Malawi Multiple Indicator Cluster Survey 1995

Publication date: 1996

1ft m m 1 ti iC = en en a: C) .=: u Cl z .1 c .r u C) + ) -z cJ. en 0 M.l ~ v ~ "B> -V') 1 u :1 ~ \A ci:. ~ c + Q_ c;ll . . u <.-, :E -+-uJ ~ " Vl MALAWI SOCIAL INDICATORS SURVEY 1995 A Survey of the State of Health, Nutrition, Water, Sanitation, and Education of Children in Malawi Ministry of Economic Planning and Development, National Statistical Office, and the Centre for Social Research September 1996 TABLE OF CONTENTS LIST OF MAPS . . . . . . . . . . . . . . . . . . . i LIST OF FIGURES . . . . . . . _. . . : . .ii LIST OF TABLES . . . ; . . . . . . . : . . . . . . .iv LIST OF ABBREVIATIONS . . . . . . . . . . . . . . viii PREFACE . . . . . . . . . . . . . . ~ . . . . . . . . . . . : . ix '. ACKNOWLEIXiEMENTS ·············· ············ ·········· ········· ·· ······ ············· ··.··········· ·· ···: ··.::::························· .x EXECUTIVE SUMMARY . . . . . . . . . . _ . . . xi CHAPTER ONE . . . . . . . . . . . . . . . . . . . 1 INTRODUCTION . . . . ' . . . . . . . . , . , . . . . 1 CHAPTER TWO . . . . · . . . : . 3 PROFILE OF MALAWI . . . . . . . 3 2.1 Demography . . . . . . . . . . . . . . 3 2.2 Economy . . . . . . . . . . . . . 4 2.3 Policy Environment . . . . . . . . . . : , , ! 4 CHAPTER THREE . . . . . . . . . . . . . . . . 7 SURVEY Jv!ETHODOLOGY . . . . . . , . 7 CHAPTER FOUR . . . . . . . . . . . . . 9 HEALTH DELIVERY . . . 9 4.1 Access to Health Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 4.2 Assistance and Place o_f Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 CHAPTER FIVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 5.1 Infant and Child Mortalit_v . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 5 2 Or11hans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 CHAPTERSIX . . . 21 IA1Aff.JNIZATION . .' . . . . ~ . . . . . . . . . . . . . . . . 21 6.1 Situation in Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 6.2BCG . . . . . . . . . . . . . . 28 6.3 Nleasles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 6.4DPT . . . . . . . . . . . 30 6.5 Polio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6.6 Tetanus Toxoid for Mothers . 32 6. 7 Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 CHAPTER SEVEN . . . . . . . 37 DIARRHOEA . . . . . . . . . 37 7.1 Situation in Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 7.2 Prevalence of Diarrhoea . . . . . . . . . 38 7.3 Diarrhoea Treatment . . . . . . . 39 7.4 Conclusion and Recommendations . . . . . . . 43 CHAPTER EIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 CHILD NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 8.1. Protein-energy Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 8.2 Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 8.3 Salt /odization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 8.4 Breast Feeding and the 'Baby Friendly' Hospital Initiative . . . . . . . . . . . . . . . . . . 73 8.4.1 Exclusive breast .feeding . . . . . 74 8.4.2 Baby Friendly Hospitallnitiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 CHAPTER NINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 WATERANDSANITATION . . . . . 81 9.1 Situation in Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 9.2 Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 9 .3 Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 9.4 Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 CHAPTER TEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 EDUCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 10.1 Situation in Malawi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 10. 2PrimarySchoolEnrollment . . . : . . . . . . . . . 91 10.3 Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 CHAPTEltELEVEN . , . , . , . 103 CONCLUSJONSANDJ.ECOMIJENDATIONS . . , . 103 11.1 Districts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 11.2Health . , . ; . , . 104 11.3 Nutrition . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 ll.4·Wateralfti&mitmion . · . · . , . ~,. 107 11.5 Educt~fiott. . . , . , . . . . . . . . . . . . . . . . . . . . . . . . . 108 REFERENCES APPENDICES APPENDIX I Sampling and Estimation Procedure APPENDIX2 109 Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 APPENDIX3 Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 APPENDIX4 Salt Iodization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 APPENDIX5 Water and Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 APPENDIX6 Single-year Age Distribution of the Household Population by Sex . . . . . . . 120 APPENDIX7 Household Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 APPENDIX8 es onnazre cw rac1 1t1es . . Qu ti . So . I 'C' ·1· . 137 Map 1 . Map2 Map3 Map4 Map5 Map6 Map7 Map8 Map9 LIST OF MAPS Sampling Points . . . . . . . . 6 Fully Immunized . 20 Underweight . . . , . 48 Moderate Stunting . . . . . . . . . . . . 50 Moderate Wasting . . , . . . . . 53 Access to Safe water . 82 Access to some Sanitation . : . 85 Net Primary Enrolment . . . 93 Enrol at _correct age . : . . . . . . . 98 .· ~ ' LIST OF ·FIGURES Fig 5.1 Trends in Child Mortality . . . . . . . . ~ . . , . 19 Fig 6.1 Percentage ofChildren 12-23 Months Vaccinated by 12 Months of age, DHS 1992 and MSIS 1995 . . . . . . 22 Fig 6 .2 PercentageofChildren 12-23 Months who were Fulty Vaccinated by the Time ofthe Survey . . . . . . . . . . . . 23 Fig 7.1 · in Prevalence and Treatment of Diarrhoea since 1992 . . 3 7 Fig 8.1 Regional Differences in Rates of Moderate Malnutrition, 1995 . . . . 55 Fig 8.2 Regional Differences in Rates of Severe Malnutrition, 1995 . . 55 Fig 8.3 Urban/Rural Differences in Rates of Moderate Malnutrition, 1995 . . 55 Fig 8.4 Urban/Rural Differences in Rates of Severe Malnutrition, 1995 . . . . . . 55 Fig 8.5 Age-specific Moderate Stunting Levels (Height-for-age) 1992 and 1995 . 57 Fig 8.6 Age-specific Severe Stunting Levels (Height-for-age) 1992 and 1995 . . . 57 Fig 8.7 Age-specific Moderate Wasting Levels (Weight-for-Height) 1992 and 1995 . 57 Fig 8.8 Age-specific Severe Wasting Levels (Weight-for-Height) 1992 and 1995 . . . 57 Fig 8.9 Age-specific Moderate Underweight Levels (Weight-for-Height) 1992 and 1995 . . . . . . , . . . . . . . . . 57 Fig 8.10 Age-specific Severe Wasting Levels (Weight-for-Height) 1992 and 1995 . 57 Fig 8.11 Underweight, Stunting and Wasting (0-59 months) 1981, 1992 and 1995 . . 58 Fig 8.12 Children aged 6 Months to 5 Years Who received a vitamin A Capsule in past 6 Months . . . . . . . . . 62 Fig 8.13 Vitamin A Capsule received by mother at birth, by who assisted . . . 64 II Fig 8.14 Proportion oflnfants Breast Feeding and Eating Complementary Foods . 76 Fig 10.1 Children(%) entering School at Age 6, by Mother's and Household head's Education . . . . . . . . 99 Fig 10.2 Change (%) in Primary School Enrollment since 1990 . . . I 00 iii LIST OF TABLES Table 4.1 Distribution of households by gender of head of household . 1 0 Table 4.2 Distances to health facilities, by district . . . . . . . . . . . . 12 Table 4.3 Distances to under-5 clinics, by district . 13 Table 4.4 Place of delivery, by district . . . 14 Table 4.5 Assistance at birth, by district . . . . . . . . 15 Table 4.6 Children (%) died or survived at birth for last three pregnancies, by place of delivery . . . . . . . . . . 15 Table 4.7 Children (%) died or survived at birth for last three pregnancies, by type of assistance at birth . . . . . . 16 Table 5.1 Child Mortality rates by 5-year Approximate reference periods prior to survey . . . . , . . . . . . . 18 Table 6.1 The percentage of children 12-23 months who have received specified vaccines by 12 months of age . . . . . . . . . . . 24 Table 6.2 Vaccination rates of children 12-23 months old, and vaccination rates of same age group before their first birthday, by source of information . . . . 25 Table 6.3 Distribution of children(%) of ages 12-23 months, immunized by their first birthday, by education of mother . . . . . 26 Table 6.4 Distribution of children(%) of ages 12-23 months, immunized by their first birthday, by education of household head . 27 Table 6.5 Percentage of children 12-23 months who had received specific vaccines by the time of survey, by selected background characteristics from all sources . 27 Table 6.6 Mothers(%) who have received Tetanus Toxoid, by geographic area . . . 33 Table 7.1 Proportion (%) of children with diarrhoea by region, residence, gender and mother's education . . . . . . . . 38 IV Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 8.1 Table 8.2 Table 8.3 Table 8.4 Table 8.5 Table 8.6 Table 8.7 Table 8.8 Table8.9 Table 8.10 Table 8.11 Prevalence(%) of diarrhoea, by district . 39 Proportion of children(%) with diarrhoea, by water, sanitation, hygiene and breast feeding . : . 40 Treatment of diarrhoea by region, residence, gender and mother's education . 41 Amount of food and fluids taken by children with diarrhoea . 42 Under-weight rates* (%)of children, by gender, location and socio-economic characteristics, 1992 and 1995 . 49 Stunting rates* (%) of children by gender, location and socio-economic characteristics, 1992 and 1995 . 51 Wasting rates* (%)of children by gender, location and socio-economic characteristics, 1992 and 1995 . , . 52 Wasting rates* (%)of children in urban districts . 54 Age-specific nutritional status(%), by gender . 56 Children(%) aged 6 months-5 years who received a vitamin A capsule in the previous 6 months . 63 Children (%) who consumed at least one vitamin A-rich food with oil in the week preceding the survey, by region, residence, and mother's education . 65 Children(%) who have consumed at least one vitamin A-rich food and groundnuts in the week preceding the survey, by region, residence, and mother's education . 66 Under-Ss (%)who consumed vitamin A-rich fruits and vegetables in the week preceding the survey, by the fruits and vegetables they consumed . 66 Children who had eaten at least 3 vitamin A-rich foods in the week preceding the survey . 67 Prevalence(%) oflodine Deficiency Disorders in the severe most affected districts, 1983 . 70 v Table 8.12 Households(%) using salt with an Iodine content of at least 20 ppm, by geographic divisions . 71 Table 8.13 Under-5s (%)who were ever breast fed, by selected background characteristics . 74 Table 8.14 Proportion(%) of infants less than 4 months of age who are exclusively breast fed, 1992 and 1995 . 75 Table 8.15 Under-3s (%)who are still breast feeding . 75 Table 8.16 Under-3s (%) w·ho were breast fed at least once in the previous 24 hours, by selected background characteristics . 76 Table 8.17 Breast feeding children(%) who receive supplements, by age . 77 Table 8.18 Under-2s (%)who used a bottle with a nipple at least once in previous 24 hours, by background characteristics . 78 Table 9.1 Use and accessibility(%) of safe water, by region and residence . 83 Table 9.2 Type of water facility used(%), by region . 84 Table 9.3 Access to adequate sanitation(%), by region and residence . 86 ' . Table 9.4 Type of toilet facility(%), by region and residence . 86 Table 10.1 Distance to primary schools by district . 90 Table 10.2 Net enrollment of6-13 year olds (%),by district, 1992/93 and 1995 . 91 Table 10.3 Net enrollment(%), by region, gender and residence . 92 Table 10.4 Net enrolment(%), by district and gender . 94 Table 10.5 Students(%) repeating the school year, by standard . 95 Table 10.6 Children reaching standard 5, by region, gender and resid~nce . 95 Table 10.7 Children(%) who reach standard 5, by district . 96 VI Table 10.8 Students(%) dropping out of school, by standard . . 97 Table 10.9 Children(%) entering school at the correct age, by region, gender and residence . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Table 10.10 Children(%) entering school at the correct age, by district . . . . . 99 Table A.2a Stunting Rates under-5s(%), by location and gender . . 112 Table A.2b Wasting Rates under-5s(%), by location and gender . . . . . 113 Table A.2c Underweight Rates under-5s(%), by location and gender . 114 Table A.3 Consumption of vitamin A, by district . . . . . . 115 Table A.4 Households (%)with salt of an iodine content at least 20 ppm, by district. . 116 Table A.5a Accessibility to safe water(%), by district . 117 Table A.5b Type of water facility by district . 118 TableA.5c Access to adequate sanitation(%), by district . . 119 Table A.6 I>escription of the sample . : . . 120 vii AFP AIDS BCG CDD CHSU CSR DHS DPT EPI Ha HIV IBFAN IDD IEC IMPACT Kni MCH MSIS MOHP MUAC NCHS NSSA NSO OPV ORS ORT PPM PPS SE SRS sss TBA TT UNICEF VIP WHO LIST OF ABBREVIATIONS Acute Flaccid Paralysis Acute Immune Deficiency Syndrome Bacillus Calmette Gufrin Control of Diarrhoeal Diseases Community Health Sciences Unit Centre for Social Research Demographic and Health Survey 1992 Diptheria Pertussis Tetanus Expanded Programme of Immunization Hectare Human Immuno-deficiency Virus International Baby Food Action Network Iodine Deficiency Disorders Information, Education and Communication Initiative for the Mobilization of Private Action Kilometre Maternal Child Health Malawi Social Indicators Survey Ministry of Health and Population Mid-Upper Arm Circumference National Centre for Health Statistics National Sample Survey of Agriculture National Statistical Office Oral Polio Vaccine Oral Rehydration Solution Oral Rehydration Therapy Parts per million Probability Proportional to Size Standard Error Simple Random Sampling Sugar Salt Solution Traditional Birth Attendant Tetanus Toxoid United Nations International Children's Fund Ventilated Improved Pit World Health Organization viii PREFACE fTI his report presents the findings of the Malawi Social Indicators Survey (MSIS). The l.U preparation of the Survey took place in collaboration with the Technical Working Committee of the Poverty Monitoring System, with representation of all the line ministries. This Committee also verified the findings of the survey. The MSIS fieldwork was undertaken in October 1995 by the National Statistical Office (NSO). The data were processed by the NSO and the Centre for Social Research (CSR) in October and November 1995. The first findings were provided by CSR in December 1995 and presented by the Ministry of Economic Planning and Development at the Consultative Group Meeting in Bournemouth, England. The primary objective of the MSIS was to collect information on indicators that measure Malawi's progress in reaching the end-of-decade goals set by the World Summit for Children in New York in 1990 and the Malawi National Programme of Action for the Survival, Protection and Development of Children in the 1990's. The survey was also expected to provide a comprehensive picture of the general well-being of children in Malawi. The data were collected from 6206 households throughout the country, and are presented at the district, regional and national level. The data were gathered on orphans, access to health services and education facilities, infant and child malnutrition and mortality, immunization coverage, the incidence and treatment of diarrhoea, Vitamin A, breast feeding, salt iodization, access to potable water and proper sanitation facilities, and primary education. The study was not to focus solely on Malawi as a whole, but on the individual districts within the country. This information will help the government, donor and NGO programme designers and implementers as well as communities to target assistance more precisely in their effort to attain the goals as defined by the World Summit and the National Programme of Action (NP A). Information is provided on the way residential location, gender, level of educational attainment and other socio-economic factors influence the status of indicators. ~ G? Alex C. Gomani, SECRETARY FOR ECONOMIC PLANNING AND DEVELOPMENT lX ·-·--· --- ----- ACKNOWLEDGEMENTS r:TJ he Poverty Monitoring System is based in the Ministry of Economic Planning and ~ Development. The Ministry would like to express its appreciation for the support provided by several institutions and individuals in the production of this report. Our gratitude goes to the National Statistical Office for collecting the data, and to the Centre for Social Research for analysing it and producing this report. The National Statistical Office has shown professionalism in this undertaking through effective sampling, enumerator training, data collection and weighting. The Commissioner for Census and Statistics, Mr. L. Golosi, along with Messrs. S. Konyani, L. Kochelani, H.B. Moyo, G.T. Mazunda, M.J. Khwepeya, and R.S Mkandala, all of the National Statistical Office, deserve special thanks. The Ministry of Agriculture and Livestock Development has provided enumerators and the Community Health Sciences Unit has analysed salt samples. Our gratitude goes to these institutions as well as to all the enumerators, data entry clerks and interviewees whose contributions made this report possible. UNICEF has been very supportive of the project, especially Dr. Natalie Hahn, UNICEF Representative, Ms. Wia Berends, Monitoring and Evaluation Officer, as well as all Project Officers. UNICEF provided financial and technical assistance, and constructive comments in the preparation of the survey and this report. The Director of the Centre for Social Research, Dr. Stanley Khaila, provided valuable comments and direction in the conduct of data analysis and report writing. Our appreciation goes to him and Mr. Nyson Chizani, the Centre's Data Analyst, and Ms. Sue Ridley (UNICEF Consultant) for their assistance in producing the data. Dr. Diana Cammack edited the text and production was completed by Mr. Abdi Edriss of Business Engineering and Computer Services International. The authors of this report deserve special acknowledgement. These are Dr. Wycliffe Chilowa, Mr. James Milner, Ms. Ann Marie Brouder from the Centre for Social Research, and Mr. Efreim Chirwa of the Economics Department, Chancellor College. Mr. Cecil Kamanga from CHSU and Mr. Ladislas Mpando from the National Statistical Office provided the input for the calculation of the infant mortality rate, for which also assistance was obtained from the United Nations Commission for Africa through Mr. Kampion Banda . X - ----- - --··· -· Malawi ADMINISTRATIVE REGIONS AND DISTRICTS CENTRAL REGION ._ .·, . imllnunization levels since the 1992 .· shown signill:eant deere~, as hilS the percentage of those fully CXI'Iaii:led by alack of vacCines in the oountry over a three month sh£)wj:ilgllhe.·gre~st; ac;hie:veJlnents. and c~ges over the past few years has been enroJn:tent rate now stands at 83 percent,. compared to 53 percent . ofchilldi-ett·•···••Stittrtillg. at the correct age (six years) is now 51% and the Northern region has higher educational indicators. The CHAPTER ONE INTRODUCTION m n 1990 more than 150 governments from around the world carne together to discuss ~ the state of children world-wide. This World Summit for Children formally adopted a set of measurable goals to be achieved by the year 2000. These goals included a one-third reduction in under-five death rates, support for breast feeding by all maternity units, a reduction of under-five malnutrition rates by one-half, the achievement of a 90% immunization rate for under-ones and a 90% reduction of measles cases, the eradication of polio and neonatal tetanus, completion of primary education for 80% of children, and universal access to clean water and safe sanitation for all communities. An intermediate set of social development goals was also established for 1995. Reaching these will demonstrate progress toward achieving the end-of-decade goals. The mid-decade goals include realizing an 80% immunization rate for the six major vaccine-preventable diseases of children, virtual elimination of both neonatal tetanus and vitamin A deficiency, the reduction of measles cases by 90%, the elimination of polio in selected countries, the achievement of both a 'baby-friendly' status for all major hospitals and an 80% ORT use, and the universal iodization of salt. To measure progress towards reaching both sets of goals and to assess the st&te of children in Malawi in 1995, this report was commissioned by UNICEF. Data were collected in a survey done in October 1995 by the National Statistical Office (NSO). The data were processed and the report was written by the Centre for Social Research. Similar reports were commissioned in other countries to measure progress towards the same goals and they provide a basis for comparison. However, this report is primarily a report about the state of children in Malawi. A total of 6206 households were included in the survey. The households included 8175 females over 10 years of age. In urban areas 86% of households were male headed while in rural areas the figure was 69%. The proportion of households headed by men varied considerably for each district, with the lowest number in Chiradzulu (52%) and the highest number in Dowa (86%). A total of 11,776 children under the age of five were included in the survey, of which 48.4% were boys and 51.6% were girls. Some of the indicators assessed in this study were reported in the 1992 Demographic and Health Survey produced by the NSO and Macro International Inc. These include rates of infant mortality, immunization, breast feeding, diarrhoea, water and sanitation, and malnutrition. Data on other indicators -- e.g., salt iodization and vitamin A deficiency -- have not been collected before in any detailed format and thus there is a limited basis for comparison over time. Collecting data for analysis at the national and regional level was deemed to be inadequate. Instead the sample was designed for analysis at district level. This report identifies districts with the most severe problems, and it should, therefore, help decision-makers target their resources effectively. The most significant differences revealed by the report are those at district level. Malawi Social Indicators Survey 1995 Malawi has made significant strides in the area of primary education, where enrolments have substantially increased. However, one area of concern is child malnutrition, where figures have not improved in recent years. The overall drop in immunization levels is also worrying. Where before the immunization programme in Malawi was very successful, now rates of immunization show a tendency to decline. High rates of infant mortality remain, and proper measures must be taken to address this problem as well. Safe water at a reasonable distance from dwellings is only available to a minority of the population, while improvements in sanitation facilities are also needed. The report indicates that Malawi still faces serious problems in the social sector. However, efforts are being made to reach the goals established by the World Summit for Children. In order to do so resources are needed that will match the commitment evidenced daily in the field by social development workers throughout the country. 2 CHAPTER TWO PROFILE OF MALAWI fUI alawi is a landl~ked c~untry in southern Africa, bordered by Tanzania, Zam~ia li4l.l and Mozambtque. Sttuated mostly on a plateau of 750-1500 meters, Wtth mountains reaching to 3000 meters, the verdant northern part of the country is dominated by Lake Malawi, which comprises 20% of Malawi. The Shire River drains the Lake and winds through the low lying and arid landscape south of the escarpment. Administratively Malawi is divided into the Northern, Central and Southern regions, which are further sub-divided into 24 districts. There are four major urban centers, in which reside approximately thirteen percent of the population. 2.1 Demography The country has some eleven million people, and a population growth rate of 3.1% per annum (6% in towns). According to the World Bank, this means that the population will double in the next twenty years. Almost all people marry -- half by the age of 18 years -- and about one-fifth of men over forty have more than one wife. One-third of women become mothers while still teenagers. In fact, Malawi's fertility rate of 6. 