REPORT ON UPDATE OF HEALTH ASSESSMENT

UNFPA, UNICEF, UNAIDS, MINISTRY OF HEALTH AND WHO

MALAWI SEPTEMBER 2002

Introduction

A rapid health assessment was conducted by WHO in collaboration with MoHP and partners in April 2002. The main findings of that assessment became the guiding principles for the design of the health projects outlined in the Consolidated Appeal that was launched in June 2002.

The health information and indicators reflected in the appeal have to be updated regularly as part of the planned activities, hence the need for this reassessment exercise that was carried out during the month of September 2002.

Objectives

The general objective of the reassessment was to continue to determine the impact of the humanitarian crisis on the people of Malawi, especially on the most vulnerable groups: children under 5, women and people living with HIV/AIDS (PLWH), with special emphasis on significant changes since the month of June.

The specific objectives can be described as:

  • To assess if the access to preventive services by the vulnerable people was being jeopardized by the crisis;
  • To assess the excess burden of disease the crisis has put on the PLWH;
  • To assess the impact at the community level by measuring mortality.

Study design

The health facilities and communities to be visited are the same chosen for the first health assessment and are included in the group of districts reported by WFP as most vulnerable.

In the seven districts that had been visited five months ago the same villages were selected for the community-based data. In the three new districts newly classified by WFP as vulnerable the communities were chosen by the local District Health Management Team (DHMT).

Data was collected at two different levels (strata): secondary data from the HMIS, the EPI division and the National TB Control Programme and primary direct data from the community level through household interviews.

Sample size

For the institution-based secondary data it was agreed that districts would be included whole.

For the community-based survey it was agreed that 20% of all households should be interviewed in each community. A total of 40 villages and 1079 households (5932 people) were interviewed.

Study area

The ten selected districts were: Salima, Thyolo, Ntcheu, Blantyre, Dezda, Mchingi, Mzimba, Dowa, Kasungu and Karonga. The list of villages visited within each district can be found in Annex 1.

Participating agencies

UNFPA, UNAIDS, UNICEF, WHO and Ministry of Health and Population (MoHP).

Material and methods

The assessment will collect secondary information from health facilities and central level. The data to be collected from the health facilities was:

  • First visit to antenatal services/month
  • Number of children receiving DPT3/pentavalent vaccine/month
  • Number of new admissions to the tuberculosis treatment program/month

Based on the guidelines given by the UN Regional Southern Africa Co-ordination Office the periods to be compared will be March to May 2002 versus June to August 2002.

Mortality (crude mortality rate, CMR and CMR in under 5) was collected at the community level through household interviews.

Data collection forms were prepared for both the primary and secondary data.

Methodology

At district level

A letter of introduction from the Epidemiology Unit on behalf of this exercise was faxed in advance to the District Health Office informing them of the arrival of the teams.The first step once on the field was to visit the District Health Officer (DHO) in order to explain the purpose of the assessment and request his support by appointing somebody from his office to accompany and introduce the team to the communities.

At the community level

The purpose of the assessment was explained to the village headman and the Health Surveillance Assistant responsible for the chosen village. They would provide the number of households (see “field definitions” below) or families living in the village and together the number of households to be visited would be predetermined (20%).

At the household level

The information collected at the household level was:

  • Gender of head of household;
  • Reasons for a woman to be the head (see field definitions)
  • Head of household younger or older than18
  • Number of people in the household
  • Number of members of the household deceased since March 2002 (Easter, end of rains)
  • Age of the deceased

Field definitions

  • “Household”: equivalent to “family”. It is a unit normally composed by the mother and her children. The husband may be part of it (monogamous) or not (several wives). It can also contain grandparents, other siblings and increasingly so, orphans that used to belong to other family units.
  • “Female-headed household”: When there is no male breadwinner in the family, the head is either widowed or divorced. She is the sole provider of the family unit.
  • “Child-headed household”: when the head of the family is under the age of 18. Normally the other members are not his/her offspring but siblings. No adult as provider exists.

Data analysis

The data was analysed using Microsoft Excel.

