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Global Health

USAID supports national Family Planning programs to promote voluntary and informed childbearing as Malawi faces a serious population boom in the next 10 years
USAID supports national Family Planning programs to promote voluntary and informed childbearing as Malawi faces a serious population boom in the next 10 years
Photo Credit: Health Policy Plus

USAID resources have contributed to improved health for Malawians. For example, Malawi is among the few countries which met the Millennium Development Goal (MDG) 4 to reduce child mortality by two-thirds between 1990 and 2015. The country also witnessed a reduction in malaria prevalence in children under 5 from 33 to 24 percent between 2014 and 2017 and a reduction in under-five malnutrition from 47 to 37 percent between 2010 and 2015. There has also been a dramatic increase in the modern contraceptive prevalence of married women of reproductive age from 7% in 1992 to 59% in 2016.

Despite these gains, Malawi’s maternal mortality ratio places it among 13th worst worldwide. Malawi has also been hard-hit by HIV/AIDS. While HIV prevalence among adults aged 15-49 has fallen from a high of 16 percent, it still stands at ten percent. USAID has an annual health budget for Malawi of approximately $100 million, which funds a comprehensive health program. This includes maternal, neonatal and child health, HIV, TB, Malaria, Nutrition, WASH, Family Planning, and Health Systems Strengthening.

In the spirit of integration and sustainability, USAID has integrated maternal and child health with infectious disease prevention and treatment to meet the goals of the Malawi national roadmap for accelerating reduction in maternal and neonatal morbidity and mortality into one flagship project known as Organized Network for Everyone’s Health (ONSE) in 16 of 28 districts.

President’s Malaria Initiative (PMI)

The goal of the President’s Malaria Initiative (PMI) is to reduce malaria-related mortality and morbidity in focus countries. Initially in 15 sub-Saharan countries when PMI launched in 2005, PMI now works in 24 countries and the greater Mekong region. Malaria prevention and control remains a major U.S. foreign assistance objective.

Malawi became a PMI focus country in FY 2006. Since that time, the USG has committed over $260 million to the fight against malaria in Malawi through PMI. Malaria is endemic in more than 95% of the country. Transmission occurs year round in most parts of the country and peaks after the start of the annual rains that typically begin in November and last through April. PMI supports the MOHP and the National Malaria Control Program (NMCP) to implement the Malaria Strategic Plan.

Since PMI began in Malawi, all cause child mortality has decreased by 48% - a significant portion of the reduction is estimated to be due to malaria interventions; mortality from malaria has continued to decline. With PMI support, malaria prevalence among children under 5 dropped from 33 percent in 2014 to 24 percent in 2017.

Maternal Newborn and Child Health; Nutrition; Family Planning Water, Sanitation, and Hygiene (WASH)
The maternal mortality ratio in Malawi remains alarmingly high at 439 deaths for every 100,000 live births, despite having 91 percent of pregnant women deliver in health facilities. The major causes of maternal mortality in Malawi are postpartum hemorrhage, eclampsia, sepsis, and abortion-related complications. Twenty-six percent of girls age 15-19 have begun childbearing, where there is increased risks of death and disability to both mother and child during pregnancy and childbirth. Adolescent pregnancies comprise about 20 percent of maternal deaths in Malawi.

In addition, lack of access to quality services in the public and private sectors during antenatal care (ANC), delivery, and postnatal care contribute to these statistics. Although 95 percent of pregnant women seek ANC from a health provider, fewer than 50 percent attend ANC the prescribed four times. USAID integrates high-impact, evidence-based practices into activities that address vital MNCH issues in households, communities, and health facilities.

USAID actively supports the MOHP in enforcing standards for improved quality of maternal, newborn, and child care in all health facilities. USAID programs strengthen and increase coverage of high impact interventions, including improved antenatal care, basic and comprehensive Emergency Obstetric and Neonatal Care, special support for premature/low birth weight babies, highly effective equipment to address respiratory distress , techniques to address birth asphyxia, and, where possible, neonatal intensive care units with the ability to treat infections/pneumonia.

In addition, USAID programs strengthen community-based services provided by Health Surveillance Assistants who track pregnant women, provide antenatal counseling, promote facility antenatal care and delivery, support emergency referrals, and timely postnatal checkups. USAID/Malawi implementing partners also have redoubled efforts to strengthen routine immunization.


