Malawi - Population sector study (Vol. 1 of 2) : Main report

Report No. 8513-MAI Malawi Population Sector Study (In Two Volumes) Volume l: Main Report May 29,1992 MICROFffCHE COPY Population and Human Resources Division Report No. 8513-MPI Type: (SEC) Southern Africa Department Title: POPULATION SECTOR STUDY African Regional Office Author: HILL L .t THEA Ext.:34088 Room:J-9083 Dept.:AF6PH FOR OFFICIAL USE ONLY Docunt of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  List of Abbreviations ADB African Development Bank ADD Agricultural Development Division AEES Agricultural Extension Education Service AIDS Acquired Immune Deficiency Syndrome ARI(s) Acute Respiratory Infection(s) ASFR Age-Specific Fertility Rate AV Audio Visual AVSC Association for Voluntary Surgical Contraception BBC British Broadcasting Corporation CBD(s) Community-Based Distribution/Distributor(s) CCAM Chitukuko Cha Mai M'Malawi CCCD(project) Combating Childhood Communicable Diseases (project) CDA(s) Community Development Assistant(s) CIDA Canadian International Development Association CMS Central Medical Stores CO(s) Clinical Officer(s) CPR Contraceptive Prevalence Rate CS Child Spacing DC District Commissioner DDS District Development Committee DEVPOL "Statement of Development Policies, 1987-1999" DHO District Health Officer DHS Demographic and Health Survey DOI Department of Information EAB Extension Aids Bureau, Ministry of Agriculture EARU Evaluation and Action Research Unit, EAB ECS Economic Common Service ENM(s) Enrolled Nurse/Midwife(-wives) FA(s) Field Assistant(s), MOA FAO United Nations Food and Agriculture Organisation FHA(s) Farm Home Assistant(s), MOA FLE Family Life Education EC European Community EP&D Department of Economic Planning and Development FFS Family Formation Survey HEU Health Education Unit HIV Human Immune-Deficiency Virus HA(s) Health Assistant(s) HI(s) Health Inspector(s) HID Health Institutions Development (project) HSA(s) Health Surveillance Assistant(s) HRID Human Resources and Institutfonal Development (project) IEC Information, Education and Communication ILO United Nations International Labor Organization IPPF International Planned Parenthood Federation IUD Intra-Uterine Device JH/PCS Johns Hopkins University Population Communication Services JHPIEGO Johns Hopkins Program for International Education in Obstetrics and Gynaecology  FOR OMCIAL USE ONLY iSI John Snow International KAP Knowledge, Attitudes and Practice of Family Planning MA(s) Medical Assistant(s) MaC Malawi Broadcasting Corporation MCH Maternal and Chlld Health (Care) MIS Management Information System MOA Ministry of Agriculture MOCS Ministry of Community Services MOE Ministry of Education MOH Ministry of Health MOLG Ministry of Local Government MSH Management Sciences for Health NCSCC National Child Spacing Coordinating Committee NCWID National Council for Women in Development NDS National Demographic Survey NFWC(M) - National Family Welfare Council (of Malawi) NGO Non-Governmental Organization NPAC National Population Advisory Committee NPDP National Physical Development Plan NPSC National Population Steering Committee NSO National Statistical Office NSSA National Sample Survey of Agriculture ODA Overseas Development Agency (of UK) OPC Office of the President and Cabinet PCS Population Change Survey PHAM Private Hospitals Association of Malawi PHC Primary health care PHICS Promoting Health Interventions for Child Survival (project) PHRD (Unit) Population and Human Resources Development (Unit) PPU Population Planning Unit RAPID Resources for the Awareness of Population Impacts on Development RAPID(M) Resources for the Awareness of Population Impacts on Development (model no. ER) SCN(s) State Cerified Nurse(s) SEATS Service Expansion and Technical support (to family planing) SOMARC Social Markedng for Change SRN(s) State Registered Nurse(s) STD(s) Sexually-Transmitted Disease(s) TBA(s) Traditional Birth Attendants TFR Total Fertfility Rate TH(s) Traditional Healer(s) UK United Kingdom (of Great Britain) UNDP United Nations Development Program UNESCO United Nations Educational and Cultr Organizdon UNFPA United National Family Planning Association UNICEF United Nations Fund for Cbildren USAID United States Agency for Intrnadonal Development WHO United Nations World Health Organization This document has a restricted distribution and may be used by rcipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Malawid Poguladon S=crRgr Volume I ~~~~,~, ~~~~~~~. . .......