Malawi - Basic needs

Report No. 3461-MAI Fl Malawi Copy Basic Needs May 8, 1981 Eastern Africa Regional Office FOR OFFICIAL USE ONLY Document of the Vbrld 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.  CURRENCY EQUIVALENTS Currency Unit = Kwacha (K) Exchange Rate Kwacha 1 = US$ US$1 = Kwacha Average 1973 1.2206 0.8193 Average 1974 1.1888 0.8412 Average 1975 1.1577 0.8638 Average 1976 1.0953 0.9130 Average 1977 1.1075 0.9029 Average 1978 1.1851 0.8438 Average 1979 1.2241 0.8169 ABBREVIATIONS CCDC - Capital City Development Corporation DDC(s) - District Development Committee(s) JCE - Junior Certificate of Education MCC - Malawi Correspondence College MCP - Malawi Congress Party MHC - Malawi Housing Corporation PHAM - Private Hospital Association of Malawi THA(s) - Traditional Housing Area(s) WHO - World Health Organization FISCAL YEAR April 1 - March 30  i FOR OFFICIAL USE ONLY PREFACE 1. This report is one of a series of six special reports that have been produced as the result of the 1979 Basic Economic Mission.l/ The major purposes of the Basic Economic Mission were to review the performance of the Malawian economy since independence (1964) and to assess the future prospects for growth over the next decade or more, identifying the major constraints to development and making recommendations for their relief. The focus of the basic economic mission was upon macroeconomic perfolmance (the national accounts, balance of payments, budget and public enterprises and employment), the development of agriculture and manufacturing; and the provision of government resources for the development of human capital and for meeting basic needs. 2. Despite the country's extremely low level of development at independence, the Malawi Government opted for an outward-looking strategy of rapid growth, based on encouragement of private enterprises, use of the market mechanism, favorable treatment of foreign capital, low levels of protection and wage restraint. The public sector investment program has emphasized the direct support of the commodity producing sectors through the provision of agricultural services, internal and external transport links and power. The development of the social sectors (education, health, etc.) received relatively less attention until recent years. 3. These policies have been successful and the Malawian economy has recorded an impressive list of accomplishments since independence. Real GDP has grown at about six percent per annum and growth in all sectors (except subsistence agriculture) has been rapid. Wage employment has grown almost as rapidly as modern sector output, suggesting a relatively labor-intensive pattern of development. Export volumes, at least those of the agricultural estate sector, have increased significantly. Domestic investment has grown from about 9 percent of GDP at independence to an average of 25 percent in recent years, while domestic savings have increased from virtually nil to 17 percent of GDP. The Malawian economy has also attracted large increases in foreign capital for private/public enterprise investments and for government projects. In addition, the domestic rate of inflation has been relatively low. 1/ The six reports are: The Development of the Agricultural Sector The Development of Manufacturing The Fiscal Performance of the Public Sector Employment Aspects of Economic Development The Development of Human Capital Basic Needs I 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.  ii 4. Despite this record of accomplishiments, there is now concern about the prospects for future growth owing to: - the slow growth of smallholder output and exports; - the relatively poorer prospects for traditional estate exports; - the projected decline in the external terms of trade (relative to those of the 1970s); - the continued rapid growth of.population and labor force (and the rapid decline of unutilized cultivable land); - the deterioration in budgetary and public enterprise performance; and - the continued shortage of skilled manpower. 5. The basic economic report explores the possibilities for improving the output, trade, and employment performance of agriculture and industry through changes in price-tax-tariff policies, improvements in sectoral institutions, and improved government services. It analyzes the possibilities for improved resource management through better government revenue performance, increased allocations for recurrent operations to raise the payoffs to past government investments and measures to improve the efficiency and profitability of public eniterprises; it also analyzes the effects on future budgetary balance of changes in the growth and composition of government investment expenditure or in the amounts and terms of foreign financing. In addition, it assesses the nature and magnitude of Malawi's manpower constraint, estimates the returns to investments in secondary education, examines the costs of expanding social services for meeting basic needs and, in the face of likely government budgetary constraints, explores the possibilities for meeting some of these costs.through higher user charges. 