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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)
www.africatravelpictures.com
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
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
• 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
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)
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
Long term consequencesUnderweight and stunted childrenPoor intellectual ability
Short term consequencesMaternal and child: mortality, morbidity
Short term consequencesMaternal and child: mortality, morbidity
Illness of mother
and children
Illness of mother
and children
SocialEconomic
EnvironmentalPolitical
SocialEconomic
EnvironmentalPolitical
Lack of resources:
human, financial, natural
Lack of resources:
human, financial, natural
Poverty housing, education, low income infrastructure
Poverty housing, education, low income infrastructure
Food insecurity
Food insecurity
Unhealthy living
environment
Unhealthy living
environment
Inadequate health and health care
Inadequate health and health care
Inadequate nutrition of
both mother and children
Inadequate nutrition of
both mother and children
Poor quality of health services for MCH and
Primary health care
Poor quality of health services for MCH and
Primary health care
Causal Chain Analysis
Scanning the national responseMalawi growth and
economic development policy
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
•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
Infl
uen
ce i
n P
oli
cy
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
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.