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii m m ...................................................... Hxi M Al c 9. . . . . ................................... x 1 A: DemographIc Charateisdcs and Trnds . 1 B: PopulalnProjectons .5 C: Soco-economic pliUcionm of Populatn Trd .. 13 IL blicies Md EMWU In Naiad ..................... ~~~25 A.: Poplaton-satd Polcie .. 25 B: Populeion-Retd Planning titutions and Adities ... 27 IlL ChDf4n Maird . .... 29 A.: H stoty and Deveqment of Child SpaingAedviA cs. .s 29 B: TrahlnfIngtheCOildSpwcinProgrm .34 C: Supplls andLogics intheChildSpacingPogram .36 D: Record Keeig and Informain Systems in te Chfid Spacing Program.37 E: Th Flanclng ofdeChildSpacn gProgram .38 rv. Demd mg Demand-EnAncMn= for Child Snganin Malawi ..49 A: Cumn Demand and Needs .49 B: CuorrentECSuucuxrein MaSla.51 C: Proble andConstralintsteCSIECField in Mabw . 58 V. TheRoleof d WoW *Banka dOief DMnors .6 YL. IaauAa..aud..Bin?ondatis.............................67.... 67 A: IsseRelated to PouldoninDevelopmn Plai_ng .67 B: bssuesR.lad to dieCl dSpacnSgProgram .71 INS Pop"oS Study is basd on the finding of a main muldideoro/Gov t m isdo.d in July, 1989, a_hinted by tq fwwup minions in May, 1990 ad May, 1991. Mm mai insion waujoiny led by Albea, Hi (Wod ak APTPN, Seio D=onVr and W. Bill Muk (UMNPA Comtq Dreto for MaIawi. Miss l m included Geootp Zi_ana (economis, PPU, EP&D), Nelso Kd. (economis, MO*) Ron aChyir (CS pogm coomodar, MOB), W. Maga (dha wkr, NSO), DAvid Se (Wodd B1k AFPN, Sekior Pubio Ralt Spealit), Moms Mus (Wold Bank cmtnt in CS pgng..), Ranit Oftbm (WoedM Bk consultant in MC), Ua Pool (UNPPA oett in ), T _ La Clegq UPPA o _W in WOrn in Dvelopnt), Roy Iaobeti (aief of Tning Dhion Office of Popuio, USAID Waddnon), Cad Stevens (USAM cmulgt bin weonom) ad Rm.h Sreba (hult ialiat UNCEF Mawi offAc). TM wlm a&W reciwed valub maport fivm Gay Non (Populatio ad eld Offi cr, USAMD Malw) d Ken WDhliue (UNIWCE Cuny Direcow r Maaw), as wel as fiom nor officids of MON, MOCS, NSO ad BP&D. AdMona folow-up w* on CS finnng and AIDS wu cuowed out by Rolbut Hach (Wodd Bank AP, Sior Nomooad) n4 May But= (Word Bak AMP coomist); Rodolfo BulPo (Wodd Bak PHREN, demoap*e) p_ot moo mods w of t evoluow of AIDS used in to Study. Th Study wa w4Uia by At Hill ad pduoo by 1Nod BMWs, K1j Nab and David TnW-lo. Da de rrTi nd S8ehen. Daring w eciy do maging Division Csu ad Dep_uia Dieco for is secor wuek  hae No. 1.1 Family and Mortality Assumptions for Polon Projectlons ....... ........... 8 1.2 Projected Sze of the Ppuldon of Malawl (in ilUons) ....................... 11 1.3 Projected Average Annual Pouton Growth Rate of MalavI (percent) . ............. 11 1.4 Projected Age Strucue of the Population of Malawl . ....................... . 13 1.5 PonplatIon Pressure on Arable Lad Resources ........ . .............. 15 1.6 Pressureof PpuatonGrowthonEmployment ..16 1.7 Prssue of Population Growth on Plmnary Education .1....................... 17 1.8 Pressure of PopuladonGwwthonMCH SrSces ..19 1.9 Projected Savig on Primary School Expenditure from Fertiity Decline (1989 Prices) .... 20 1.10 Projected Savings on Secndary Education Expenditure from Fertil Decline (1989 Prices)..20 1. 1 Price is) ................................ ^s)........................... ............. 21 1.11 Projected Savings on MCH Servces Expenditur from Fertiity Decline (1989 Prices) ....21 1.12 ProjectedCostsofeChbildSpacingProgram (1989Prices) .................... . 