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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(1999-2001) (2009-2011)

North NorthCentral CentralSouth South

20

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140

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200

120

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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

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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

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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