Mapping Health Care Access in Malawi: Update 1

In my attempt to study the state of health care in Malawi – a small country in southeastern Africa – I have divided my research into three parts: reviewing literature to gain context, completing training for the software system ArcGIS, and compiling maps generated with ArcGIS alongside my literature findings to write a paper summarizing my findings. With this first update, I will draw together some themes I discovered while reading current research reports and learning about the culture and health policy in Malawi. I dug into Google Scholar as well as databases available through William & Mary to find these scholarly articles focused on equity, under five mortality, maternal mortality, access to care, and more in sub-Saharan Africa and, more specifically, Malawi. In order to gain a historical perspective informed by long-term work in Malawian communities, I also read reports and web articles from non-governmental organizations working in Malawi. These NGOs helped give me a realistic view of both the organization of Malawi’s health care system and the struggles preventing effective public health service provision.

 

Malawi was a British colony from 1891 to 1964. After gaining independence, Malawi’s first president established a one-party state which renounced freedom of speech, silenced political opponents, and experimented with cash-and-carry health care financing. Malawi has progressed to holding democratic elections and attempting free public health care with the introduction of the Essential Health Package (EHP) in 2004, however corruption, inefficiencies, and inequities prevent drastic improvements to the nation’s health outcomes (2). The EHP highlights the eleven most prevalent, morbid diseases and conditions in Malawi in order to improve the health system’s resource availability, capacity to treat, and accessibility in order to improve health outcomes (20).

 

Malawi’s national public health care system offers services free to all Malawians at the point of delivery, and it is separated into three tiers: primary, secondary, and tertiary. The primary tier comprises community initiatives, health posts, dispensaries, maternity units, health centers, rural hospitals, and other local establishments that meet primary health needs. The secondary level includes district hospitals which provide specialized services to patients. Most laboratory, imaging, and testing facilities are only available at these district hospitals. The tertiary tier is a system of hospitals in major urban centers that provide more specific care (11, 1, 13).

 

For its population of over 18 million, Malawi only has 0.018 physicians for every 1000 people which equates to roughly 320 physicians for the entire nation (17). In response to this lack of human resources within the health system, Malawi established a network of Community Health Workers (CHW). CHWs include Health Surveillance Assistants (the only paid CHW position), community-based distribution agents, village health committee members, and volunteers (14). Most CHWs operate from small health posts, serve as community health educators, and follow national protocol to provide basic treatment to children (5, 18). CHWs are integral health promoters within the community, and their role is even more crucial in rural areas that are located far from formal health facilities. However, health planners must still work to define the specific link between CHWs – a first line of defense health worker with limited ability to provide care – and Malawian communities – who have shown that visiting CHWs decreases the likelihood of attending formal health facilities – in order to strengthen the overall health system and affect patients’ health seeking behavior (5).

 

Despite the development of the EHP and the introduction of CHWs, Malawi has one of the worst maternal mortality rates in sub-Saharan Africa at 634 deaths per 100,000 live births as well as a shockingly high under-five mortality rate of 55.1 deaths per 1000 live births (16). Many systematic deficiencies and inefficiencies explain these poor health outcomes: barriers to allocative efficient supply of health resources include insufficient quantity, inadequate quality, and inappropriate allocation while constraints on demand include factors such as distance, cost, perceived quality, level of health knowledge, and culture (9). The supply of competent, available medical professionals is hindered by Malawi’s abundance of unfilled health-related positions, excess of absences among health professionals due to unnecessary trainings, pervasive ignorance about the EHP and other health policies, and insufficient knowledge of common health conditions. Budget constraints and administrative delays also result in shortages of essential medications at public health centers (8). The EHP’s promise of free services at the point of delivery remains largely unfulfilled because these inefficiencies often drive citizens to seek health care outside of the public health system, incurring a cost. Because public health care utilization is lowest among poor Malawians, the least healthy cohort, targeting interventions towards the benefit of the least well off has the greatest potential to improve national health outcomes (9).

 

Nationally, Malawi’s leading causes of death include HIV/AIDS, malaria, and acute respiratory infections (11). In Malawi, the prevalence and morbidity of these conditions illustrates the need to enable health care access because early, affordable, and consistent treatment can decrease the mortality of these manageable, treatable conditions.

