THE STATE OF MATERNAL, NEONATAL AND CHILD HEALTH IN MALAWI AND AN ANALYSIS OF THE

NATIONAL RESPONSE: A REVIEW OF CRITICAL ISSUES AND RECOMMENDATIONS FOR MEETING GLOBAL

TARGETS

GROUP 3Tutor: Marcio Estrada Paneque

Emmanuel Calderón Espinosa (Mexico)

Rocío Fernández Méndez (Spain)Alena Kulyapina (Russian

Federation)Thidar Pyone (Myanmar)

Rodrigo Sarmiento Suárez (Colombia)

Liaquat Ali Shaikh (Pakistan)Mariela Silveira (Australia)Henock Taddese (Ethiopia)

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Maternal and child health (MCH) refers to the health of mothers, infants, children, and adolescents. It also refers to a profession within public health committed to promoting the health status and future challenges of this vulnerable population (Breslow, 2002) Using the concept Maternal Neonatal and Child Health,

MNCH, emphasizes the specific consideration of the new-born.

MNCH DEFINITION

“We know how to save the lives of mothers and children and yet, every year about nine million children die and half a million women die due to pregnancy-related causes...” (World Health Organization, 2009)

GLOBAL INFANT MORTALITY

GLOBAL MATERNAL MORTALITY

2006: Under-five mortality rate of the developing world estimatedat 80 per 1,000 live births (plus under-reported cases)*

Around 500,000women die annually during childbirth or due to complications from pregnancy (99% in developing regions)*

•MDG 2008 Report• Images: http://www.worldmapper.org

SOME KEY MILESTONES IN MNCH AT THE GLOBAL LEVEL

Consideration of MATERNAL, NEONATAL AND CHILD HEALTH (MNCH) amongst the key target areas in the Millennium Development Goals, MDGs of 2000

Goal-5: Improve Maternal HealthTarget: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

Goal-4: Reduce child mortalityTarget: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate

MDGs and images at: http://www.undp.org/mdg/

Current thinking: BROADER VIEW OF MATERNAL AND CHILD HEALTH

- beyond the narrow consideration of pregnancy and child birth related issues

- take into account factors affecting the health of women across their life span: social, economic and cultural issues

Country situation, Malawi

• Land-locked country, highest population density (105/km2) in the southern part of Africa.

• 12.9 million people, 83% rural areas

• Agriculture, the major source of livelihood

• One of the poorest countries in the world with a GNI of 170 USD/capita

• 65.5% of its population live under the poverty line with a HDI rank of 165 out of 177 countries

Lake Malawi

Table 1 : General and basic demographic indicators of Malawi

Indicators Value Year

Total population (millions)

Population growth rate per year (%)

Total fertility rate (per woman)

Urban population (%)

12.9

2.2*

6.1*

17

2006

1995-2004

2004

2005

Children <15 years (%) 47 2006

Crude death rate (per 1000 population)

Life expectancy at birth (in years)

43.6*

41

200

2004

Source: WHO, Country system fact sheet-Malawi, 200614* National Statistical Office, Zomba & UNICEF (2006) Multi-Indicator Cluster Survey16

State of the health care system• Low access to health care services with high inequality• Severe shortage of qualified health personnel (61%) vacancies• The move for decentralisation across government ministries and sectors• Annual expenditure on health/capita= <16.6 USD.

DENSITY PER 1000 OF THE HEALTH WORKFORCE IN MALAWI 2002

0.02

0.58

0.004 0.057

0.2

1.17

0.0570.17

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Physicians Nurses and midwives Laboratory technicians Other health workers

MALAWI AFRICAN REGION

Figure on comparison of country system fact sheet on human resource comparison

• Traditional healers and traditional birth attendants• Increase in the out of pocket expenditure

Financial Contribution of Health System in Malawi (2004)

60%

37%

1%2%

Ministry of Health Planning (MoHP)Christian Health Association of Malawi(CHAM)Ministry of Local government (MLG)Others (private, commercial companies, army,etc.)

Fig. 2 based on data from Thomsom, H.I. (2004)

Based on data from Thomsom, H.I. (2004)

Trend of Maternal Mortality Ratio

MMR of Malawi is 9th of 169 WHO member countries.

Childbirth: a joyful occasion or one of grief?

