General Information About Healthcare in Malawi
RIPPLE Africa receives many general enquiries each month asking about the conditions of health and healthcare services in Malawi, Africa. To help those wishing to learn more, we have provided a page with information about what healthcare is like in Malawi, and most specifically, in the Nkhata Bay District where RIPPLE Africa is based.
RIPPLE Africa’s healthcare aims are mainly delivered through its support of Mwaya Community Dispensary and other local clinics and hospitals. Much of that support is delivered through the important volunteer work of our overseas doctors and nurses who provide much needed assistance to the community.
250,000 people live in the Nkhata Bay District where RIPPLE Africa is based. Important general healthcare indicators for Malawi include national life expectancy from birth which is 61 for men and 65 for women compared with 81 years in the UK and 79 in the US (2016 World Bank). This low life expectancy in Malawi can largely be attributed to malaria, HIV/AIDS, chronic malnutrition, sub-standard health services, and inadequate access to safe drinking water and proper sanitation.
The under-5 mortality rate per 1000 live births is 68 while the maternal mortality rate stands at 510 per 100,000 live births in the country. The maternal mortality rate in Malawi is one of the highest in Africa with obstetric complications contributing to a significant number of deaths.
The leading causes of death in Malawi include:
While Malawi has made strides in reducing the number of HIV infection in the country over the last decade, AIDS remains the number one killer in the country. In 2012, 27.1% of all reported deaths in the country were HIV/AIDS related. almost 1 million Malawians are living with HIV with approximately 550,000 children orphaned by AIDS. 13% of women and 8% of men in the country are living with HIV. An estimated 50,000 new infections occur every year. Pregnant mothers are at risk of infecting their children. Multiple sex partners, low usage of condoms, and inadequate ARVs are some of the reasons for the high deaths as a result of HIV/AIDS in the country. Most Malawians also do not feel personally susceptible to HIV infections and therefore do not take necessary precautions to prevent the infections.
- Acute Respiratory Infections
Acute Respiratory Infection is the second leading cause of death in Malawi accounting for 8.6% of all reported deaths. Pneumonia-related deaths are common among children under the age of 5, causing 13% of all deaths for this age group. Lack of access to health facilities for the treatment has led to significant deaths.
According to the World Health Organization, malaria-related deaths in Malawi were recorded as 9,484 accounting for 6.3% of the total recorded deaths in the country. Malaria accounts for 40% of people hospitalised in the country. Use of insecticide-treated nets for malaria prevention is still very low in Malawi thus exposing the majority of the population to the risk of contracting malaria. The high cost of treating malaria has led to significant deaths especially among the poor communities.
Health Service Provision in Malawi, Africa
Most health centres have very basic facilities
The government of Malawi has a national healthcare service which is government funded, and free to all Malawians at the point of delivery. Government healthcare is provided in three forms: Health Centres at the local level, Regional/Rural Hospitals one level up, and District Hospitals at the highest level. According to WHO, total expenditure on health per capita is US$93, and expenditure on health as a percentage of GDP is 11.4%. With little funding, investigations are limited by resources, and diagnosis is largely based on clinical presentation. Most laboratory, imaging, and testing facilities are often only available at the major District Hospitals. Malawi has very few doctors (only one for every 88,300 people in Malawi), so hospitals are staffed by Clinical Officers (trained for a minimum of four years, and who are very experienced practitioners), and Medical Assistants (trained for a minimum of three years.) The Clinical Officers and Medical Assistants are usually in charge of their workplace, and manage any in-patient care. They diagnose, treat, and prescribe.
All clinics and hospitals will have a team of nurses (trained in midwifery and nursing), who also diagnose and prescribe. Health Surveillance Assistants (HSAs) have a diverse role, including the management of the community health needs, assisting in clinics, collating all records, and performing VCT (Voluntary Counselling and Testing for HIV/AIDS.)
Malaria in Malawi, Africa
There are often shortages of medicines in the rural health centres
Cerebral malaria can kill very quickly if the patient is not treated
According to WHO, about 3.3 billion people (half the world’s population) are at risk of malaria, and malaria kills nearly one million people worldwide every year. Malaria is transmitted by the bite of an infected mosquito, and causes fever and flu-like symptoms which, if left untreated, can lead to death. Of course malaria is a completely treatable disease; however, survival depends on early diagnosis and access to medication before the disease progresses. This makes access to proper healthcare facilities and trained physicians essential. In addition to quick diagnosis and treatment, malaria can also be controlled and reduced by taking a number of preventative measures.