6. The basic economic report places the themes outlined in the preceding paragraph in a macroeconomic framework for an analysis of the future economic development possibilities in Malawi. We expect that the draft basic economic report will be discussed with Government in July 1981 and that circulation of the final version will shortly follow. The members of the basic economic mission were: William A. McCleary (Mission Chief) Gilbert Brown (Basic Needs) Peter Hansen (Public Finance) Kazuko Hashimoto (General Economist, Agriculture) Stephen Heyneman (Education) Richard LaCroix (Consultant, Agro-industry) Ben Lehbert (Industrial Economist) Katherine Sierra (Employment) Robert Wesselman (Consultant, Agricultural Extension) Dennis Wood (Consultant, Agro-industry) Shirin Velji (Research Assistant)  - iii - MALAWI BASIC NEEDS Table of Contents Page No. Preface.i Summary and Conclusions ......................................... v I. INTRODUCTION .................................................... 1 General Development Strategy .................................... 1 Administration, Self-Help and Participation ..................... 3 II. EDUCATION ....................................................... 5 III. HEALTH .......................................................... 13 Mortality and Morbidity ......................................... 15 Health Characteristics of the Urban and Rural Populations .... ... 20 Determinants of Health Status ................................... 22 Primary Health Care Progam ...................................... 22 Supporting Hospitals ............................................ 25 Medical Personnel ............................................... 27 Preventive Medicine ............................................. 28 Assessment of the Health Sector ................................. 32 IV. NUTRITION ....................................................... 33 V. SHELTER ......................................................... 36 Water ........................................................... 36 Sanitation ...................................................... 41 Housing ......................................................... 42 Assessment of the Housing Sector ................................ 51 LIST OF TABLES No. 1 Primary School Enrollment Rates by Region and Sex, 1975/76 No. 2 Form I Enrollment Rates by Sex No. 3 Number and Percentage Distribution of Outpatients by Disease and Age Group, 1976 No. 4 Distribution of Inpatients by Disease Group and Cause of Death, 1977 No. 5 Distribution of Inpatients by Infective and Parasitic Diseases, 1977 This report was written by Mr. Gilbert Brown, South Asia--Office of the Regional Vice President.  Table of Contents, cont'd - iv - No. 6 Selected Rural and Urban Population Statistics No. 7 Medical Institutions and Numbers of Beds, 1977, 1974 and 1968 No. 8 Basic Health Units No. 9 Medical and Paramedical Personnel in Malawi No. 10 Annual Number of Trainee Entrants of Selected Health Personnel No. 11 Present and Projected Rural Water Supply Service No. 12 Urban Water Supply Service by Type, 1990 No. 13 Rural Water Supply Service by Type, 1990 No. 14 Rural Population to be Served No. 15 Economic Rents, MHC Permanent Housing No. 16 Construction Costs per Plot, Selected Sites and Services Projects No. 17 Malawi Housing Corporation-- Increments in Numbers of and Waiting Lists for Permanent Housing and Sites and Services Plots ANNEX I--Charts for Intercountry Comparisons 1. Life Expectancy and Income per Capita, All LDCs and Africa South of Sahara 2. Crude Birth Rate and Income per Capita, All LDCs and Africa South of Sahara 3. Infant Mortality Rate and Income per Capita, All LDCs and Africa South of Sahara 4. Child Death Rate and Income per Capita, All LDCs and Africa South of Sahara 5. Calorie Intake (% of Requirements) and Income per Capita, All LDCs and Africa South of Sahara 6. Access to Safe Water and Income per Capita, All LDCs and Africa South of Sahara 7. Primary Enrollment and Income per Capita, All LDCs and Africa South of Sahara 8. Female Enrollments and Income per Capita, All LDCs and Africa South of Sahara 9. Secondary Enrollments and Income per Capita, All LDCs and Africa South of Sahara 10. Population per Physician and Income per Capita, All LDCs and Africa South of Sahara 11. Population per Nurse and Income per Capita, All LDCs and Africa South of Sahara 12. Adult Literacy and Income per Capita, All LDCs and Africa South of Sahara 13. Income Distribution (Highest 5%) and Income per Capita, All LDCs and Africa South of Sahara 14. Income Distribution (Lowest 20%) and Income per Capita, All LDCs and Africa South of Sahara 15. Table: Comparison of Basic Needs Indicators--Africa South of Sahara Ranked by per Capita Income  MALAWI BASIC NEEDS Summary and Conclusions i. The main emphasis of Malawi's development strategy since independence in 1964 has been on economic growth and efficiency. Nonetheless, an important element of the strategy has been the alleviation of rural poverty with primary emphasis on projects to raise agricultural productivity and secondary emphasis on education and (more recently) health. This orientation has succeeded in giving Malawi perhaps the highest economic growth rate in Africa while meeting the basic needs of its population at least as well as most other countries in the region. ii. Direct government provision of basic needs consists mostly of expenditures on education and health. Together, education and health account for over 80 percent of government outlays for basic needs with water supply, sanitation and housing accounting for the remainder. Government authorities spent an equivalent of 19 percent of budgeted expenditures or 6 percent of GDP on basic needs-type activities in 1977/78; expenditures on education and health have expanded rapidly during the past three