7% is one of the highest in the world -- as are its current rates for under-5 mortality (211/1 000) and maternal mortality ( 620/1 00,000). Life expectancy at birth stands at 48 years-- up from 37 years in the late 1950s --and reflects normal global gender differentials from birth. At the same time Malawi has a young population and it is getting younger, with half its citizens expected to be under 15.5 years by the year 2000. Malawi's land mass is small and as a result Malawi has one of the highest population densities in Africa. This creates tremendous pressure on the land, with 56% of the land under cultivation, representing most of the cultivable land. Land holdings are divided into small holdings and estates (tea, tobacco and sugar). Some fourteen hundred estates cover 9% of Malawi's land area (850,000 ha.) of which a third is reportedly under cultivation. Meanwhile some 1.6 million smallholder families occupy 1.8m ha. of customary land. While some of the poorest people in Malawi live and work as labourers on the estates, the vast majority of poor people in Malawi are smallholders. In fact, over one-half of rural households farm less than 1 ha., while one-quarter cultivate less than a half-hectare. Due to the low level of farm technology, inadequate irrigation, and a shortage of cash and credit to buy hybrid maize seed and.iertilizer, those with between one-half and one hectare can produce only 40-70% of their staple food requirement, and by June (only a few months after harvesting) most rural people are reduced to eating two meals per day. In some districts 70-80% ofhouseholds run out of food by December. As a result, in 1992 and still in 1995, over a quarter of its under-5s were underweight, and more than one-half were stunted by long-term malnutrition. In 1990 the World Bank estimated that over one-half of the population lived below the poverty line, estimated at an annual income equivalent ofUS$40/adult. 3 - - -·- - - · Malawi Social Indicators Survey 1995 Particularly hard hit are female headed households, which comprise about one-quarter of households nationally. Importantly, female headed households are both smaller and have fewer adults, and therefore less labour power-- an important factor during labour-intensive periods of the agricultural calendar. Moreover, women are handicapped by a higher rate of illiteracy, less skills training, and traditions that discourage female business initiatives. Almost all female headed households are in the rural areas, though in the Northern and Central regions they make up one-fifth of all households, and in the Southern region (where poverty is more prevalent) they comprise nearly a third. 2.2 Economy The reasons for Malawi's continuing high level of poverty are complex. In part it is the result of insufficient good agricultural land made worse by rapid population growth and environmental degradation. Malawi is not endowed with mineral wealth and there is little mining. There is very little fishing for export, and relatively little industrial production. Moreover, the economic policies adopted by the former government favoured commercial farmers, providing them with land, labour, credit, extension and marketing services, and with favourable pricing policies. The peasant majority was left to grow subsistence crops with relatively little technical or financial assistance. As a consequence, in the twenty years following independence in 1964, estate production (tea, tobacco and sugar) rose at an average annual rate of 17%, while smallholder production grew by only 3.2% per annum-- hardly sufficient to keep pace with population growth. These policies have had a devastating effect on rural well-being, and especially on the social development of children. Since 1992, just as pressure for multi -party democracy became a potent political force, the economy has been eroded by a series of shocks, including three years of successive drought, temporary suspension of non-humanitarian aid in 1992, the flotation of the Kwacha, an increase in government expenditure and a contraction of revenues. The annual inflation rate has skyrocketed from 12% in 1991 to more than 50% currently, while subsidies on fertilizer and maize have been removed, privatization and public service retrenchment have begun, and other structural adjustment measures that at least initially, impact negatively on the poor have been implemented. 2.3 Policy Environment Since 1990 Malawi has seen many changes. After thirty years of single-party rule, the new government under the leadership of H. E. President Bakili Muluzi immediately set new priorities, including the expansion of primary education to include all Malawian children.One of President Muluzi's first acts as president was to lead a march to raise public awareness of HIV I AIDS. These two events demonstrated a new era of reform and openness in Malawi. Though the democratic transition has been relatively smooth, the new government continues to face a wide range of economic and social problems that were not sufficiently addressed during the previous thirty years. In addition to the problems enumerated above, this list includes a high rate of unemployment, deforestation, food insecurity at the national level, discrimination 4 Chapter Two - Prorale of Malawi against women, and the need to retrench a portion of the large civil service while at the same time committing additional human and financial resources to education and health. A lack of resources at the household and national levels hampers government initiatives to address these wide ranging problems. But the cycle of poverty will be broken by a combination of political will and appropriately targeted human and financial resources. This report assists this process by identifying problem areas where policy-makers and development workers can focus their energies and resources. 5 KarongaAOO Mzuzu ADO Kasungu ADD _._ __ • Lilongwe ADD SELECTED CLUSTERS • Rural clusters EB Urban clusters • ADD Headquarters 6 Blantyre ADD Shire Valley ADD Map 1: Sampling Points ADO CHAPTER THREE SURVEY METHODOLOGY ~J~~~~he data presented in this report are drawn from the Malawi Social Indicators Survey ~ (MSIS) of6206 households that was carried out between 12 and 30 October 1995 for the purpose of ascertaining the social indicators in the areas of health, nutrition, education, water and sanitation. The sample· selection of this survey was based on the National Sample Survey of Agriculture (NSSA) of 1992/93. For the purposes of this survey, the NSSA strata were then allocated according to ecological features, such as rainfall and soil type. District divisions were then considered, and ecological strata that crossed over district boundaries were assigned to the district that contained the largest area of the stratum. A sample total of 600 enumeration areas or clusters were selected for the NSSA according to probability proportional to population size, with each stratum containing a full set of enumeration areas. The sample was divided among the strata based on the population size of each stratum. It was decided that a sub-sample of the NSSA sample be selected for the purpose of this survey. At least 200 households were needed in each district to ensure that the results were accurate at district level. These households were selected randomly from sub-sample enumeration areas within each stratum. The number of households selected varied according to the number of sub- sample enumeration areas selected within each district. As the NSSA only covered the rural areas of the country, the MSIS developed a sample for the urban areas. Each of the four urban areas of Lilongwe, Blantyre, Mzuzu and Zomba was considered as an independent stratum. A list of enumeration areas/clusters was drawn up for each stratum, and ten were selected according to probability proportional to population size. The sample size was designed to be large enough for results to be valid at district level. However, in order for all indicators to have been accurately presented at district level, the sample size would have been too large for available financial resources. This is why it was decided that the indicators on Vitamin A supplementation, tetanus coverage and the use of ORT would be reported at the national and regional levels, but not the district level. For the other indicators in the design of the sample, the assumption was that there would be no variability within the cluster. For some of the clusters this assumption proved to be invalid, and this is expressed by means of the standard error. The authors decided to include the standard errors in parentheses throughout the report. The questionnaire used in the field was based on the standard Multiple Indicator Cluster Survey questionnaire developed by UNICEF in collaboration with the World Health Organization (WHO), United Nations Statistical Office, United Nations Population Fund (UNFPA) and the 7 Malawi Social Indicators Survey 1995 . Centres for Disease Control of the U.S. Public Health Service. It was then modified to reflect the national situation after consultation with the various ministries. Within each of the households selected, both the head of the household and the women in the household were interviewed. An additional questionnaire was used for each village to record the availability and proximity of services in the district. Training of enumerators took place in September 1995, during which time the questionnaire was pre-tested. After revisions, a second training session was held on October 5. Listing of households was done shortly thereafter. By the end of October data collection was complete. The main problems faced during the survey were transport and the quality and quantity of equipment. The questionnaire was divided into sections on health, nutrition, education, and water and sanitation. It was designed to present an overall assessment of social indicators, and especially of the state of children under 5 years old in Malawi. 8 CHAPTER FOUR HEALTH DELIVERY rn t is .widel~ ~ecognized ~at the health status of a population ~s the result of various tU social, pohtlcal and envrronmental factors, although the exact Impact of these on the health situation is not always clear nor acted upon. Principal elements beyond the health sector, as normally defined, which affect health status include the economic situation, political and social changes, rapid population growth and urbanization, ecological and environmental deterioration, nutritional issues, safe water and sanitation, provision of basic education, especially to women, and the status of women. The economic situation has a profound impact on every aspect of life. It determines investment in the social sectors, including health. By lowering purchasing power, it also affects the ability of families to maintain their health. The exact causal linkages between the national economy and the population's health status are complex. In Malawi public expenditure on health has risen. The social sector, of which health is part, has enjoyed increased government budgetary allocations. However, there is still an acute shortage of appropriately trained health staff. Lack of career structure and lack of access to further training are factors often cited as contributing to reduced morale and an inability to provide quaiity and user-friendly care. Moreover, there have been acute shortages of drugs and essential supplies. Political and social changes affect the environment in which the health sector operates. For instance, the previous government's reluctance to discuss HIV I AIDS made it difficult for health workers to inform people about the disease, or to take steps to halt its spread. Similarly, an inability to openly discuss hunger and its causes made it hard to tackle malnutrition and its relationship to morbidity and mortality in this country. After the transition to democracy a refreshing sense of openness became evident. Difficult issues, such as AIDS and hunger, birth control and sexuality, are for the first time on the public agenda, where politicians, health workers, the media, and the population can analyse causes and debate options. Population growth in Malawi continues at the very high annual rate of 3.1 %. The total fertility rate in Malawi is 6.7, in contrast to the global average of3.5. The increase in the number of women of child bearing age (15-49 years) will influence population growth, even if family planning activities are successful and result in women having fewer children. The influence of the increase in population on development is likely to remain very strong and will have serious implications for health, social development, and economic progress. Infant and childhood mortality rates have remained high, as a result of high rates of malnutrition and poor health generally, and inadequate health and education services, and sanitation and water supply. Recent increases in the rate of inflation and of prices have reduced more families to penury. The AIDS epidemic has affected mortality rates, both directly and indirectly -- directly, due 9 Malawi Social ~ors Survey 1995 to the death of infants born with HIV, and indirectly, through the deaths of parents who leave orphans, who are economically and socially disadvantaged. Urbanization is of increasing importance. Although still a predominantly agricultural society, more Malawians have recently moved to urban and peri-urban areas. An estimated 13.3% of the population was urban based in 1995, compared to 11.9% in 1990. From a public health point of view, urbanization does not necessarily mean improve~ living conditions. The rapidly expanding settlements in Lilongwe, Blantyre and Zomba, for instance, have now exceeded the sanitary carrying capacity. Environmental and ecological factors are important to Malawi. Rainfall is seasonal, extremely variable, not only within a year, but over the years. In the 1990s Malawi has experienced severe drought in succeeding years, which has seriously affected the health and nutrition of the society. Population pressure, the over-harvesting of fuel wood, run-off from heavy rains and erosion, and the lower water table all contribute to the loss of land for fruitful human use. Nutritional factors, such as protein-energy malnutrition, nutritional anaemia, vitamin.A deficiency and iodine deficiency disorders have been identified as the most serious health problems in Malawi. Malnutrition has a negative impact on the survival and development of children and women, and on work productivity. In addition, the practice of breast feeding is a crucial contributor to the survival and health of infants. The problems of the provision of safe water and adequate disposal of garbage and excreta, and the maintenance of hygienic conditions in homes and surrounding neighborhoods are of great concern in the Malawian setting. The inadequacy of safe water and sanitation, and poor housing create conditions for the transmission of infectious diseases. In areas where communities have to fetch water from snail-infected streams and lakes, bilharzia is a danger. Overcrowding increases the chance of spreading airborne infections, such as tuberculosis. The low status of women, the relatively powerless roles adopted by women, and the lack of educated women in Malawi diminish women's and girls' opportunities to obtain an adequate level of health knowledge, or to adopt healthy attitudes and practices. Of great significance is the number of girls who stay in school through Standard 5, at which point the beneficial effects of education are likely to have a life-long impact. Most families are deprived of the basic information needed for healthy living -- e.g., basic concepts of nutrition and of the cause of illness. To combat illnesses related to hygiene and hunger, initiatives have been taken to teach mothers about the three food groups; how to draw, carry and dispense clean water; and how to dispose of waste safely . In general the status of women in Malawi is low and discrimination starts from early childhood. Some customs and cultural activities endanger the lives and health of children and women. These include early marriages, some initiation rites, female circumcision, some traditional methods of caring for the sick, food taboos, etc. 10 Table .u Distribution of households by gender of head of household Residence National Urban Rural Male 70.4 86.0 69.0 Female 29.6 14.0 31.0 Chapter Four - Health Delivery According to the MSIS survey, in the rural areas the proportion of female headed households is 31% (Table 4.1). Most of these households are poorer and have lower levels of health. Traditions of inheritance unfavourable to women contribute to this situation, as does a lack of appropriate information. To improve the health of children and women requires the involvement of all sectors of society. It is clear, however, that an adequately functioning health system, especially at district, health centre and community levels, is also a necessary condition for achieving child health goals. The Government of Malawi is committed to Primary Health Care (PHC) in order to decrease childhood morbidity and mortality. The global goal of Health for All by the year 2000 was adopted by the Ministry of Health in 1979. Since then a strategy has been developed for strengthening Primary Health Care, which advocates community participation in the health delivery system. The Ministry of Health and Population operates health facilities at three levels, with dispensaries, maternity units and health centres at the primary level, district hospitals at the secondary level, and central hospitals at the tertiary level. The PHC system has been extended to all districts throughout the country. The process of identifying health problems is initiated by using existing committees and leadership structures at the village, area and district levels. PHC teams have been set up at these levels; they are usually headed by the highest ranking health personnel at each level. At the community level, an estimated 5000 traditional birth attendants (TBA) are usually responsible for antenatal care, nutrition surveillance, and other Mother Child Health (MCH) related activities, including deliveries. At this level outreach activities, such as under-five clinics and pilot PHC activities, are operated by health staff. Other community members, depending on problems and activities identified, are responsible for tasks like ensuring safe water and sanitation, and treating eye infections, malaria and diarrhoea. In keeping with the mid-decade goals, the survey concentrated on those diseases that afflict children, but are preventable and/or curable. Data were also collected on Malawi's current child and infant mortality rates, but no information on AIDS and malaria, the two major killer diseases of children in Malawi, was gathered. To present an overall view of access to health care, the distances from villages to health centres and under-5 clinics were determined. In addition, the locations where deliveries take place, and the persons assisting at births were ar :;essed. 4.1 Access to Health Facilities As the transport sector is underdeveloped in Malawi and most rural people are required to walk to social service outlets, the distances to health centres and clinics affect both attendance and mortality figures . This is especially the case for over-worked mothers with small children, who generally must walk long distan<:es with infants on their backs to reach health centres and clinics. 11 Malawi Sociallndic:ators Survey 1995 Table 4.2 Distances to health facilities, by district NatiOn! -· District · Malawi Chitipa Karonga) Mzimb~t i ' Nkha.taBily RumphiX- . Dedza Dow a Kasungu Lilongwe Mchinji -. · :_ NkhQtakota · Ntcheu Ntchisi Salima* B!Bntyre · Chikwawa Chiradzulu Machinga · Mangochi Mulanje Mwanza · Nsanje ThyQlO Zomba * Small Sample Size In village 3.1 1.8 11.0 0.8 0.8 22.5 11.2 5.8 ' 9.4 . 4.3 _'::, I3.o· 6Z.5 ' 35.3 - -.-. 16.9 12.5 · 8;2 22.2 1-Jkm >5km 14.5 57.1 13.6 50.4 ' 6.0 32.2 15.1 49.3 2.2 35.6 19.1 23.0 61.9 3.0 92.4 100.0 17.7 65.2 20.1 70.8 40.0 37.3 25.1 48.8 24.7 31.5 100.0 4.2 57.1 34.6 42.6 21.5 57.6 3.8 59.1 7.7 64.2 11.7 59.4 11.7 85.2 85.5 38.0 41.3 The survey found that over one-half (57 .1%) of Malawian households are located over 5 kilometres from a health centre. Forty percent of the population walks between one and five kilometres to reach a centre-- 3-5 km. (19.5%), 1-3 km. (14.5%), less than one km. (5.8%). Only 3.1% of people live in a village where a health centre is located(Table 4.2). Districts with higher proportions of households near health centres include Chikwawa, Mangochi, Thyolo and Nkhata Bay. Those that have lower proportions of nearby centres include Dowa, Kasungu, Mchinji, Mwanza, Nsanje and Salima. The degree of access to under-5 clinics is slightly better, but a third (33.3%) of households within Malawi are still located over 5 kilometres from the nearest clinic(Table 4.3). Nearly one-half of the population must travel from 1 to 5 km. to reach a clinic-- 1-3 km. (25.3%) and 3-5 km. (22.0%). Only 11.2% of Malawians are less than one km. from a clinic, and 7.9% have a clinic within their villages. 12 --- - ----- ---· - - --- - - Table 4.3 Distances to under-5 ctinics, by district In village 7.9 1.8 44.9 7.8 4.9 4.2 15.7 11.0 9.4 11.1 3.3 3.0 12.8 22.5 11.2 9.0 1-Jkm 25.3 26.5 6.7 26.4 36.7 16.4 18.9 16.2 32.8 26.6 29.0 32.9 24.7 76.0 34.6 42.4 36.5 10.4 7.7 25.2 11.7 78.4 44.3 Cbapter Four - Health DeUvery >5km 33.3 20.5 5.8 7.8 2.2 24.0 45.7 66.0 50.8 39.6 33.1 34.1 24.0 24.0 24.0 Districts that recorded higher proportions of nearby under-5 clinics included Chikwawa, Karonga, Nkhata Bay and Rumphi. Those that recorded lower proportions included Chiradzulu, Dowa and Mwanza. An improvement in access to health facilities must be seen as necessary to improve the mortality and health statistics in Malawi. 4.2 Assistance and Place of Delivery The survey assessed where the majority of mothers give birth and who assists them. Nationally, it was found that 40.5% of mothers have their babies at home. About one-half choose a hospital (29%) or a health centre (22.6%), while 7.8% prefer a TBA 's house. District figures vary widely (Table 4.4). 13 Malawi Social Indicators Survey 1995 Table 4.4 Place of deUvery, by district · l"fattODI t: DUtrid : .• ' ~·--; }.~· · · ·. ~L~ : Home TBAIIouse·· 40.5 32.6 43.3 35.4 28.7 19.5 29.4 58.4 50.2 35.9 50.5 19.8 33.2 51.9 57.5 20.2 52.6 34.5 61.7 52.4 42.0 54.9 36.3 33.3 40.9 Health Centre Other 22.6 0.1 22.7 0.5 21.9 0.2 27.5 0.9 29.7 1.7 53.7 0.8 29.9 0.2 1.9 0.2 21.0 1.0 16.9 0.2 19.7 0.7 22.8 1.4 28.4 0.9 26.6 1.4 9.8 0.3 26.9 0.2 27.8 0.4 23.0 10.1 0.1 34.5 0.1 30.9 24.6 1.3 11.1 0.2 31.4 0.3 5.5 0.0 Within urban areas, hospitals are the most common choice of birthplace ( 61.7% ), with onl} 13.2% opting for a birth at home. 'lbe situation is reversed in rural areas, where 43% choose a home birth and 26.2% go to hospitals to give birth. Almost one-half of births (48.2%) are assisted by a nurse or midwife. Family members assist in one-third of cases (33.8%). Nearly one-tenth (9.7%) are assisted by a TBA. Medical assistants/clinical officers and physicians attend 1.4% llfbirths, while ward attendants assist with 1.2%. Nearly one woman in twenty (4.4%) has no one in attendance during births. Again, district figures vary widely (Table 4.5). 14 Cbapter Four - Health Delivery Table 4.5 Assistance at birth, by district .NatioDI Nobody Family TBA Nune Ward Med. Other District •·· Member Midwife Attendant aut., etc. Malawi 4.4 33.8 9.7 Chitipa 2.0 28.7 20.7 Karonga 5.3 33.0 12.6 Mziniba 9.6 23:6 5.2 NkhataBay · 2.8 17.6 7.6 Rump hi 1.8 19J 4.0 Dedza 1.6 26.2 12.9 Dow a 3.1 53~0 8.1 Kasungu · 4.2 42.5 17.2 Lilongwe 3.0 31.8 18.5 Mchinji 4.2 42.2 12.9 Nkhotakota 2.1 19.9 19.1 Ntcheu 2.8 27.8 11.9 Ntchisi 7.3 44.0 12.7 Salima 1.2 49.1 12.5 Blantyre 4.0 15.7 10.0 Chikwawa 4.8 44.6 2.1 Cbiradzulu 8.2 26.4 10.9 Macbinga 9.2 49.0 3.7 Mangochi 4.4 39.1 9.7 Mulan' . tJe 6.7 34.0 2.2 Mwanza 6.5 26.6 4.9 Nsanje 2.4 30.9 2.3 Thyolo 4.2 29.4 8.1 Zomba 2.1 41.6 3.9 Table 4.6 Children (%) died or survived at birth for last three pregnancies, by place of delivery Home TBAHouse 0 Health CeatUe 0 ~ ' Hospital ·--- - N Child die4 at Child sa.n1Yed birtll birtll 24.6 17.2 17.8 16.1 15.4 82.8 83.9 48.2 1.2 1.4 1.3 47.9 0.4 - 0.3 46.2 0.6 1.5 0.7 . 54.5 3.0 Ll 2.7 64.1 2.6 2.6 2.7 ·72.7 0.8 L6 - 55.4 0.7 2.0 1.0 31.3 2.1 0.9 1.6 33.0 -0.3 1.2 1.6 41.3 1.5 1.8 2.0 35.6 2.9 1.3 0.9 55 .6 . 1.0 1.8 0.6 54.2 0.6 0.4 2.2 27.1 7.0 0.6 ' 1.3 34.0 0.7 1.7 0.7 67.5 0.2 2.7 - 44.2 1.1 - 3.1 54.6 - - - 36.3 - 0.5 1.2 45.6 0.7 - 0.6 51.1 - 5.3 0.7 39.9 2.8 0.5 18.8 61.7 1.4 0.3 1.1 54.0 3.6 0·.7 - . 