21 1.13 Projected Annual Costs and Savins of the CS Program (USS millions at 1989 Prices) ..... 22 1.14 Projected Anmual Costs and Lagged Savins of the CS Program (US$ milion at 1989 Prices) 22 3.1 Performance Indicators for the CS Trhin Program at the Lilongwe School of Health Services .. S34 3.2 Mistry of IH h Re'`urrenwt- tExpndireas Percent of Central Govenmment RecurrentAccount Expmedu 1981/82thru 1977/97 ......................... 39 3.3 Esimated Natind Recurrent Health Expenditures and Sources of Fiacing, 1980/81 (Kwachamiks) ........... 40 3.4 FunonadCosfionofMOH Epei4u4l98788..42 3.5 Beds and Bed Occpancy Rates (BORs) for Central and District Hospits, January 1991 ... 43 3.6 National ChildSpacing Program, 1991-95, Mistry of Health Summary Costs (Constant US$000) with Amorized Capla Costs . ..4 3.7 Cost of National Child-Spacing Prograim, 1991-95, I-Service Trahin Plan . .......... 45 3.8 Natonal Child-SpaUc Program, 1991-95, Local Personel Costs (US$'00) . ......... 45 3.9 Cost of Natonal Cild-Spacing Progmn, 1991-95, Cotracepive Commodie . ........ 46 3.10 Prposed dget for National Family Welfare Council (Kwacha') . .............. 47 lid of Figu Fig 1 Pree sd Po in of bhaw ........................................ 9 Fig 2 Ptojected Populatin Grwth Rate in Maaw.... 10 Fig3a ProjectedPercenopaeofCadrenintdhPopulationofMalawi ........... ......... 12 Fig3b Projected PrcenptofEderly inthe PbpulatonofMalawi . . . ...... 12 Fig3c ProjectedTrendsIntheDependencyRation In Malawi ........................ 12 Fig4 PopWadonPressueonLandResourcesandEinploymentby2010 .... . . 14 Fig 5 Popilation Pmeasue n Primary Schoo ......................g......... 18 Fig 6 Populadon PeMssure on MC Services .... .............. 18 Fig 7 MOH Recurrent Expendiure as Percentage of Central Goverment Recurrent Expendir 1981-1997 ..... 41  Volume II Annexes 1. Demographic Note ........... 1 II. A: 1977 Census District-level mortality and fertility tables .19 B: AFEMOPC computer program print-outs for districts in 1977 and for national level in 1970-72, 1977, 1982 and 1984 . 21 C: Computer program print-outs for analysis of adult mortality, 1970-72, 1977, 1982 and 1984. 125 D: PROJ PC Computer program population projection print-outs. .... ......... 173 E: Bongaart's Formula Lotus print-outs ........ ..................... 210 m. Note on the Demographic lmpact of AIDS in Malawi ........................ 213 Table of Comoarative Socio-Eoonomnic. Health and Family Pbnnins Indicators for Malawi Malawi hmAverfor Averauc for Sub-Sahn AU Low-lacme AWiia Counrie 3NP per capita, 1989 (US$) 180.0 340.0 330.0 GDP Aveg Annual Growth Rate (%) 1980"9 2.7 2.1 6.2 Pent Share of Agriulr in GDP, 1989 35.0 32.0 32.0 External Debt as Percent of GNP, 1989 91.0 97.0 32.0 TotalPeity Rate, 198 7.6 6.6 3.9 Modem C ocpie Prevae, 1988 3.0 1-36 Ran 1-77 Range (Prca Maied Women of Childbearing Age) Poplation per nuree, 1984 3130 2130 2150 Percet Binhs Uende by heat staf 1985 59 2-74 Rane 2-100 Rw4e Daily per capita CdOri SpIy, 1988 2009 20tl 2331 Pacent of Age Group in Pdimy School, 1988 Btb SO 72 67 lOS Girla 65 60 95 Percent of Age Group in Secondary Schoo, 1988 Both Sem 4 18 37 *Gils 3 14 29 Source: World Development Reports, 1989, 1990 and 1991, except for Modem Con tde P enc for Malawi and for upper bound for Sub-Sahan Africa. (Source: Thi Study and the 1988 Zimbabwe Demogmaphic and Health Fmnal Report, r ypectvey).  - {ii - uliadon Sector So Overvie 1. Malawi faces one of the most urgent problemn of rapid populadon growth in Africa today. The country's single major natural resource - agricultural ld - ib under sever pressure from the explosivt, population growti of rece decades, which has more ta doubled populadon numbers just since i nce. Yet it wil be difficult for ndustry and the formal employment sector to grow fast enough over te net few decades to absorb the rapidly swelling and Increasingly landless labor force. There is also serious question whether Hmited government budget and low household incomes will be able to cover the huge increas In needs for esta social services, such as education and health, that will be gnerated by the fast growWg and youthful population of Malawi. 