 

Malawi’s continued struggle with malaria exemplifies the inefficiencies in its health care system. In this malaria-endemic country, 40% of all hospitalizations are malaria related (11). International research and technology advancements concluded that the use of insecticide treated nets (ITNs) drastically decreases exposure to mosquitoes and, therefore, they decrease the risk of contracting malaria. Since this research was published in the late 1990s, Malawi has dispensed ITNs around the country through public health facilities and short-term mass distribution campaigns, especially focusing on vulnerable groups including children under 5 and pregnant mothers. However, utilization of these prevention tools still remains low, and ITN coverage is much higher in urban areas than rural communities (6). Seeking formal health care is also inhibited by widespread tendencies to overlook malaria’s symptoms or misattribute the condition’s symptoms to non-fever causes such as poor sanitation and mothers’ reproductive tract illnesses. In order to effectively address its high malaria rates, Malawi needs to redirect current ITN distribution campaigns to the poor, rural areas that lack ITN coverage and exhibit higher rates of malaria. Malawi also needs to collaborate with traditional healers and community health promoters to disseminate accurate educational messages about the vector-borne disease and the importance of seeking immediate care (3). Much like other health threats in Malawi, resources exist to decrease malaria rates, but strategic distribution as well as community-based efforts to encourage ITN use and improve knowledge of malaria’s causes and symptoms are still needed.

 

Malawi’s poor health outcomes also reflect the presence of health-diminishing conditions and risk-inducing cultural phenomenon. Malnutrition – as a result of poverty, unaffordable food prices, crop failure, and lack of advanced farming practices or materials – stunts growth in nearly 50% of children under 5. Chronic lack of iron resulting from shortages of eggs, fruit, vegetables, meat, beans, and fish also causes anemia which impacts children’s cognitive and physical development. Access to clean drinking water is also limited in Malawi. In communities without boreholes as safe water sources, water is collected from open water sources that serve as breeding grounds for mosquitoes and engender the spread of waterborne diseases. Also, family size is an ideological consideration that affects health. Large families are valued as symbols of wealth, power, and fertility in Malawian culture. However, the risk of maternal mortality that Malawi’s high fertility rate introduces is compounded by limited access to contraception, high prevalence of home births, and shortages of health professionals to drastically increase the risk of maternal mortality and health complications (11).

 

Used as a proxy to indicate overall health within a country, under five mortality calculates the number of deaths that occur per 1000 live births. In Malawi, the under-five mortality rate is 55.1 deaths per 1000 live births (16). The leading causes of deaths in children under five are preventable, treatable, infectious diseases: malaria, diarrhea, and pneumonia (15). Recognizing the preventable nature of the leading killers and the continued high rate of deaths occurring at home suggests the importance of access to health care (12). And in this definition of access, distance to health care could play an integral part.

 

While reading about the history and current circumstances in Malawi, I thought it was also important to look at factors outside of the immediate realm of health, hoping to explore the complexity of Malawi’s health outcomes and identify potential confounding variables (factors that lie outside of the explicit link between distance to health care and health outcomes yet could help explain the health seeking behaviors shown by the statistics). Gender inequality influences health in several ways: education rates for girls are consistently lower than for boys, regardless of socioeconomic status (10). Due to the strong association between education and health outcomes, education and health initiatives must target girls more specifically to improve Malawi’s overall health outcomes. A pervasive lack of female empowerment also hinders women’s ability to pursue health care without permission or financial backing from a male household member. Encouraging male involvement in maternal, newborn, and child health care services as well as making health care facilities more conducive to male attendance is also expected to have a positive impact on Malawi’s poor health outcomes (12, 3, 7).

 

Another factor inhibiting the success of Malawi’s Essential Health Package is corruption. While Malawi theoretically has a decent budget for health services, the 2014 Cashgate scandal shed light on several years’ worth of misused and illegally allocated government funds (2). Corruption can directly affect health funding because when public subsidies are lacking or unavailable, Malawians must pay more out-of-pocket to receive care. This added cost makes it impossible for many to afford health services. Also, donors often withdraw aid to punish corruption scandals which further decreases the funding for essential services. With about 30 percent of the national budget lost to corruption and fraud up until 2013, it is no question that the provision of health services suffered (10).

 

A network of inequalities affecting health also arose as I looked into the distribution of wealth in Malawi. Nearly 85% of Malawians live in rural areas, yet more public health facilities are located in urban areas (18, 10). This inefficient placement of public health facilities away from the majority of the population creates an access problem. Along with higher rates of poverty within these heavily populated rural areas as compared to urban areas (56% and 25%, respectively), Malawi’s rising Gini coefficient of wealth (measured by household ownership of durable assets) of 0.564 in 2011 suggests that the impoverished populations living in these rural districts are increasingly incapable of turning to private health care (4, 10). Furthermore, inequities in health and health care utilization show that Malawi’s health system disproportionally favors the non-poor (19). Because Malawians from rural districts cannot afford private health care, they must rely on public provisions; however, these public health facilities are often a several hour or days’ walk away. Distance must therefore be considered when examining the barriers to health care access.