Tuberculosis (TB) remains a major public health problem in Malawi. The 2014 National TB prevalence survey revealed that the TB burden in Malawi was three times higher than previously estimated by the World Health Organization (WHO). The prevalence of Multi-drug Resistant TB (MDR-TB) is estimated at 0.75% among new TB patients and 6.4% of among previously treated TB patients. HIV remains the most important risk factor for developing active TB disease in Malawi: Half of registered TB patients are also infected with HIV. Nearly all (99%) of registered TB patients know their HIV status and 97 percent of those with HIV-positive status in fy2017 initiated antiretroviral therapy before or during TB treatment.

USAID shares the National Tuberculosis Control Program’s (NTCP) vision of a tuberculosis-free Malawi and works to reduce the morbidity, mortality, and transmission of TB until the disease is no longer a public health problem. More than 90% of national TB program budget is donor funded. Besides the Global Fund, USAID is the largest funding partner to the National TB Control Program.

USAID is providing technical support to the NTCP to find the “missing” TB cases, successfully treat those identified, prevent further TB transmission, and help the government of Malawi implement their Global Fund grants effectively to ensure the program remains on track. USAID has been working on improving TB diagnosis through installation of GxAlert system to a total of 60 GeneXpert platforms which will help improve the utilization and optimal functioning of these platforms as well as rehabilitation of the National TB Reference Laboratory (NTRL) helping NTRL attain Biosafety level Class III.

Health Systems Strengthening

Significant health system bottlenecks limit service coverage and provision of quality health care. This includes a critical shortage of key health systems inputs (human resources, medicines and medical supplies, and poor/inadequate infrastructure), as well as poor governance and accountability (including poor public finance management).

USAID works intensively to build supply chain management capacities at both the central and district levels. USG is funding the procurement of antimalarial medicines through its PMI, and FP/RH commodities in support of the national reproductive health program. USG is also providing direct technical assistance on key supply chain activities, e.g. national quantification to inform national budgeting for drug procurement and placement of supply chain experts for key programs and GOM departments.

USG plays a critical role in the storage of live-saving antimalarial and FP commodities, and supports monthly distribution of these commodities to over 620 healthcare facilities. USG also a led a multi-donor team to plan reintegration of a parallel supply chain system into the GOM-managed system.

Human Resources for Health

Because one of the most significant problems with health services is the recruitment, retention, and productivity of health workers, USAID supports pre-service training of nurse midwife, technicians, and pharmacy assistants to address the shortage of staff in health centres, supports their in-service capacity (e.g., skills for managing sick children), improves working conditions for midwives, focuses on improved management of health commodities, supports human resource capacity building with essential skills, and strengthens referral systems to improve access to emergency care for those in remote hard-to-reach areas.

Malawi is one of 57 countries that does not meet the WHO’s criteria and has been experiencing a critical Health Care Worker (HCW) shortage with less than one HCW per 1,000 people across all critical cadres. Insufficient numbers of adequately trained HCW remains one of the most significant challenges of the health sector in Malawi. Staff shortages across all professional cadres, lack of professional development and low capacity of training institutions across the country all persist despite recent efforts by the Ministry of Health.

USAID also supports the MOH in its design of ambitious health sector reforms; namely: 1) establishing a Social Health Insurance (SHI) scheme; 2) creating a Health Fund; 3) decentralizing district and central hospital level service provision; and 4) reviewing institutional arrangements between the GOM and the Christian Health Association of Malawi. Ensuring these reforms benefit the most vulnerable populations is paramount and in keeping with the National Health Policy endorsed by the MOHP. Substantial investment by the GOM will be required to ensure these reforms are well designed and responsibly implemented. Improving accountability in the sector is fundamental to the success of these reforms.

Major Challenges/Issues

  • Severe Health Financing gaps: Malawi has the third lowest GDP per capita in the world and the lowest total health expenditure per capita in the SADC region at $39 per annum, compared to the SADC average of $229. The country’s forward-leaning approach to task-shifting to community cadres has facilitated major gains in child health. However, further progress on health indicators such as maternal mortality requires further investment in the health system.
  • Human Resources for Health: Malawi is tied with Niger for 190th among 193 countries on physicians per capita and 174th of 189 on nurses and midwives. Efforts to increase the size of the health workforce are hampered by the capacity of training institutions and inadequate funds.
  • Accountability remains a key concern, but there are some promising signs under current Minister of Health.

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Last updated: August 27, 2018

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