50.8 1.4 0.1 0.1 A higher rate of use of nurses and midwives is registered in urban areas (73%) than in rural areas ( 46% ), which corresponds to the reduction of family members in attendance in urban areas. Again not surprisingly, there is a significant difference between the rate of deaths-at-birth when births are assisted by a family member as opposed to a nurse/midwife. The fact that nurses and other medical professionals have higher rates of children surviving is even more significant as it is probable that more complicated cases seek their care. Specifically, births assisted by family members have a proportionally higher nun;tber of deaths, while the opposite is true for births assisted by nurses or midwives. These figures emphasize the need to have trained personnel attend births(Tables 4.6 and 4. 7). 15 ~wi Social Jndicators Survey 1995 Table 4.7 Children(%) died or survived at birth for last three pregnancies, by type of assistance at birth Assistance at Child died Child survided birth at birth birth Nobody 20.5 79.5 Family Member 25.2 74.8 lBA 18.0 82.0 Nurse/Midwife 16.7 83.3 Ward Attendant 27.6 72.4 Medical assistant /clinical officer 17.5 82.5 /Physician Findings on the relationship between birth attendants, places of delivery and survival rates should be emphasised in training programmes, and raised with mothers during antenatal care, along with issues such as breast feeding, immunization and the efficacy of vitamin A capsules and iodized salt. 16 CHAPTER FIVE MORTALITY 5.1/nfant and Child Mortality m nfant mortality is the mortality of live-born infants who have not attained their first l.!J birth-day whereas under-5 mortality is the mortality of live births at ages younger than 5. Infant mortality is a major contributor to deaths occurring in communities with low expectations oflife at birth. Many a study has unearthed the inverse relationship between indicators of infant mortality and socio-economic development. A decline in infant mortality is a mark of socio-economic development. For example, the infant mortality rate (IMR) like the under- 5 mortality rate (U-5MR) decreases as the level of maternal education improves and the place of residence changes from rural to urban areas. The MSIS included questions on the last three pregnancies that eligible female respondents had had. Thus, it generated data from which infant mortality as well as under-5 mortality could be estimated. Besides, it collected data on parity of eligible women and survivorship of their children thereby adding to the data inputs for estimating infant and under-5 mortality. Data Quality and Estimation of Infant and Under-5 Mortality Rates The infant mortality rate is conventionally defined as the number of deaths among infants below the age of one per 1000 births in the same period. However, the IMR thus defined suffers from end-effects. Refinement is achieved by calculating average infant mortality rates for periods of several years. This serves just as well if an annual estimate is not vital. This more refined definition appeared satisfactory for the purposes of this survey. Digit preference, or the tendency of respondents to misreport age by showing preference for numbers ending in digits 5 and 0 , was not evident. The MSIS respondents did not show this preference as the clearly negligible age heaping detected in the data on age at death occurred at other unlikely digits. Diagnostic application of the direct method of estimating the under-5 mortality rate in order to compare the resulting value to the one from the Brass Technique, showed that the survival status of live births was misreported to a considerable extent. For cultural and psychological reasons Malawian mothers tend to be reticent about providing details about their children who have died. There was no evidence to suspect that their reluctance was dependent upon the age at which their children died. The data on parity and number of children having since died were not thoroughly edited. For example, few women in the 15-19 age. bracket had implausible parity entries .ofup to 10 children. These data were therefore edited by fixing age-specific maxima for the first 4 age brackets for these variables. These maxima were 4, 8, 12 and 16 for the age brackets, 15-19, 20-24, 25-29 17 Malawi Social Indicators Survey 1995 and 30-34 in that order. Finally, the age distribution ofunder-5 deaths was adjusted within the constraints imposed by the total number of deaths implied by the under-5 mortality rate for the total number of reported live births. The reported number ofbirths was found credible as facts of motherhood are a source of pride and hence tend to be freely and accurately reported. In view of the expected independence between the mother's reticence on details pertaining to her dead children and the children's age at death,_ proportionate adjustment of under-reported figures appeared defensible. The U-5MR was estimated by using the Brass Technique. The IMR and the CMR were estimated by applying the refined definition of the IMR as well as that of the CMR to the adjusted age distribution ofunder-5 deaths. The Situation in Malawi Table 5.1 and Figure 5.1 provide the findings of the MSIS survey. The infant mortality rate during the five year period prior to the survey in October 1995 was 133/1000 on average, which is virturally unchanged from the DHS figure in 1992 of 134/1000. Table 5.1 Child Mortality Rates by 5-year Approximate Reference Periods Prior to Sun-ey Approximate Infant Mortality Child Mortality Under-5 Mortality Reference Period Rate Rate Rate (q(5)) Source Prior to Survey (q(l)) (III) 3-7 134 115 234 DHS 8-12 138 126 246 DHS 13-17 136 141 258 DHS The MSIS found that the child mortality rate was 90/1000 on average during the five year period proceeding the survey, which confirms the downward trend reported by the DHS survey in 1992. Therefore, it can be stated that a child 's chance of survi'. a1 is improved once he/she gets beyond the first birthday. It is likely that the rate of immunization at age I is a factor. The MSIS found that the U5MR in the five years proceeding the survey has been 211/1000 on average . The corresponding figure from the 1992 DHS is 23411000 which difference is statistically significant from the current figure. This indicates that under-five mortality is continuing to decrease. 18 :·?_ 25~ ·.; ·, l2oo . K ·::: 5.2 Orphans Chapter Five - Mortality Fig 5.1: Trends in Child .Mortality ~~·~·~·~·~--~246 r---------~-,------------ • • • • • • • • • • 234 - IMR 134 - 1.985 " . 1990 . Appro1d.m.a~e Re1erence Year ----· . CMR • • • • •. U·5 MR In the survey an orphan was defined as a child whose two parents are dead. The number of orphans in Malawi at this time is directly related to the impact AIDS is having on the country. AIDS not only increases the number of orphans, but it also raises the dependency ratio -- the number of children compared to the number of economically active adults in a household -- which negatively affects productivity. The MSIS estimates that the current number of orphans, both AIDS related and otherwise, is between 80-88,000 children under 15. As deaths from AIDS are obscured by ignorance and opportunistic diseases, it was not possible to determine which children were orphaned as a result of AIDS. Projections for 1995 were I 00,361 AIDS orphans, while the National Aids Secretariat at the beginning of 1996 estimated that there would be a cumulative number of 281,000 AIDS-related orphans by 2000. This figure did not take into account the number of children who will die as a result of AIDS. 19 %Fully Immunized II 30.0 to 58.0% II 58.0 to 68.0% EJ 68.0 to 81.0% 20 I Map 2: Fully Immunized I , II CHAPTER SIX IMMUNIZATION ~ lobally, immunization has saved millions of young lives from the six 'Expanded ~ Programme of Immunization' (EPI) diseases: polio, measles, tetanus, whooping cough, diphtheria and tuberculosis. Twenty-five years ago, less than ten percent of the world's children were immunized. But by 1990 over sixty developing nations had reached an 80% rate of immunization. This commendable achievement has been mostly due to serious and sustainable collaboration between governments, WHO and UNICEF. At the World Summit for Children in 1990, the mid-decade target of 80% was established for childhood immunization for EPI diseases and tetanus tox,oid vaccine for women of child-bearing age, for all countries that had not yet reached this rate of coverage. A target of 90% was set for all nations to be reached by the year 2000. The EPI follows the World Health Organization guidelines for vaccinating children. In order to be considered fully vaccinated, a child should receive the following vaccinations: BCG evidenced by a scar (against tuberculosis), three doses of polio, three doses of DPT (against diphtheria, whooping cough and tetanus), and measles. DPT and polio vaccinations are usually given at the same time-- DPT as an injection and polio vaccine as drops taken orally. These are given at a minimum interval of four weeks. The last vaccination given is measles, after 9 months of age. WHO recommends that all children receive the complete set of vaccinations before their first birthday. The MSIS collected information on vaccination coverage for all children born in the five years preceding the survey. The information on immunization coverage has been recorded by MSIS in two different ways. Children vaccinated in Malawi are normally given vaccination cards which indicate date of birth, vaccinations given, and the dates given. If the card was available to the surveyors, details were recorded from it. If not, the mother was asked to recall whether her child(ren) received the various vaccinations. 6.1 Situation in Malawi According to the findings of the Malawi Social Indicators Survey the percentage of children 12-23 months who have been fully immunized by their first birthday is 61%. ' The MSIS survey found that 61% of Malawian children aged 12-23 months were fully vaccinated by the time of their first birthday. The highest rate of coverage is for BCG at 91%, followed by polio at 80%, DPT at 76%, and measles at 70%. Three-quarters (75%) of children aged 12-23 months were immunized by the time of the survey, indicating that many children had been vaccinated after their first birthday. This implies that a considerable number of children complete the vaccination scheme. 21 Malawi Social Indicators Survey 1995 The coverage for each antigen differs. Of those who have been fully immunized by their . first birthday, the highest proportion is for BCG (91%), while polio (80%), OPT (76%) and measles (70%) follow. (See Table 6.1 and Figure 6.1). Comparisons with coverage recorded in the OHS survey in 1992 indicate that apart from measles, whose rate has been maintained at 70%, the rates of immunization for all the other antigens is now lower, with OPT and BCG showing significant drops. One explanation is undoubtedly the unavailability of some vaccines, especially OPT and measles, in 1995 as a result of logistical problems and a reduction in funding for operational costs. Fig 6.1: Percentage of Children 12-23 Months Vaccinated by 12 Months of age, DHS 1992 and MSIS 1995 100 80 c 60 Cl) e :. 40 20 0 ALL BCG ,. , 1 , • DHS 1992 DPT3 POLIO 3 MEASLES • MSIS t995 Seventy-five percent of children in Malawi are still immunized before 18 months of age. However, this s\lfVey has found that the coverage by 12 months of age has dropped for OPT and measles to less than 80%, and for polio to 80%. As the impact of vaccinations on child survival is higher when immunizations are given before the first birthday, this trend is worrying . Furthermore, the percentage of fully immunized children is also showing a downward trend, for only 61% of the children were fully immunized by 12 months of age. This is a significant drop from the 1992 OHS figure of 67%. These results are the first evidence of a downward shift in EPI performance in the last decade, and they have to be taken as a warning sign. Apart from measles, whose rate has been maintained, the rates of immunization for all the other antigens is now lower than at the time of the DHS survey in 1992. The downward trend in EPI performance appears to be, at least in part, a result of the imposition by central government of the cash budget system, where ministries are not allowed to over-spend. Anecdotal evidence of the negative impact this is having on immunization has been collected during EPI field monitoring trips. Measles is the most likely to have lower coverage by 12 months of age because the window of opportunity to have this vaccination completed before the first birthday is narrow even under the best of circumstances. Thus, any decrease in the number of possible contacts (such as decreased outreach clinic visits) is likely to affect measles coverage first. 22 Chapter Six - lmiDunization The fact that DPT coverage is lower than oral polio vaccine coverage is undoubtedly due to the three month-long DPT vaccine shortage that occurred in early 1995, a shortage caused by late planning in vaccine procurement and by constraints in the production of OPT vaccine world-wide. Fig 100 80 20 Percentage .of Children 12-23 Months who were _Fully Vacdnated by the Time o~ the Su'rvey Malawi Urban Rural North Central " - . • '"'1"71 MSIS 1995 , ' • , DHS 1992 L::.,l The survey also reveals that 77% of mothers of 0-11 month olds had at least 2 doses of tetanus toxoid vaccine within 3 years of their child's birth, which protected their newborns against neonatal tetanus. Not surprisingly, the rate of coverage differs according to whether families live in rural, or the better provided urban areas. The full coverage rate for urban areas is 69%, compared to the rural figure of 60%. However, this difference cannot be considered statistically significant. Immunization coverage differs at the regional level. The coverage rates of children 12-23 months old who have been fully immunized by their first birthday are higher in the Northern region (at 67% coverage) compared to the Southern (62%) and Central (58%) regions. - The Central region has the lowest rate of complete coverage of all vaccinations by the second birthday, at only 72% compared to 77% for the Southern, and 80% for the Northern regions. Moreover, coverage at the district level varies significantly, and ranges from less than one- third to over four-fifths of children being vaccinated before their first birthday. (Table 6.1). Coverage for Ntchisi (30%), Machinga (35%) and Lilongwe (50%) districts are significantly lower than the national average. On the other hand, coverage in Chitipa (81%) and Ntcheu (80%) districts is significantly higher (with a 95 percent confidence level). The survey results reveal, then, that only Chitipa and Ntcheu districts have achieved the mid-decade goal of 80% coverage. On the other hand, neither are anywhere near the 90% goal set for the end of the decade. The Ntchisi results seem to point to a generally lower coverage for all antigens ·compared to the national figure. 23 Malawi SodaiiDdlcators Survey 1995 Table 6.1 'l1le perceatap of cblldrea 12-23 months who have received specified vaccines by l2 months of Number ofCIUldrea bathe Sample 76 ( 1.8) 80 ( 1.7) 975 . ilt 3J)) 81(.3.4} - 71 ( 4.1) 186 . 71 (~~~> . 72f( .2.5) . 71 ( 2.6) 438 80(2;8) ' 13( 2;7) 69( 3.7) 351 81 ( 7.6) 92 ( 4.7) 93 ( 3.9) 89 ( 4.6) 84( 7.2) 33 52 (11.6) 100( 0.0) 78 ( 8.2) 74 ( 7.4) 59 ( 8.7) 24 74 ( 5.0) 88 ( 7.0) 87 ( 7.3) 86( 7.7) 67 ( 8.9) 29 63 ( 7.0) 91 ( 4.3) 78 ( 3.7) 77 ( 5.5) 71 ( 9.1) 72 74 13.1) 98 ( 2.7) 90( 8.4) 90( 8.4) 81 ( 9.1) 28 . . 97J'2;.1): 7S( .$.§) ' 87( 4.7) 6()( 7.4) 35 .89( ·$.1) . 62( 1.1} . 62(. 8.7) 51 (14.2) 34 6%(,.5.5) . 71 ( 5.4) . 69( 4.7) 127 7l (ll .S) 80(8.9) 75 ( 4.4) 47 ·77(7.7).' 73 (tO.S) . 68( 9.6) 33 70(~.0)i 74( 6,8) . 43 sot 4.7) ~- 80( 2.9) 36 - 37: (·' .5.4~ 88(4.2) 83 ( 6.4) 40 59(t Sl7) :··· 67( 3.4) · SO( 8.7) 43 Maugochi 63 ( 9.6) 94 ( 3.8) 88 ( 7.0) 77 (10.1) 69 ( 7.8) 37 Machinga 35 (10.6) 89 ( 4.9) 54 ( 6.8) 77 ( 8.5) 48 (12.9) 37 Zomba 73 ( 7.2) 91 ( 5.3) 80 ( 2.5) 77( 4.7) 81 ( 2.5) 49 MwaDza 64 (11.4) 92 ( 4.2) 72( 8.2) 83 ( 4.9) 78 ( 6.9) 41 Blantyre 71 ( 6.4) 94 ( 3.3) 91 ( 4.6) 89 ( 5.1) 74 ( 6.1) 53 MulaDje 58 (12.9) 87 ( 7.4) 78 ( 8.4) 81 ( 7.9) 58 (12.9) 23 Thyolo 63 (13.9) 87 ( 5.3) 83 (11.3) 86 (10.6) 72 (14.9) 23 Chiradzulu 79 (10.3) 100 ( 0.0) 87 ( 8.9) 93 ( 7.2) 82 ( 8.6) 22 Chikwawa 56 (10.7) 98 ( 2.1) 78 (10.2) 91 ( 4.4) 80 ( 5.8) 30 Nsaoje 58 (21.3) 83 ( 3.6) 71 (10.1) 78 ( 5.0) 56(17.4) 36 -.:' . ,_ ~( 5,8) . 78( 7:4{ ' 79(7~) . 78( 7.6) 108 92( 1.0) _76 ( ·1_:9) .·: 80( 1.7) · 69( 2.1} 867 Geader Male 59 ( 2.9) 90 (1.8) 75 ( 2.6) 80 ( 2.5) 68 ( 2.7) 482 Female 62 ( 2.8) 93 (1.4) 76 ( 2.3) 80 ( 2.0) 72( 2.5) 491 -1bree doses of DPT and oral polio vaccines Standard errors in parentheses 24 If the World Summit Goal is to be reached, resources should be concentrated on raising levels in the districts with the lowest rates of coverage, while at the same time, not neglecting the other districts. Finally, the gender differential in immunization coverage is slight. Fifty-nine percent of males 12-23 months old have been fully immunized by the age of one, compared to 62% of females. In order to assess rates of coverage, the enumerators asked to see health cards: They discovered that under-5 cards are retained for 88% of children aged 12-23 months, which is an increase of 2% on the 1992 DRS figure. The retention rate of mothers' tetanus toxoid vaccination cards is 85%. Interestingly, card retention is higher in the rural than the urban areas. Data on vaccination coverage according to the source of information used to determine coverage - i.e., the vaccination card or mother's report -- are presented in Table 6.2. These data are for children aged 12-23 months, the age at which they should be fully vaccinated. According to the vaccination cards, 85% of children have received a BCG vaccination, the same rate as the 1992 DRS result (85.9%). Another ~lo of children did not have a card when surveyed in 1995, but were reported by their mothers to have received the BCG vaccine, for which the scar was checked. This, therefore, implies that overall 94% of children aged 12-23 months are vaccinated against tuberculosis, down 3% on the 1992 DRS figure (this difference is significant at the 95% confidence level). Table 6.2 Vaceinatlon rates of chlldren 12-23 month• old. and vaceinatlon rata of •ame ap poup before their fint birthday, by 10urce of information Vaccinat&:d . . ·. by12 DJ.onthS ofagc= . . • BCG, measles, three doses of DPT and polio vaccines Coverage for the first courses of polio stands at 93%, as does coverage for DPT 1. This · figure is not significantly different from that for BCG (94%). What is of concern, though, is that coverage of DPT and polio decline with subsequent doses. This could be explained by a number of factors, including unavailability of vaccines and mothers' fatigue. 25 ---------- ---- - - ---- -- - -Malawi Social Iodk:ators Survey 1995 Another wonying trend is late vaccinations. Only 700/o of children were given their measles vaccination before the recommended age of one year, while another 13% received it between their first and second birthdays. Less than two-thirds ( 61%) of children had all their vaccinations before their first birthday, compared to three-quarters by the time of the survey. Six percent of children had no vaccinations by their first birthday, though half of these had some vaccinations before reaching their second birthday. Between 1992 and 1995, OPT 3 declined from 82% to 76% and polio 3 from 84% to 80%; other differences were not significant. There is a slightly higher coverage for boys than girls, though there is a marked difference in measles vaccinations (85% for girls and 79% for boys). All other vaccine types have similar coverage. There is no significant difference in full immunization by the time of the survey in urban and rural areas. This seems to indicate that both rural and urban mothers are eager to complete the basic vaccinations. However, rural women face more logistical problems than urban mothers, and the latter are more likely to succeed in completing the course of immunization within their children's first 12 months. Full vaccination coverage by 12 months of age is, therefore, shown by this survey to be higher for urban than rural residents. There is a positive correlation between the education levels of mothers and household heads, on one hand, and the rate of coverage of each antigen as well as full immunization coverage, on the other (Tables 6.3 and 6.5). As the level of education of both the mother and household head increases, iinmunization coverage is also likely to increase. Table 6.3 Distribution of chUdren (%) of ages 12-23 months, immunized by their fint birthday, by education of mother lfotllCr'• ·····-Bdllftdoa --·: . _- ··:::-.·-; ' - . ·.- '.--~ None > Primary.l-4 Primaf}'$.8 Secondary+ •·oPVJ 18 79 - 87 88 Measles 67 67 79 •: 83 ~ 54 72 76 Specifically, complete timely coverage increases with maternal education, from 58% of children whose mothers have no education to 72% of children whose mothers have an upper primary education. The number rises to 76% for those children of mothers with some secondary education, but· this figure should be treated with caution because the number of mothers with secondary education who were surveyed was small (42) and the percent standard error is high (almost 11% SE)_ 26 Chapter Six - Immnnizatiou Table 6.4 Distribution of dUidren (~•) of ages 12-23 months, immunized before their fint birthday, by education of household bead Interestingly, all of the children 12-23 months old in the urban areas whose mothers have some secondary education had received some vaccines by the time of the survey. This means that those children in urban areas with relatively well educated mothers are more likely to do better in EPI coverage. Table 6.5 Pen:entage of chlldren 12-23 months who had received spedf'IC vaccines by the time of the sun'ey, by seleded bacqround characteristics from all soun:es All Children 94 93 89 84 94 89 81 82 75 3 997 88 Tasks undertaken to date The coverage to date has been possible as a result of the Expanded Programme of Immunization undertaken by the Ministry of Health with the assistance of UNICEF. This support 27 Malawi Sodallndk:ators Survey 1995 has taken the form of supplies, equipment, training, management capacity building and the solicitation of funds from bilateral sources, and has also strengthened monitoring and evaluation activities, human resources development and Social Mobilization. The vaccination programme is now routine and demand-driven and requires a minimum amount of popular persuasion. However, parents and conununities need to be reminded periodically of the importance of immunization and their further participation is needed for sustainability. Constraints There has been a discernible decline in funding levels for operational costs· since 1990. This has led to a severe curtailment of activities during 1995. Also, certain types of vaccines, especially . DPT, have not been available in the country at times. Other vaccines, such as for measles, were always available in Malawi, but logistical problems made them periodically unavailable in certain parts of the country. Financial problems threaten to reverse the benefits achieved in Malawi thus far. The outreach strategy -which brings health care to the people -- and the supervision of health workers, supplies and deliveries have, in the recent past, been severely affected as a result. A renewed effort by those organizations with resources is needed if the general decline in immunization coverage is to be reversed. During the period 1996 to 2000, support from EPI Donors in the areas of vaccines and cold chain and related equipment are also needed. District level figures show considerable divergences in immunization coverage (which should be interpreted in light of their standard errors). To counter district differences, more resoW"Ces generally, and a more precise targeting of funds are needed to support operational costs in weaker districts. To sustain and increase a district's ability to carry out essential tasks and avoid a major decline in coverage, planning for the required support must be the immediate task The monitoring of outbreaks of disease, especially measles, must be strengthened, too. If such assistance can be made available, it will go a long way towards alleviating the current problems and reversing the general downward trend. The MSIS survey collected data about individual vaccination coverage, which are intended to help policy makers pinpoint specific problem areas. 