amsa-iua: conference proseedings_jan 2013 - 13. malawi

8/13/2019 AMSA-IUA: Conference Proseedings_Jan 2013 - 13. Malawi

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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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