2. The govenment of Malawi is aware of these serious population is and has taken a nber of steps to address them. Impressive progress has been achieved in all aspects of the population field during the seven years that have elsed since the Bank's previous Popuadon Sector Review mission in 1984. The two principal o of that Review are being implemented, namely the establishment of a population planning capacity in the new Populalm and Human Resources Development Unit and the rapid expasion and st teni of the Child Spacing Program, and the government dese much credt for its rapid and effective acdons to date. 3. Yet much more remains to be done, and done urgently. This Study Mals gea aroach and dietions in me pulation field, and recognies tat the major isue and needs discussed in the following sections have already been identified within the ountry, togt with preliminary steps and strategies to address them. Still, govenmn will need to move quickl and effctiel over the next few ye arst manainmdaclrt urn oetm the deveWlment of omiIam iUonzcans. Such action wiffl rqui In tm of both fiding and manpower, as well as urgen atenton to the mny tehnial issues that need to be addresed and resolved in the fields of both nulati in dtni l=l and the child spacing program itselt. 4. With regard to g=pnhation in gde mcplannij, the Ppulation and Human Resources Development Unit's mandate and work progam are appropriate, if ambitious, and well-designed. An adequate data base for assessmt of population charactest and trends has been provided by the National Statical Office. he anlyical caacity for assessmn of these charactescs and trends and their linkages with develpnt has been s by dte creaion through a UNFPA project of the Demographic Unit at the Unvety of Malawl. IREI now be necessary to build on this sound initial foundation in order to ensure that attion to populaton concems becomes roosne tey d in Malawi's develom1_ S. With regard to ChildSoda& Progrmm m, Malawl's pogrm has grown rapidly since its inception in 1982. Child spacing services are now avallble at nealy one third of healt facilities through the country and numbers of new clients have ieased more than tenfold si the start of the program, from around 3000 in 1984 to a minimum of 34,000 in 1988. Thes are real achievements for a very young prgram in a poor, high-fertlity and low-education population.  - ii - 6. Nevertheless, it is clear that a huge challenge lies ahead for the child spacing progm in Malawi in raising prevalence of modern contraceptive use to a level consistent with good nuternal and child health and national and family welfare, as regards both demand and Maply. There clearly is enough dmand for child spacing services among Malawian families to surpass the current capacity of the program to supply them, and to allow easy fulfillment of the program's current target of 12 percent prevalence of modern contraceptive use by 1995. It is also clear however, that there is still widespread ignorance and misunderstanding of the correct contraceptive usage patterns for maximization of maternal and child health and family welfare. A necessary first step in this regard is ,fe dLUegg= and imeon of a ggMre0sie integaed and multi-secto s gy ad plan of action for S nrmation. education and prodmion, together with the iniuIgna stren@gthening and building of inteaency linkaes required for successful implementation. A principal guideline in strategy and plan design should be maximum reliance on LQca talent. expertise and experience, Including neighboring countries. 