Jul 2, 2015 - JULY 2015. Malawi. uNDerSTANDING ProGreSS oN cHILD SurVIVAL. MALAWI DrAMATIcALLY. IMProVeD cHILD SurVIVAL,
Countdown Country Case Study
Malawi
UNDERSTANDING PROGRESS ON CHILD SURVIVAL aims to build a portfolio of studies that assess multiple outcomes across the continuum of care, and that include attention to success stories as well as areas where progress was not made, and analyse the reasons why. Countdown case studies are led by in-country institutions that are independent of RMNCH program implementation.
early ADOPTION OF EVIDENCE-BASED POLICIES CONTRIBUTED TO HIGHER COVERAGE
Under-5 Mortality Rate
164 162
150 152
Joint programme of work (JPCW and Sector Wide Approach (SWap) 2004-2010
Health sector strategic plan 2011-2016
Prevention of mother-to-child HIV transmission (PMTCT) was scaled up rapidly, and from 2011 HIV+ pregnant women were guaranteed life-long antiretroviral treatment. National and community-level action on food security and undernutrition strengthened Malawi’s ability to withstand repeated droughts. Source DHS 2000, MDG Endline Survey 2014 JULY 2015
161
124
Thyolo
Chikwawa
Blantyre
Balaka
Mchinji
Chiradzulu
Dedza
96 97 99
Insecticidetreated bednets
Hib immunization
Essential health package (EHP): Service Level Agreements (SLA)
93
78 %
%
0%
6%
Careseeking for pneumonia
62 %
Long lasting Nets (LLINs)
Integrated Management of Childhood Illness (IMCI)
187
COVERAGE: CHILDHOOD ILLNESS PREVENTION/TREATMENT
TIMELINE OF SELECTED POLICIES
Insecticide treated nets
MULTI-SECTORAL ACTIONS ADDRESSED HIV AND CHILD NUTRITION
178
106 106 107 110 99 104 104
Zomba
Ntcheu
92 94 94
Kasungu
Dowa
89
Salima
Nkhota KotA
Annual rate of reduction
156
Machinga
Nkhata Bay
56 58 59
2013
Lilongwe
87 82 83 86
Phalombe
79
Mwanza + Neno
78 73 77
ntchisi
3.3%
159
171
163 136
103
Rumphi
5.4%
23
153
172 173 170 173
121
Mzimba and Mzuzu
71
Newborn Mortality Rate
50
163
144
137 114
186
172
The Roadmap to accelerate maternal Revised in 2011 Policies required quality, and newborn survival integrated child health services Accelerated Child Survival Child Health across all levels of a strengthened and Development Strategy Strategy health system; updated programs (ACSD) were supported by increased TIMELINE OF IMPLEMENTATION OF SELECTED PROGRAMMES international funding. Coverage for disease prevention and Haemophilus influenza vaccine introduction with Pentavalent vaccine treatment markedly improved. Sources Policies/programs: Countdown case study timeline (selected); Coverage: DHS 2000, MDG Endline Survey 2014 (Note: Coverage data in this brief was re-analysed by Countdown for consistent indicator definition across time.)
Southern Region 1999-2001 2009-2011
190
247
1990
Central Region 1999-2001 2009-2011
Mulanje
Northern Region 1999-2001 2009-2011
Mangochi
Deaths per 1,000 live births
UNDER-5 MORTALITY RATE BY DISTRICT, AROUND 2000 AND AROUND 2010
Karonga
Sources National estimates: UN Inter-agency Group for Child Mortality Estimation, 2014 District estimates: Countdown case study analysis of all available surveys
UNDER-5 AND NEWBORN MORTALITY RATES, 1990 AND 2013
Chitipa
In 1990, one in 4 Malawian children died before age 5; by 2013, only 1 in 14 failed to survive to their 5th birthday. Child mortality declined markedly in every district, but mortality remains highest and progress has generally been slowest in the Southern region.
Learn more about Countdown Country Case Studies at www.countdown2015mnch. org/countdown-at-thecountry-level.
Over 30% of Malawi's population lives in severe poverty, yet it is one of only a few countries in sub-Saharan Africa on track to achieve MDG 4 by reducing under-5 mortality by two-thirds between 1990 and 2015. A team of national and international researchers, led by the Malawi National Statistical Office, conducted an in-depth Countdown Country Case Study to better understand Malawi’s successes and challenges in improving health and development among women and children. The study’s findings, being prepared for publication in 2015, are summarised in this brief.
Countdown supports in-depth Country Case Studies that seek to understand and explain how progress on women’s and children’s health was achieved. By strengthening country-level capacity to conduct this research, Countdown
MALAWI DRAMATICALLY IMPROVED CHILD SURVIVAL, BUT MADE SLOWER PROGRESS FOR NEWBORNS
See Malawi’s 2014 Countdown country profile, as well as a detailed equity profile, at: www.countdown2015mnch. org/country-profiles/malawi.