Trend of Infants and Child Mortality Ratios

Indicators Value (Year)

Antenatal care at least 1 visitAt least 4 visits

94% (2000)55% (2000)

% of pregnant women received tetanus toxoids for 2 times 65.3-71.5% (rural-urban)1

% of skilled attendance delivery 50% (nurse or midwives)6% (doctors)1% (patient attendant)

Contraceptive prevalence rate Total fertility rate

30.6%(2000)6.1

Immunization of children by 1 year BCG DTP3 Polio3 Measles HBV 3

89.7% 76.5% 73.2% 62.7%87%

State of Maternal and child health services in Malawi

Sources: Country Health system fact sheet, 2006. Malawi. 1Maternal and child health, A. Phoya and S.Kang’oma

Major causes of maternal mortality in Malawi 2005(Hospital based data)

Puerperial sepsis29%

Post abortal complication

24%

Ecclampsia6%

Others10%

Infectious conditions20%

Obstetric haemorrhage

11%

Fig. 5 data from UN Development Program & Government of Malawi (2008)

Major Causes of Under 5 children deathsin Malawi

(2000-2003)

Pneumonia22%

Neonatal causes22%Diarrhoeal diseases

18%

HIV/AIDS14%

Malaria14%

Others8%

Injuries2%

Fig. 6 data from UN Development Program & Government of Malawi (2008)1

Long term consequencesUnderweight and stunted childrenPoor intellectual ability

Short term consequencesMaternal and child: mortality, morbidity

Illness of mother

and children

SocialEconomic

EnvironmentalPolitical

Lack of resources:

human, financial, natural

Poverty housing, education, low income infrastructure

Food insecurity

Unhealthy living

environment

Inadequate health and health care

Inadequate nutrition of

both mother and children

Poor quality of health services for MCH and

Primary health care

Causal Chain Analysis

Scanning the national responseMalawi growth and

economic development policy

•Describes links between poverty and health•Maternal and child health as key objective areas for strategy•Lack of pro poor targeting and monitoring of results •No clear mechanisms for multi sectoral action

Health Sector

• A number of policies and strategies aimed at accelerating progress

• Mainly

– Essential Health Package

– The National Road Map for accelerating the Reduction of Maternal and Neonatal mortality

– The integrated management of child hood illnesses programme (2000 – 2015)

...Health Sector

• Main lines of action of policies and strategies.

– Decentralisation of health infrastructure– Health infrastructure development– Health personnel training and deployment– Enhancing access to basic drugs and equipments– Community health Workers – link PHC with

community

Key observations from the SLOTStrengths

• MCH prioritised in national policy

• Coordination body for action on MCH (different partners)

• Adoption of innovative, appropriate strategies for service provision

Limitations

• No clear mechanism for inter-sectoral collaboration

• Severe shortage of health personnel

• Corruption• Low quality of

health services

Malawi:115th in world ranking (index 2.8)

http://www.transparency.org.uk/

SOME LIMITATIONS

Opportunities • Democratisation

(1994) and decentralisation (1998)

• Political commitment (Health Expenditure -9.64 %)

• Considerable international aid (% of aid?)

Threats • Low

empowerment of women

• Recurrent drought • Global economic

crisis• Multi faceted

effects of HIV/AIDS

Stakeholders’ Analysis

Significant Donors

MoHP

Somewhat MLG

NGO

Little Private sector

NoPublic (beneficiaries)

No Little Some Significant

Interest in Policy

Influ

ence

in P

olic

y

Main conclusion points

• Observed lag in maternal mortality rate

• Attempts at a multi sectoral approach – lack of follow through in practice and evaluating outcome

• Enhanced focus and action in the health sector, but structural challenges

Main recommendation points – Public Policy Level

• Develop a framework for enhancing multi-sectoral action

• Mechanisms for enhancing community participation

• Enhance the ‘woman’s health approach’ – gender mainstreaming

Main recommendation points – Public Policy Level

• Actively target the women and children cost of HIV/AIDS

• Step up anti corruption action

...Recommendations – Health Sector

...Recommendations – Health Sector

Situation Analysis

Global & response

ActorsCurrent thinking

National response

Key FindingsReview vis-a-vis

International Protocols

SLOT of Policy and Programmes Stakeholder Analysis

matrix

Conclusion

Framework for actions

Regional context

Major causes, trends and

health system

Thematic

and setting agreed

National Context

Review of MNCH

MCH lectureMCH Review,

milestones, current thinking and mechanisms

Popu

latio

n Ap

proa

ch a

nd tr

iang

ulati

on.

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