6.2BCG The MSIS survey found that there has been a drop in BCG coverage (i.e., vaccination . against tuberculosis) of children aged 12-23 months by their first birthday. It now stands at 91%, · or 4% down on the 1992 DHS survey figures (Figure 6.1). This was found to be statistically significant at the 95% confidence level. There are no significant differences in coverage between the three regions -- North (93% coverage), South (92%) and Central (91%) regions. 28 Chapter SII - Jmmnnbatioo District level coverage rates, however, reveal significant differences, with the lowest (Nsanje) at 83% and the highest (Karonga and Chiradzulu) at 100% (Table 6.1). Chikwawa and Nkhata Bay have significantly higher rates than the average for Malawi, whilst Nsanje has significantly lower. For the same age group, BCG coverage in the urban areas is 86% whereas coverage in the rural areas is 92%. BCG coverage for female children of the same age group (93%) is slightly higher than for their male counterparts (90%). For children aged 12-23 months who had received various vaccines by the time of the survey, BCG coverage was 94%, 3% down from the 1992 DHS figure. 6.3 Measles There has been no change since 1992 in the rate of coverage (70%) of measles vaccinations for children aged 12-23 months who had the vaccine by 12 months of age (Figure 6.1 ). There is no significant difference in coverage between the three regions, with the rate only slightly higher for the North and Centre (71%) than in the South ( 69% ). District level coverage rates, however, reveal significant differences, with the lowest (Machinga) at 48% and the highest (Ntcheu) at 83% (Table 6.1). Ntchisi has a coverage rate significantly lower than the mean rate for Malawi, while Ntcheu's rate is significantly higher. In the same age group, measles coverage in the urban areas (78%) is not significantly different than in the rural areas (69%). Measles coverage for female children of the same age group is higher (72%) than their male counterparts (68%). For children aged 12-23 months who had received vaccines by the time of the survey, measles coverage is 82%. This is 4% down from the level identified by the 1992 DHS survey. Tasks Undertaken to Date The epidemiological picture of measles appears to be changing. Specifically, older children (5 years and over) are more likely to get the disease, and there seems to be a longer interval between outbreaks. Although this is a sign of a successful EPI programme, it calls for a reassessment of immunization strategies and measures. A significant reduction of cases has been recorded over the period 1990-1995. The measles rate among under-5s declined from 248/10,000 population in 1990 to 12/10,000 population in 1994. In-patient cases of all ages fell from 11,988 in 1990 to 531 in 1994, with total deaths of all ages from measles reduced from 1,166 in 1990 to 56 in 1994. -------------------------· .-. -- 29 Malawi Sodallndk:ators Survey 1995 In 1990 there were 1,015 under-5s measles deaths nationally, while this figure· fell to 45 deaths by 1994. In 1994, most deaths ofunder-5s from measles were in the Central region (28), compared to the North (8) and the South (9). At the district level these 45 deaths were located in Blantyre (3), Nsanje (2), Mangochi (1), Chiradzulu (3), Lilongwe (19), Kasungu (8), Dowa (1), Karonga (7) and Mzimba (1). Localized measles outbreaks were reported in 1995 in Machinga, Mulanje, Zomba and Mangochi in the Southern Region and in Salima, Dedza, Lilongwe, Ntcheu and Nkhotakota districts in the Central Region. Since the global goal is the reduction of measles cases and deaths, it seems that this is achievable in Malawi in the long term. Constraints With the spread of measles to older children, and an unprecedented outbreak of measles in infants below nine months, there is a need to clarify the epidemiological situation if appropriate measures are to be recommended. Additional research is therefore necessary. Any new measures will have to be implemented and closely monitored for impact. Major Tasks Planned In the EPI programme, measles outbreaks will be monitored, and 'catch-up' vaccination campaigns and containment activities undertaken. Special attention will be given to low-coverage and hard-to-reach areas in all districts. Case definitions which have been printed in poster form will be widely distributed to health facilities in order to improve diagnosis. A Disease Surveillance course planned for peripheral health staff will emphasize measles case definitions and surveillance, and briefings on measles in the villages will be started. The challenge in the years to come will be to attract sufficient funding for the programme and to maintain a functioning, decentralized primary health care system. 6.4DPT The MSIS results reveal that for children aged 12-23 months who had received vaccines by 12 months of age, DPT3 coverage is down 8% from the figure obtained during the 1992 DHS survey, to 76% (Figure 6. 1). This was found to be statistically significant at a 95% confidence level. There are significant differences in coverage between the three regions. The North again ranks first (83% coverage), compared to the South (80%) and Central (71%) regions. District level coverage rates also reveal significant differences, with the lowest (Machinga) at 54% and the highest (Chitipa) at 93% (Table 6.1). Machinga, Ntchisi and Lilongwe districts were 30 '·- all significantly lower than the mean for Malawi, whilst Chitipa and Blantyre districts were significantly higher than the mean. There is little difference in DTP3 coverage between the urban areas (78%) and the rural (76%). Nor is there a significant difference in coverage for girl and boy children of the same age group (76% and 75%, respectively). For the children aged 12-23 months who had received various vaccines by the time of the survey, DPT coverage (at 81 %) is 8% lower than the rate reported by the DHS in 1992. 6.5 Polio For children aged 12-23 months who had received various vaccines by 12 months of age, full polio coverage (OPV3) stands at 8()8/o, 4% down from the 1992 DHS (Figure 6.1). This difference was not found to be statistically significant. There are slight differences in coverage between the North (81% coverage), the South (83%) and Central (78%) regions. District level coverage rates, however, reveal significant differences, with Mchinji district (62%) significantly lower than Chiradzuludistrict(93%) (Table 6.1). Mchinji and Ntchisi districts' rates are significantly lower than the mean, while the rate in Chikwawa district is significantly higher. Polio coverage for the urban areas is not significantly different from the rural areas (i.e., 79% and 80%, respectively). Polio coverage for female children of this same age group is the same as for males (800/o). ' For children aged 12-23 months who had received various vaccines by the time of the survey, polio coverage stands at 84%, or 4% down on the 1992 DHS survey figure. The mid-decade goal is the elimination of poliomyelitis in selected countries and regions, which will contribute to achieving full eradication of poliomyelitis world-wide by the year 2000. This is achievable in Malawi as long as district level coverage is intensified, with an improved surveillance system, and all bottlenecks substantially removed. Tasks Undertaken to Date Significant strides have been made in terms of improving polio surveillance. Eradication measures have been put in place and are widely practised. Specifically, the achievement of high rates of vaccination coverage and maintenance ofthat coverage since 1990 have had an impact. There were only 3 cases of polio in 1990, one each in Nsanje, Thyolo and Zomba districts. The last 31 Malawi Social Indicators Survey 1995 confirmed case of polio was reported in 1991. (From 1992 to date no cases have been confirmed though suspects were subjected to rigorous investigations, including stool specimens to isolate the polio virus.) Community briefings for various groups have taken place, during which drama groups sometimes support and enhance the dissemination of messages. Constraints The surveillance system is not sensitive enough and it is suspected that some Acute Flaccid Paralysis (AFP) cases are not being reported as they should be. It is not yet clear why this is the case. The tendency seems to be to withhold reporting of AFP cases once polio is ruled out. There is also difficulty in getting information from herbalists, who may be treating Acute Flaccid Paralysis cases. More effort should be exerted locally in extending surveillance mechanisms beyond the formal health system. Major Tasks Planned First, it is necessary to improve the reporting system ofr community organizations and other structures, such as the NGO, Malawi Against Polio. Moreover, to eradicate polio it is also important to check all forms of paralysis to ensure that they are not caused by polio. Because it is difficult to distinguish between the various forms of paralysis and polio, it is necessary to follow-up these cases. National Immunization Days for polio are planned for implementation in June and July 1996. The aim is to eradicate polio world-wide. This year 26 countries in southern and East Africa agreed to undertake these national campaigns. 6.6 Tetanus Toxoid for Mothers A survey in 1983 established a neonatal tetanus mortality rate of 12/1000 births. A repeat survey in 1990 indicated a reduced rate of 4.6/1000 births. A third survey was planned for 1995, but was cancelled on the advice of WHO because the surveillance system has improved and it was felt that there is little need to do a special survey to monitor trends. Since then the surveillance system continues to be strengthened with prompt reporting, investigating and mapping of every case in order to identify low coverage, high risk areas. Major activities from 1990 have centred on expanding the coverage of tetanus toxoid vaccine to all women of child-bearing age. · Nationally, about three-quarters (77%) of mothers of 0-11 months old children received at least 2 doses of tetanus toxoid in the 3 years before giving birth. This means that they either received at least two doses of IT during their last pregnancy or had the last dose within the appropriate interval for the total number of doses given in a life time. 32 Table 6.6 Motben (•/e) who have received Tetanus Toxoid. by geographic area Malawi Region North Centre South District Chitipa Karonga Rump hi Mzimba NkhataBay Kasungu Mchinji Lilongwe Dow a Nkhotakota Salima Dedza Ntcheu Ntchisi === Zomba Mwanza Blantyre .Mulanje Thyolo Chiradzulu Chikwawa Nsanje Residence Urban Rural Percentage 77 (2.1) 64( 6.6) 82 ( 2.6) ·· 76( •. 3.3) . 50 ( 9;6) 95().0) 78( 9.7) ~g ( 9~9) . 48H9.2J n< 8~6J 81 (10.6) 84 ( .4.4) 89( .15( 7S( 8.4) 92 ( 3.0) 89(6;6) 37(11.9) . ··. : < ·. . ·.65(9,0) . 86( 5.5) 90( 3,9} 65( 6A) 81( 5.2) ·. ·. 57( .93) . 75 (14.2) 77 ( 6.8) 84( 5.4) . 76 ( 6.3) . 83 ( 3.9) 76 ( 2.3) Number of mothen 1304 . ···284 509 511 Chapter Six - Immunization There are significant differences in coverage between the three regions. In the North coverage is low (64%), higher in the South (76%), and higher still in the Central region (81%). Distdct level coverage rates also reveal significant differences, with the lowest (Ntchisi) at 37% (standard error of 12%) and the highest (Karonga) at 95% (standard error of 3%). Tetanus Toxoid coverage for new mothers in the urban areas is 83%, whereas the coverage for the rural areas is 76%. The number of neonatal tetanus cases reported through EPI routine reporting have fallen from 94 in 1990 to 7 m 1995. These seven cases were reported in six districts (Chiradzulu, Ntcheu, Mchinji, Karonga, Chitipa and Nkhata Bay), while the other districts reported none. These figures demonstrate that the situation in Malawi has improved, but has not yet reached the mid-decade goal of eliminating neonatal tetanus. Additional effort is necessary. This is especially true since the incidence of neonatal tetanus in the villages, about which no data were collected by MSIS, remains significant. Wide coverage of non-pregnant women of child-bearing age is a goal that is still not met. Any attempt to expand coverage necessitates extra vaccine supplies and improved logistics. Long- term (to the year 2000) financial, logistical and to some extent, technical support are required to increase coverage. Additional strategies have to include reaching women outside health facilities. 33 Malawi Sodal Indiadon Survey 1995 Major Tasks Planned Planned activities focus on active surveillance of neonatal tetanus and identification of high risk areas, both of which will lead to 'catch up' campaigns. In addition, it is planned to extend the surveillance system to Traditional Birth Attendants and Herbalists, using a 'Yellow Card System' for follow-up. The extended surveillance system will investigate each neonatal death. The TBA is supposed to send a yellow card within a few days after a child's death, reporting it to the local health centre or hospital. Health centre staff then follow up these reports, in order to determine if the deaths were related to neonatal tetanus, which has specific signs. Health centre staff have to be trained to recognize these signs, and to encourage pregnant women in the villages to get vaccinated. If health facilities report zero cases, they have to be sure that this figure is accurate and reflects what is happening in the villages. This will entail training of the peripheral health staff to establish proper and effective linkages with TBAs. A Disease Surveillance Module adapted from WHO has been printed and is to be used for this training. A trial course was conducted in early November 1995 and district-based courses are expected to follow in all three regions during 1996. During 1996-2000 the surveillance system will be made more sensitive by enforcing a zero reporting system by all health facilities. 6. 7 Conclusion and Recommendations These results are the first evidence of a downward shift in the last decade in EPI performance and should be taken as a warning sign. Two-thirds (61%) of children 12-23 months are now fully immunized by the first birthday. That figure rises to three-quarters (75%) for the same age group, who were fully immunized by the time of the survey. If individual antigens are considered, the figure is higher. Specifically, the percentage of those 12-23 month old children who are immunized by their first birthday stands at 91% for BCG, 76% for OPT, 80% for polio, and 70% for measles. By the time of the survey over 800/o children 12-23 months old were immunized for each antigen (Table 6.2). Wonying, then, is the drop in the figures for children immunized before their first birthdays. OPT coverage has fallen from 84% in 1992 to 76%, while polio has dropped by four percent to 80%in the same time period. Measles coverage (at 700/o) has not improved, while BCG coverage has fallen slightly. Furthermore, the percentage of children fully immunized by their first birthday shows a downward trend. In 1992, 67% of children were fully immunized by 12 months, compared to only 61 o/o now. These results are the first evidence of a downward shift in the last decade in EPI performance, and serve as a warning. There has been a discernible decline in the funding levels for operational costs since 1990. This has led to a severe curtailment of activities during 1995. Certain vaccines, especially OPT, have been periodically unavailable due to global shortages in the production of vaccines. Other vaccines, such. as for measles, were available in Malawi, but logistical problems made them scarce in certain periods. 34 C1lapeer Sh- ,_ . In the elimination of neonatal tetanus, the constraint is in providing tetanus vaccinations to non-pregnant women of child-bearing age. Any attempt to expand immunization in this area demands extra vaccine and improved logistics, which increase expenditure. In this time ofbeh- tightening, it is difficult to expand this necessary programme. The outreach strategy, the supervision of immunizations, the supply of vaccines and their timely delivery have all been severely affected by insufficient resources, exacerbated by the cash budget. The net effect is reduced service delivery. If Malawi is to achieve the Summit goal by the year 2000, this trend must be reversed. Moreover, if Malawi is not to go backwards in its rate of coverage - ending the decade with lower rates than five years ago -- the resource constraints underlying this reversal must be addressed. In order for Malawi to achieve the immunization goal set at the World Summit for Children, energies and resources must be applied in several areas: . There is an acute need for funds to support operational costs of the EPI programme at district level; . From now until 2000, donor support for the EPI programme is necessary in the areas of vaccines, and cold chain and related equipment; . Government will need to become progressively more responsible for vaccines and other costs; . Districts must immediately begin to plan for the support required to enable them to carry outimnnmization programmes. To sustain a district's ability to carry out essential tasks and avoid a major drop in coverage, planning for the required support must be the immediate task; . The monitoring of disease outbreaks, especially measles, must be strengthened; . Technical assistance in the form of a team of experts is needed to help assess and make recommendations for the changing epidemiology of measles. Any new measures will have to be implemented and closely monitored for impact; . Measles outbreaks should be monitored and 'catch-up' campaigns and containment activities supported. Special attention should focus on low coverage and hard-to-reach areas in each district. Case definitions that have been printed in poster form should be widely distributed; . There is need to pay more attention to providing local briefings on measles to village communities; . Disease Surveillance courses for peripheral health staff should emphasize measles case definitions and surveillance; Acute Flaccid Paralysis reporting should be enforced; 35 • The Ministry of Health and Population is committed to primary health care. This, along with recent efforts to strengthen the role of Health Surveillance Assistants and to collaborate with Village Health Committees, should be supported and encouraged~ • Fmaocial, logistical, and to some extent, technical support is required until 2000, to combat neonatal tetanus~ • Raising levels of literacy of mothers and households heads should be an educational priority, as literacy rates have a direct bearing on levels of timely childhood immunization. 36 CHAPTER SEVEN DIARRHOEA IJll ehydration resulting from severe diarrhoea is a major cause of morbidity and ~ mortality among children. It is estimated that world-wide over 3 million children below five years die every year due to diarrhoea and dehydration. The problem is particularly severe in developing countries, where almost a quarter of the deaths among children under 5 years of age are caused by diarrhoea. Most of these deaths could be prevented through Oral Rehydration Therapy (ORT). 7.1 Situation in Malawi Diarrhoeal diseases have been, and continue to be a major cause of child morbidity and mortality in Malawi. In 1991 the National Morbidity, Mortality and Treatment Survey showed that the average child suffered six diarrhoeal episodes each year. If this figure is multiplied by the approximately two million children under five years old in Malawi, then the magnitude of the problem is clear. Fifteen percent of children under the age of 5 had dia"hoea in the two weeks preceding the survey. Four in five of those were treated with some form of Oral Rehydration Therapy. Among those under-5s hospitalized for diarrhoea in 1992, the case fatality rate was 8.6%, making diarrhoea the fifth most common cause of death among inpatients in this age group. The main cause of death from acute diarrhoea is dehydration, which results from the loss of fluid and electrolytes in diarrhoeal stools. Other important causes of death are malnutrition and infections, such as malaria and pneumonia. Diarrhoea ts also among the top five causes of outpatient attendance of under-5s. As each under-5 child will expect to suffer 5 or 6 diarrhoea episodes each year, by the age of five years they will have spent a total of 4-5 months of life with diarrhoea. 37 The National Policy for Control of Diarrhoeal Diseases Programme emphaSizes effective case management in homes and health facilities as the primary strategy for decreasing diarrhoeal mortality in young children. Effective case management is recommended to include provision of additional fluids, continued feeding (including breast milk), and appropriate use of drugs and ~ferral practices. 7.l Prewllence of Diturltoea This Malawi Social Indicators Survey revealed that 14.6% of children under the age of 5 yan bad diaRboea in tbe two "Weeks preceding the survey. Significant differences are recorded for childRm. of ditfemtt ages and living in different regions (Table 7.1 ). Specifically, children in the Ccatal region sutJa- more from dian:hoea. However, there are no significant differences in the JRValeace of dianhoea with respect to the mothers education or the child's gender. Till* 7.1 .,_._(%)of c:lliNnll widt dianiloea by _. residnace, a-der aad lllodler's ed•atioa Medler's U.C.tion No Education Primaryl-4 Primary 5-8 Secondary+ Standard enon in parentheses 15.0 (1.4) 15.7 (1.8) 12.2 (1.3) 17.8 (4.6) A child's age is correlated with the prevalence of diarrhoea, with low levels recorded when the child is less than six months old. The prevalence rises until the child reaches two years, when it again starts to fall. The likely reason for this is that breast feeding at ages above 6 months tends to be intermittent, and these children are increasingly given prepared foods. In addition, children above 6 months are more mobile and independent, and are likely to put unhygienic items in their mouths. · Diarrhoea is more prevalent in Dowa, Lilongwe and Mulanje districts in particular, though the incidence is high in several others, including Nkhotakota, Mchinji, Nsanje, Salima and Kasungu (Table 7.2). Diarrhoea is most prevalent where mothers wash hands only after food has been eaten (Table 7.3). However, statistically significant differences exist between washing hands 'before and after meals' and 'other' times. There exists a direct relationship between the prevalence of diarrhoea and the socio- 38 I I Chapter Seven - Dlarrboea economic characteristics of the family. Using correlation and regression analyses reveals that the age of a child is more significant than other factors, such as whether the child is breast fed, the level of the mother's education, family residence, or access to safe water and sanitation. Those most at risk are children aged 6-23 months. This is also the age at which malnutrition levels increase dramatically. Those infants who are exclusively breast fed (Table 7.3) are less likely to suffer from diarrhoea (8.5%) than those who receive other food and water (14.5%). These findings confirm a previously recognized fact that children who are exclusively breast fed have less diarrhoea. 7.3 Diarrhoea Treatment Effective case management of diarrhoea consists of the replacement of lost electrolytes and body fluid, continued feeding of the child during and after each diarrhoeal episode, and referral to · Dedza Dowa Kasungu Lilongwe Mchinji Nkhotakota Ntcheu Ntchisi Salima 8.6 (2.5) 22.0 (3.7) 15.6 (4.6) 20.3 (2.2) 16.8 (3.3) 17.9 (3 .5) 13.2 (3.1) 16.4 (3.8) 15.7 (4.2) a health unit if the situation worsens or becomes severe. To assess the effective case management in the home by mothers and caretakers, respondents were asked what fluids and food were given to their children when they were sick with diarrhoea. The MSIS survey found that three-quarters (78%) of under-5s with diarrhoea are given either ORS sachets or gruel. At a regional level, the proportions remain high, with 83% of children in the Central region having some form of ORT treatment, followed by ~hildren in the Northern region (74%) and the South (72%). In the analysis an attempt was made to find explanatory factors for the differences in treatment of diarrhoea. It was found that mother's education and residence have a negligible effect on whether children are provided with ORT (Table 7.4). The low use of ORS saehets can partly be accounted for by the difficulty in obtaining ORS sachets outside the health system in the last three years. There were also fewer supplied by government and donors due to the change in the policy regarding treatment. 