malawi and mdg4: early adopter, early achiever and mdg4: early adopter, early achiever. ... hmis...
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MALAWI IN-DEPTH COUNTRY CASE STUDYFINDINGS
Lilongwe, Malawi 27 July 2015
Malawi and MDG4:Early adopter, early achiever
Background
• Countdown to 2015 for Maternal, Newborn and Child Survival (“Countdown”) tracks progress in coverage for proven interventions in maternal, newborn and child survival
• Countdown is supporting a series of in-depth country case studies to produce generalizable lessons about scaling-up RMNCH programs
• Malawi (NSO) competed successfully to conduct one of the Countdown case studies
Trends in U5MR from 1990 to 2015 as estimated by IGME using all surveys up to 2013-14 MDG Endline Survey
64 U5 deaths per 1,000 live births
247 U5 deaths per 1,000 live births
Malawi Case Study Objectives
1. To explain how Malawi achieved MDG4 at national level
2. To examine roles of other programs (nutrition, maternal health, HIV), equity and contextual factors
3. To describe variations in district progress 4. To share lessons learned so that they can guide
future policies and programs in Malawi and similar countries
Organization of the work: 5 teams
Mortality
• National, regional, district
• 5 household surveys with full birth histories, 2000-2014
Coverage/nutrition
• National, district• 5 household
surveys, 2000-2014
• Recalculation and quality assessment of all indicators
Program documentation
• National: 25 interviews, document & data base review
• 10 districts: 150 key informant interviews; Review of district HMIS & program reports
• Tracking of contextual factors
Financing
• National: National Health Accounts; Countdown ODA data
• Districts: Integrated Financing Management Information System; AID data; 41 in-depth interviews.
Lives Saved Tool (LiST)
Consistency LiST: measured national estimates
Contribution of specific interventions
Analysis and writing workshop to bring components together and synthesize.
Process
Working meetings: 1. November 2013, Lilongwe2. March 2014, Ku Chawe3. November 2014, Lilongwe
Participants:
Government of Malawi
Findings
Under-five mortality, national, 1990-2015
Malawi will have reduced U5MR by 5.4% per annum between 1990 and 2015 Substantially faster than
the 4.4% goal of MDG-4 In absolute terms,
decline is remarkable: 247 to 64 per 1,000 live births
Neonatal mortality declined more slowly, at only 3.3% per annum
Trends in U5MR from 1990 to 2015 as estimated by IGME in 2014
64
247
Under-five mortality rates, district, ≈ 2000 & ≈2010
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≈2010
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(1999-2001) (2009-2011)
North NorthCentral CentralSouth South
20
40
60
80
100
140
160
180
200
120
Unde
r-fiv
e m
orta
lity
rate
Child lives saved
Lives saved in 2013 by intervention group, National
Yearly lives saved by intervention group 2000 – 2013, National
Trends in intervention coverage
Trends in coverage vary widely by intervention, national, 2000-2014
Sources: 2000, 2004, 2010 DHS, 2006 MICS, 2013/14 MDGE
Important reductions in undernutrition among children under five! National, 2000-2013
Sources: 2000 DHS, 2013/14 MDGE
Programs and policies
Health sector policies: focus on women and children
From 2005, a focus on women and children in national health sector strategies complimented by
specific acceleration plans.
Technical policies for high impact interventions
Essential child health programmes continuously updated to include state-of-the-art, evidence-based
interventions
Addressing major risk factors – nutrition and HIV
Combating HIV and improving nutrition essential for sustaining and enhancing child health and
development
Integration, access and quality of high impact interventions
Providing quality, integrated child health services across all levels of the health system
including the community
Health system bottlenecks to progress
• Health workforce: • A substantial proportion of positions in the establishment plan are vacant
(analysis in progress)• Performance of trained personnel not meeting required standards (IMCI QoC
survey, hospital assessments)
• Medicines and supplies:• Stock-outs of essential life saving commodities in health facilities and in
village health clinics (iCCM evaluation, EmOC assessments, SPA)
• Mentorship and skills improvement • Infrequent supervision (iCCM evaluation, IMCI QoC survey)• Limited observed clinical practice
• Governance• Limited predictability of health sector funding at district level (case reports)• Budget allocations too low for needs (case reports)
Financing
Share of government budget going to health –remains well below Abuja target
02468
10121416
2006 2007 2008 2009 2010 2011
%
GoM Health Budget/Total Government Budget (Domestic + GeneralBudget Support)GoM Health Budget / Total Domestic Budget
Abuja target
Source: NHA 2010; NHA 2012/13
Total health expenditure by financing source
020406080
100120140160180
2006 2007 2008 2009 2010 2011
Cons
tant
201
3 bi
llion
Kw
acha
Donor Gvt HH Other
• Gradual increase with speed up post 2009
• Very dependent on partners (66-70%) –increase post-2009 driven by partner funding
• Government and Household contributions have been stable (14-17% government and 10% households)
Source: NHA 2010; NHA 2012/13
Key Messages
Good news on child survival!
Under-5 mortality in Malawi has declined sharply from 1990 to 2014 by 5.4% per yearMalawi will easily exceed the MDG-4 target
Most of the decline has been between the ages of 1 and 60 monthsMuch slower improvements in neonatal mortality
All parts of the country have seen rapid declines, but they have been faster in the North than in the SouthBut some standout districts in all regions
Differences in risk of child mortality by education of mother and urban-rural residence are smallAnd the differences by education of mother have gotten even smaller
between 2000 and 2010
Major gains in some areas
Overall, the Malawi Government has been an early adopter of policies supportive of child survival Solid gains in increasing coverage for effective
interventions and reducing deaths, for example: pneumonia (Hib and pneumococcal vaccines, careseeking for pneumonia)malaria (ITNs, treatment) HIV (prevention and treatment)
Access to interventions is highly equitable – few differences between urban and rural, educated and less educated mothers. Important gains in reducing child undernutrition.
Important work remains to be done
Increased efforts are needed for newborns.Overall decline 2000-2014 of 3.3% per annum
There is an unfinished agenda for children aged 1-59 months. High and equitable coverage must be maintained Further gains needed in coverage for treatment of childhood illnesses Increased focus on service quality, and ensuring every service contact is
used to provide high-impact interventions
Some districts are performing much better than others, and this gap must be closed. Analysis is ongoing. Health system strength must continue to improve:
continuous supplies of drugs and commodities; human resources and supports for health worker performance.
Thank you