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 3 Tutor: 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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MNCH DEFINITION 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.

“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

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

GLOBAL MATERNAL MORTALITY

Around 500,000 women 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 1948 1987

• THE UNIVERSAL DECLARATION OF HUMAN RIGHTS • INTERNATIONAL SAFE MOTHERHOOD CONFERENCE (Nairobi)

1997

• SAFE MOTHERHOOD INITIATIVE’S 10TH ANNIVERSARY • De-emphasis training TBA • Maternal death as multisectoral problem • Comprehensive advocacy campaign increased visibility of &support for maternal

health.

1999

• Making Pregnancy Safer project

2000 2003

• MILLENIUM DEVELOPMENT GOALS: 4TH & 5TH* • SEXUAL AND REPRODUCTIVE HEALTH as integral comp. of health rights • PARTNERSHIP FOR MATERNAL, NEWBORN AND CHILD HEALTH (PMNCH)*

2005

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 Health Target: Reduce by three quarters, between 1990 and 2015, the

maternal mortality ratio

Goal-4: Reduce child mortality Target: 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 (%) Children <15 years (%) 12.9 2.2

* 6.1

* 17 47 2006 1995-2004 2004 2005 2006 Crude death rate (per 1000 population) Life expectancy at birth (in years) 43.6

41 * Source: WHO, Country system fact sheet-Malawi, 200614 * National Statistical Office, Zomba & UNICEF (2006) Multi-Indicator Cluster Survey16 200 2004

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

1.4

1.2

1 0.8

0.6

0.4

0.2

0 0.2

0.02

Physicians 0.58

1.17

Nurses and midwives 0.004

0.057

Laboratory technicians MALAWI AFRICAN REGION Figure on comparison of country system fact sheet on human resource comparison 0.057

0.17

Other health workers

Financial Contribution of Health System in Malawi (2004)

2% 1% 37% 60% 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)

• • Traditional healers and traditional birth attendants Increase in the out of pocket expenditure Based on data from Thomsom, H.I. (2004)

Trend of Maternal Mortality Ratio

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

Childbirth: a joyful occasion or one of grief?

Trend of Infants and Child Mortality Ratios

State of Maternal and child health services in Malawi

Indicators Value (Year)

Antenatal care at least 1 visit At 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 Contraceptive prevalence rate Total fertility rate Immunization of children by 1 year BCG DTP3 Polio3 Measles HBV 3 50% (nurse or midwives) 6% (doctors) 1% (patient attendant) 30.6%(2000) 6.1

89.7% 76.5% 73.2% 62.7% 87% Sources: Country Health system fact sheet, 2006. Malawi. 1 Maternal and child health, A. Phoya and S.Kang’oma

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

Ecclampsia 6% Others 10% Obstetric haemorrhage 11% Infectious conditions 20% Puerperial sepsis 29% Post abortal complication 24% Fig. 5 data from UN Development Program & Government of Malawi (2008)

Major Causes of Under 5 children deaths in Malawi (2000-2003)

Malaria 14% Others Injuries 8% 2% HIV/AIDS 14% Diarrhoeal diseases 18% Pneumonia 22% Neonatal causes 22% Fig. 6 data from UN Development Program & Government of Malawi (2008)1

Causal Chain Analysis

Social Economic Environmental Political Lack of resources: human, financial, natural Food insecurity Poverty housing, education, low income infrastructure Unhealthy living environment Inadequate health and health care Inadequate nutrition of both mother and children

Long term consequences

Underweight and stunted children Poor intellectual ability Illness of mother and children Poor quality of health services for MCH and Primary health care

Short term consequences

Maternal and child: mortality, morbidity

Scanning the national response

Malawi 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 SLOT

Strengths Limitations

• • • MCH prioritised in national policy Coordination body for action on MCH (different partners) Adoption of innovative, appropriate strategies for service provision • • • • 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)

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SOME LIMITATIONS

Opportunities Threats

• • • Democratisation (1994) and decentralisation (1998) Political commitment (Health Expenditure 9.64 %) Considerable international aid (% of aid?) • • • •

Low empowerment of women Recurrent drought Global economic crisis Multi faceted effects of HIV/AIDS

Stakeholders’ Analysis

Significant Somewhat Little Private sector NGO MLG MoHP Donors No No Little Public (beneficiaries) Some Interest in Policy Significant

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

• Strengthen SWaps • Strengthen the Emergency Human Resources Programme • Bolster efforts aimed at unsafe abortion – legislation • Scale up innovative, good practice – Kangaroo Mother care • Improve logistical management

...Recommendations – Health Sector

• Strengthen IEC/BCC for tackling cultural barriers • Sustainable means to health care financing • Strengthen partnerships with Global Actors – PMNCH • Actively monitor, reflect, and share lessons learnt

MCH lecture Thematic and setting agreed National Context Review of MNCH Regional context Current thinking Global & response Actors National response Key Findings Review vis-a-vis International Protocols MCH Review, milestones, current thinking and mechanisms Situation Analysis Major causes, trends and health system SLOT of Policy and Programmes Stakeholder Analysis matrix Conclusion Framework for actions

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