monitoring control activities, including dissemination of information to the public and media
  • monitoring resource utilization.

In addition, epidemic readiness and intervention guidelines to respond to outbreaks/epidemics have been developed for use at district level.

Laboratories are essential to disease surveillance, as they not only offer confirmation of suspected cases in an outbreak but also provide a current and dynamic picture of the disease burden in the community. Most effective surveillance systems require a laboratory component.

Neglected tropical diseases

Most of the neglected tropical diseases in Malawi are localized, occurring is some districts but not countrywide. For instance, onchocerciasis is mostly found in eight districts in the southern region of the country. Human African trypanosomiasis occurs in five districts around Nkhotakota Game Reserve, Kasungu National Park focus and in the North Vwaza Marsh focus.

There is considerable overlap in the geographical distribution and endemicity of lymphatic filariasis, onchocerciasis, schistosomiasis, trachoma and soil-transmitted helminthiasis. Lymphatic filariasis has been found to be endemic throughout the country.

Mass drug administration is the main strategy used for controlling some of the neglected tropical diseases in Malawi. The diseases targeted with this strategy are ochocerciasis, lymphatic filariasis, soil-transmitted helminthiasis, schistosomiasis and trachoma.

Non-communicable diseases and conditions

In Malawi, noncommunicable diseases are increasingly becoming significant causes of morbidity and mortality in adults and are thought to be the second leading cause of deaths in adults after HIV/AIDS.

A STEPS survey[5] conducted in Malawi in 2009 clearly demonstrates that noncommunicable diseases and their risk factors are a significant public health problem. A total of 32.9% of individuals aged 25–64 years are hypertensive, while 8.9% suffer from cardiovascular diseases. Over 75% of those with hypertension are unaware that they are hypertensive. The prevalence of diabetes is estimated at 5.6%, while injuries, other than road traffic accidents, are at 8.9%. The prevalence of cardiovascular diseases is 8.9% and that of asthma is 5.1%. The prevalence of road traffic accidents is estimated at 3.5%.

Key Determinants
Risk factors for health
Risk factors for noncommunicable diseases, Malawi, 2009[5]

There is an urgent need to have health-facility-based and community-based programmes for treatment, prevention and control of noncommunicable diseases and promotion of health lifestyles.

The risk factors for noncommunicable diseases are shown in the table. Results from the STEPS survey[5] show that 14.1% of the respondents smoke, 16.9% consume alcohol, 9.5% have low levels of physical activity, 21.9% are overweight and 4.5% are obese. With the exception of obesity and low levels of physical activity, more men experienced risk factors than women.[5]

The physical environment

Urbanization in Malawi is growing at 6.3% per annum due to high rural–urban migration and population growth. This has resulted in increasing urban poverty, manifested in the growth of slums that continue to develop in and around the cities and towns. These settlements are characterized by poor access to physical infrastructure such as roads and electricity, poor access to social services such as health and education, and poor housing conditions.

The goal of the Malawi Growth and Development Strategy 2011–2016[6] is to create a sustainable, economically and socially integrated urbanizing system. The Government of Malawi intends to:

  • implement strategies to provide support to processes of urban renewal and slum development;
  • support the development of utilities and structures in local authorities and urbanizing systems in the provision of urban infrastructure;
  • enforce rules and regulations on land use and physical plans.
Food safety and nutrition

The Government of Malawi, through the Ministry of Agriculture and Water Development, implemented farm input subsidy programmes for the fifth time in the 2009–2010 growing season. The programmes mainly administered maize seed and fertilizer for maize and legume seeds in order to improve crop productivity and hence increase food security at both household and national levels. The Ministry of Agriculture has developed an agricultural sector-wide approach to be implemented during 2008–2013. This approach aims to improve food security and increase productivity of food and cash crops.

The food export trade has been limited in order to meet the domestic market first before food can be exported. Owing to increased food production in the past 5 years, food imports, especially maize, have been insignificant. However, some food items have been imported to complement domestic production.

Social determinants

According to the 2008 Population and housing census,[7] Malawi has a total population of 13.08 million. The population is growing at an annual growth rate of 2.8%. Census results indicate that:

  • 7% of the total population is aged under 1 year
  • 22% is aged under 5 years
  • 46% is aged 18 years and older
  • a further 4% is aged 65 years and older.

This indicates that Malawi has a youthful population with potential to grow.

The population of Malawi is unevenly distributed among the three regions: 45% reside in the Southern Region, 42% in the Central Region and 13% in the Northern Region. Urbanization is low in Malawi, with just 15.3% of the population residing in urban areas in 2008.



References
  1. To the year 2020: a vision for the health sector in Malawi. Lilongwe, Government of Malawi, Ministry of Health and Population, 1999
  2. Health management information systems (HMIS) annual bulletin, July 2009–June 2010 (Word 1.51Mb). Lilongwe, Government of Malawi, Ministry of Health, 2010
  3. Malawi malaria program performance review (pdf 1.08Mb). Lilongwe, Government of Malawi, Ministry of Health, National Malaria Control Programme, 2010
  4. 4.0 4.1 4.2 Malawi demographic and health survey 2010 (pdf 3.85Mb). Zomba, National Statistical Office and Calverton, Maryland, ICF Macro, 2011
  5. 5.0 5.1 5.2 5.3 Malawi national STEPS survey for chronic non-communicable diseases and their risk factors. Final report (pdf 1.45Mb). Lilongwe, Government of Malawi, Ministry of Health, and WHO, 2010
  6. Malawi Growth and Development Strategy II (2011─2016) (draft). Lilongwe, Government of Malawi, 2011
  7. 2008 Population and housing census. Preliminary report (pdf 194.86kb). Lilongwe, Government of Malawi, National Statistical Office, 2008