years. While the level of capital and recurrent expenditures allocated to the social sectors has not been high as compared with many other LDCs, this does not imply a lack of commitment to implementing social programs. iii. The strong organizational structure linking the Central Government to district and village levels helps to explain Malawi's relative success in improving basic needs satisfaction. A high degree of efficiency and effective- ness in the use of resources has characterized the system, and there has been a considerable reduction in the capital costs of basic needs programs through the use of self-help village labor for construction purposes. In addition, the strategy consists of extensive goal-oriented cooperation between government ministries and units in the field, and between program and policy planning levels. iv. The Central Government undertakes major infrastructure investment in basic needs-related sectors, such as secondary schools, and central hospitals. The initiation of smaller-scale projects such as primary schools, health clinics, teacher and health worker housing, and wells and gravity-fed piped water systems are the responsibility of the self-help district development committees (DDCs). Established in 1966, these committees are broadly based advisory and major decisionmaking bodies responsible for the completion of projects. These committees bring together central government officials, the national and local political leadership and experts and leaders from each district. Members include senior district officials from central government ministries, all members of parliament and leading members of the Malawi Congress Party, and some local government officials. Self-help labor, provided by project beneficiaries, is an important component of these projects. Each DDC is decentralized downward to area action groups and village headmen. The decentralized structure ensures extensive local participation in the selection and planning of projects.  - vi - v. Malawi has an adult literacy rate of 25 percent, which is above the income-predicted level for sub-Saharan countries but below the predicted level for all developing countries. In 1976, the primary schoool enrollment ratio was 63 percent, the female primary school enrollment ratio was 50 percent, and the secondary school enrollment ratio was 4 percent. The primary school enrollment and female primary school enrollment ratios were above the income- predicted levels for African countries but below those for all LDCs. The secondary school enrollment ratio is below the income-predicted level for African countries. Primary school enrollments more than doubled (from 332,000 to 675,000) between 1962 and 1978; over the same time period, secondary enrollment increased fivefold (from 3,000 to 15,000 students). However, enrollment has varied widely by district and region, and by sex. vi. After independence in 1964, the Central Government entered the education sector at all levels. Local governments were given major responsibil- ities in primary education except for the burden of primary schoolteachers salaries (90 percent of the recurrent primary school budget). Central Govern- ment programs concentrated on the development of the middle- and high-level workforce: secondary education was expanded and improved and the University of Malawi was established. Capital expenditures on secondary education and the university have absorbed about three-quarters of the Ministry of Education's capital budget during the 1970s (as high as 90 percent in the early 1970s). vii. Most of the primary schools visited by the IBRD mission had less than adequate facilities (buildings, furniture, textbooks and supplies). The lack of resources and supplies in many primary schools means that most of the burden of education is borne by the teacher. This is especially true of the rural areas, where 20 percent of primary schoolteachers are not qualified to teach and another 30 percent are underqualified. However, a major expansion of primary teacher education is in progress, and the Central Government is now launching a program to finance primary school mathematics, English and Chichewa textbooks. The Government also accords high priority to increasing the numbers of qualified secondary schoolteachers, both to speed up the replacement of expatriate teachers and to increase secondary school enrollment. viii. Notwithstanding the limitations of personnel, facilities and budgets, education is making a significant contribution to the satisfaction of basic needs in Malawi. Both the primary and secondary school curricula have been broadened to include instruction in health, nutrition, and agriculture-related subjects. Efforts to expand non-formal education by the health, community development and agricultural ministries are reaching large number of adults, particularly mothers of young children. Courses cover homecraft, nutrition, health and child care, sanitation, crop and animal husbandry. ix. The early establishment of quality education in the north continues to be reflected in higher levels of school enrollment, better qualified and more experienced teachers, lower ratios of students per qualified teacher, and higher average scores on national tests. Some steps are being taken to reduce regional inequalities. Regional quotas are increasing the intake of students from districts and regions with the weakest educational systems into national secondary schools and the University of Malawi. While