Nsanje
Countdown to 2015 tracks coverage levels for health interventions proven to reduce maternal, newborn and child mortality, together with data on equity of coverage, health financing, policy and health systems, and other determinants of coverage. It calls on governments and development partners to be accountable, identifies knowledge gaps, and proposes new actions to improve health and reduce mortality. Countdown’s data and analysis cover 75 countries that account for over 95% of all maternal and child deaths. The annual Countdown to 2015 country profile enables countries to track their progress and identify key areas where more progress is needed.
Oral rehydration for diarrhoea
64%
27%
IMCI addressing newborn
48%
Integrated case management (iCCM) Low-osmolarity Oral Rehydration Salts (ORS)
2000
01
02
03
HIV AND NUTRITION INDICATORS
04
05
PMTCT coverage
06
07
08
09
Exclusive breastfeeding coverage
2000
0%
44%
2014
76%
70%
10
11
12
13
2014
Stunting
Underweight
2000 2014
2000 2014
54% 42 % 21% 16 % 22% Percentage 20% Percentage reduction reduction
2000
2014
Wasting
2000 2014
7 % 4% 44% Percentage reduction
FOCUS ON NEWBORN SURVIVAL HAS INCREAsed, BUT MORE EFFORT IS NEEDED Newborns account for 38% of under-5 deaths (2010), but attention to newborn health only intensified after 2005, and donor support has been insufficient. Coverage has increased for many key childbirth interventions; the Every Newborn Action Plan aims for universal coverage of high-quality care for mothers and newborns. Sources Funding: Countdown ODA database Coverage: MICS 2006, DHS 2010, MDG Endline Survey 2014
MALAWI ACHIEVED EQUITABLE INCREASES IN COVERAGE FOR MANY ESSENTIAL SERVICES
DONOR FUNDS GOING TO MNCH PROJECTS MENTIONING OR BENEFITING NEWBORNS (US$ MILLIONS)
Skilled birth attendance
150
Early Initiation of Breastfeeding
89 % 120 90
74%
54%
Maternal/Child Health funding
2006
59 %
2010
Postnatal care for mother
60
Postnatal care for newborn
80 % 30 0
Grant mentions Newborns
78 %
56 %
2006
55 %
2014
2003
04
05
06
07
08
09
10
11
2012
EQUITY TRENDS: MORTALITY AND COVERAGE
143
Urban
Under-5 mortality rate, BY URBAN/RURAL RESIDENCE
2000
Contraceptive prevalence rate, by maternal education
2000
Source DHS 2000 & 2010; MDG Endline Survey 2014
Skilled birth attendance, by wealth quintile
2000
HOW MALAWI SAVED HUNDREDS OF THOUSANDS OF CHILDREN’S LIVES
ESTIMATED UNDER-5 DEATHS AVERTED THROUGH HEALTH INTERVENTIONS, YEAR 2013: (TOTAL 40,400)
The rural poor have not been left behind as national mortality and coverage indicators improved, and equity gaps have narrowed for some key interventions.
COVERAGE: Care Around Childbirth
84
2010 No Education
26 %
45 % 53 %
2010
173 Rural
102 Secondary + Education
62 %
42 %
Poorest
78 %
Wealthiest
83 %
2014
95 %
Each square represents 100 child lives saved.
In the period from 2000 through 2013, an estimated 280,000 child deaths were prevented through scale-up of high-impact child health interventions. The annual number of under-5 deaths was cut by more than half, from an estimated 103,000 in 1990 to 41,000 in 2013. Sources Estimated annual deaths: UN Inter-agency Group for Child Mortality Estimation; Estimated deaths averted: Lives Saved Tool (LiST) estimates (see published paper for strengths/limitations of LiST analyses)
10,000 Lives saved by malaria prevention AND TREATMENT
INTENSIFIED EFFORT IS NEEDED TO BUILD ON MALAWI’S ACHIEVEMENTS Malawi’s success in reaching the MDG 4 child mortality target was founded on several key factors. Malawi was an early adopter of evidence-based policies, enabling equitable increases in access to and quality of essential health services. It took concerted action to strengthen its health system, increase the number of health workers, and conduct regular surveys to generate evidence for action. It vigorously addressed HIV and undernutrition as major causes of child mortality and illness. But a great deal of important work remains to be done.
JULY 2015
8,300 Lives saved by vaccine programs
5,900 Lives saved by improvements in nutritional status
5,000 Lives saved by diarrhoea & pneumonia treatment
4,500 Lives saved by HIV interventions
3,500 Lives saved by improved childbirth care
3,100 Lives saved by other interventions
Key actions needed to build on Malawi’s successes: ¡ Improve newborn survival by achieving universal access to high-quality care at birth, including for small and sick babies
¡ Deliver on the Government's commitment in the Abuja Declaration of 2001 to allocate at least 15% of total government spending to health
¡ Take action to eliminate the unmet need for family planning and increase coverage for treatment of childhood illnesses
¡ Address remaining health system constraints, strengthen the supply chain for essential medicines, and train and deploy more skilled health workers
¡ Develop effective strategies to close remaining equity gaps and address lower coverage and higher mortality in the Southern region
¡ Coordinate and harmonize implementation strategies across communities and health facilities, benefiting from lessons learned in best-performing districts