- Firstly, the mosquito which carries the malarial parasite is most active at night, so the use of mosquito nets when sleeping can prevent the opportunity for a malaria-infected mosquito to bite its host. In Malawi, many people have access to mosquito nets; however, not everyone has them, and not everyone is consistent about using them. (We have seen many people using their nets for fishing instead!) In order for mosquito nets to be effective at combating malaria for an entire community, 80% of a community population has to be using them.
- Secondly, control of the mosquito population at large can also help prevent the disease and Malawi has recently introduced a scheme where houses are being sprayed with insecticides which are very effective at killing mosquitoes, and last up to 12 months. As with the mosquito nets, however, this residual spraying must take place in at least 80% of homes in an area to be an effective preventative measure to the community at large. People do have access to medication to treat malaria, but often wait until the last minute to seek medical care, especially where a healthcare centre is a great distance from their home. The longer someone waits before seeking treatment, the greater the risk of complications.
RIPPLE Africa helps fight malaria by ensuring communities have immediate access to healthcare services for quick diagnosis of the disease. Patients presenting with malaria make up the majority of the cases at both the Kachere Health Centre and the Mwaya Dispensary which RIPPLE Africa supports, and RIPPLE Africa volunteers drastically increase both facilities’ abilities to cater for more patients.
HIV/AIDS in Malawi, Africa
Like many countries in Africa, the rate of people living with HIV/AIDS in Malawi is extremely high. WHO officially recognises that 12% of the population in Malawi is HIV positive; however, our experience at the clinics in our area has revealed that number to be much higher – as high as 30%! Despite the huge proportion of people living with HIV/AIDS, there is still a social stigma attached to the disease in Malawi. Culturally, most people in Malawi are still hesitant to talk about HIV/AIDS, and many are too afraid to be tested. Many people feel they will be ostracised from their communities if they are discovered to be HIV positive, and thus continue to live with the disease without treatment, and continue to risk the infection of others.
Unprotected heterosexual sex is the main mode of HIV transmission in Malawi, accounting for 88% of new HIV infections. Despite this, there are several key populations that are increasingly vulnerable to HIV infection.
- HIV disproportionately affects women in comparison to men in Malawi. The 2010 Malawi Demographic and Health Survey found that HIV prevalence among women was 12.9% compared to 8.1% HIV prevalence among Malawian men. This disparity is especially prominent among young people, with 3.7% of 15-17 year old women living with HIV in comparison to 0.4% of 15-17 year old men. This difference could be reflected in young men having more comprehensive knowledge of HIV than females.
- Young people account for 50% of new HIV infections in Malawi, with HIV prevalence higher among some young populations, such as 15-17 year olds. 4.5% of young females aged and 2.7% of young men aged 15-24 years old are living with HIV in Malawi. Early sexual activity is high in Malawi, especially among young men, with one in five sexually active before age 15. With young people engaging in sex at an early age, addressing the sexual and reproductive health needs of this population is critical.
- Homosexual men have been identified as a key affected population within the Malawian HIV epidemic. Data on this group remains very limited, although some studies have found HIV prevalence as high as 21%. Efforts to address this increased vulnerability were, until very recently, limited by laws that rendered homosexuality an illegal behaviour. Homosexuality was decriminalised in 2012 and it is hoped that this legal change will bring more support for this underserved, high-risk population.
- Sex work is criminalised in Malawi, limiting the amount of available data on this key population. It has been found that HIV prevalence among sex workers is as high as 71%. Sex workers in Malawi face high levels of discrimination when seeking HIV services further increasing their vulnerability to HIV, especially from police when seeking victim support services.
- An estimated 170,000 children are living with HIV in Malawi. Malawi has shown immense progress in reducing child HIV infection rates with a 67% reduction in children acquiring HIV, the largest country decline across sub-Saharan Africa. However, only 23% of children living with HIV were on treatment in 2013.The 2014 Malawi Progress Report further identified early infant diagnosis as a priority for the national HIV and AIDS response. Supporting the needs of orphans and other children made vulnerable by AIDS is identified as a main element of the national Malawian HIV response. Factors such as poverty are preventing the roll-out of adequate support and services for these children.