this may reduce regional inequalities and increase educational opportunities for some low-income families, it has the obvious cost of denying entrance to better qualified students from  - vii - other areas (some of whom may come from equally disadvantaged families). In addition, the shift of teachers to civil services status in 1977 will help to redress regional imbalances as qualified teachers will be assigned where the need is the greatest. x. A rather inclusive formal and informal education system is now in place, and a structure exists for utilizing most opportunities for basic needs education both inside and outside the formal education system. However, the expansion of both the formal and informal education systems so that they can reach more of the population requires more resources. The Government allocated approximately 2.4 percent of GNP and 14-15 percent of its recurrent budget expenditures to education. This compares unfavorably with about 4 percent of GNP and 18-25 percent of recurrent expenditures for the typical developing country. Underqualfied teachers, lack of textbooks and other materials and equipment contribute to high dropout and repetition rates, resulting in major inefficiencies in the system. Hence, more resources are required at the primary level, both to upgrade the quality of education of those now attending school and to reach those who are not. On the other hand, there are spaces in secondary school for only about 10 percent of those who pass the Primary School Leavers Examination. The continued shortage of trained labor in Malawi suggests that more of these students are needed to continue on to more advanced studies to help overcome shortages of primary and secondary schoolteachers, technicians and managers. xi. Health status and life expectancy in Malawi are about average for sub-Saharan Africa. Life expectancy at birth is 46 years. The infant mortality rate of 142 per thousand, however, is nearly 20 percent higher than the average for sub-Saharan Africa. The child death rate is 27 per 1,000. Malawi's lack of family planning programs is reflected in the crude birth rate of 52 live births per 1,000 population--the highest rate in the African sample. Average annual calorie availabilities of 103 percent of requirements are substantially higher than the sub-Saharan or developing country average. Thirty-three percent of the population had access to safe water in 1975, placing Malawi above the income-predicted level for both the African and all-developing country samples. It is estimated that about 55 percent of Malawians had access to safe water by the end of 1980. Malawi had the third highest number of persons per physician of countries in the African sample. To compensate for the small number of fully-trained doctors, Malawi depends heavily on nursing and other professional and paramedical staff. xii. Government commitment to improvement of health standards in Malawi has grown in the last several years, with increased budget allocations and plans for considerable expansion in training of health personnel. The use of health facilities is also increasing. As many as three-fourths of those suffering from illnesses now go to a health facility for treatment. An estimated 90 percent of the population is reached by one or more health education programs. About 7.5 percent of central government recurrent budget expenditures has been allocated to health since 1975/76. xiii. The incidence of death and illness is much higher in rural than in urban areas. Two important factors explaining the substantial differences in urban and rural mortality rates are the quality of drinking water and nutri- tion levels. Other factors include the greater availability of health  - viii - facilities in urban areas, higher average educational levels, greater access to health education, and higher income levels that reduce the likelihood of malnutrition. The solution to these high mortality rates does not lie solely in providing more curative health facilities and personnel, but also in environ- mental efforts and control of communicable diseases. The Government is taking action in these areas and is in the process of expanding the Primary Health Program to provide health facilities to the entire population, including considerable health education and preventive work (e.g., under-five clinics for immunization and health monitoring), nutrition education ahd rehabilitation units, prenatal and maternal-child health clinics. xiv. The Primary Health Care Program is a community centered and supported health care program developed by WHO (and others) as the only way to bring health care to an entire population in LDCs where budget resources are a severe constraint to implementing the practice of western medicine. Malawi's model, adopted by Government and covering the period 1973-1988, calls for a primary health care center, staffed by a clinical officer (who in Malawi, functions as a doctor), a registered nurse and other personnel, serving a population of 50,000. In addition, there would be four subcenters serving as dispensary and maternity units and as a base for health education and mobile clinics. Each subcenter would serve 10,000 people (with the primary center serving the 10,000 people closest to it) and would be staffed by one medical assistant, one enrolled nurse/midwife, and hospital servants. In addition, each subcenter and the primary center would also have four health posts under its supervision, each