39 Malawi SodaiiDdk:ators. Survey 1995 Only one-third (32.8%) of dianhoea cases are treated with ORS sachets. But the use of ORS sachets differs for girls and boys, and for children of different ages. More than one-third of girls (37.9%), but just over one-quarter of boys (28.6%) will be given ORS sachets when they have diarrhoea. Further research is needed to determine why there is a gender difference. With respect to a child's age, the use of ORS sachets for children less than six months of age is significantly lower than for children aged 6 to 35 months. After children reach three years of age, they are less likely to receive ORS packets. The use of ORS sachets for the age groups 36-47 and 48-59 months are significantly lower than for age groups under 36 months. This may correspond to the more frequent visits made to health centres or under-five clinics by the younger children, since free ORS sachets are now only provided through the health system. Table 7.3 Proportion of children (•/e) with diarrhoea, Nearly two-thirds (63 .8%) of by water, sanitation, hygiene and breast feeding children are treated for diarrhoea with Water Safe Water Unsafe Water Sanitation Safe Sanitation Unsafe Sanitation When Hands Were Washed: Before Meals After Meals Before and After Other 14.0 16.1 Exclusively Breastfed Children Children Receiving Food and Water ~~~~--+-+-~~ regional level (60-69%) remains the In any event, home-made solutions are most popular form of diarrhoea . u . u., . " everywhere in Malawi. Still, there significant differences between treatment of diarrhoea by region, the use of ORS sachets in the North much lower than in the Centre, treatment with ORS and gruel is lll};:nc:sc in the Central region. 1 Data suggest that as a mother'~ education increases, her children are more; likely to be treated with either gruel o~ ORS during bouts of diarrhoea. ~ There are no significanti differences between the treatment of: dianhoea of those children living in urban rural areas. Furthermore, no significant differences1 emerge on the use of gruel in respect of different socio-economic characteristics. There are also no ' variations in treatment of diarrhoea with, either ORS sachets or gruel by socio-economic. characteristics, except for a mother's education. Prior to 1993 mothers were encouraged to give ORS sachets or sugar salt solutions to: children suffering from diarrhoea. This policy was changed when it became clear that giving children the wrong mixture of sugar salt solutionwoulchggravate the situatiorr."Since·then mothers: have been encouraged to undertake the following;bome . tr~atment oLdiarrhuea instead: ' In order to prevent dehydration, the child should be given more (home available) fluids than normal as soon as the dianhoea starts. Mothers should continue feeding the child the usual diet 40 Chapter Seven - Diarrhoea in adequate quantity during and after the bout of diarrhoea, which means at least 5 times a day. In other words, dietary frequency and amount should be increased by an extra 2 or 3 meals each day. If the condition becomes worse or severe, the child should be taken to the health centre. Child's Age (months) < 6 6- 11 12-23 24-35 36-47 48-59 14.7 (6.4) 37.5 (5.1) 37.9 (4.3) 32.8 (6.2) 19.1 (4.6) 18.2 7) 68.0 (9.0) 62.5 (6.1) 62.5 (3.8) 71.6 (5.2) 61.0 (7.6) 60.1 72.4 (7.5) 77.3 (6.2) 81.0 (3.1) 80.7 (4.4) 72.6 (8.7) 68.4 In order to assess how effectively the new treatment is being practised, mothers and caretakers were asked if their children with diarrhoea received much more, about the same, less, much less, or no fluids and food. The findings revealed that only 12% of children with diarrhoea receive more fluids and even fewer (5.3%) are also fed. About one-third of the children with diarrhoea (32%) are treated with sugar salt solutions. Overall, the rates of giving food and liquid to children with diarrhoea are low in all regions. These results are worrying because dehydration is the main cause of death of diarrhoea sufferers. The data indicate that the newly recommended home treatment is not being practised correctly, or has been only partially adopted. Increasingly mothers and caretakers are using home available fluids for the treatment of diarrhoea, which indicates that at least part of the message has 41 Malawi. Sodallndkators Survey 199! been taken into account. At the same time, though, there is non-compliance with recommendations to increase fluids and to continue feeding these children. This may be caused by the message, which is not clearly understood; by the belief that feeding will worsen the diarrhoea; or by the inability to meet the requirement due to poverty and food shortages. ·· Measures Undertaken, 1990-1995 Amount of fluid• taken when chUd i1 1ick with diarrhoea 10.5 (7.3) 34.9 (2.7) 18.1 (3 .3) 23.0 (2 .6) 12.0 (4.1) 1.1 10.3) Before 1993 oral rehydration therapy was promoted in Malawi in the form of three interventions: the preparation and use at home of oral rehydration solution (ORS) made from water and commercially produced packets of oral rehydration salts, the provision of mixed ORS by health facilities, and the preparation and use in the home of various grain-based rehydration fluids (such as rice water and maize water). As noted above, after 1993 the correct case management of diarrhoea has been to increase fluids and continUe feeding. This is more cost effective, easier for mothers, and reduces the risk of a mother giving her child too much salt. A new five year Plan of Action has been d,eveloped by government to control diarrhoeal disease, and includes in-service training of health workers on appropriate case management of diarrhoeal diseases at home and at health centres. It also includes raising awareness of diarrhoeal diseases in caretakers, promotion of personal hygiene, improvement in water and sanitation facilities, reduction of childhood immunizable diseases, improved nutrition, effective home-based case management, effective health-facility based case management, improvement of logistics and availability of supplies, institutional strengthening and capacity building, and improved monitoring and evaluation and reporting. Constraints Problems at the household level are a result, in part, of caretakers' lack of understanding of diarrhoea and personal hygiene. Compounding this are water shortages, inadequate supplies of safe drinking water, and unhygienic methods of drawing, transporting, storing and serving water. Moreover, there is a lack of resources to improve hygiene. Weaning foods are introduced at an earlv stage, mothers oftentime believe that teething is the cause of diarrhoea, and that feeding will worse~ 42 . Chapter Seven - Dlarrboea it. Overall, poverty, which has an impact on the quality of care, is the underlying cause of the problem. Health workers in the health centres have little knowledge of, and inadequate skills in diarrhoea case management. Furthermore there is no budget allocation for diarrhoeal control activities, no supervision, few storage facilities, and no mechanism to determine the availability and consumption of ORS at national, regional and district levels. A limited supply of ORS sachets is available to users. The cash budgeting system adopted by the government combined with poor drug procurement procedures have adversely affected the supply of ORS sachets to hospitals. There has also been a reduction in the supply of ORS packets from UNICEF, due to financial limitations and the expressed intention of other donors to provide ORS sachets. Due to widespread poverty, most households cannot afford ORS packets from shops. The limited supply of ORS sachets has resulted in an increase in the use of home made treatments. However, the message to increase the intake of fluids and to continue feeding has yet to be widely adopted. 7.4 Conclusion and Recommendations The prevalence of dianhoeahas decreased (from 22% to 15%) since the 1992 Demographic and Health Survey. However, it has increased aptongst children over 36 months. The use of ORS sachets has remained the same, but the use of home-based solutions has dramatically increased from 39% in 1992 to the current 64%. As a result the number of children receiving either the recommended ORS sachets or home-based solution has in_creased from 63% to 78%. One worrying trend, however, is that the proportion of children with diarrhoea who are given increased fluids is less than one-third of what it was in 1992, dropping from 38% to 12%. , As part of a larger programme to control diarrhoeal diseases, the mid-decade goal is to increase the usage ofORT or additional fluids to 80%. In Malawi, this has almost been achieved. The end-of-decade goal is to cut under-5s' deaths from diarrhoea by one-half, and to reduce the prevalence of diarrhoea by one-quarter, compared to their 1990 levels. In Malawi, the prevalence of diarrhoea has already fallen by 25% since 1992. Now emphasis should be put on maintaining this relatively low figure, and reducing mortality due to diarrhoea. Among under-5s hospitilized fordianhoea in 1992 the case fatality rate was 0.6%. No data are yet available for 1995. The use of home made oral rehydration solutions has shown a dramatic increase since the 1992 survey. Still, the number of children receiving increased fluids when they have diarrhoea remains exceptionally low, as does the number of children receiving increased fluids and continued feeding. The government has also agreed in principle to introduce 'the integrated sick child initiative'. The initiative promotes a shift away from vertical programmes, like the Control of Dianhoeal Diseases and the Acute Respiratory Infections programme, to an integrated approach in 43 ~wi ~ ~t.!»!S Survey 1995 ·~ "'"Xrcwr· - = the treatment of sick children. This will require training and the development of training materials for implementation in Malawi, which will be done by the Ministry of Health and Population m collaboration with WHO and UNICEF among other agencies. In light of the data collected, the following recommendations are made: • The message that caretakers should increase the amount of fluids given to, and continue feeding a child with diarrhoea has not been assimilated. It remains unclear whether this is because the information campaign was poorly designed and/or implemented, or whether the caretakers' knowledge of, and experience with diarrhoea makes it difficult for them to accept the message. The information programme and the content of the messages need investigating and possibly, reform. ORT comers should be established in all health facilities. • Data have shown that low cost treatments of diarrhoea are more frequently used than ORS sachets. However, the recommended low cost treatment -- i.e., giving children additional fluids and continued feeding-- is not always followed correctly, which is of grave concern. This may be caused by confusion about the changed treatment policy, and because the new treatment has not been effectively communicated. ORS sachets that are available in shops are too expensive for most Malawians. To this end, the promotion of home-based fluids for the treatment of diarrhoea should be intensified. . Programmes should explain to fathers and mothers why children between 6 and 24 months are more likely to have diarrhoea, and how this can be prevented. . Particular attention should be paid to the districts of Mulanje and Dowa, which have a higher proportion of children with diarrhoea. The link between diarrhoea and water sources needs further examination. The quantity and quality of water at these reportedly 'safe' sources should be investigated, as should the quality of sanitation facilities. Training of men and women in collecting, transporting and serving water in clean vessels should be extended. • Because there is a positive correlation between breast feeding and non-incidence of diarrhoea, breast feeding should be encouraged and general hygiene emphasized. v- · -· w ~ ox ·-wzw ··:e· -- r::zt- x ·wntt ·z · · 44 CHILD NUTRITION hild malnutrition contributes to stunted mental and physical growth world-wide, "'iiiiiliiiliii• and to the death of many children under 5 years old. In fact, over 50% of the 13 million child deaths each year are due to a combination of illness and malnutrition. Children with severe malnutrition are 8 times more likely to die than well nourished children, while moderately malnourished children are 5 times more likely to die. But even if a child survives and nutrition improves, losses in physical and mental development may be irreversible. A child has only one chance to grow. Although malnutrition is common in children living in low income families, it is not the direct result of low income. Lack of food is one factor, but good health and proper care are also necessary. Some families may not have enough food for everyone, but there is usually enough for a little child. Poor access to health services, an unhygienic environment, and an inability to properly care for young children are often more important causes of malnutrition. Frequent illness reduces the child's appetite, inhibits food absorption, burns away calories in fever, and drains away nutrients in vomiting and diarrhoea. Therefore, preventing and controlling illnesses, especially through child immunization and oral rehydration therapy, help to reduce malnutrition. Breast feeding can protect a child against many common illnesses. Although extended breast feeding in Malawi is common practice, exclusive breast feeding should be encouraged for infants, and complementary foods should be introduced at the right age. When weaning begins too early, the risk of disease and malnutrition increases, which explains why child malnutrition typically peaks in the second year of a child's life. When weaning begins too late, growth begins to falter. Infrequent and inappropriate feeding also contributes to malnutrition. Young children have small stomachs, so they need to eat small meals often, perhaps five or six times a day. They also need protein to develop properly. Their food should be enriched by fats and oils. Vitamin A deficiency causes blindness in many children every year and leaves many more susceptible to diarrhoeal disease, measles and pneumonia. Even a mild vitamin A deficiency can raise a child's chances of dying from common infections by 20%. It can be easily prevented by adding fruit or green vegetables to the daily diet, or by giving the child Vitamin A capsules twice a year. The most visible S)'mptom of iodine deficiency is a swollen th)'Toid gland, or goitre, in the neck. Some demonstrate the most severe symptom, overt cretinism. Thousands of children are stillborn or brain damaged because their mothers lacked small, but essential amounts of iodine during pregnancy. They grow up stunted, listless, mentally retarded, and often incapable of normal speech, hearing or movement. 45 Malawi Social lndk:aton Survey 1995 8.1. Protein-energy Malnutrition Malawi is in the intermediate group of developing nations, whose malnutrition rate (weight-for-age) for children under five years old ranges between 15% and 30%. Malnutrition in Malawi is caused by a number of factors, including: • National and household food insecurity, due to low levels of agricultural productivity resulting from rudimentary technology, insufficient cultivatable land, environmental degradation, inadequate crop diversification, insufficient irrigation, and drought; insufficient industrialization and trade; losses of food during storage and processing; lack of employment and business opportunities; insufficient and costly food. • Frequent infections due to inadequate information, education and communication; limited access to and utilization of social services; improper food handling; unsanitary surroundings; inadequate water supply; and nutrient deficiencies. • Poor eating habits and traditions, such as early weaning and too few meals each day for small children; the bulkiness of the maize diet; the exclusion of certain healthy foods (e.g., eggs when pregnant); and the dominance of single crop production. • Insufficient vitamins and minerals, especially vitamins A, B and C, and iron and iodine, due to inadequate information and education; low intake of (especially, dark green leafy) vegetables; reduced protein intake; and low fat intake.leading to poor absorption of vitamin A. • Heavy workloads and poor nutrition of mothers, especially in the 'hungry season' before harvesting, due to the insufficiency of domestic and agricultural labour saving devices; many and frequent pregnancies; and a high dependency ratio (number of children to adults), especially in female headed households. • HIV infection leading to frequent illness, loss of labour and earnings, and an increased number of orphaned children . . • Population pressure and environmental degradation leading to a shortage of fuelwood, inadequate water supply, and low crop yields. The rate of stunting of under-fives in Malawi now stands at 48.3%. The rate of wasting has worsened since 1992 and is now at 7%. The rate of underweight children is 29.9%. Protein-energy malnutrition can be measured using three types of anthropometric indicators. Each of these indicators measures different aspects of malnutrition and gives different information about the growth of children's bodies. This information is used to estimate the nutritional status of individual children and populations. In this survey, estimates for all three indicators have been included for the under-five age group (0-59 months). 46 Chapter Eight -Child Nutrition Underweight (low weight-for-age) is a measure of a child's weight according to his/her age compared to the median value of a standard reference population. This indicator is used to monitor the growth of an individual child, but is also useful to describe the overall magnitude of malnutrition in a population. However, underweight does not distinguish between chronic malnutrition (stunting) and acute malnutrition (wasting). Stunting (low height-for-age) is a serious problem in Malawi. It is caused by long-term or chronic malnutrition, which is manifest in children who are too short for their age when measured against an international standard. (Use is normally made of the National Centre for Health Statistics, NCHS, reference population). Acute malnutrition, or wasting (low weight-for-height), refers to a situation where a child weighs too little and is too thin for his/her height. The NCHS reference is again used. Wasting is a very sensitive indicator; levels can change rapidly and show marked seasonal patterns associated with changes in food availability or disease prevalence. The rate is generally higher during drought and other emergencies. It is also a measure of mortality risk, when death is possible because of inadequate food or a high incidence of disease. Underweight The weight-for-age measurement is a combination of wasting and stunting. Data collected by the MSIS survey (Table 8.1) show a deterioration in the nutritional status of under-5s since 1992. Significant differences exist between male and female children, between those living in the three regions, and between those whose mothers have different levels of education. Over 30% of the children in ten districts are underweight. These districts are Lilongwe, Chiradzulu, Mulanje, Nsanje, Salima, Tjlyolo, Zomba, Mwanza, Mchinji and Ntchisi. The rate in the last,hree named districts is particularly bad, at 39%, 40% and 40%, respectively. Mchinji also has a high stunting rate, while both Ntchisi and Mwanza perform poorly in other indicators, such as education and access to safe water. Stunting In 1981 the National Sample Survey of Agriculture (NSSA) found that the rate of stunting in Malawi was 56%, i.e., the percentage of under-5s falling below ~2 standard deviation of the reference mean for height-for-age. There was some improvement by 1992, when the Demographic and Health Survey revealed a stunting rate of 48.7%. The findings of the MSIS demonstrate that the rate of moderate stunting ofunder-5s did not change significantly between 1992 and 1995. It is now 48.3%. Likewise, the severe stunting rate, now at 24.2%, has not shown a significant change since 1992. On the other hand, the incidence of stunting has increased significantly in the urban areas, from 11.1% in 1992 to 19.1% in 1995. This has probably been caused, at least in part, by the migration to the cities of people without an adequate means of subsistence. 47 % UNDERWEIGHT ~ 15.3 to 25.2% II 25.2 to 31.6% 31.6 to 39.9% 48 / Map 3: Underweight I ' II I Chapter Eight - Child Nutrition Table 8.1 Underweight rates*(%) of children, by gender, location and socio-economic characteristics. 1992 and 1995 "Proportion ofWlder-Ss below -2 and -3 standard deviation of the NCHSIWHO reference population according to weight-for-age anthropometric index of nutritional status. nla: no data available Source: DHS, 1992, MSIS, 1995 Since stunting is a reflection of the cumulative effects of chronic under-nutrition and long term deprivation, the continuing high rates of moderate and severe stunting indicate that over the years nutritional status has not improved. Indeed, there is little reason to think that it would, as real 49 %STUNTED ~ 36.1 to 42.5% II 42.5 to 50.7% - 50.7 to 68.5% 50 . [Map 4: Moderate Stunting I Chapter Eight - Child Nutrition income levels and per capita GNP figures have fallen. Moreover, the recent drought has aggravated normal food insecurity at both the national and household levels. The differences in the stunting rates of boys and girls, and of children· resident in the Southern and Northern regions are not Table 8.2 Stunting rates * (%) of children, by gender, location and socio-economic characteristics, 1992 and 1995 Height-for-Age (Stunting) Percent Below Percent Below Number of -JSD -JSD -2SD -2SD Children in 1992 1995 1992 1995 MSIS Sample Age in Months <60 22.9 24.2 48.7 48.3 3548 '),C-y ,"(: Gender tl.-(J . _r';. 0--'1.- '9: Male 24.5 26.9 48.7 49.7 1741 Female 21.4 21.5 46.5 47.0 1807 Residence ,'/ Urban 11.1 19.1 35.0 33.5 447 Rural 24.3 24.6 50.3 49.7 3101 Region North 17.5 17.8 44.7 46.1 679 Centre 25.0 26.7 50.5 51.5 1587 South 22.5 22.8 48.1 45.4 1282 Mother's Education None 26.4 28.2 51.7 51.3 1429 Standard 1-4 23.1 25.5 51.7 46.6 868 Standard 5 + 15.3 15.6 39.4 41.6 1144 Occupation of Head of Household Fanning (self) n/a. 25.5 n/a. 50.9 2868 Tenant " 37.1 " 51.4 88 Ganyu Labour (agri) " 36.4 " 59.7 97 Ganyu Labour (non-agri) " 24.0 " 50.3 97 Paid Employment " 20.3 " 42.2 334 Self-employed " 13.0 " 29.9 361 Other " 17.4 " 39.4 140 None " 21.6 " 48.7 34 *Proportion ofWlder-5s below -2 and -3 standard deviation of the NCHS/WHO reference population according to height-for-age anthropometric index of nutritional status. n/a: no data available. statistically significant Nor does stunting in a child depend on the occupation of the household head alone. The only significant difference exists between ganyu (piecework) labourers in agriculture and heads of household who are self- employed. The former are often the poorest in a village, and take poorly paid piece work because they are unable to feed their families in any other way. The poorest are also likely to have the lowest level of education and that, al<,>ng with inadequate health care, results in higher rates of malnutrition, which is confirmed by the survey results. On the other hand, household heads who are self- employed are apparently better able to feed their families, and therefore, have fewer stunted children. However, Source: DHS, 1992, MSIS, 1995 there are significantly higher rates of stunting in the Central region. Also, stunting is worse in the rural areas than in the cities, and amongst families where the mother has no education. Those children in families where the mothers have a Standard 5 or above education are less likely to be stunted. 51 Malawi Social Indicators Survey 1995 Ten districts recorded a stunting rate over 50%: Chitipa, Mzimba and Nkhata Bay in the Northern region; Kasungu, Lilongwe, Mchinji, Ntchisi, and Dowa in the Central region; and Machinga and Mwanza in the South. Particularly bad is Mchinji, with a massive 69% (Table A2.a in appendix). Table 8.3 Wasting rates*(%) of children. by gender. location and socio- economic "h•1 tics. 1992 and 1995 Weight-for-Height (Wasting) Percent Below Percent Below Number of -JSD -JSD -2SD -2SD Children in 1992 1995 1992 1995 MSIS Sample Age in Months <60 1.4 2.0 5.4 7.0 3532 !J._ Gender 1- Male 2.0 1.9 6.0 8.5 1729 Female 0.9 2.0 4.9 5.6 1803 ~I, Residence .,.