Findings and conclusions

The main results and conclusions from the analysis of the data are:

  • The Crude Mortality Rate (CMR) remains at 1.96 deaths/10.000 population/day and the under 5 CMR has been found to be 3.9.
  • These results are not completely comparable to the CMR of 1.97 obtained in the initial assessment because the 2 periods measured overlap by one month.
  • These results are very worrying, since the period between March and October (dry) is considered the “good season”: there is no cholera, there is less malaria, the crops are in and there is food available. Therefore these new results should be interpreted as a worsening of the situation and forecast a very dire upcoming rainy season in terms of human survival. See annex 1
  • The excess mortality affects similarly all ages; both the CMR and the CMR in children under five has about doubled from the emergency threshold.
  • The most vulnerable districts in terms of morbidity and mortality are Karonga, Mchingi, Salima and Dezda.
  • The number of new TB cases diagnosed and admitted into the TB program has more than doubled between the first and the second quarter of the year 2002.TB cases can be used as a measure of underlying HIV/AIDS in the community since over 80% of all new TB cases in Malawi show HIV co-infection. The remarkable increase shows that the humanitarian crisis has put an extra burden on PLWH, specially women. See annex 2
  • In the most vulnerable districts above mentioned the attendance rate to antenatal services has declined markedly since June; this leads to 2 worrisome conclusions: access to services is declining in the worst affected districts, and of course the fact that more women may be at risk of unplanned pregnancies. See annex 2
  • A very similar picture is seen from the access and utilization of EPI programs. See Annex 2.

Recommendations

These are the main recommendations:

  • WHO as the lead agency in the health sector must strive to convince donors to support the areas of action proposed in the consolidated appeal that have never been acted upon;
  • The functional implementation of an integrated disease surveillance system is a priority, especially in the most vulnerable districts.
  • Epidemic preparedness (especially for cholera) must be implemented during the coming 2 months (before the next “cholera season”).
  • Health coordination among all partners must be reinforced and better synergy should be achieved among the various, abundant and sometimes simultaneous assessment exercises.
  • The indicators chosen for this reassessment were limited in order to provide essential information quickly for immediate dissemination and action. Nevertheless the results are sufficient to show a worrying picture of the health situation in Malawi. A more in-depth survey should be carried out by the interested agencies. That survey should include data on factors relating to the spread of HIV/AIDS.
  • The community-based mortality survey should be repeated in 6 months’ time.