serving 2,000 people (and the subcenter the remaining 2,000). The primary health care system is in turn supported by an existing structure of two central hospitals (Queen Elizabeth's in Blantyre and Kamuzu in Lilongwe), a general hospital (Zomba) and 21 district hospitals, plus 20 mission hospitals associated in the Private Hospital Association of Malawi (PHAM). xv. While the number of health care units has expanded, budgetary constraints have prevented expansion from fulfilling the requirements of the population. In 1978, the number of primary health care centers was nearly half the number required to fulfill the goal of one center per 50,000 of population; the number of subcenters was 87 percent of the required amount. Health posts, however, have received a relatively low priority and only about 2 percent of requirements have been established. xvi. The high incidence of communicable diseases has recently led to increased emphasis on preventive health measures--particularly mass immunization, health education vector control and water, sanitation and housing improvement programs. The main diseases subject to such contral are malaria, schistoso- miasis, diseases of childhood and infancy (including measles, gastroenteritis, respiratory infections and eye diseases), tuberculosis, leprosy, diarrheal diseases including cholera, and malnutrition. A national action program for malaria control is now being formed. Mosquito control programs are being carried out in Blantyre and Lilongwe and will gradually be expanded to a national basis. Antimalarial suppressive drugs are being distributed to children and pregnant women at under-five and prenatal clinics. Diseases of childhood and infancy are being attacked mainly through the under-five clinics and prenatal clinics which provide immunizations, primary health care, health and nutrition education, and distribution of foods, vitamins and iron.  - ix - Children now receive seven immunizations at under-five clincis: smallpox, polio, dyptheria, whooping cough, tetanus, tuberculosis and measles. Immunization rates in mid-1979 are estimated at 40-50 percent of the under-five population and the target rate is 80 percent. Diarrheal diseases are being attacked mainly by improvements in water supply and sanitation. xvii. The emphasis on expansion of the primary health care system and expansion of a number of preventive health programs (including improved water supplies), indicate that the proportion of the population whose basic health needs are being more adequately met is expanding fairly rapidly. The directions of policies and programs are very much in line with recommendations of the WHO. From a basic needs viewpoint, the emphasis on improving rural health care and the goal of near universal health services (limited only by difficul- ties in serving sparsely populated areas) at no cost to recipients is attractive. Since the shortage of budgeted funds is a major limitation on how fast the quantity and quality of medical service can be improved, however, it is possible that even poverty groups might be better served if small charges were made for services and drugs, thereby increasing available financial resources, with patients who could not afford to pay being served without charge. In addition to limited budgetary resources, a key bottleneck and the most expensive to overcome is the shortage of medical personnel. xviii. Malnutrition in Malawi is concentrated in young children and at certain seasons of the year. Since average annual calorie and protein avail- ability appear to be adequate, the major causes of the observed cases of malnu- trition appear to be "lean season" shortages, lack of adequate breast feeding supplements and weaning foods, and poor food distribution within the family. Severe cases of malnutrition are referred to nutrition rehabilitation centers or classes. However, evaluating the effectiveness of such centers is difficult because no systematic follow-up studies of their long-run consequences have been made. Much of Malawi's malnutrition problem appears amenable to relief through education and government preventive health programs. The Government is now giving greater priority to such programs and appears to have the capacity to implement them effectively. xxi. The Government has adopted the goal of safe water and sanitary waste disposal for the entire population by 1990. Seventy percent of urban residents now have safe drinking water and by 1980 fifty-five percent of rural families will also have safe water supplies. In the rural areas, water is free. This policy is justified by the large component of self-help labor which goes into the construction of gravity systems and shallow wells, and by the low maintenance costs. Even in the case of the more expensive borehole water systems, free access for rural residents is justified because the capital costs of rural water schemes are largely financed by grants and loans from foreign donors and because many urban residents receive much larger subsidies for housing. xx. Waterborne sewerage systems serve about 15 percent of Malawi's total urban population. In other areas septic tanks or pit latrines are used. Projects are underway to expand the extend the overloaded Blantyre system and to provide sewerage for Liwonde. Although lot sizes are adequate and densities are low enough in most other urban areas to continue dealing with human waste by means of septic tanks and pit latrines, one problem has been the inadequate