Fortunately, many people in Malawi have access to free ARVs (antiretroviral drugs), a combination of drugs which considerably prolong the life of a patient living with HIV/AIDS by many years, if not decades. ARVs also significantly reduce the chance of mother-to-child transmission, so mothers who are HIV-positive can give birth to healthy babies without passing the disease on to them. Despite these miracle results, the reality of ARV use in Africa is complicated. However, following an ARV regime is complex and side effects have to be carefully monitored. For many people in Malawi, it is not enough that the ARVs themselves are free. Basic factors such as the cost of the bus fare to get to a clinic for treatment on a weekly basis, and regular access to enough food and water to be taken with the medication can prevent people from taking ARVs consistently or at all. Healthcare resources are also extremely limited, so physicians have much less at their disposal to monitor treatment than would be used or recommended elsewhere in the world.
However, the greatest obstacle to ARV use in Malawi is still the low percentage of people who get tested early, with the majority only confirming that they have the disease once they have progressed to the final stages of AIDS. When people leave their diagnoses and treatment until the very end, their options are very limited and many people turn to traditional medicine, where treatment is often harmful, costly, and of course ineffective.
An HIV/AIDS awareness campaign
RIPPLE Africa volunteers work with many patients who are living with HIV/AIDS and promote HIV/AIDS awareness at schools, clinics, and community level. RIPPLE Africa has also been involved in public health campaigns to tackle the stigma associated with the disease, and encourage people in the community to get tested.
Malnutrition in Malawi, Africa
Malnutrition is one of the major health problems facing the developing world, and is one of the leading causes of death in Malawi. Malnutrition is a condition which is caused not just by a lack of food, but by taking a diet which is so unbalanced that the body lacks certain nutrients altogether, while other nutrients may be in excess, causing nutritional disorders which are not only harmful, but are potentially fatal. WHO cites malnutrition as the single greatest threat to the world’s public health.
In Malawi, droughts, floods, inflation and lack of diversified farming have exposed a large part of the population to food insecurity. An estimated 1.4 million (9.5 percent of the total population) were at risk of severe food insecurity in 2013, with 21 out of 28 districts affected due to extreme dry spells in the Northern and Central regions.
In Malawi, the majority of the population is heavily reliant upon nsima as the staple of their everyday diet. Nsima is a porridge-like substance made of ground maize or cassava flour which is mixed with water to form a doughy carbohydrate which is then served with different relishes to flavour it, such as potatoes, fish, boiled vegetables, tomato soup, etc. Nsima is eaten all throughout Africa, and is also known as nshima in Zambia, sadza in Zimbabwe, ugali or posho in East Africa, banku or fufu in West Africa, and pap or mieli-meal in South Africa.
As a staple carbohydrate, nsima is popular because it helps Malawians to feel full, and because maize, and particularly cassava, is a dependable crop which grows well in hot climates. While nsima might be a reliable choice for a staple food, it has little nutritional value. Eaten with fish or meat for protein, eggs or oil-based soups for fats, and vegetables for important vitamins and minerals, nsima is part of a balanced diet. However for many Malawians, poverty, food prices, crop failure, poor agricultural skills, a failure to practice crop rotation, a lack of irrigation, fertilisers, pesticides, over-fishing and more all contribute to a lack of access to a variety of foods, and many of the poorest people eat nothing but nsima, or at least not enough relish to make up the nutritional content the body is lacking. As a result, many Malawians are malnourished, and children and pregnant women are particularly vulnerable, where malnourishment not only exacerbates existing health conditions, but can be fatal in its own right.
Undernutrition in women and children remains a persistent public health and development challenge in Malawi. Nearly half the children suffer from chronic undernutrition (stunting) and micronutrient deficiencies, including iron and vitamin A. Rural children are more likely to be stunted (48%) than urban children (41%). There is little regional variation, with stunting high in all the regions. Education and wealth are both inversely related to stunting levels.
Though rates of exclusive breastfeeding have increased during early infancy, only 19% of children 6-23 months of age receive a minimum acceptable diet, which has a major impact on their growth and development. (USAID 2014)
According to WHO, almost half of children under five in Malawi are identified as stunted (low height for their age), 4.2% are identified as wasting (low height for their age). Stunting reflects the cumulative effects of undernutrition and infections, even since before birth, and for children who are critically underweight, the risk of infection and death is severely increased. While weight loss can be corrected, the long term effects of malnutrition in the first two years are irreversible.