~ Urban 1.0 2.1 2.6 8.7 440 Rural 1.5 2.0 5.8 6.8 3092 .'l ,., y-. ' ) Region North 0.4 2.4 3.5 6.3 677 Centre 1.0 1.6 4.5 7.0 1576 South 2.1 2.3 6.7 7.1 1279 Mother's Education None 1.9 0.6 6.2 6.9 1426 Standard 1-4 1.2 2.7 4.9 9.6 860 Standard 5 and above 0.7 2.0 4.4 5.1 1138 Occupation of Head of Household Fanning (self) n/a 1.9 n/a 7.1 2868 Tenant " 3.4 " 10.9 88 Ganyu Labour (agri) " 4.0 " 6.0 97 Ganyu Labour (non-agri) " 10.1 " 18.2 97 Paid Employment " 2.1 " 7.5 334 Self-employed II 3.1 II 6.3 361 Other " 2.9 II 5.4 140 None II 0.0 II 0.0 34 • Proportion ofWlder-5s below -3 and -2 standard deviation of the NCHSIWHO reference population according to weight-for-height anthropometric index of nutritional status. n/a: no data available Source: DHS, 1992 MSIS, 1995. These areas where the rates are especially high need additional research to determine the cause, and to analyse the relationship between the rates and such factors as income levels, household labour dependency ratio, landholding size, the gender of heads of households, educational levels, and access to health facilities and supplementary feeding centres. This is needed to generate appropriate action by communities, government, NGOs and donors. Wasting There is evidence that the rate of wasting (acute malnutrition) is rising, for in 1992 it stood at 5.4% and it · now is 7.0%. The increase undoubtedly reflects the decline in household food security caused by the drought and the generally worsening economic climate. It is likely, too, that the rate of wasting will have climbed after October 1995, when the survey was done, for according to the Ministry of Agriculture, over 52 %WASTED 0J 1.8 to 5.4% II 5.4 to 7.8% - 7.8 to 13.9% I Map 5: Moderate Wasting I 53 Malawi Social Indicators Survey 1995 a third of smallholders run out offood by September in a normal year, and 80% by December. Not surprisingly, farmers with the smallest landholdings run out of food the earliest. Ironically, there seems to be a decrease in the short-term nutritional status of children whose mothers went to school beyond Standard 4. There are hardly any statistically significant differences in wasting rates at the regional level or between families whose household heads have different occupations. It seems that those whose parents do ganyu or work on estates are more seriously wasted, but when applying the significance tests Table 8.4 Wasting rates * (%) of children in urban districts these differences appear not to District Weight-for-Height (Wasting) Percent Below Number of Children -JSD -2SD in Sample Blantyre Urban 1.3 (0.9) 4.8(2.1) 84 Rural 1.8 (1.2) 5.8 (2.6) 116 Lilongwe Urban 3.0 (1.4) 13.2 (1.6) 137 Rural 1.9 (0.9) 7.0 (1.8) 341 Mzimba Urban 0.0 (0.0) 3.4 (2.3) 124 Rural 0.4 (0.4) 5.7 (2.5) 139 Zomba Urban 4.4 (2.6) 16.5 (6.5) 95 Rural 4.1 (3.5) 9.6 (6.8) 120 Total (all4 districts) Urban 2.1 (0.7) 8.7 (1.5) 440 Rural 2.0 (0.8) 7.1 (1.6) 716 -Proportion ofWlder-5s in urban and rural areas falling below -3 and -2 standard deviation of the NCHSIWHO reference population according to weight-for-height anthropometric index of nutritional status. Standard errors in parentheses be sufficiently explained by occupation alone. However, there is a significant difference in moderate wasting rates between boys and girls. This gender difference may reflect the general weakness of boys due to genetic differences. Four districts have wasting rates of over 9% -- Chitipa, Dedza, Salima and Zomba -- while the rates in both Mulanje (12.3%) and Thyolo (13.1}0/o) are higher, but should be interpreted by taking into account the standard error. A separate analysis of wasting for those districts with urban areas was carried out (Table 8.4). Wasting in the urban areas is rising, with a rate of 2.1% in 1992 increasing to 8.7% in 1995. Source: DHS, 1992, MSIS, 1995 The significantly higher rate of wasting in Lilongwe is a reflection of the extent of poverty in the capital, which results, in part, from the immigration of poor people from rural areas. Water shortages during the drought have raised the rate of diarrhoea in Lilongwe, which also probably contributed to an increase in wasting. The difference in the rates of wasting between the urban and rural areas of Zomba, Blantyre and Mzimba districts is not significant. 54 Chapter Eight - Child Nutrition Regional and residential variations Disparities in regional (Figures 8.1 and 8.2) and residential (Figures 8.3 and 8.4) rates of moderate and severe malnutrition are depicted below. The various measures of malnutrition generally indicate lower rates for children in the North and in the urban areas. ·· Fig 8.1: Regional Differences in Rates of Moderate Malnutrition, 1995 60 50 - 40 c fl 30 ~ 20 10 0~--r---~r-----r-----~' • North . .• Central 0 South Fig 8.3: Urban/Rural Differences in Rates of Moderate Malnutrition, 1995 50 40 ~ 30 !: t. 20 10 0~--T-----~~--~~--~-' Stunting Wasting Underweight 0 Urban • Rural Gender and age variation ·. Fig 8.2: Regional Differences in Rates of Severe Malnutrition, 1995 30 25 .c 20 ~ 15 <II Q. 10 5 0~~-,----r-----r----~_/ • North IIJ Central '0 South Fig 8.4: Urban/Rural Differences in Rates of Severe Malnutrition, 1995 25 20 ~ 15 !: t. 10 5 0~-,-----,------r-----~-' Stunting Wasting Underweight II Urban • Rural Malnutrition rates also differ according to the gender and age of the child (Table 8.5). Significant differences are found in the rate of severe and moderate stunting in the age group 6-11 months. High rates of moderate wasting were recorded for boys aged 12-23 months. Also statistically significant are the rates of severe and moderate underweight children in the age group 24-35 months. Finally, male children aged 48-59 months have significantly higher rates of moderate 55 Malawi Social Indicators Survey 1995 underweight measurement. The differences between the other variables are not statistically significant. T ble85 A a . ll!e-spec tc nutntton status (Yo), by gender ifi . al 0 Age in Gender Severe Moderate Number of Months Children STUNTING 6-ll male 16.7 (2.9) 35 .2 (3.5) 242 female 7.6 (2 .0) 22.6 (3 .8) 220 12-23 male 23.1 (2.7) 42.5 (3.2) 459 female 16.7 (2 .5) 46 .6 (3 .2) 470 24-35 male 25.0 (3 .0) 46.1 (3.3) 379 female 21.3 (2 .3) 46 .6 (2 .6) 433 36-47 male 35.9 (3.4) 62.1 (3.2) 357 female 30.2 (3 .0) 54.8 (3.4) 395 48-59 male 32.9 (3.5) 62 .6 (3 .3) 303 female 34.5 (5 .1) 55.0 (4.8) 282 WASTING 6-ll male 1.2 (0.6) 7.9 (1.9) 245 female 4.1 (1.6) 9.9 (2 .7) 221 12-23 male 4.2 (1.3) 16.1 (2 .6) 453 female 4.0 (1.3) 8.1 (1.7) 464 24-35 male 2.1 (0 .9) 6.6 (1.5) 378 female 0.7 (0.5) 4.3 (1.0) 433 36-47 male 1.4 (0.7) 4.6 (1.2) 356 female 1.1 (0.5) 5.1 (2 .2) 395 . 48-59 male 0.8 (0.5) 5.8 (1.7) 303 female 0.6 (0.6) 0.8 (0.6) 284 UNDERWEIGHT 6-ll male 6.1 (1.8) 24.0 (3 .2) 245 female 2.6 (1.1) 16.9 (3.0) 220 12-23 male 12.4 (2.0) 37.4 (3.4) 461 female 6.1 (1.3) 34.2 (2 .9) 471 24-35 male 15.5 (2.4) 38.0 (3.2) 380 female 9.2 (1.5) 28.6 (2.6) 434 36-47 male 8.5 (2 .0) 30.1 (2 .9) 358 female 8.5 (1.8) 27.8 (3.7) 397 48-59 male 8.6 (2.3) 34.6 (3.3) 304 female 7.7 (2 .8) 23.2 (3 .3) 284 Proportion of children below standards set by the NCHS/WHO reference population according to anthropometric indices of nutritional status. Standard errors in parentheses 56 .·Fig 8.5: Age-specific Moderate Stunting Levels (Height-for-A g-:) 199~ and 19.95 6-11 12-23 . ·24-36 . 36-47 48-59 Age in Months : . , · · - DH$1992 -£$] MSI$,1995 i < ' -·~ ·'' Fig 8.9: Age-specific Moderate Undcnveight Lev_els , <\Veigb~:ror-A~e.) -1?92 and 1~95 Age in Months - • • MSIS 1.995 ,., I , Appendix S - Water and Sanitation Fig 8.6: Age-specific Severe Stunting Levels · (Height-for-Age) 1992 and -1995 35,---------------~~~~~ 30~--------------~--~~~~~~~ 25~------~--~~~~~----------~ ~ 20~--~~~~~~------------------~ " ~ 15~~~----------------------------~ Q. 10 -lfll~-----------------------------f 5~----------------------------~ o4-----~------~----~------~ 12-23 24-36 36-47 Age in Months OHS 1992 - - - MSIS 1995 1'2-2~; •; '24-35 36-47 .• ,~, - ,Age In Months ,.,•-' . ·:,~,. _____ ,,_;~-~~;~~~~~~~;~~,~-~ Fig IUO: Age-specific Severe Underweight Lev els (Weight.for-Age) 1992 _and 1995_,. - ' 14 -•• , ··- '·. - . :· . ':·,;.·.,-, . ,,] !:! . Q. 12 -·'' J.lllllll"' ~~ ' 10 ~ . · I' ~ ._·._ ~-- j, - 8 ,. ""'''iiii . ~ 6 I' 4 2+--+--+--+--+--+--~~~~~ 04---~--~~---4---,L.--~~J_~ 6-11 12-23- 24-35 36-47 48-69 'Age In Months ' ·<·· •' :,>; -~, ,,.'(;t-:~ ~SIS 1995 57 Malawi Social Indicators Survey 1995 Clulnges in Malnutrition, 1992-1995 Combined rates of malnutrition for boys and girls are also presented: Figures 8.5 and 8.6 show levels of cumulative stunting, while wasting, which is worse between the ages of 6-23 months, is indicated in Figures 8.7 and 8.8. These are the months when children are weaned when thev ' - Fig 8.1h Underweight, Stunting and Wasting (0-59 months) 1981, 1992 and 1995 60 50 40 E fl 30 . Q) a. 20 10 Q.K.:._,:.---''--"~-r'-~""""-___;_-T-~--' begin eating adult foods, and when they become more mobile and put unhygienic objects in their mouths. These increase the incidence of diarrhoea, which may suppress appetite at the same time as nutrient needs during illness increase. As noted before, diarrhoea is particularly prevalent in Malawian children aged 6-23 months . Finally, Figures 8.9 and 8.10 combine stunting and wasting and indicates underweight levels. To elucidate trends, 9 1981 • 1992 ~ 1995 changes in the rates of malnutrition as measured by stunting, wasting and underweight data from the 1981 (NSSA), 1992 (DHS) and 1995 (MSIS) surveys is produced in Figure 8.11. Although it appears that malnutrition levels have worsened since 1992 (DHS), it must be borne in mind that these differences are not statistically significant. Major Tasks Undertaken In the face of declining food security, the government has unde:rtaken several activities to raise nutrition levels in Malawi. In 1990 the government produced a National Food Security and Nutrition Policy Statement. In 1993 the National Plan of Action for the Protection, Survival and ·Development of Children was produced, and by December 1995 the National Plan of Action for Nutrition was in draft form. Nutrition has been included in the government's Poverty Alleviation Framework and in the Agricultural and Livestock Development Strategy. Malnutrition is a manifestation of a social process and cannot remain the exclusive concern of any one discipline, be it agriculture, health, education, or economics. The multi-faceted nature of the immediate and underlying causes of malnutrition can, therefore, only be tackled by multi- sectoral efforts. The National Plan of Action for Nutrition is meant to be a framework for medium-term food and nutrition policy, based on consensus about the nature of the nutrition problem. Immediate causes are inadequate dietary intake and disease. Underlying causes are insufficient household 58 Chapter Eight - Child Nutrition causes are inadequate dietary intake and disease. Underlying causes are insufficient household food security, education, care, and health services, as well as an unhealthy environment. The underlying causes are linked to the availability of resources (human, economic and organizational), which is determined by who controls resources at different levels of society. This in tum is . influenced by a number of historical processes, including socio-political, ecological and ideological factors specific to Malawi. Certain problems have hampered progress in this area, including previous government policies, and past and current resource constraints. The implementation of nutrition interventions by government is still very top-down, though the situation is improving. Moreover, the commitment from government and donors to tackle malnutrition is improving, but this still needs strengthening. Finally, the drought of the last 3 years has worsened national and household food insecurity, as traditional coping strategies failed and hunger deepened. Conclusion and Recommendations The mid-decade goal is to reduce moderate and severe rates of malnutrition by twenty percent or more. But in Malawi there has been no significant change in malnutrition levels since the DHS survey in 1992. The widespread poverty faced by many Malawians, caused by factors such as drought, population growth, pressure on the land as well as inflation, can account for the lack of improvement. The continuing high rates of AIDS, leading to frequent infections and the insufficient intake of micronutrients, is a contributing factor. · The goal to be reached by the year 2000 is to cut severe and moderate malnutrition in half. Considering the mid-decade results, this goal will be difficult to achieve unless poverty in Malawi is drastically reduced. This entails nothing less than effectively tackling Malawi's underdevelopment. As the eradication of malnutrition within Malawi depends on the improvement of the general economic and social conditions within the country, the following general recommendations are made. . The National Plan of Action for Nutrition, which provides a framework for addressing nutrition problems, needs to be finalized and implemented as soon as possible. The Plan of Action will tackle malnutrition by improving household food security, protecting consumers through improved food quality and safety, preventing and managing infectious diseases, promoting breast feeding, preventing and controlling micronutrient deficiencies, caring for the socio-economically deprived and nutritionally vulnerable populations, promoting appropriate diets and healthy lifestyles, and by assessing, analysing and monitoring nutritional status. . Now that the profile of nutrition has been included in the Poverty Alleviation Framework and the Agriculture and Livestock Development Strategy, both the government and donors should recommit themselves to tackling malnutrition by allocating more resources to those sectors known to help eradicate malnutrition. Raising the educational level of mothers and the diversification of crops should be of special concern. . The nutrition situation in Lilongwe especially, is worsening, which means that efforts to raise nutrition levels should not focus solely on the rural areas. 59 Malawi Social Indicators Survey 1995 . Particular attention should be paid to districts that have a higher than average malnutrition rate. These include Mulanje, Mchinji, Dowa, Lilongwe, Mwanza, Ntchisi, Thyolo, Salima, Zomba and Chitipa. Further research is needed to determine why these districts are so badly hit, and to disaggregate the data for each district to determine if there are particular groups or areas where people are more malnourished. Higher rates of malnutrition have been recorded in children 6-23 months. Weaning problems and diarrhoea are undoubtedly a factor. Future nutrition programmes should focus on this age group, while breast feeding and safe weaning practices should be reemphasized. . Boys seem to be more vulnerable than girls to malnutrition, and further research is needed to determine the underlying causes for this (e.g., in the area of intra-household food distribution, disease incidence by gender, etc.) and in order to develop strategies for appropriate action. 60 Chapter Eight - Child Nutrition 8.2 Vitamin A Vitamin A deficiency has long been associated with blindness. But its link with reduced resistance to disease and with the deat)l of children was only recognized in the mid-1980s. According to UNICEF's State of the World's Children 1995, each year more than one-half million children are blinded as a result of vitamin A deficiency. Moreover, it is now estimated that globally two children die every minute for the same reason. These dramatic statistics have led to measures designed to counteract vitamin A deficiency, measures that range from encouraging people to eat foods rich in vitamin A, to the fortification of foods and the distribution of vitamin A capsules. Situation in Malawi It is estimated that two million children in Malawi are suffering from severe vitamin A deficiency. Vitamin A is crucial for normal growth and development, and for building a child's resistance to disease. Where Vitamin A deficiency is worse, levels of stunting, blindness and child mortality are also significantly above average. The Government of Malawi recognizes the problem of Vitamin A deficiency, and efforts are being intensified to ensure that the population has access to adequate vitamin A resources through a combination of breast feeding promotion, supplementation and measures to improve diet. Government commitment is also demonstrated through incorporating nutrition objectives in a number of development programmes, including health, agriculture and poverty alleviation. 41% of"Malawian children between 6-24 months received a vitamin A capsule in the 6 months preceding the survey. 39% of mothers who gave birth in the same time period received a vitamin A capsule. Many areas in Malawi experience high levels of subclinical vitamin A deficiency. In some places the situation is severe. WHO recognizes vitamin A deficiency as a problem of public health significance where l% of children suffer from this condition. A survey of 5436 children in the Lower Shire Valley in 1983 found that 3.9% were severely vitamin A deficient. Varying degrees of eye damage were recorded, and levels of night blindness were five times higher than the WHO criteria. In 1988 surveys were conducted in Kasungu, MchinjL Sa1ima and Dedza in the Central region and in Mzimba in the North. Prevalence of vitamin A deficiency was recorded at 1.4%. In Salima and Dedza eye c~tology tests were done and the results showed 22% of children suffering from the deficiency, and another 20% on the border line. These levels are extremely high. Vitamin A deficiency is caused by both inadequate dietary intake and frequent infections. Production of crops rich in Vitamin A is very low in Malawi and they are only available seasonally. 61 Malawi Social Indicators Survey 1995 The average Malawian diet contains inadequate fat, which is necessary for vitamin A absorption. Frequent diarrhoeal and acute respiratory infections, particularly among children, are known to deplete vitamin A reserves as surely as a poor diet. Efforts to increase dietary intake are underway. Mothers are given vitamin A capsules after giving birth. Through promotion of exclusive breast feeding for the first 4-6 months of age, infants are ensured of sufficient vitamin A intake through breast milk. Children over 6 months are given vitamin A capsules regularly until they reach the age of six years. Extension workers promote the growing and consumption of foods rich in vitamin A and fat. Vitamin A Supplementation Until 1990 the government's policy was to give vitamin A supplements to children who already had symptoms of vitamin A deficiency, or a severe illness such as measles. After 1990 preventative Fig 8.12: Children aged 6 Months to 5 Years (%) measures came to the fore. In 1992 vitamin A supplementation for all children under six years was approved. Since then 15 million capsules have been distributed, largely through under-five clinics. The current policy combines preventive and treatment regimes. Children with signs of deficiency, and those with measles, pneumonia, chronic diarrhoea or severe malnutrition are given a dose of vitamin A. Babies up to six months are not treated. Instead mothers are given one dose up to 8 weeks Who received a Vitamin A Capsule in past 6 Months 50 40 C1l ~30 E C1l ~ 20 C1l Q. 10 6 - 24 months 2 - 3 Years 3 • 5 Years ~ Children (%) postpartum, ensuring adequate vitamin A for the exclusively breast fed infant during the first six months oflife. Children between 6 months and five years of age should receive a preventive dose of vitamin A twice a year. Each dose is recorded on the child's health card. But in fact less tharl one-half of the children aged between 6 and 24 months received a capsule in the six months preceding the survey. This figure drops as the age of children increases, with only one-quarter of two year olds having received a capsule and 14% of those aged 3-5 vears. These results are not surprising because supplementation has been through the under-five clinics, where the EPI programme targets children under 2. There is no alternative channel for supplying capsules to older children. 62 Chapter Eigbt- Cbild Nutrition Breast feeding and Supplementation Under normal circumstances, infants receive vitamin A primarily through breast feeding. In Malawi this process is bolstered by giving mothers a vitamin A capsule soon after giving birth. Ninety-seven percent of children under 6 months are breast feeding and 9.4% are exclusively breast feeding, which means they are not taking any other foods or fluids. The positive results from the change in breast feeding habits (see section 8.4 below) have particularly positive implications for vitamin A coverage, especially for children under 6 months. However, in order to ensure that mothers have an adequate amount of vitamin A, they need Table 8.6 Children(%) aged 6 months-5 years who received a vitamin A capsule in the previous 6 months Standard errors in 6-24 months 40.9 (2.2) 41.8 (2.7) 40.2 (2.9) 40.9 (4.1) 38.2 (3.3) 43.6 (3.5) 33.8 (4.0) 41.4 (2.4) 39.9 (2.8) 40.2 (3.6) 46.1 (4.2) 3-5 yean 14.2 (1.7) 13.3 (2.0) 15.0(2.1) 10.0 (2.8) 14.4 (2.4) 14.8 (2.7) 10.5 (3.3) 14.5 (1.8) 12.7 (2.1) 15.7 (3.0) • ~6.4 (3.9) . 16.4 (3 .3) 1160 to receive vitamin A capsules. The s\ITVey asked mothers if they had received a vitamin A capsule within six weeks of giving birth, for the last three times they gave birth. Nationally, just over one-third (38.6%) of mothers of children under six months receive a vitamin A capsule within six weeks of their child's birth. This figure varies considerable by region, with more than one- half(51.9%) of new mothers in the Northern region taking the capsule. This figure falls for mothers in the Southern (42.7%) and Central regions (31.8%). New mothers with up to eight years of education are more likely (51.4%) to take the capsule. This figure drops to 43.8% for those with up to four years of schooling, and to 27.0% for those with no education. Importantly, only 18% of mothers who have home deliveries receive a vitamin A capsule, compared to 50% of those women who give birth at a hospital, and 60% of those delivering at a health centre. A third (33%) of those giving birth at a TBA house receive the capsule. This has important implications for vitamin A deficiencies, for a large portion of births take place at home (41%) rather than in a hospital (29%). Not unexpectedly, vitamin A capsules are more often given to mothers who are assisted by trained individuals. 63 .I Malawi Soclal Indicators Survey 1995 Interestingly, though, there is a decline in the proportion of mothers receiving a capsule when their deliveries are assisted by a ward attendant, indicating that the person assisting has a greater influence on dissemination of capsules than does the institution (Figure 8.13). This points, then, to the need for hospitals to train all of their staff. Considering the high proportion of home births, mothers should also be made aware of the importance of receiving a vitamin A capsule. Diet diversification Information about vitamin A, supplementation, and the need to eat · green vegetables has been disseminated by the media in Malawi. In order to ensure that the vitamin is absorbed, groundnuts, oil and other foods rich in fat should be consumed simultaneously with fruits and vegetables rich in vitamin A. The survey found that 86% of children under 24 months of age had eaten one food rich in vitamin A in the week previous to the survey, and 72% had eaten three. Tables 8.7 and 8.8 represent children who consumed at least one vitamin A product and either oil or groundnuts in the week preceding the survey, though it is not known whether the vitamin A was consumed at the same time as oil or groundnuts. 64 Cbapter Eight- Cbild Nutrition Table 8. 7 ChDdren (%) who consumed at least one vitamin-A rich food and oll in the week precedin& the survey. by region. residence. and mother•s education. Malawi ·· Relioa .·. >: . South Residence Urban Rural · .