numbers of septic tank cleaning services. Hence people tend to build new tanks  rather than clean out old ones. Interest in rural sanitation increased following an outbreak of cholera in 1973. As a result of health education and promotion work by the Ministries of Health and Community Development, a very high proportion of rural homes now have pit latrines. The effectiveness of such measures is suggested by the decline of laboratory-confirmed cholera cases from 1,870 in 1974 to 186 in 1978. xxi. Housing is a "basic need" problem in Malawi primarily for the nine percent of the population who live in urban areas. In the rural areas and small towns, families manage to construct adequate housing with only their own labor and freely available local materials; the "basic needs" considerations are largely those of safe water supplies, safe disposal of human wastes and education about health requirements. New urban housing has been primarily of four types. The smallest category consists of private commercial construction usually financed by firms through the new Building Society. Then there is a category of "permanent" housing put up by two government agencies--the Malawi Housing Corporation (MHC) and the Capital City Development Corporation (CCDC), the greater part of which is rented out to civil servants. The third category of urban housing is that in "traditional housing areas" (THAs), a type of site and services development. The final category of housing, increasing in volume in recent years and now probably the largest, is squatter and unplanned units. While the problem of shelter is not an acute basic needs problem in the rural sector, it is a potential problem in the urban sector. While only 9 percent of the country is urban, the urban population is expanding at about 8 percent per annum. Blantyre, together with Lilongwe, represent about 70 percent of the urban population with a network of six other towns recording populations over 10,000. Population growth rates for the smaller urban centers range between 6 percent and 23 percent. xxii. The development of THAs has been the cornerstone of Malawi's housing policy over the past decade and is implemented through a number of channels including the MHC, CCDC, the Building Society and the Ministry of Works. MHC was established in 1964 to undertake development, construction and management of houses and housing estates throughout the country on a commercial basis. It caters to the housing needs of the commercial, private, industrial and public sectors, but concentrates its resources on medium- and low-cost housing development in urban areas. Acting for the Government, MHC constructs and manages THAs for the mass of people who cannot afford housing of permanent materials (fired bricks and concrete flooring). The CCDC plays a similar role in Lilongwe. Until recently, MHC construction of permanent housing and sites and services plots (aside from construction under contract for corporations) was limited to the Blantyre, Zomba and Lilongwe areas. Now units are either under construction or being planned for a number of urban centers in more than half of Malawi's 24 districts. The largest number of completed and planned units in these new centers are located in Mzuzu, Kasungu and Balaka. While housing problems are less severe in these smaller centers, it is felt that some construction of service plots and housing is desirable in order to stimulate development of these smaller centers, disperse growth and urbanization over a number of centers, and to provide more systematically for water, sanita- tion and other utilities.  - xi - xxiii. Malawi is remarkably free from the notorious squatters' housing that blights many major cities in developing countries. Nevertheless, with MHC's annual production declining, development of squatter or "unplanned" settlements is on the increase, although confined chiefly to Blantyre. About 15 percent of the housing stock in Blantyre is considered illegal, and is located mainly in one unplanned area, Ndirande, with a population of about 50,000. In Lilongwe, there is also one major unplanned area, the Kawale Market neighbor- hood, located in the old city. In contrast with squatter areas in many other countries, much of the housing in these areas is of brick similar to that constructed on site and services plots. The unplanned areas differ markedly from THAs in lacking utility and infrastructural services and having a much higher density of dwelling units. Several years ago, the Government began to raze a few houses in the Ndirande area to clear areas for sites and services and housing development, but that was soon halted by protests that good housing was being needlessly torn down. Current thinking is to provide these areas with roads, water and perhaps other community facilities and to enforce sanitation codes, but to tear down only the minimum necessary number of houses for the construction of roads and other infrastructure. xxiv. Two problems now face Malawi's housing policy, and each has important implications for basic needs. In the first place there are substantial subsidy elements involved in MHC housing (and to a lesser extent in CCDC housing) and there is a significant variation in the amount of subsidy to different types of housing. The amount of subsidy on sites and services projects is modest compared to that on permanent housing. Secondly, urban housing construction has been lagging far behind demand, and the urban popula- tion continues to