International University of Africa

Faculty of Medicine and Health Sciences

African Medical Students Association

Health Problems in Africa: Is there any hope 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, Nursing Level 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 km 2 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 Climate
Malawi'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 and humid 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 the event 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 2004 2009 PERSONNEL Physicians Nurses Physicians Nurses RATIO 1.1 25.5 2 36.8

SITUATION ON THE GROUNDS Currently, Doctor to patient ratio is 1:50,000 against WHO requirement of 1:5000 one 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 on third 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 diseases

In 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 level This 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 distributing agents (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. Some HSAs 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. Secondary level District hospitals constitute secondary level of health care and each district 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 of EHP. 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 central hospitals 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 healers through 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 facilities have 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 district hospital, 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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HEALTH WORK FORCE

COMMUNICABLE DISEASES
HIV/AIDS
The first case of HIV/AIDS in Malawi was confirmed in 1985. Since then the HIV virus that causes AIDS, has spread rapidly throughout the country to such an extent that Malawi is rated among the highest in the incidence of HIV/AIDS in the world.. H.I.V/AIDS being one of the leading cause of death worldwide, statistics shows that per 100 000 people, 55,967 (26.86%) die annually.

MALARIA
Malaria is endemic throughout Malawi and continues to be a major public health problem with an estimated 6 million cases occurring annually. It is the leading cause of morbidity and mortality in under five

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years of age and pregnant women. The use of Insecticide Treated Nets (ITN) when sleeping is the primary 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 25 34 contributed about 40%

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of all smear positive TB cases while 20% of the cases were from the 15 24 and 35 44 age groups. Thus 80% of the cases were aged between 15 and 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 Adjusted Life 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.

Hypertension
The 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 no significant difference over the years.

TOP CAUSES OF DEATH DISEASES 1 HIV/AIDS 2 Influenza & Pneumonia 3 Diarrheal diseases 4 Malaria 5 Stroke 6 Coronary Heart Disease 7 Low Birth Weight 8 Other Injuries 9 Violence 10 Meningitis

Deaths 55,967 22,896 15,066 12,920 11,187 9,427 5,999 5,705 5,039 4,911 -181-

% 26.86 10.99 7.23 6.20 5.37 4.52 2.88 2.74 2.42 2.36

HEALTH CHALLENGES
Drug and medical supply A significant proportion of districts overspend on drugs as they buy at higher prices from the private sector. Shortage of pharmaceutical staff and this is exacerbated by low output from health training institutions. Human resource for health; Despite an investment of $53million during the EHRP on preservice training capacity, annual output of nurses only increased by 22%. Laboratory and radiology; Inadequate funding, inadequate and inappropriate equipment, lack of capacity of the National Reference Laboratory to provide reference laboratory services

CONCLUSION
Malawi has a low enrollment in its few Training Institutions which leads to reduced Medical staffs. It also suffers reduced health facilities of which 60% have drugs while 13% are running without drugs like Panado and even Oxytocin for the induction of lab our in pregnant women. It also lacks ambulances which lets other patients die while waiting to be transferred to central hospitals. Workload, low salaries (leads to brain drain), lack of access to health education and death of staffs aggravated by HIV/AIDS are leading to insufficient number working in the field. Diseases like HIV/AIDS, influenza and pneumonia mainly affect the productive age leaving Malawi with a low GDP leading to poor Malawi.

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RECOMMENDATIONS
Establishment of gateway clinics to decongest central hospitals. Increase number of well equipped hospitals. Establishment of Medical Schools. Increase number of under and post-graduate scholarships Provision of Medical Tours which shall be voluntarily working with the few specialists e.g. the orthopedics and radiographers.

REFEREES
1 1

NSO. (2009). Malawi housing and population census 2008. Zomba: NSO NSO. (2011). Demographic and health survey 2010 preliminary results. Zomba: NSO. 1 NSO. (2009). Malawi housing and population census 2008. Zomba: 1 IMF Article IV Consultation Report 10/87 of March 2010 1 NSO. (2009). Welfare monitoring survey 2009. Zomba: NSO. 1 NSO. (2009). Welfare monitoring survey 2009. Zomba: NSO. 1 NSO, (2010), Demographic and health survey 2010 preliminary results, Zomba: NSO
1 1

Malawi National Malaria Indicator indicator survey 2010 NMCP MOH 2010. Msyamboza KP, Ngwira B, Dzowela T, Mvula C, Kathyola D, et al. (2011) The Burden of Selected Chronic Non-Communicable Diseases and Their Risk Factors in Malawi: Nationwide STEPS Survey. PLoS ONE 6(5): e20316. doi:10.1371/journal.pone.00203161 EPOS Health Management. (2010). Quality improvement of health care services in Malawi: mission report. Lilongwe: MoH and GTZ.
1

MoH.(2010). Final evaluation of the Health Sector Programme of Work (2004-2010).Lilongwe: MoH. 1 MoH. (2010). Annual report on the work of the health sector. Lilongwe: MoH

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