• ;Mot!te'r•s Education : .None · . Primaryl-4 Primary5-8 ';: . :: _,, ·:.';·:::,,~·. :. ·· : '_ '· : · . - :_. · Sample Sue There is a significant difference in the consumption of oil by people in the urban and rural, areas. This may be because cooking oil is more readily available in cities, and because urban families have higher incomes. Eating food rich in vitamin A and oil is more frequent among those children whose mothers have a better education. No significant differences occur from one region to another. More groundnuts are consumed by urban children over 2 years old than by those in the rural areas. The level of a mother's education is not especially significant in this case. Nor are other social indicators. 65 Malawi Social Indicators Survey 1995 Table 8.8 Children (%) who have consumed at least one vitamin A-rich food and groundnuts in the week preceding the survey, by region, residence, and mother's education Table 8.9 Under-5s (•/e) who consumed vitamin A-rich fruits and vegetables in the week preceding the survey, by the fruits and vegetables they consumed · .·- -~~uaves · Leaves' ;,. Potato Leaves Rape ' Mustanl. Chi:tleK C11bbage 7.7 27.0 63.9 24.4 17.9 23.8 44.1 37.9 . '-{ Tot 3.2 5.6 23.3 41.6 36.6 17.5 In the week before the survey, the most frequently eaten vitamin A-rich foods (Table 8.9) included pumpkin leaves, mustard, and mangoes, whereas the least frequently consumed were pumpkins, carrots and bonongwe (amaranthus spinach). These findings generally reflect food availability and seasonality in Malawi, and a survey at another time of year would produce different results . As expected, the consumption of vitamin A-rich foods increases as the child gets older. But children in different districts eat varying amounts of these. Specifically, children under 2 years old in Karonga and Mwanza districts eat significantly less than the national average. (Many other districts could not be tested due to the small sample size. The results are presented in Appendix 3.) 66 Cbapter Eight - Cbild Nutrition Table 8.10 Children (•/e) who had eaten at least 3 vitamin A rich foods in the week preceding the survey Mother's Education None Primary 1-4 Primary 5-8 59.6 (2.5) 66.6 (2 .7) 64.0 (2.8) 79.5 (5.4) 77.6 (2.2) 77.3 (3.0) 75.7 (3 .5) 78.8 (3.1) 74.3 (2.9) 79.9 (2.9) 81.1 (2.8) Children in Malawi eat fruits and vegetables rich in vitamin A. Unfortunately, they do not conswne the oil or groundnuts necessary to absorb the vitamin A. Not surprisingly, people tend to eat certain fruits and vegetables because they are readily available in season, and because they are less expensive. Change in coverage A survey conducted in 1989-1991 assessed the percentage of 12-71 month olds attending under-5 clinics who had received a vitamin A capsule in the previous 6 months. Coverage of these children was found then to be only 14%, while 18% of one year olds had received a capsule. According to the EPI coverage survey, in 1993 over two-thirds (70%) of children under 24 months of age received adequate vitamin A, defined as receiving a capsule in the previous 12 months. Now, using the same criteria as the EPI survey, less than one-half (43.6%) of children receive adequate vitamin A. Further investigation is needed to confirm this significant decline and to assess its cause. 67 Malawi Social Indkators Survey 1995 Constraints A major challenge is to reach children over 24 months of age with vitamin A supplementation. Most mothers regularly take their babies to the clinics for vaccination, providing an effective access point for distributing capsules. After receiving the measles vaccine, attendance drops dramatically, from approximately 80% to 10%. In communities distant from the health centres, there is, therefore, a need to develop and use alternative channels for vitamin A distribution, such as community health workers. They need additional training, especially in participatory approaches. Training within this area would enable them to exert greater influence on local communities. Health staff are training volunteers to establish community-based growth monitoring centres. Children's development is being monitored within their own communities, saving the time and energy mothers spend getting to and from health facilities. Vitamin A supplementation is gradually being incorporated into the scheme, as volunteers are trained to dispense capsules and to record them on a child's card. Children living in communities closer to health centres rarely attend clinics unless they are sick. There are no growth monitoring centres there, and older children have no access to vitamin A supplements. Continued assistance is needed to increase the spread of supplementation and to diversify the normal diet. In the area of supplementation, a low dose vitamin A supplement will be marketed in 1996. This is directed at children in the target group, who do not receive a high dose Vitamin A capsule through the health system. This will enable families to give low dose capsules to their children on a weekly basis. The possibility of fortifying sugar and maize flour with vitamin A is being investigated jointly by the Malawi Bureau of Standards, the Ministry of Health and Population, producers of sugar and maize, and UNICEF. To encourage dietary diversification, the growth and consumption of vitamin A-rich foods will be promoted by NGOs and Initiative for the Mobilization of Private Action, IMPACT, in collaboration with the Ministry of Agriculture and Livestock Development. A large scale nutrition education campaign by the mass media will be organized to promote consumption of crops rich in Vitamin A. Recommendations Children in Malawi are not receiving adequate vitamin A. Supplementation rates are low both for mothers giving birth and for under-5s. Children receive most of their vitamin A through their diet However, there is a low intake of oil and groundnuts, especially in the rural areas, which is necessary to aid absorption of vitamin A. Therefore, the following recommendations are made: 68 Because the proportion ofunder-2s receiving vitamin A capsules is low, there is a need to increase promotion of vitamin A capsules and to strengthen the distribution network to ensure that these children receive capsules. Cbapter Eight - Cbild Nutrition . Dispensing of vitamin A capsules to children over two years old should be encouraged. . Messages should be disseminated clarifying the link between vitamin A absorption and consumption of oil or fat-rich foods, such as groundnuts. Affordable cooking oil is not readily available in rural areas. Research aimed at solving this problem should be undertaken, and a greater emphasis should be given by extension workers to growing and eating groundnuts, groundnut powder, and other foods rich in fat. . A small proportion of mothers are receiving vitamin A capsules when giving birth. Additional training in this field for midwives, hospital staff, TBAs, and clinic personnel is needed. Considering the large number of home births, it is also necessary for mothers to become aware of the need to take vitamin A capsules. . Additional research is needed to analyse the extent of, and the reasons for the drop in vitamin A supplementation, to ensure that the decline cannot be solely attributed to different research methods. \._ . Greater emphasis shoulQ_ be placed by health and agricultural extension workers, and through campaigns, on the· consumption of affordable and available vitamin A foodstuffs, such as pumpkin leaves. Account should be taken of the seasonality of fruits and vegetables when encouraging local fanners to diversify their crops. The goal is the virtual elimination of vitamin A deficiency by the year 2000. This is considered to be achievable in Malawi with effort. 69 Malawi Social Indicators Survey 1995 8.3 Salt lodization Iodine is an essential micronutrient for the normal growth and development of children and for the normal physical and mental activity of adults. Iodine deficiency disorders (IDD) are manifest in poor hand-eye co-ordination, partial paralysis, deaf-mutism, dwarfism, facial and physical deformity, cretinism, neurological damage, and goitre. Researchers have estimated that children that are mildly iodine deficient may forfeit as many as 10 to 15 IQ points. This has important implications for childhood educational attainment and for the productivity of adults. Babies born . to iodine deficient mothers have irreversible impairment, while an iodine deficient pregnant woman has a higher chance of miscarriage, premature delivery, and stillbirth. In Malawi iodine deficiency is caused by the inadequate dietary intake of iodine and low levels of iodine in food. In many parts of Malawi there are low levels of iodine in the soils due to leaching and erosion. Moreover, salt is not fortified with iodine in the country. Finally, there are insufficient trained personnel to combat iodine deficiency effectively. In order to prevent, control and eventually eliminate IDD, a long-term, sustainable programme is needed, in which all salt for human and animal consumption is fortified with iodine. As a party to the international agreement to achieve this goal, Malawi has adopted a policy of eliminating IDD through salt iodization. Situation in Malawi No data on prevalence oflodine Deficiency Disorders were collected in this 1995 survey. But it is known that iodine deficiency disorders are prevalent in several highland districts of Malawi. In 1983, when Malawi's population was much smaller, a national survey found that 1~2 .5 million people were at risk of developing IDD. Only 58% of salt in Malawi is sufficiently iodized. Table 8.11 Prevalence(%) of Iodine Deficiency Disorders in the seven most affected districts, 1983 Sign ·Cretinism Visible goitre An goiti-~ Prevalence · 0.3 - 1.5 . 8.7- 30.0 '' 36.0 .- 66.0 Source: Situation of Iodine Deficiencjl in Malawi, Governnient of MalaWi, Ministry of Health, 1989. · . ·. The seven most affected districts are Dedza, Ntcheu, Mchinji, Mulanje, Mzimba, Lilongwe and Chitipa. Nine other districts are moderately affected. The groups considered most at risk are children below 15 years of age, and women of reproductive age. Table 8.11 shows the IDDs in the most effected districts in 1983. This survey looked at clinical deficiency. Since then, more emphasis has been put on subclinical deficiency, which still affects mental development. 70 Chapter Eight - Child Nutrition Major Tasks Undertaken Today iodine supplementation is provided to all children from birth to 14 years, and to females from 15 to 45 years of age in areas where severe iodine deficiency disorders are endemic. Moreover, individuals with treatable cases of goitre are attended in most health facilities. In 1987 it was gazetted that all imported salt should contain the required amounts of iodine, and three years lat_er !he government decided to have all locally produced salt iodized in-country. In 1993 the UNICEF Regional Director held discussions with the President, which revitalized plans for salt iodization. In 1995 the government commissioned a study on the salt trade and the feasibility of in-country salt iodization. The results of the study were incorporated in the Salt Iodization Act, which was passed in 1995. Also in 1995, a meeting was held to inform the media about iodine deficiency and the disorders it can cause. Subsidiary ~gulations and a monitoring scheme have since been prepared. The regulations require that all salt distributed and sold in Malawi for human and animal consumption is iodized. Salt iodization plants were ordered by UNICEF and were handed to the government in 1996. The Use of Iodized Salt in 1995 During the 1995 MSIS study, an average of three salt samples were collected by the National Statistical Office from each cluster. These were sent to the Community Health Sciences Unit (CHSU) of the Ministry ofHealth and Population for analysis. A total of949 salt samples were analysed and the results were sent to Table 8.12 Households (%) using salt with an iodine content the Centre for Social Research to of at least 20 ppm, by geographic divisions Malawi Region North Centntl South Residence Urban Rural .·.· . 58.l(2.8) 85.4 (4.1) 62.0 (2c8) 48.7(502) 74.7(6.4) 56.2(3.0) ·Number of Samples 845 ) 64 . 377 304 125 720 determine the situation of iodine levels in salt consumed in households in various parts of the country. Only 845 salt samples analysed at CHSU were included in the analysis at the CSR because their cluster numbers were provided and could be linked to their districts and regions of origin. At the household level consumption of salt with an iodine Standard errors in parentheses level of at least 20 parts per million (ppm) is considered adequate to prevent iodine deficiency disorders. If at least 90 percent of households are consuming salt with at least 20 ppm iodine content, Universal Salt Iodization is considered to have been achieved in a country. 71 Malawi . Social Indicators Survey 1995 It is clear from the results (Table 8.12) that Malawi has not achieved Universal Salt Iodization at all levels. Disparities exist in the proportions of people using iodized salt in various areas, with significantly more iodized salt being consumed in the North and in the cities. Most percentages are not significantly different from the national figure , except in the Northern districts as well as in Dowa, Nkhotakota, Ntchisi, Chikwawa, Machinga and Nsanje. District level data are presented in Table A4 in Appendix 4. Special Constraints The trade in, and the consumption of iodized salt are inadequate. This is in part because most of the activities to raise awareness of the problem -- including the orientation of salt traders and the training of officials in monitoring salt -- were postponed until the Salt Iodization Act took effect. The salt iodization plants also took a long time to arrive in Malawi. Support Required and Recommendations for the Future Increasingly Malawi imports its salt from Mozambique. However, most of this salt is neither properly packaged nor iodized. Therefore, support is needed to help Mozambican salt producers and traders purify, iodize and package the salt better. Although less numerous, the small scale producers of salt in Malawi need similar technical support. Efforts to monitor compliance will be hindered by dv.·indling resources. Therefore, Malawi needs both technical and financial support in 1997-200 1, particularly to build capacity for monitoring the amount of iodine in salt and the impact of iodization on the population. Malawi is still a long way from Universal Salt Iodization. To raise levels the following recommendations are made: • The Northern region has substantially more iodized salt than the Central or Southern regions, and urban areas have more than rural areas . Research should focus on the reason -- e.g., are different brands of salt being used? Where is salt being acquired? • A sustainable salt monitoring system should be established to ensure that all regulations under the Act are adhered to. • Emphasis should be placed on sustainable adYocacy campaigns that create awareness in all groups of people. • The impact of the salt iodization intervention on iodine deficiency disorders should be monitored. 72 All import licences should specif\ the required lcYel of salt iodit.ation. and traders should be informed that they haYe the nght to query their suppliers. should the salt be of suo- standard quality . Chapter Eight - Child Nutrition 8.4 Breast Feeding and the 'Baby Friendly' Hospital Initiative Breast feeding is the best way to feed infants and young children. Breast milk is uncontaminated, and it contains all the nutrients needed by a child in the first few months of life. It also carries the mother's antibodies, thereby strengthening a baby's immunity to disease. Also, a breast feeding mother is less likely to return to fertility , thus reducing the chance of an early new pregnancy, and thereby improving her health. The duratio n and intensity of breast feeding, as well as the manner and age of weaning, affect a mother's fertility and her child's health. It is very important that children are not given any additional foods and fluids before they reach the age of four months m order not to expose them to contamination and disease . Formula feeding, for the same reason, is associated with higher rates of acute illness as well as with 1mmune system disorders, an d allergic reactions. 10 STEPS TO SUCCESSFUL BREAST FEEDING 1. Have a written breast feeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in sldUs necessary to implement this policy. 3. 1nfonn all pregnant women about breast feeding. 4. Help mother$ initiate breast feeding within a half-hour of birth. 5. Show mothers how to breast feed and how to maintain lactation, even if they should be separated from their infants. 6. Give newborn babies no food or drink other than breast millc, unless medically indicated. 7. Practice rooming-in to allow mothers and infants to remain together 24 hours a day. 8. Encourage breast feeding on demand. 9. Give no artificial teats or pacifiers. 10. Foster the establishment of breast feeding support groups and refer mothers to them on discharge from the hospital or clinic. According to WHO estimates, the death of more than 1 million infants annually could be prevented if all babies were exclusively breast fed for the first few months of life. In 1990, 31 governments met with UNICEF and WHO at the Innocenti Centre in Florence to draft the Innocenti Declaration on the Promotion. Protection and Support of Breast Feeding The Declaration set out operational targets for all countries to achieve by 1995 . Four operational targets were established: the formation of a national breast feeding committee, the establishment of 'babv-friendlv' hospitals, the establishment of regulations in the marketing of breast milk substit~tes , and the guaranteed rights of paid maternity leave and breast feeding breaks at work. 73 Malawi Social Indicators Survey 1995 The 'baby friendly' hospital initia~ive was launched in June 1991 in an attempt to enlist the support of hospitals everywhere, to encourage breast feeding. Hospitals declared 'baby friendly' follow the 'ten steps to successful breast feeding' being promoted by WHO and UNICEF. Situation in Malawi Most mothers in Malawi breast feed their children until after their second birthday (Table 8.13), regardless of the family's characteristics. Table 8.13 Under-5s (%)who were ever breast fed, by selected background characteristics . Background Percentage ever Number of Characteristic Breast Fed Children Gender Male 96.0 2055 Female 96.8 2125 Residence Urban 97.3 519 ·Rural 96.3 3661 Region North 97.4 817 Central 95.9 1845 South 96.8 1518 Mother's Education None 96.4 1749 Primary 1-4 96.0 1014 Primary 5 + 96.8 1321 All Children 96.4 4180 8.4.1 Exclusive breast feeding Traditionally, infants are given complementary food and drinks before they are four months old, which is <;trongly discouraged by health specialists. 11% of Malawian children under 4 months are exclusively breast feeding, up from 3% in 1992. The Ministry of Health and Population even recommends that babies in Malawi should be exclusively breast fed for the first six months of age. Thereafter, breast feeding should be continued 74 . Cbapter Eight - Cbild Nutrition with complementary foods for two years and beyond. Hospitals are being encouraged to promote exclusive breast feeding through the 'baby friendly' hospital initiative. Breast feeding infants maximizes their intake of the nutritional and immunological benefits of breast milk. The survey results reveal that although exclusive breast feeding of small babies under 4 months is becoming more common, there is still a long way to go. Table 8.14 Proportion{%) of infants less than 4 months of age who are exclusively breast fed, 1992 and 1995 Age in M~ll.tbi 0- 2- 0-4 . 4-5 0- Children Exchisively Brealtf!d · · . 1992 . 1995 4.8 . Table 8.15 Under-Js (%) who are still breast feeding Age in Months 0- 1 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 24-25 26-27 28-29 30-31 32-33 34-35 Children still Breastfeeding 97.3 98.0 96.0 97.3 96.2 93.4 96.5 92.1 90.7 85.7 80.0 56.6 37.8 24.4 13.6 9.7 8.1 6.1 Number of Children 155 140 157 151 175 187 170 181 155 151 172 141 160 132 137 119 126 158 Data indicate that breast feeding decreases with age, with only 6.1% of children breast feeding at the end of their third year (Table 8.15). The proportion who continue breast feeding at one year (12-15 months) is 94.2%, nearly identical to the rate found in the 1992 DHS survey. Continued breast feeding at 2 years (or 20 to 23 months) stands at 69.5%. Female and urban babies under 3 years, and those whose mothers have a Standard 5 and above education were much less likely to have been breast fed at least once in the 24 hours preceding the survey (Table 8.16). 75 Malawi Social Indicators Survey 1995 Table 8.16 Under-3s (%)who were breast fed at least once in the previous 2-1 hours, by selected background characteristics. Background Percentage of Number of Characteristic Children Children Gender Male 66.0 ( 1.7) 1377 Female 59.7 (1.6) 1406 Residence Urban 53.5 (5.0) 343 Rural 63.8 (1.4) 2440 Region North 58.1 (2.7) 545 Central 62.3 ( 1.8) 1225 South 64.5 (2.3) 1013 Mother's Education None 64.8 (1.4) 1137 Primary 1-4 65.0 (2.2) 678 Primary 5 + 57.8 (2.3) 906 AJI Children 62.9 (1.4) 2783 Fig 8.14: Proportion of Infants Breast Feeding and Eating Complementary Foods 100 80 'E 60 GJ u ~ 40 Q. 20 o~~~~---r~~~~----~--- 6-7 8-9 6-9 Age in Months • DHS 1992 ~ MSIS 1995 Fewer babies of6 months and older now receive complementary foods in addition to breast milk (Figure 8.14) than in 1992. This is a discouraging trend as it indicates a reduction in the timely introduction of complementary foods. 76 Chapter Eight - Child Nutrition Table 8.17 Breast feeding children(%) who recein supplements, b~· age Vitamins, Minerals Number Age in Infant Other Solid/ or of Months Formula Liquids Mushy food sss ORS Medicine Children 0- 1 4.6 89.4 8.1 1.2 4.4 12.9 160 2-3 4.9 85.5 25.8 0.8 1.0 14.2 143 4-5 5.4 82 .2 40 .2 6.0 0.1 10.2 161 6-7 7.8 65.3 55.7 7.6 2.9 10.1 153 8-9 9.6 65.4 56.7 5.9 5.0 22.8 179 10-11 6.7 73.7 69.6 5.9 1.1 12.3 1Q.! 12-13 8.3 63.9 57.7 8.6 2.4 19.0 l"o 14-15 6.2 63.9 68.3 7.6 6.3 18.2 90 16-17 7.3 65.7 60.4 4.7 3.2 11.0 160 18-19 5.5 71.6 61.5 3.4 3.5 15.7 153 20-21 5.6 69.3 60.7 3.2 2.8 10.2 174 22-23 5.4 64.3 66.1 2.5 0.6 17.8 141 24-25 2.3 70.9 58.6 4.5 0.0 8.1 163 26-27 6.5 72.0 65.5 3.0 0.0 0.0 135 28-29 2.1 91.1 73.6 0.0 0.0 0.0 139 30-31 0.0 73.7 33.6 0.0 0.0 0.0 122 32-33 0.0 77.1 72.6 0.0 0.0 0.0 133 34-35, 0.0 85.3 29.2 0.0 0.0 0.0 160 0-35 -1.5 73.6 53.9 3.9 1.9 10.7 2836 *Other fluids include sweetened or flavoured water. fruit juice. sweet tea. or other liquids. Food is introduced to infants as early as one month after birth, when 8.1% of infants are given solid or mushy food (Table 8.17). generally made from nsima (maize meal). However, in general. children below the age of 36 months receive proportionally more fluids than solid or mushv foods. 77 Malawi Social Indicators Survey 1995 Table 8.18 Under-2s (%)who used a bottle with a nipple at least once in previous 24 hours, by Region North Central South background characteristics 58.1 (2.7) 62.3 (1.8) 64.5 (2.3) 545 1225 1013 Bottle feeding of babies is still relatively uncommon (Table 8.18), which is beneficial for the prevention of infections. · 8.4.2 Baby Friendly Hospital Initiative The Malawi government embraced, and began implementing the Baby Frie,ndly Hospital Initiative in 1993. A core team of national trainers in lactation management and breast feeding promotion was developed and several orientation training courses have been conducted. Out of nine hospitals assessed in 1995, only one-- St. Montfort hospital in Chikwawa district -- was found to be 'baby friendly' in accordance with this global standard. Six hospitals received a certificate of commitment to become 'baby friendly' by meeting more than five of the ten steps. These include Malamulo (Thyolo), Dedza, Rumphi, Ekwendeni, Chikwawa, and Nsanje hospitals. These should be ready for re-assessment in 1996. 