ANNEX 1 VILLAGES VISITED IN EACH DISTRICT

# HH / # F HH / # people / # under 5 / # deaths / # deaths U5 / CMR / CMRU5
SALIMA / 79 / 12 / 376 / 95 / 11 / 8 / 1.63 / 4.68
Ndovu / 30 / 8 / 132 / 28 / 6 / 4 / 2.53 / 7.94
Chikunda / 12 / 1 / 57 / 18 / 1 / 1 / 0.97 / 3.09
Kanvanjilou / 17 / 1 / 91 / 22 / 2 / 1 / 1.22 / 2.53
Wirize / 20 / 2 / 96 / 27 / 2 / 2 / 1.16 / 4.12
THYOLO / 85 / 5 / 566 / 75 / 4 / 2 / 0.39 / 1.48
Warani / 28 / 0 / 300 / 38 / 2 / 1 / 0.37 / 1.46
Jeremiya / 9 / 0 / 40 / 4 / 0 / 0 / 0.00 / 0.00
Mpenda / 33 / 1 / 162 / 24 / 1 / 1 / 0.34 / 2.31
Lisiyano / 15 / 4 / 64 / 9 / 1 / 0 / 0.87 / 0.00
NTCHEU / 115 / 38 / 604 / 101 / 17 / 1 / 1.56 / 0.55
Chitsulu / 24 / 10 / 118 / 22 / 5 / 1 / 2.35 / 2.53
Kalumba / 26 / 10 / 158 / 30 / 5 / 0 / 1.76 / 0.00
Dzaole / 45 / 15 / 226 / 31 / 1 / 0 / 0.25 / 0.00
Ben Chinseu / 20 / 3 / 102 / 18 / 6 / 0 / 3.27 / 0.00
BLANTYRE / 110 / 22 / 548 / 96 / 3 / 3 / 0.30 / 1.74
Jiya / 37 / 11 / 197 / 32 / 0 / 0 / 0.00 / 0.00
Kamtukule / 43 / 7 / 209 / 40 / 1 / 1 / 0.27 / 1.39
Kadikira / 24 / 3 / 118 / 20 / 2 / 2 / 0.94 / 5.56
Mlongoti / 6 / 1 / 24 / 4 / 0 / 0 / 0.00 / 0.00
DEZDA / 142 / 38 / 724 / 157 / 36 / 15 / 2.76 / 5.31
Tembwe / 31 / 1 / 176 / 33 / 2 / 1 / 0.63 / 1.68
Mtachire / 14 / 3 / 93 / 27 / 6 / 0 / 3.58 / 0.00
Mtawanga* / 46 / 17 / 253 / 52 / 11 / 9 / 2.42 / 9.62
Kamgunda / 51 / 17 / 202 / 45 / 17 / 5 / 4.68 / 6.17
MCHINGI / 70 / 18 / 408 / 75 / 18 / 8 / 2.45 / 5.93
Kaluza / 22 / 8 / 120 / 26 / 8 / 1 / 3.70 / 2.14
Filimoni / 14 / 4 / 70 / 12 / 4 / 3 / 3.17 / 13.89
Tongole / 12 / 3 / 72 / 13 / 1 / 1 / 0.77 / 4.27
Mtondo / 22 / 3 / 146 / 24 / 5 / 3 / 1.90 / 6.94
MZIMBA / 105 / 27 / 556 / 85 / 11 / 6 / 1.10 / 3.92
Chikondowanga / 40 / 11 / 187 / 38 / 2 / 1 / 0.59 / 1.46
Simeon Mvula / 25 / 10 / 152 / 19 / 2 / 1 / 0.73 / 2.92
Kacherera Soko / 9 / 2 / 54 / 6 / 4 / 3 / 4.12 / 27.78
Ndabambe Gausi / 31 / 4 / 163 / 22 / 3 / 1 / 1.02 / 2.53
DOWA / 74 / 15 / 465 / 95 / 22 / 5 / 2.63 / 2.92
Ntsilu / 21 / 4 / 129 / 24 / 1 / 0 / 0.43 / 0.00
Kantepa / 12 / 3 / 100 / 26 / 12 / 2 / 6.67 / 4.27
Misi / 36 / 8 / 205 / 42 / 7 / 1 / 1.90 / 1.32
Mbota / 5 / 0 / 31 / 3 / 2 / 2 / 3.58 / 37.04
KASUNGU / 102 / 14 / 606 / 122 / 21 / 7 / 1.93 / 3.19
Chiwera / 40 / 5 / 244 / 54 / 10 / 2 / 2.28 / 2.06
Kasinjeni / 26 / 1 / 179 / 29 / 6 / 4 / 1.86 / 7.66
Chikwiya / 20 / 0 / 100 / 22 / 3 / 1 / 1.67 / 2.53
Kaninga / 16 / 8 / 83 / 17 / 2 / 0 / 1.34 / 0.00
KARONGA / 197 / 55 / 1079 / 244 / 66 / 25 / 3.40 / 5.69
Mwakalomba / 40 / 7 / 204 / 48 / 4 / 3 / 1.09 / 3.47
Maxwell / 27 / 8 / 121 / 26 / 21 / 8 / 9.64 / 17.09
Chimalabantu / 86 / 27 / 496 / 120 / 17 / 5 / 1.90 / 2.31
Yalero* / 44 / 13 / 258 / 50 / 24 / 9 / 5.17 / 10.00
TOTAL / 1079 / 244 / 5932 / 1145 / 209 / 80 / 1.96 / 3.88
* 1 child-and-female-headed household found in the village
An average of 22.6% of households are female-headed
The average size of HH is 5.5 persons, oscillating between 4.8 in Salima and 6.7 in Thyolo
The worst affected districts are Karonga, Mchingi and Dezda, followed by Kasungu, Salima and Dowa.
Karonga has 28% of female-headed households
Dezda has 27% of female-headed households
Ntcheu has 33% of female-headed households

