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International University of Africa
Faculty of Medicine and Health Sciences
African Medical Students Association
Health Problems in Africa: Is there anyhope left?
10 11 January 2013 AD/ 28 -29 Safar 1434 AH
Khartoum - Sudan
Major Health Problems in Southern Africa
Malawi
Prepared by:
Aisha Katita, MBBS Level 3;Grace Sabili,NursingLevel 3;
Emily Rasheedah Asedi, Nursing Level 4
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1. INTRODUCTION
1.1 Geographical Location and Administrative System
Malawi is a small, narrow and landlocked country and 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 km2 of
which 94,276 km2 is land area. The country is divided into 3
administrative regions namely the northern, central and southern regions.
Malawi has 28 districts. Each district is further divided into traditional
authorities (TAs) who are ruled by chiefs. The village is the smallest
administrative unit and each village is under a TA. A Group Village
Headman (GVH) oversees several villages. There is a Village
Development Committee (VDC) at GVH level which is responsible for
development activities. Development activities at TA level are coordinated
by the Area Development Committee (ADC). Politically, each district is
further divided into constituencies which are represented by Members of
Parliament (MPs) and in some cases these constituencies can combine
more than one TA.
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1.2 Population
The population is approximately 16,323,044 (July 2012 est.) with a
growth rate of 2.758% per annum (2011 est.). The fertility rate is
estimated at 5.35 children born/woman (2011 est.), which is mainly
attributed to early marriages, early first pregnancies, relatively closely
spaced births, and low contraceptive prevalence rates. Almost half of the
population is under 15 years of age and the dependence ratio has risen
from 0.92 in 1966 to 1.04 in 2008. About 7% of the population is
comprised of infants aged less than 1 year, 22% are under-fives and about
46% are aged 18 years and above.
Malawis health indicators are among the worst in the world.
Life expectancy at birth stood at total population: 52.31 years, male:
51.5 years female: 53.13years (2011 est.). It is predominantly a
Christian country (80%).
1.3 ClimateMalawi's climate is generally tropical. A rainy season runs from
November to April. There is little to no rainfall throughout much of the
country from May to October. It is hot and humid from September to
April along the lake and in the lower Shire Valley, with average daytime
maxima around 27 to 29 C (80.6 to 84.2 F). Lilongwe is also hot andhumid during these months, albeit far less than in the south. The rest of the
country is warm during those months with a maximum temperature during
the day around 25 C (77 F). From June through August, the lake areas
and south are comfortably warm, with daytime maxima of around 23 C
(73.4 F), but the rest of Malawi can be chilly at night, with temperatures
ranging from 1014 C (5057.2 F). High altitude areas such as Mulanje
and Nyika are often cold at night (around 68 C / 42.846.4 F) during
June and July. Karonga in the far north shows little variation in
temperature with maximum daytime temperature remaining around 25 to
26 C (77 to 78.8 F) all year round but is unusual in that April and May
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are the wettest times of the year due to strengthening southerly winds
along the lake.
1.4 Poverty and health
Malawi is currently one of the poorest country in the world with
a Gross Domestic Product (GDP) per capita has grown from less than
$250 in 2004 to $313 in 2008. During the implementation of PoW
there has been remarkable economic growth rate ranging between 6%
and 9%, This has contributed to a reduction in the proportion of
Malawians living below the poverty line from 52% in 2004 to 39% in
2009. The Proportion of people living below the poverty line was
higher among rural residents (43%) in 2004 compared to urban
residents (14%) in 2009. The prevalence of diseases such as malaria,
ARIs and diarrhea are higher among poor people compared to those
who are rich. Therefore, the successful implementation of the HSSP
will depend to a large extent on the reduction of poverty.
Malawi is predominantly an agricultural country and this sector
accounts for about 35% of the GDP, 93% of export earnings primarily
from tobacco sales, and provides more than 80% of employment. The
sources of revenue for funding public services are taxes on personal
income and company profits, trade taxes and grants from donors. In theevent of insufficient revenue to cover the budgeted expenditure, the
financing of the deficit is met either from the domestic bank and non-bank
sources, or from foreign financing in a form of loans from donor and
overseas banks. In such a scenario, the financing of public services in
Malawi is inextricably linked to the aggregate of each of these revenue
sources. For instance, in the 2008/09 financial year, the major public
sector sources of finance contributed in the following proportions:
domestic taxes had a share of 77.9% and trade taxes had a share of 10.1%,
while non-tax revenue was 12.0%. These revenues represented 24.5% of
GDP. In terms of recurrent expenditures, health was the third at 10.2%after General Administration (33.9%), Agriculture (18.9%) and Education
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1.3 Health Information
Chronic poverty has devastated every sector of Malawi for
decadescontributing to a faltering economy and applying enormous
pressure on an overextended and under resourced government. Severe
food shortages and a lack of access to health services rest firmly and
often fatally on undereducated individuals and starving children. A
fragile health care infrastructure is aggravated by the poverty problem
and has increased the prevalence of HIV & AIDS, tuberculosis,
malaria, malnutrition, and other epidemics. Malawi has some of the
worst health indicators in the world and one of the highest maternal
mortality rates in Africa.