Anaemia, caused traditionally by a lack of iron in the diet from a shortage of foods such as eggs, red meat, oily fish, beans and pulses, green vegetables, and some fruits, can increase the risk of maternal and child mortality, has a negative impact on the cognitive and physical development of children, and reduces physical performance and the work capacity of individuals and entire populations. Vitamin C, which is found in fruits such as papaya (pawpaw), oranges and lemons, mangoes, and pineapples, can help the body to absorb iron, making it another essential element of a healthy diet. Deficiency in Vitamin A, found in foods such as liver, carrots, broccoli, spinach, and guava fruits can cause night blindness, permanent blindness altogether, maternal mortality, poor outcome of pregnancy and lactation, and a diminished ability to fight infection.
RIPPLE Africa is helping communities to grow fruit trees to improve nutrition
RIPPLE Africa helps communities to establish vegetable gardens for HIV sufferers
RIPPLE Africa volunteers help fight malnutrition in Malawi by monitoring the weight of babies and children at the Under Fives Clinics run by staff at Kachere and Kande Health Centre on a weekly basis. These clinics help identify children in the community who are at risk, and those identified as critically malnourished join the Malnourished Children’s Project to correct the imbalance. Women and children at the clinics also receive critical supplements, including vitamin A. RIPPLE Africa’s Tree Planting Project, includes fruit trees giving access to nutritious food sources at household level. In addition to being an important source of nutrition, fruit can also be sold to allow families to buy different varieties of food, particularly meat and other products to which they might not otherwise have access.
Water and Sanitation in Malawi, Africa
For many people in Malawi, access to safe drinking water and basic sanitation is limited, which is a major factor contributing to health issues in the country. Running water at household level is very rare, and most Malawians have to make a daily trip to a communal borehole, well, river, or the lake to collect water. In the Nkhata Bay District of Malawi, people are very fortunate to be near the lake which not only provides water from the lake itself, but provides a good source of groundwater from which boreholes can extract safe drinking water.
In the immediate area in which RIPPLE Africa works, villages are very well set up with community boreholes. However, venturing just a few kilometres from the lake and this becomes more difficult, and where a borehole does not exist, many people collect water from exposed sources which can contribute to a number of waterborne diseases. Most Malawians still have to make a daily trip to their water sources once or twice a day, and how water is stored and used will also have an impact on how safe it remains to drink.
A typical borehole pump where most households collect their water every day
Some women walk for several kilometres with buckets of water every day
Sarah, a RIPPLE Africa volunteer, paid for and organised the installation of an electric pump at Kachere Health Centre
For those who do access water from open sources, proximity to household latrines inevitably affect to the safety of that source. In rural areas, the majority of people use unimproved pit latrines (outdoor pit toilets which are simply dug into the soil and have not been reinforced with construction materials.) Only the minority of rural families use improved latrines, or drop toilets, which have been reinforced with materials such as cement. Flushing toilets do exist where there is formal plumbing, such as in the cities; however, the national average of people with access to improved latrines shows little difference between rural and urban areas.
In the rainy season, household waste from an unimproved latrine can easily wash into water sources, leading to waterborne diseases such as cholera, dysentery, typhoid fever, gastroenteritis, botulism, severe diarrhoea, and more. Open wells are also a breeding ground for mosquitoes which lead to malaria. Waste and garbage disposal is also a problem in Malawi, with no national refuse system. At household level, waste disposal is by rubbish pit and burning of waste. Despite a lack of sanitation, only 66% of families in the district have soap for washing their hands after they use the toilet or handle rubbish.
A template is used to construct the cement cover for our RIPPLE Crapper composting toilet
Another new RIPPLE Crapper has been completed
The cement cover is placed over a circular hole to provide a composting toilet which can be used for nine months, and then the toilet is relocated
RIPPLE Africa is helping to improve access to safe water and proper sanitation at community level by installing boreholes and building improved latrines in our schools and healthcare facilities. RIPPLE Africa is always looking for donors who can help raise money for additional toilet and boreholes in these facilities, please contact us if you can help!