 

Existing literature has confirmed an association between longer distances to health care facilities and higher transport costs, higher indirect costs in foregone caregiver salaries, and lower rates of insecticide treated net (ITN) possession and use in Malawi (5, 6). When accessing health care requires several hours or even days, caregivers are also discouraged from seeking care early, and waiting until patients’ conditions are truly grave which often limits the opportunity for effective treatment (6). For time-sensitive conditions such as falciparum malaria, a severe form of malaria which can cause death only hours after the onset of symptoms, distance to health care was among the factors that delayed treatment (3). While the majority of literature confirms this harmful effect of distance on health outcomes, some studies question this association, noticing the tendency of cross sectional studies to affirm and longitudinal studies to refute the significance of distance (12). With the remaining two segments of my research – completing ArcGIS training and creating my own maps using data from Malawi – I will continue to explore this relationship between distance and health outcomes in order to conclude whether decreasing distance to care would be an effective intervention to decrease mortality rates.

 


 

Works Cited

  1. African Health Observatory. Comprehensive analytical profile: WHO African region. Retrieved July 9, 2018, from http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Analytical_summary_-_Service_delivery
  2. British Broadcasting Corporation. (2018, March 05). Malawi profile. Retrieved July 9, 2018, from https://www.bbc.com/news/world-africa-13881367
  3. Chibwana, A. I., Mathanga, D. P., Chinkhumba, J., & Campbell, C. H. (2009). Socio-cultural predictors of health-seeking behaviour for febrile under-five children in Mwanza-Neno district, MalawiMalaria Journal, 8(1).
  4. Demographic Health Survey. (2005). National Statistical Office of Malawi: Integrated household survey 2004- 2005. Retrieved July 13, 2018, from https://www.dhsprogram.com/pubs/pdf/FR175/FR-175-MW04.pdf
  5. Ewing, V. L., Lalloo, D. G., Phiri, K. S., Roca-Feltrer, A., Mangham, L. J., & Sanjoaquin, M. A. (2011). Seasonal and geographic differences in treatment-seeking and household cost of febrile illness among children in MalawiMalaria Journal, 10(1).
  6. Larson, P. S., Mathanga, D. P., Campbell, C. H., & Wilson, M. L. (2012). Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in MalawiMalaria Journal, 11(1).
  7. Manda-Taylor, L., Mwale, D., Phiri, T., Walsh, A., Matthews, A., Brugha, R., Mwapasa, V., & Byrne, E. (2017). Changing times? Gender roles and relationships in maternal, newborn and child health in MalawiBMC Pregnancy and Childbirth, 17(1).
  8. Mueller, D. H., Lungu, D., Acharya, A., & Palmer, N. (2011). Constraints to implementing the essential health package in MalawiPLOS ONE, 6(6).
  9. Odonnell, O. (2007). Access to health care in developing countries: Breaking down demand side barriersCadernos De Saúde Pública, 23(12), 2820-2834.
  10. Oxfam International. (2015, November). A dangerous divide: The state of inequality in Malawi. Retrieved July 8, 2018, from https://d1tn3vj7xz9fdh.cloudfront.net/s3fs-public/file_attachments/rr-inequality-in-malawi-261115-en.pdf
  11. RIPPLE Africa. Information About Healthcare in Malawi, Africa. Retrieved from https://www.rippleafrica.org/healthcare-in-malawi-africa/healthcare-in-malawi-africa
  12. Rutherford, M. E., Mulholland, K., & Hill, P. C. (2010). How access to health care relates to under-five mortality in sub-Saharan Africa: Systematic reviewTropical Medicine & International Health, 15(5), 508-519.
  13. The Malawi Project. Hospitals & Healthcare Facilities. Retrieved July 9, 2018, from https://www.malawiproject.org/zzz/hospitals-healthcare/
  14. (2015, October). Community healthworker incentives in Malawi: Lessons learned. Retrieved July 8, 2018, from http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/chw_incentives_malawi_brief_ash_final.pdf
  15. (2016, September 26). Malawi maternal, neonatal and child health fact sheet. Retrieved July 8, 2018, from https://www.usaid.gov/malawi/fact-sheets/malawi-maternal-neonatal-and-child-health-fact-sheet
  16. The World Bank. Malawi. Retrieved July 10, 2018, from https://data.worldbank.org/country/malawi
  17. World Health Organization. (2018, February 22). Density of physicians. Retrieved July 9, 2018, from http://www.who.int/gho/health_workforce/physicians_density/en/
  18. World Vision International. (2015, November 15). Malawi’s community health workers. Retrieved July 8, 2018, from https://www.wvi.org/sites/default/files/CHW Profile Malawi.pdf
  19. Zere, E., Moeti, M., Kirigia, J., Mwase, T., & Kataika, E. (2007). Equity in health and healthcare in Malawi: Analysis of trendsBMC Public Health, 7(1).
  20. Zere, E., Walker, O., Kirigia, J., Zawaira, F., Magombo, F., & Kataika, E. (2010). Health financing in Malawi: Evidence from National Health AccountsBMC International Health and Human Rights, 10(1).

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