PHYSICIANS AND NURSES RATIO PER 100,000 PATIENTS
YEAR PERSONNEL RATIO
2004 Physicians 1.1
Nurses 25.5
2009 Physicians 2
Nurses 36.8
SITUATION ON THE GROUNDS
Currently, Doctor to patient ratio is 1:50,000 against WHO
requirement of 1:5000one of the lowest levels in the world. However,
according to statistics compiled by the Economist has shown that
Malawi has the highest number of patients per doctor standing at
88,321: 1. This puts Malawi on number one on the list of countries with
the highest patient to doctor ratio followed by Congo at 71,642 and onthird position is Tanzania whose ratio is at 45,012: 1 doctor. Although
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funding for healthcare has increased, there is simply not enough trained
staff available.While the shortage of medical staff in Malawi has partly been
caused by factors such as migration and a lack of access to education, it
has also been directly aggravated by AIDS. The National Association of
Nurses in Malawi (NONM) estimates that four nurses are lost to HIV and
AIDS related illness every month. 60% of Health facilities are having
insufficient drugs while 13% are completely running without drugs.
Malawi government provides almost 9.7% of its total budget to
Health instead of 15% as agreed at Abuja conference.
Global burden of diseasesIn 1990, it was communicable diseases that were topping the list of
diseases affecting humans. Looking at the current statistics, it is showing
that by 2020, the top 3 will be non-communicable diseases including road
accidents.
Risk factors causing death
Childhood underweight malnutrition High blood pressure Unsafe sex which leads to STD/I and HIV/AIDS Unsafe water, poor sanitation, unhygienic condition which
leads to Diarrhea, Cholera, especially in rain season, Typhoid.
Levels of Care
1 Primary levelThis level consists of community initiatives, health posts,
dispensaries, maternities, health centres and community and rural
hospitals. At community level, health services are provided by
community-based cadres such as HSAs, community-based distributingagents (CBDAs), VHCs and other volunteers from NGOs mostly. HSAs
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provide promotive and preventive health services including HIV testing
and counseling (HTC) and provision of immunization services. SomeHSAs have been trained and are involved in community case management
of acute respiratory infections (ARIs), diarrhoea and pneumonia among
under 5 children. Services at this level are conducted through door-to-door
visitations, village clinics and mobile clinics. Community health nurses
and other health cadres also provide health services through outreach
programs. VHCs promote PHC activities through community participation
and they work with HSAs to promote preventive and promotive health
services such as hygiene and sanitation. At primary level health centres
support HSAs. Each health centre has a Health Centre Advisory
Committee which ensures that communities receive the services that they
expect in terms of quantity and quality through monitoring of performance
of health centres in collaboration with VHCs. Health centres are
responsible for providing both curative and preventive EHP services. At a
higher level there are also community hospitals (also known as rural
hospitals). These facilities provide both primary and secondary care. They
have admission facilities with a capacity of 200 to 250 beds.
2. Secondarylevel
District hospitals constitute secondary level of health care and eachdistrict is supposed to have a District Hospital. They are referral facilities
for both health centres and rural hospitals and have an admission capacity
of 200 to 300 beds. They also service the local town population offering
both in-patient and out-patient services. CHAM hospitals also provide
secondary level health care. The provision and management of health
services has since been devolved to Local governments following the
Decentralization Act (1997). The district or CHAM hospitals provide
general services, PHC services and technical supervision to lower units.
District hospitals also provide in service training for health personnel and
other support to community-based health programs in the provision ofEHP. Health services are managed by the DHMT. The DHMT receives
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direct technical support and supervision from Zonal Health Support
Services (ZHSOs).
3. Tertiary level
The tertiary level comprises of central hospitals: these provide
specialist referral health services for their respective regions. Specialist
hospitals offer very specific services such as obstetrics and gynaecology.
There are currently 4 central hospitals namely: Queen Elizabeth in
Blantyre, Kamuzu in Lilongwe, Mzuzu in Mzimba and Zomba in Zomba
with admission capacities of 1250, 1200, 300 and 450 beds, respectively.
