Healthcare in Malawi

Healthcare in Malawi and its limited resources are inadequate to fully address factors plaguing the population, including infant mortality and the very high burden of diseases, especially HIV/AIDS, malaria and tuberculosis. In July 2013, the CIA World Fact Book estimated Malawi’s population to be 16,777,547.^[1] Due largely to the shortcomings of available healthcare, life expectancy at birth is 52.78 years.^[1]

There is a three tier healthcare system in Malawi in which each level is connected by a patient referral system. Patients enter into the system at the first tier and flow to higher tier facilities as needed.^[2] Medical supplies and human resources, however, flow in the opposite direction. The already limited resources are first allocated to the top tier facilities, leaving the second and third tier facilities with little to no resources.^[3]

Health issues

The leading causes of death in Malawi are largely preventable and therefore appear to result from the failures of its healthcare system.^[4] There is a high degree of risk for major infectious diseases, including bacterial and protozoal diarrhea, hepatitis A, typhoid fever, malaria, plague, schistosomiasis and rabies.^[5] Malawi has been making progress on decreasing child mortality and reducing the incidences of HIV/AIDS, malaria and other diseases; however, according to the United Nations Development Programme Malawi, the country has been "[performing] dismally" on reducing maternal mortality.^[6]

Top 10 causes of death in Malawi

In 2011, the University of Malawi released an article by Cameron Bowie that listed the following as the top ten causes of death in Malawi.^[7][8]

1. HIV/AIDS (25%)
2. Lower respiratory infections (12%)
3. Diarrhoeal diseases (8%)
4. Malaria (8%)
5. Cerebrovascular disease (4%)
6. Ischemic Heart Disease (4%)
7. Perinatal conditions (3%)
8. Tuberculosis (3%)
9. Road traffic accidents (2%)
10. Chronic obstructive pulmonary disease (1%)

Health indicators

The CIA World Fact Book’s “country comparison to the world” ranking indicates how Malawi’s health indicators compare to other countries in the world. Malawi’s rankings:^[1]

• 9th: HIV/AIDS adult prevalence rate (11%)
• 12th: People living with HIV/AIDS (920,000)
• 9th: HIV/AIDS deaths (51,000)
• 15th: Total fertility rate (5.26 children born/woman)
• 10th: Infant mortality rate (76.98 deaths/1,000 live births).

Healthcare system

Malawi’s Ministry of Health is responsible for healthcare in Malawi. 62% of health services are provided by the government, 37% are provided by the Christian Health Association of Malawi (CHAM), and a small fraction of the population receive health services through the private sector. Private doctors and non-governmental organizations (NGOs) offer services and medicines for a nominal fee.^[9] The public health system has three separate tiers (primary, secondary, and tertiary care). A system of referrals links these three tiers.

Primary care, “where the bulk of health care actually happens in Malawi,”^[10] consists of community-based outreach, manned and unmanned health posts, dispensaries, urban health centers and primary health centers (including rural/community hospitals).^[2][11] At the primary level (third tier), hospitals have holding beds, post-natal beds, holding wards and are able to provide out-patient, maternity, and ante-natal services.^[11] If the patient’s condition is considered to be too critical for primary care facilities to handle, they will be referred to the next level of the healthcare system. Secondary level care is provided by district hospitals that are located in each of Malawi’s 28 districts. These hospitals are equipped to provide the same basic services as the primary care facilities (mentioned above) in addition to a few more, such as: x-ray, ambulance, operating theatre and a laboratory. The top tier of care is provided by the central hospitals located in the major urban areas. These hospitals differ from the second tier hospitals in the existence of various specialized services.^[3]

Financing

According to the World Health Organization’s statistics on Malawi, there has been a sharp increase in health expenditures in the past decade. From 2002 to 2011, the per capital total expenditure on health (PPP int.) increased from $27.2 to $77.0 and per capita government expenditure on health (PPP int.) increased from $16.4 to $56.5.^[12] These statistics indicate that the healthcare in Malawi is receiving greater attention and resource allocation. They also reflect the increased health focus of the government of Malawi. From 2002 to 2011, the percentage of total government expenditures allocated to health increased from 13% to 18.5%.^[12] Malawi's increased government expenditure on healthcare has coincided with a decrease in the country's dependence on external healthcare resources, such as international and non-governmental aid. In 2009 external resources were responsible for 97.4% of total health expenditures, in 2011 they were responsible for 52.4%.^[12]