78 Cbapter Eight - Child Nutrition Measures Undertaken 1990-1995 Most measures to improve the rate of breast feeding by mothers were carried out from 1993. In that year, nurses, midwives and nursing school tutors were trained in the 18 hour Lactation Management Course by the IBF AN Regional Co-ordinator. This training was followed by an intensive 80 hour course for three trainers in Swaziland. In 1994 five Malawians participated in an international course in formulating and monitoring a national code for marketing breast milk substitutes. A draft national code was also produced. During the same year Information Education Communication materials were produced. In 1995 the national co-ordinator was trained and guidelines were formulated on baby friendly hospital policies. Subsequently these were introduced to district health staff, who are, in tum, orienting health centre staff. A special course for physicians was held so that they cano influence hospital maternity practices. Constraints and Recommendations The increase in the breast feeding rate in Malawi is one of the most positive aspects of this report. Significant improvements were made in all aspects of breast feeding, especially in the exclusive breast feeding of children under 6 months old. This is particularly significant as it has happened within three years. The implementation of the 'baby friendly hospital' policy was hindered by the late training of hospital policy-makers, which meant there was little support for the changing of hospital practices. In addition, early training sessions did not adequately cover global criteria for creating a 'baby friendly' hospital. Moreover, hospitals lacked important training materials. In light of these mixed findings, the following recommendations are made: • A need exists to continue to promote breast feeding through mother and 'baby friendly' initiatives and nutrition education. • Both technical and financial support is needed to carry out tasks already planned for fostering breast feeding, including the provision of training materials; further training of health st:ati: production ofiEC materials; promotion of breast feeding through traditional arts and culture, and the media; and the development of breast feeding support groups. • Because there has been a reduction in the timely introduction of complementary foods, there is a need to continue with efforts to promote breast feeding and improved young child feeding practices through mother and 'baby friendly ' initiatives and nutrition education. 79 Malawi Social Indicators Survey 1995 • Most improvements have been made since 1992 and the DHS survey. A thorough study of the breast feeding campaign is needed in order to ascertain which policies have been most successful. • Mothers' breast feeding practices are often influenced by grandmothers and other important relatives and elders in the community. If mothers are to continue with practices learned at 'baby friendly' hospitals, these influential .leaders should also be sensitized. • Only one Malawian hospital has been declared a 'baby friendly' hospital. Renewed emphasis on training for hospital staff is needed to increase the number. The end-of-decade goal is to have all women breast feed their children exclusively for 4-6 months, and to continue breast feeding well into a baby's second year while offering complementary food. This is not considered achievable in Malawi by 2000. Instead, the goal is to achieve a rate of 30% nationally. 80 CHAPTER NINE WATER AND SANITATION Wsufficient supply of clean water for drinking and hygiene, and an adequate means ~ of waste disposal are fundamental rights an4 necessary for public health and personal well-being. However, vast numbers of people in developing countries, mostly in rural areas, have neither. In 1990, only 52% of the population in Africa had access to safe water and 40% had proper sanitation facilities . 9.1 Situation in Malawi Water development in Malawi began in the colonial period, with more than four hundred wells dug and equipped in the 1930s. A major effort followed independence, with up to five hundred boreholes completed and equipped annually between 1969 and 1972, when large scale agricultural projects began. In the mid-l970s, a low cost water development programme was initiated to increase coverage in the rural areas. Shallow ground water was exploited and pipe systems were installed in springs and streams. More than one-third of Malawians have convenient access to safe drinking water. Only 6% have access to proper sanitation facilities. By the mid-1990s, though, an estimated 30% of water facilities were out of order at any time due to breakdO\ms and water sources drying out from drought. Meanwhile, little attention had been given to developing a systematic or wide-ranging sanitation system. 9.2 Water The findings of the Malawi Social Indicators Survey reveal that only one-third (37%) of the Malawian population has access to safe water for drinking that is located within a distance of less than one-half kilometre. This figure increases to 48% when the distance is increased to one kilometre (Table 9.1). Safe drinking water is defined as water piped into the dwelling, a public tap, a borehole, or a protected well or spring located either on the premises or less than one-half kilometre away. People in the Northern region are best served when considering distances of less than one- hal !'kilometre. while those in the South are best served when extending the distance to one 81 % ACCESS II 4.2 to 23.1% II 23.1 to 38.2% ~ 38.2 to 67.0% 82 I Map 6: Access to Safe water I ' ' Chapter Nine - Water and Sanitation kilometre. (There are significant differences in accessibility to safe water at less than 1 km. distance between the Central and Southern regions only, as none of the other differences are statistically significant.) Table 9.1 Use and accessibility(%) of safe water, by region and residence Access to Safe Water (<O.Skm) 36.8 (2.3) 41.0 (4.8) 33.0 (2.6) 39.3 (4.2) 80.3 (6.4) 32.2 (2.5) Number of Children in Sample 6204 1238 2418 2548 839 5365 Not surprisingly, there are significant variations between urban and rural areas, and city dwellers have more than twice the level of access to safe water as rural people. The greatest variations in accessibility to a safe water source occur at district level (Table 5a in Appendix 5). Two-thirds (67%) of the population in Rumphi district have convenient access to safe water, for instance, while less than 5% of people in Ntchisi and Mwanza do. This figure increases to 14% for Ntchisi when the distance is increased to one kilometre. The most common type of water facility used in Malawi is an unprotected well or spring, while the most popular safe source of water is a borehole (Table 9.2). In urban areas the most common form of water supply is a public tap. There are some variations from the norm at district level (Table 5b in Appendix 5). Mwanza district's low figure with respect to safe water can be accounted for by the frequent use of unprotected wells and springs, rivers and streams. Kasungu has the highest dependence (72%) on unprotected wells and springs, while 82% ofNsanje's population uses boreholes, and over one-half of Blantyre district's residents use public taps. 83 Malawi Social Indicators Survey 1995 Table 9.2 Type of water facility used(%), by region Piped in . Public' Bore Well/ Well/ River/ Lake Other Dwelling Tap hole Spring Stream Dam (Unprotected) ''('·: ; Malal\'1 2.1 5.1 35.7 11.1 1.7 ·· ),{~on ' }'~forth 1.9 22.3 26.5 3.2 35.1 9.7 0.5 ·centre 2.6 9.8 27.4 5.3 43.6 10.7 0.2 0.4 SOuth 1.7 20.9 28.3 5.3 29.0 11.7 3.1 0.0 16.5 65.9 8.2 1.7 5.6 1.3 0.8 0.5 11.2 29.9 5A 38.9 12.1 1.8 0.2 9.3 Sanitation Only 5.5% of the Malawian population has access to adequate sanitary facilities located within a convenient distance of dwellings . The principal reason for the extremely low figure is the high use of traditional pit latrines. A pit latrine consists of a hole in the ground, with a wooden and mud platform and a mud or straw structure for privacy constructed on top. Nearly 30% of the population is without any sanitary facility. A safe sanitation facility includes a toilet that flushes to a sewage system or a septic tank, a ventilated improved pit (VIP) latrine, or a latrine with a conc:rete sanitation platform (a sanplat) located less than 50 metres from the user's dwelling. Districts where the population has particularly poor access (less than 1 %) to adequate and nearby sanitation facilities include Chitipa, Mwanza and Chiradzulu. Ntchisi has the highest proportion of safe sanitation facilities, but that figure (at I 7%) is still extraordinarily low. People in the Northern region have the poorest access to adequate sanitation facilities, even when extending the definition to include pit latrines. The regional differences are statistically significant for access to sanitation with a pit latrine, but not for access to adequate sanitation. 84 % ACCESS II 35.9 to 64.9% II 64.9 to 75.1% 0 75.1 to 88.4% " , Map 7: Access to some form of sanitation 85 Malawi Social Indicators Survey 1995 There is a substantial and significant difference in the coverage of sanitation facilities in urban and rural areas. Nearly one-quarter (23%) of the urban population has access to adequate sanitation facilities located within a convenient distance, compared to only 4% of rural people. Table 9.4 Type of toilet fuility (% ), by region and residence Flush to Latrine Sceptic Tank with San plat 0.9 3.9 0.6 2.4 1.2 3.4 0.8 4.6 7.2 10.2 0.3 3.2 Over one-half of the population in Chikwawa district, and over one-third of the population in Salima, Mwanza, Mzimba and Nsanje districts have no sanitary facilities. Where facilities exist, they tend to be pit latrines. 86 Chapter Nine- Water and Sanitation 9.4 Conclusion and Recommendations In order to reach the mid-decade goals in Malawi, various measures have been taken to improve water and sanitation facilities. Since 1990, over 2000 water points have been installed in the rural areas in a joint effort by government, donors and NGOs. In addition, water points were equipped with hand pumps, about 2300 improved pit latrines were installed with sanplats, and hygiene education was intensified, with emphasis placed on hand washing and the two-cup system of serving water. About 400 village health and water committees have been formed, and about one- half of these have been trained in community procedures, hand pump maintenance, and sanplat making. Constraints The major constraints to achieving universal access to water and sanitation have been limited funding and a lack of government capacity to maintain the existing facilities. Sanitation development is plagued by poor policy formulation and work plans, and complex institutional arrangements. There is no sanitation policy, and activities in the field of sanitation are undertaken by three different ministries: Local Government, Health, and Water and Irrigation. The Water Policy is implemented by the Ministry of Water and Irrigation through five regional Water Boards. The Water Department has developed clear policies and strategies for the improvement of water resources under the National Water Development Project. The objectives of the Development Project are to achieve by the year 2010 almost 100% coverage in public water supply to the urban areas and 7 4% coverage to the population in the rural areas. Further goals include twenty-four percent sanitation coverage through waterborne sewerage and septic tanks in urban areas, implementation of the water resource management, environmental protection policies and comprehensive institutional reforms. The Project will rehabilitate or construct more than 20 gravity piped, community-managed water schemes~ rehabilitate more than five thousand hand pump-equipped boreholes and shallow wells; and construct another 16,400 boreholes with hand pumps. Until recently communities were not empowered to take control of water and sanitation projects. Nor were they involved in the planning, operation or maintenance of these facilities. Persistent drought in Malawi, especially in the 1990s, has meant that most safe sources of water within convenient distances have dried up. Finallv, because infrastructural development was for so long determined by political factors rather than ne;d, some districts were better provided for than others. Taken together, these problems 87 Malawi Social Indicators Survey 1995 have ensured that people in many districts have less than average accessibility to nearby water and sanitation facilities, and that most development has been top-do,,n and with little community input. The new National Water Development Project will tackle this through the promotion of community participation, village level operations and maintenance, and personal hygiene through health campaigns. To achieve universal access to safe drinking water and adequate sanitation by 2000 will require tremendous effort. First and foremost, both government and donors will have to allocate additional financial resources in order to increase accessibility to water and sanitation facilities in the country. But other support is also required to foster hygiene and sanitation education, rehabilitation of existing water points and hand auguring techniques, development of community based management and sector monitoring, and provision of appropriate technologies and provision of emergency water supply in areas where there are disasters or civil strife. · Recommendations Universal access to safe water and sanitation facilities remains a major challenge for this country. Less than one-half of the population consumes safe water, and most use inadequate sanitation facilities. Therefore, the following recommendations are made: Districts identified in this survey as being poorly served should receive special assistance. Interventions should be governed by needs assessment rather than by political expediency . There is a need to create a National Sanitation Policy. airued at improving the sanitation conditions in Malawi. The quality and quantity of water sources need further investigation, as should the quality of sanitation facilities . . There is need to harmonize the development of water and sanitation facilities in the rural and urban areas and to eliminate the bias against sanitation development. Government capacity at district le,·el should be strengthened in order to facilitate the management of water Stnd sanitation facilities by communities . . Training of men and women in collecting, transporting and serving water in clean \"essels is needed to ensure that they understand the importance of safe water. Community-based management of water and sanitation facilities should be extended . 88 CHAPTER TEN EDUCATION 1ft ducation for all is the most important basic building block of development. Though Lm the importance of female education has finally been acknowledged in Malawi, education for all has not yet been achieved. The underlying constraints include the limited access marginalized communities have to education as well as the problems children encounter when entering school. these include the poor quality of education, and consequently, high repetition, drop out and failure rates. Hence, progress in education can no longer be seen simply as raising the rate of enrolment, but must include improving the quality and relevance of education. 10.1 Situation in Malawi Before the introduction of free primary education in Malawi, just over one-half of eligible Malawian children were enrolled in primary school. Drop out rates were high, and the school system lost about half of its students before they reached a state of permanent literacy. This had important negative consequences for national development as well as personal growth. The new goverrunent targeted education as one of the main areas for development. In 1994 it introduced a policy of universal access to basic education for all children. The budget allocation for education, which had never reached more than 13% before, rose to 23%, of which 65% was allocated to primary education. The most important policy changes included the abolition of school fees and uniforms for primary school, and the possibility of providing government assistance and teachers to previously unassisted community-based schools. Some 4000 retired teachers were called back to service, and another eighteen thousand para-professional teachers were recruited and given three weeks of training before being sent to classrooms. Improvements were also made in the area of educational infrastructure to enable the system to cope with the additional influx of pupils and to ensure that communities in marginalized areas would also have access to education. Still, the government has a long way to go, for it estimated that some 38,000 additional classrooms and 25,000 more teachers must be added to the service to bring the teacher-pupil ratio to at least 1:50, which is the current goal. It was recognized that access to education had to be made easier for people in marginalized areas. Therefore, the establishment of community schools in rural and urban areas was promoted. 89 I· I I I I I Malawi Social Indicators Survey 1995 The importance of female education was also acknowledged, and changes were made to the curriculum to make it more gender sensitive. The policy that previously excluded girls because they became pregnant was reviewed to make it possible for such girls to re-enter the system. Eighty-six percent of children who enter Standard 1 reach Standard 5. Studies have shown that a number of factors, including poverty, easy access to schools, poor learning conditions, demand for domestic and agricultural labour in peak seasons, and the low social value attached to being educated have an impact on enrolments and the retention of pupils in Malawian schools. Table 10.1 Distance to primary schools by district 90 In village 19.5 43.4 33.6 15.2 25.9 24.5 15.7 11 .8 1.6 39.2 18.5 18.4 40.0 15.5 10.5 28.8 58.6 29.3 1-Jkm 39.9 44.2 35.0 38.1 9.5 32.1 26.2 41.6 51.7 47.2 40.7 72.5 16.0 76.0 27.7 15.0 51.9 37.9 27.0 17.4 47.7 85.5 71.6 54.1 >5km 3.8 9.8 19.8 4.1 18.6 0.7 7.5 9.4 7.2 2.2 7.4 Chapter Ten - Education Access to Primary Schools The MSIS survey found that less than one-half of Malawians live between 1-3 km from a primary school. A fifth (20%) live 3-5 km, while 4% live further than 5 km from a school. Seventeen percent live less than one kilometre from a school, while another one-fifth (20%) have a school within their village (Table 10.1). Populations living in Nkhata Bay, Rumphi and Chitipa districts have shorter than average distances to travel to school, while those in Mchinji, Ntchisi and Dowa districts must go further. 10. 2 Primary School Enrollment On a national level 83% of primary school-age children (6 through 13 years old) were enrolled in primary school at the time of the survey in · October 1995. (Net enrolment is defined as the number of primary school-age children enrolled in primary school, expressed as a percentage of the total number of children that age.) District figures (Table 10.2) reveal substantial differences m . enrolments. For instance, enrolments in Dedza, Mwanza, Ntchisi and Salima districts were all significantly lower than average-- with Dedza showing the largest difference. By contrast figures for Blantyre, Mzimba, Nkhata Bay and Rumphi districts were all significantly higher. There are significant regional differences (Table 10.3) in enrolment figures as well, with children in the North more likely to enter school than those in the Central or Southern regions. There are a number of reasons Table 10.1 Net enrollment of 6-13 year old• (%),by dbtrlct, 1992193 and 1995. 7"71'J?i7?S.\0?;!;Vc' Chi tip a Karonga Mzimba NkhataBay 89.8 (4.1) 89.3 (2.8) 90.9 (2.5) 94.3 (2.0) 91.9 (3 .3) Blantyre 48.5 90.7 (2.3) Chikwawa 45.3 74.5 (5.1) Chiradzulu 54.4 89.3 (3.3) Machinga 47.8 83.4 0.7) Mangochi 49.0 86.5 (3.5) Mulanje 41.9 80.9 (3.1) · Mwanza 57.9 64.6 (6.7) Nsanje 57.1 83.3 (3.3) Thyolo 48.5 • 75.0 (9.2) Zomba 51.5 90.5 (2.8) Source: Ministry of Education, 1992/93 and MS~S, 1995. for this. First, the North has a tradition of educating children. There are also more primary schools located within a convenient distance of villages in the North -- 36% of children are less than 1 km. from a primary school, compared to 13% in the Central region, and 16% in the South. 91 Malawi Social Indicators Survey 1995 Table 10.3 Net enrollment(%), by region, gender and resi~ence 92 Not surprisingly, there is a significantly higher net enrolment in the urban areas than in the rural areas. As expected, mothers' educational levels have a significant influence on whether children are enrolled at school. For instance, net enrolment for children of mothers with a secondary education is 93.5%, compared to 78.8% for children whose mothers have no education. Analysing gender and district figures (Table 10.4) reveals little variation in net enrolment rates. Only three districts show statistically significant differences between male and female enrolment -- Karonga and Mulanje districts have more males than females enrolled, while Salima district has more girls than boys. Salima district's figures may reflect the strength of the matrilineal system there. On the other hand, Salima is on the lake shore, where many boys engage in fishing and may forego schooling. J Map 8: Net Primary Enrolment I ' It %ENROLLED II 64.5 to 78.2% II 78.2 to 87.1% WI 87.1 to 94.4% 93 Malawi Social Indicators Survey 1995 Table 10.4 Net enrolment(%), by district and gender Chitipa Karonga Mzimba Urban NkhataBay Rwnphi Blantyre Blantyre urban Chikwawa Chiradzulu Machinga Mangochi Mulanje Mwanza Nsanje Thyolo Zomba Zomba urban Standard errors in parentheses 94.9 ( 1.3) 93.5 ( 2.0) 86.9 ( 4.9) 94.1 ( 1.7) 94.2 ( 1.8) 91.8 ( 3.7) 90.0 ( 3.1) 91.2 ( 3.0) 81.7 ( 2.9) 87.9 ( 2.7) 84.4 ( 6.3) 85.4 ( 5.7) 88.1 ( 1.8) 61.8 ( 6.5) 84.1 ( 4.2) 80.9 (10.2) 90.4 ( 4.8) 88.0 ( 4.7) 86.4 ( 7.0) 83.1 ( 3.4) 93.6 ( 2.0) 90.2 ( 2.5) 94.6 ( 4.3) 93.7 ( 2.8) 91.8 ( 2.3) 90.2 ( 3.1) 71.5 ( 8.0) 89.8 ( 5.3) 81.8(5.1) 85.7 ( 3.1) 74.2 ( 3.8) 66.6 ( 9.0) 80.8 (4.3) 70.5 (10.5) 91.3 (2.0) 90.1 (4.4) The high enrolment rates obscure the fact that a considerable number of students repeat classes (Table 10.5). Repetition rates are particularly high in Standard 1, and there are significant differences in repeat rates in urban and rural areas for Standard 1. However, no other significant differences emerge. At the same time continuation rates are quite high. In other words, students seem to choose to repeat classes instead of dropping out of school completely. 94 I· Chapter Ten - Education Table 10.5 Students(%) repeating the school year, by standard Malawi Region North Central · South Gender Male Female Residence uman Rural Standard errors in parentheses Stdl 47.3 (2 .1) 48:3 · (~.1) . 46AJ3.7) 44.0 (2.8) 49.8 (2.4) ; . -. . ·· 34J~(fi.O) 4!U(2 . l) Stdl 22.4 (2 .0) 18.0{4.1) 2L4(t.8) 24.1 (3 .2) 19.6 (2.2) 25 .0 (2 .7) 33:8(7.3) .·. 21,2(2.0} .· Stefl 23.3 (2.5) 19.4 (3.5) 21.6(3.4) 25.3(4.2) 24.9 (3.5) 21.5 (2.9) . . 20.~(7.4) . . 23.6(2·7) Std4 17.6 (2.4) 18.6 (3.9) 21.6(4.2) 14.2(3.7) 18.0 (3.5) 17.2 (2 .9) . -·.· - . 12.6 (7.4) t8;4(25) High rates of repetition in the primary grades could be an indication that students are not receiving an education of a sufficient standard to enable them to pass from one standard to the next. While students may not be prepared to start primary school due to a lack of pre-school education, repetition rates of such magnitude indicate that the cause is not solely due to the calibre of students, but could also be a fault of the system. The repetition rate has serious implications for classroom sizes and facilities, particularly in Standard 1 where the rate is particularly high. Continuation Rates In 1995, it was estimated that 86% of children continued their education up to Standard 5. This figure was reached by calculating the dropout rate per standard for Standards 1 through 5, and aggregating them to assess their cumulative impact. This national figure obscures considerable differences at district level (Table l 0. 7), for some districts have over 95% of their students reaching Standard 5, while others have much less. There is a considerable difference between the regions as well (Table 10.6), with the Northern region pertorming better than either the Central or Southern regions in this and other indicators. Urban areas are more likely than rural Table 10.6 Children reaching Standard 5, by region, gender and residence Malawi :~~ ·North · Central South Gender Male Female Residence Urban Rural · ··. < ~Pottioa 'who.) · . reaCh $taftdmt 5· 86 94 83 86 89 83 96 85 95 Malawi Social Indicators Survey 1995 areas to keep their children in school -- 96% reach Standard 5 in towns, compared to 85% in the countryside. This can be attributed in part to the accessibility of schools in urban areas as well as the age children start school, which seems to be higher in cities. A substantially greater number of children whose mothers have achieved Standard 5 or higher stay in school. This is also the ca

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