Queen Elizabeth and Kamuzu Central Hospitals are also teaching hospitals
because of their proximity to College of Medicine and Kamuzu College of
Nursing. Currently, CHs, however, also provide EHP services which
should essentially be delivered by district health services. The plan, as has
been mentioned earlier, is that over the HSSP period. The CHs are also
responsible for professional training, conducting research and providing
support to districts. Tertiary care is also provided by Zomba Mental
Hospital. The Plan makes a recommendation that gateway clinics will be
established at all central hospitals in order to decongest central hospitals.
These clinics will be run by the DHOs. Urban clinics will be strengthened
so that patients can first go to these facilities and only visit centralhospitals if referred.
The Role of Private Sectors
The private sector plays an important role in the delivery of health
services. At community level, numerous NGOs, FBOs and CBOs deliver
promotive health services but the majority of the providers and the
services they offer are unknown to MoH and stakeholders. The MoH and
stakeholders in the health sector have mainly involved TBAs which were
introduced to expand maternal and child health (MCH) services to the
community. The relationship between the MoH and traditional healers has,
however, been weak. The Malawi Traditional Medicine Policy has since
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been put together and it guides the practice of traditional medicine in
Malawi. The health sector will continue to work with traditional healersthrough the Malawi Traditional Healers Umbrella Organization
(MTHUO).
CHAM is a non-profit health services provider and is the biggest partner
for the MoH. It provides services and trains health workers through its
health training institutions (TIs). It owns 11 out of the 16 TIs in Malawi
and most of these are located in rural areas. CHAM facilities charge user
fees to cover operational costs and are mostly located in rural areas. The
charging of user fees constitutes a major barrier to accessing services for
most poor rural people; hence gross inequality to those living in catchment
areas of CHAM facilities. This is especially the case as catchment areas of
CHAM and GoM health facilities rarely overlap. The GoM heavily
subsidizes CHAM by financing some Essential Medicines Essential
Medicines and all local staffing costs in CHAM facilities. In order to
increase access to EHP services, the MoH has encouraged DHOs to sign
service level agreements (SLAs) with CHAM and BLM facilities to
remove user fees for most vulnerable populations. To date the MoH has
signed SLAs with 72 of the approximately 172 facilities mainly for the
delivery of maternal and newborn health (MNH) services. A few facilitieshave SLAs for an entire EHP. SLAs involve the transfer of a fee from the
DHO to a CHAM facility in exchange for the removal of user fees. Many
CHAM SLAs are dormant and contractual conflicts are yet to be resolved.
Discussions about the potential inclusion of other sections of the private
sector especially for profit health care providers have not started yet.
Currently, SLA guidelines with the private sector exist for AIDS and
Tuberculosis.
Health Services There are currently 4 central hospitals at tertiary level District Hospitals : 22
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Health Centers : 700
Community hospitals: 15
Annex 4 The number of health facilities in Malawi 2003-2010
MEDICAL SCHOOLS
Malawi College of Health Sciences
Malawi College of Health Sciences (MCHS) is a major training
institution for health care workers in essential health care services in
Malawi. The products of the institution are very important for the
implementation of the Program of Work (POW 2004-2010) and the
Essential Health Package (EHP). Since EHP is meant to combat the main
causes of disease burden in the country in a cost-effective manner, MCHS
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is shouldered with the responsibility of contributing to education and
training of health workers who are to be based at three levels, the districthospital, the health centre and the community levels. MCHS therefore
plays a significant role in the delivery of the EHP.
The college has three campuses, i.e. Lilongwe, Zomba and Blantyre
campuses. Currently, the college runs basic and post-basic upgrading
certificate and diploma courses that are recognized and accredited by
health professional regulatory authorities in Malawi, i.e. the Medical
Council of Malawi, the Pharmacy, Medicines, and Poisons Board and the
Nurses and Midwives Council of Malawi. The college also provides short
courses in various areas as part of continuing medical education for health
care workers in Malawi.
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years of age and pregnant women.
The use of Insecticide Treated Nets (ITN) when sleeping is theprimary control strategy for preventing Malaria. Malaria parasite prevalence
increased with increasing age whilst severe anemia showed the opposite
trend, both Malaria parasite and severe anemia prevalence rates were higher
among children who did not sleep under an ITN the previous night.
The prevalence of severe anemia in children under 2 years of age
who did sleep under an ITN the night before showed 25.7% compared to
rate of 13.6% among those who did sleep under a net the previous night.
This was found to be higher in the poor wealth quintile.
At present 60.4% of pregnant women are reported to have taken 2
or more doses of the recommended intermittent preventive treatment (IPT)
as compared to 48% in 2006. Currently coverage of Insecticide Residual
Spraying (IRS) is low with poor diagnostic capacity, abuse of ITNs, low
coverage of second dose of SP in pregnancy, unavailability of quality
ACTs in the private sector, poor adherence to treatment guidelines and
policies have affected the implementation of malaria interventions.