Human resources

In Malawi’s health profile, last updated in May 2013, the World Health Organization reported that there were only .2 physicians per 10,000 population and 3.4 nurses and midwives per 10,000 population.^[13] Malawi’s shortage of healthcare personnel is the most severe in the region. Additionally, the minimal body of health workers are not evenly distributed in the healthcare system. Challenges that lead to this shortage are low outputs of medical training institutions, health worker retention, and disease.^[2] In her novel A Heart for the Work: Journeys through an African Medical School, Claire L. Wendland gives insight into the environment in which health care is provided: “Malawi’s medical students become doctors in one of the poorest countries on a poor continent, where maternal and child mortality are high and life expectancy is low, where the dual scourges of HIV/AIDS and international economic policies ravage the hospitals and threaten both biomedical workers and their patients.”^[14]

In the 1990s Malawi stopped training auxiliary nurses and medical assistants. In 2001, this training was resumed in an effort to increase human resources for health care. In 2005, Malawi began to implement its emergency human resource program which concentrates on increasing output of trained medical personnel, improving health worker compensation and retention.^[2]

Accessibility to healthcare facilities

Limited access to health services in Malawi affect a large number of Malawians. Only 46% of citizens live within a 5 km radius of any kind of health facility.^[2] Despite most public health services being free for the patients, there are often costs associated with transportation to and from a facility.^[2] These costs deter many individuals that may be in dire need of care but cannot afford to assume the costs of transportation. Additional transportation needs complicate matters when an individual is referred from either a rural hospital to a district hospital or a district hospital to a central hospital.^[2]

Healthcare in Malawi’s poverty cycle

In their article titled “The Economic and Social Burden of Malaria,” Pia Malaney and Jeffrey Sachs present an argument for the prominent social theory regarding the intimate relationship between disease prevalence and poverty. They state that where malaria prospers most, human societies have prospered least.^[15] In Poor Economics authors Banerjee and Duflo explain how poor healthcare contributes to the poverty trap.^[16] That is, inadequacies of Malawi’s healthcare lead to an increased prevalence of disease and other health issues, which, in turn, results in increased poverty incidence.^[17] A comparison of income in malarious and non-malarious countries indicates that average GDP (adjusted to give purchasing power parity (PPP)) in malarious countries in 1995 was US$1,526, compared with US$8,268 in countries without intensive malaria — more than a fivefold difference.^[18] According to Jaimeson, effective intervention at the level of healthcare provision will have the greatest rate of return in the form of improved health.^[19]

Government efforts for healthcare improvement

The Ministry of Health explicitly states the goals of healthcare improvement efforts in Malawi.^[20]

1. Range and quality of health services for mothers children under the age of 5 years expanded
2. Better quality health care provided in all facilities
3. Health services to general population strengthened expanded and integrated
4. Efficiency and equity in resource allocation increased
5. Access to health care facilities and basic services increased
6. Quality of trained human resources increased, improved equitably/efficiently distributed
7. Collaboration and partnership in health sector strengthened
8. Overall resources in health sector increased

These objectives have been addressed in a variety of ways. In 2002, Malawi published the Poverty Reduction Strategy which included the Essential Health Package (EHP).^[3] The EHP was derived from estimates of the most significant burdens of disease in Malawi provided in 2002 by the World Health Organization.^[21] Its central focus is to combat 11 health issues that most greatly affect the poor.^[2] In 2004, the government of Malawi, in collaboration with partners, developed a six-year program of work (POW) that revolved around the EHP and guided the implementation of a health sector-wide approach (SWAp). In 2007, POW transitioned to become the Health Sector Strategic Plan, effective from 2007 to 2011.^[2] Measuring the outcomes of interventions, such as those facilitated by the SWAp, is very difficult due to the absence of a vital registration system and surveys to track changes in mortality.^[21]

Reception of global health initiative funds

The shortage of health workers in Malawi is an obstacle to utilizing Global Health Initiatives (GHI) funds effectively.^[22] Increasing health services such as HIV/AIDs treatment commonly prompt an increase in the number of minimally trained health care workers and a modest increase in clinical staff members.^[22] According to an extensive study published in 2010, when Malawi received a large amount of GHI funding from the Global Fund to fight AIDS, Tuberculosis, and malaria, there was an increase in faculty and staff across all levels of the health system. This increase in paid health workers was supported by task-shifting to less trained staff.^[22]

Malaria intervention

Malaria affects numerous aspects of social and economic life in Malawi. High malaria prevalence affects fertility, savings and investment rates, crop choices, schooling and migration decisions.^[15] There are a wide variety of cost-effective approaches to reduce the burden of malaria. Some current intervention tactics include case management, the use of insecticide-treated bed nets, indoor residual spraying, and environmental vector control measures such as larvaciding (controlling mosquitoes at the larval stage through the use of chemicals) and filling and draining of breeding sites.^[23] Each of these interventions has proven to have a high value of health gains achieved per dollar.^[15] More specifically, mosquito nets are one of the most effective and widely used approaches. They are most effective in that they require a minimal amount of resource input and result in a large decrease in the prevalence of Malaria.^[17]

References