ANNEX 2

Number of First ANC Visits by District and Month (March-August, 2002)
District / March / April / May / June / July / August / Total
Karonga / 379 / 350 / 412 / 380 / 425 / 389 / 2,335
Dedza / 2,832 / 1,372 / 1,081 / 973 / 910 / 895 / 8,063
Dowa / 805 / 1,785 / 1,162 / 977 / 1,086 / 834 / 6,649
Kasungu / 1,444 / 1,975 / 1,713 / 1,702 / 1,754 / 1,769 / 10,357
Mchinji / 2,836 / 3,040 / 2,658 / 4,050 / 3,869 / 4,140 / 20,593
Ntcheu / 2,168 / 1,480 / 1,306 / 1,275 / 1,200 / 1,160 / 8,589
Salima / 899 / 1,291 / 1,114 / 1,130 / 1,195 / 1,250 / 6,879
Mzimba / 1,207 / 1,301 / 1,297 / 1,360 / 1,250 / 1,300 / 7,715
Blantyre / 2,481 / 2,498 / 2,550 / 2,244 / 2,210 / 2,299 / 14,282
Thyolo / 983 / 2,459 / 2,050 / 2,350 / 2,390 / 2,040 / 12,272
Total / 16,034 / 17,551 / 15,343 / 16,441 / 16,289 / 16,076 / 97,734
Number of <1 Children who received DPT-Hep B+ Hib 3 by District and Month.
(March-September, 2002)
District / Target Pop / March / April / May / June / July / Aug / Sept / Total
Karonga / 10,716 / 127 / 357 / 469 / 437 / 419 / 410 / 430 / 2,649
Dedza / 22,284 / 327 / 989 / 1,387 / 1,699 / 1,787 / 1,837 / 1,985 / 10,011
Dowa / 22,320 / 313 / 717 / 1,019 / 1,375 / 1,450 / 1,569 / 1,689 / 8,132
Kasungu / 27,312 / 621 / 1,430 / 1,709 / 1,777 / 1,850 / 1,903 / 2,090 / 8,669
Mchinji / 17,388 / 368 / 988 / 1,085 / 1,252 / 1,468 / 1,623 / 1,858 / 8,274
Ntcheu / 18,768 / 1,050 / 1,251 / 1,710 / 2,076 / 2,155 / 2,460 / 2,790 / 12,442
Salima / 17,112 / 288 / 884 / 883 / 698 / 607 / 589 / 570 / 4,231
Mzimba / 24,409 / 1,839 / 2,040 / 2,300 / 1,990 / 2,340 / 2,440 / 2,350 / 13,460
Blantyre / 43,428 / 1,711 / 1,149 / 3,771 / 2,701 / 3,260 / 3,757 / 4,060 / 18,698
Thyolo / 23,364 / 1,297 / 1,926 / 2,000 / 2,068 / 2,136 / 2,199 / 2,345 / 12,674
Total / 227,101 / 7,941 / 11,731 / 16,333 / 16,073 / 17,472 / 18,787 / 20,167 / 99,240
New Cases of TB* by District and Quarter (Jan-June, 2002
District / First Quarter / Second Quarter / (%) M / (%) F
Male / Female / Total / Male / Female / Total
Karonga / 19 / 14 / 33 / 31 / 32 / 63 / 63 / 129
Dedza / 61 / 75 / 136 / 77 / 94 / 171 / 26 / 25
Dowa / 37 / 29 / 66 / 52 / 36 / 88 / 41 / 24
Kasungu / 77 / 73 / 150 / 93 / 54 / 147 / 21 / -26
Mchinji / 49 / 62 / 111 / 56 / 53 / 109 / 14 / -15
Ntcheu / 38 / 46 / 84 / 56 / 51 / 107 / 47 / 11
Salima / 42 / 53 / 95 / 64 / 70 / 134 / 52 / 32
Mzimba / 68 / 63 / 131 / 150 / 179 / 329 / 121 / 184
Blantyre / 499 / 434 / 933 / 522 / 543 / 1,065 / 5 / 25
Thyolo / 109 / 139 / 248 / 140 / 157 / 297 / 28 / 13
Total / 999 / 988 / 1,987 / 1,241 / 1,269 / 2,510 / 24 / 28
* This includes all cases of TB (smear +ves, smear -ve but with clinical diagnosis and
extrapulmonary TB)

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