Tuberculosis (TB)
TB data in Malawi on incidence is obtained from quarterly reports
from hospitals that diagnose TB passively in the country. The incidence of
TB in Malawi in the recent years has had the following characteristics:
Annual increases in TB cases of all forms
Increased caseload is among people aged 15 to 44
The ratio of men to women is 1.1
The age-sex distribution resembles that of HIV/AIDS: there are more
women among TB patients of younger ages and more men among TB
patients of older ages
60% of all TB cases come from the southern region of Malawi
Attack rates (new cases per 100,000 population) are highest in people
between 25 and 44 years. The age group of 2534 contributed about 40%
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of all smear positive TB cases while 20% of the cases were from the 15
24 and 3544 age groups. Thus 80% of the cases were aged between 15and 44.
Prevalence
The actual prevalence of TB in Malawi is not known. Modeling
work done by the World Health Organization (WHO) predicts that
Malawi only diagnoses around 48% of the prevalent TB cases and 36%
of the prevalent smear positive TB cases.8 Although passive case
finding may lead to missing cases the WHO figure cannot presently be
contested in the absence of a prevalence survey. Such a survey is
currently being designed in Malawi.
One way of estimating the smear positive prevalence rate, the
major source of TB infections, has been through calculating the Annual
Risk of Infection (ARI). The average annual risk of infection is calculated
from the proportion of 6 year-old children, who have not been vaccinated
with BCG, who are tuberculin skin test positive in a particular area. This is
done in form of a community survey.
NON-COMMUNICABLE DISEASES
Accounts for approximately 12% of the Total Disability AdjustedLife Years(DALYs) which is fourth behind HIV/AIDS, other infections,
parasitic and respiratory diseases. NCDs are thought to be the second
leading cause of deaths in adults after HIV/AIDS.
The Health Sector Strategy Plan( HSSP )has therefore incorporated
NCDs in the Essential Health Package( EHP and interventions include
screening for cervical cancer, hypertension and diabetes and providing
treatment NCDs in the EHP and interventions include screening for
cervical cancer, hypertension and diabetes and providing treatment.
HypertensionThe STEPS survey published in 2010 identified a high level of
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high blood pressure (see annex 8) and diabetes. The level of hypertension
is higher in Malawi (35% of adults) than United States of America (USA)and United Kingdom (27%).Prevalence rate is 32.9% NCD STEP survey
2009 and Death rate of 0.93 %( 1,994/100,000 population)
Malnutrition
Malawi has one of the highest prevalence of protein-energy under
nutrition in the world. 30% of under five year old children, underweight,
49% are stunted and 7 are wasted (20). The ages of peak prevalence are
usually at 12 months for underweight and stunting while wasting peaks at
18 months
Prevalence of Malnutrition in Malawi
48% of under-fives are stunted 22 % of under-fives are underweight 5% under-fives wasted
Many babies were born with low birth weight; there has been nosignificant difference over the years.
TOP CAUSES OF DEATH
DISEASES Deaths %1 HIV/AIDS 55,967 26.86
2 Influenza & Pneumonia 22,896 10.99
3 Diarrheal diseases 15,066 7.23
4 Malaria 12,920 6.20
5 Stroke 11,187 5.37
6 Coronary Heart Disease 9,427 4.52
7 Low Birth Weight 5,999 2.88
8 Other Injuries 5,705 2.74
9 Violence 5,039 2.4210 Meningitis 4,911 2.36
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HEALTH CHALLENGESDrug and medical supply
A significant proportion of districts overspend on drugs as theybuy at higher prices from the private sector.
Shortage of pharmaceutical staff and this is exacerbated by lowoutput from health training institutions.
Human resource for health;
Despite an investment of $53million during the EHRP on pre-service training capacity, annual output of nurses only increasedby 22%.
Laboratory and radiology;
Inadequate funding, inadequate and inappropriate equipment,lack of capacity of the National Reference Laboratory to providereference laboratory services
CONCLUSION
Malawi has a low enrollment in its few Training Institutionswhich leads to reduced Medical staffs.
It also suffers reduced health facilities of which 60% have drugswhile 13% are running without drugs like Panado and evenOxytocin for the induction of lab our in pregnant women.
It also lacks ambulances which lets other patients die whilewaiting to be transferred to central hospitals.
Workload, low salaries (leads to brain drain), lack of access tohealth education and death of staffs aggravated by HIV/AIDS areleading to insufficient number working in the field.
Diseases like HIV/AIDS, influenza and pneumonia mainly affectthe productive age leaving Malawi with a low GDP leading topoor Malawi.
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