7. On the ,s=1y side, the challenge is still more formidable. Both coverage and quality of child spacing services need to be expanded rapidly even to satisfy the current demand in most parts of the country, let alone to meet Malawi's full needs now and in the future. Yet-there are mOr overarching resource constraints on any such expansion which are related to general health financing issues. and which MUst be confronted: for example, achievement of the child spacing program's 12 percent target contraceptive prevalence by 1995 would require expenditure for that year on child spacing services amounting to nearly half as much as the total amount spent on all other primary health care services. Substantial increases i funding for health services from bot government and non-government sources - particularly donors - will be essential to relieving these constraints, in combination with ,a sstematic emphasis on low-cost, cost-efficient and cost- effective approaches to child spacing Mogam desien. S. In addition, important technical Issues of service delivery and quality need attention. Among the most important of these are the expansion. acceleration and strejig nof =baig in child Ming, the extension of the non-governmental network of health/cL ild spacing service outlets by vat estates and _ _anle, and the establishment of an outreach capability which could provide community-based distribution of child spacin services. Effective use will also need to be made of the newly-established National Family Welfare Council of Malawi. 9. Forunately, however, there is widespread agreement within government and the donor community on both the diagnosis and the possible soludons to these problems and constraints. Still more importantly, there is a real commitment on all sides to a joint and coordinated effort by government and donors towards furiher progress in this vital sector. This Study itself, based on a joint mnission in which governent and major donors participated, was designed to provide a common analytical base on which both donors and government could draw for design and preparation of their forthcoming population strategies and program. These programs, if successfully implemented, should go far towards addressing the issues and constraints outlined above.  Executive Sumnnfa 1. Soclo-Economic Backround to Population Issues (V) Malawi faces enormous fundamental constraints in the drive for socio-economic development. These include a natural resource base limited largely to moderately fertile arable land which covers only half the country's land surface and must be cultivated with only one short rainy season per year; a landlocked 3nd isolated geographical location; and the national and family-level poverty arising from such narrow resources. Nonetheless, economic growth was excellent during the first 15 years of Independence, due to a focus on rapid expansion of the agricultural estate sector which produced for export; but the smaliholder sector stagnated. With the subsequent shocks of the 1980s and falling per capita incomes, came a fresh appreciation of these fundamental constraints to development, as well as a new realization of the breadth and depth of poverty, deprivation and malnutrition in the country. The importance of human resource development has also been recognized, as well as the need to monitor welfare measures. New approaches and strategies for socio-economic development will now include agricultural productivity improvements, smallholder sector development, poverty alleviation and investments in human resource development. Particular attention also will be given to the position of women, who are still disadvantaged in Malawi today despite impressive government initiatives. HI. Demographic Trends and Their Implications Demo&[n dic Charcestics and Trends ii) The ulion of Malawi in mid-1991 is estimated at around 8.7 miflion, excluding over 900,000 Mozambican refugees.(see the population projections in Volume HI, Annex II.) The current anmnal DUouation growth rate, excluding refugees, is estmated by the Bank at around 3.5 percet, enough to double the population within another 20 years. National g=laflo d