Maternity and Family Planning in Malawi, Africa
Culturally, Malawians value large families and women in Malawi on average give birth five times in their lifetime. This makes obstetrics a very important part of the Malawian healthcare system, and access to quality delivery facilities and skilled birth attendants a critical element in addressing women’s health at a national level. However, in 2014, there were 634 maternal deaths per 100,000 live births (World Bank 2015) due to direct causes such as haemorrhage, infection, unsafe abortion, pre-eclampsia /eclampsia, and obstructed labour, and indirect causes including malaria, anaemia, HIV/AIDS, and tuberculosis.
Traditionally in Malawi, women have given birth at home with the assistance of their mother, mother-in-law, or a traditional birth attendant (TBA). Most of these traditional midwives have no medical training but rather learned their skills ‘on the job,’ and it was extremely common for women to experience complications during birth which would lead to the death of the mother, the baby, or both.
The majority of maternal deaths are considered preventable, yet they persist in Malawi due to the combination of the high total fertility rate and limited access to contraception, weak health infrastructure, shortages of health professionals, and low institutional capacity. While the percentage of births taking place in health facilities has risen to an estimated 73%, the overcrowding of facilities and systemic health system failures mean that there are still significant risks to mother and baby.
According to WHO, of all the reasons for death in children under 1 month in Malawi, 31% were due to prematurity, 28% were due to birth asphyxia and birth trauma, 19% to sepsis and infection, 10% to birth defects, 5% to pneumonia, 5% to other conditions, 1% to tetanus and 1% to injuries.
The Malawi government passed a law in 2007 requiring all women to give birth at a local healthcare facility with a Skilled Birth Assistant (SBA). In Malawi, midwifery is not considered a separate discipline from nursing, and nursing students undertake a year’s midwifery training as part of their overall skill set, although this is not compulsory. According to the Impact Evaluation of the Sector-Wide Approach in Malawi published in 2010, 79% of nurse/midwives had midwifery skills, and could be counted as a SBA. While the value of giving birth with a professionally trained nurse/midwife was self-evident, passing a law without increasing access to medical facilities meant that women often have to walk for hours, if not days, to get to the nearest health centre. According to WHO, 87% of all births in Malawi take place in rural areas, compared to 13% in urban areas where most health centres and hospitals are concentrated.
Malawian women in rural areas have to make the difficult journey to their nearest health centre, many while in labour, and others journey to a health centre weeks in advance and camp outside the facility until they start labour. Most health centres have just one room for delivery, and are staffed by a single nurse/midwife with no one to relieve them. Understaffed, lacking critical resources, and oversubscribed, these health centres often struggle to cope, and in the event of complications many still lack the medical facilities to handle emergency situations, including C-sections.
Young mothers with babies and small children at an Under Fives Clinic
Motherhood in Malawi is obviously a dangerous undertaking; however, having a traditionally large family is still an important part of Malawian culture. For many women, however, the use of birth control is becoming more prevalent, and women are beginning to have more control over their own family planning. Common methods of contraception in Malawi include condoms, birth control pills, Depo-Provera, IUCD, Norplant, and sterilisation. Still, the numbers are very low. According to World Bank in a report published in 2016, modern contraceptive use among married women over the age of 20 is 44%; and 50% amongst unmarried sexually active adolescent girls, but only 26% amongst married adolescent girls. Malawian culture is still very male-dominated, and many women feel they have little right to make family decisions (including about contraception and family planning) without the permission of their husband. For men, large families are seen as a status of wealth, power, and fertility. Gender inequality still presents the greatest difficulty in women accessing contraception in Malawi. As things change, however, and women have greater access to education, conscious family planning is slowly becoming more common, but it is still not the norm. RIPPLE Africa sees many of the brightest female students drop out of school at an early age due to teenage pregnancy, which could have been prevented by the use of birth control.
Indeed, at a national level, World Bank reveals that 30% of women aged 15-19 are mothers or pregnant with their first child. The huge growth in population is also one of the major contributing factors to poverty in Malawi, where a finite number of resources are being divided between a population which is growing in Malawi by over 3% annually (that’s a 30% growth in population in a decade!) There is obviously a desperate need in Malawi for better family planning, but access to contraception, proper health education and information, and issues of gender inequality all must be addressed before this is likely to happen.
RIPPLE Africa’s support of maternal health is largely through the Kachere Health Centre, which has basic delivery facilities.