grow, resulting in overcrowding and long commuting times. xxv. The THAs development, successfully implemented over the past decade should continue to be emphasized and expanded since this is where the need is greatest, the costs low and the implementing machinery efficient. For the Government to continue present policies of subsidizing permanent housing is clearly unsatisfactory since it serves only a minority of those needing housing, and many of those who are the poorest live in seriously overcrowded housing and pay a private landlord substantially more for sharing one room with others than the landlord pays to MHC for his entire plot. Others of the poor live in squatter areas under probably no better conditions, although no empirical survey data are available. Still others of the poor live outside urban areas but commute long distances on foot or bicycle to urban jobs. A partial and necessary solution would appear to be to sharply reduce or eliminate subsidies on urban housing in order to have more budget funds to permit MHC (and CCDC) to attempt to triple their rates of housing and service plot construction as appears to be required. The MHC Annual Report for 1977 calculates that if urban population, as predicted, grows from less than 600,000 people in 1977 to 1.9 million in the year 2000, the cumulative number of housing units required annually would be approximately 16,000, in order to replace existing obsolescent units and house the expanded population. This contrasts with record levels of 4,410 new services plots and 822 permanent houses in 1978. Even if housing subsidies were to be eliminated, it might be difficult for MHC and CCDC to efficiently supervise the construction of such a large building program. Elimination of subsidies, however, might also make it possible for private contractors to compete in  - xii - building and selling houses. At present, with MHC and CCDC benefitting from free land and other government support, and with most of their units being rented out at heavily subsidized rates, private contractors have not been able to build and sell houses in competition with the Government.  MALAWI BASIC NEEDS I. INTRODUCTION 1. The distinctive feature of the basic needs approach to development is to view poverty as consisting of specific deprivations: of hunger and mal- nutrition, ill-health, illiteracy and inadequate shelter, water and sanitation facilities. The basic needs approach has evolved from earlier approaches to development; it does not supplant but supplements the previous emphasis on incomes and distribution, consumption, employment and their growth. The basic needs approach it not itself a development strategy, but a vehicle for viewing alternative development strategies. Country studies have shown that basic needs can be met at quite low income levels by a variety of political regimes, ideologies and development strategies. 1/ 2. The central emphasis of Malawi-s development strategy since inde- pendence in 1964 has been on economic efficiency and growth, but an important component of that strategy has been rural poverty alleviation and human development primarily through investments aimed at raising agricultural and rural productivity, with secondary emphasis on education and (in recent years) health. This strategy has succeeded in giving Malawi perhaps the highest economic growth rate in Africa, despite its lack of mineral resources, and at the same time in meeting the basic needs of its citizens as well as in most other countries of the region. 3. An important factor in Malawi's relative success in improving basic needs satisfaction since independence has been the strong organizational structure linking the central Government to district and village levels. Benefits from this system have been a high degree of efficiency and effec- tiveness with which resources have been used, considerable reduction in the capital costs of basic needs programs through use of self-help village labor for construction purposes, and extensive goal-oriented cooperation between government ministries and units at the field, program and policy planning levels. General Development Strategy 4. While basic needs can be satisfied under a wide range of economic systems and development strategies, the effectiveness of any specific set of programs in meeting basic needs will depend upon the specifics of a particular country's economic and sociopolitical structure. To the extent that basic needs are met through a household's own production and purchases, income levels and distribution (along with consumer knowledge and preferences) will largely determine the satisfaction of those needs. 1/ This paragraph summarized from draft policy paper on "Basic Needs and World Bank Operations," July 9, 1979, pp. 1-2.  5. As discussed in the report on employment, 1/ government policies to encourage agricultural production and to keep wage levels down have assured a relatively labor-intensive and essentially full employment pattern of development. Since anyone can still obtain free land for farming, though this may soon have to change in view of the steadily declining land:person ratio, the question so far has not been whether one can find a means of livelihood, but rather at what occupation and income level. These policies have also served to keep most of the population on farms (although there is considerable and increasing off-farm employment), and have avoided problems of extensive urban unemployment and underemployment. 6. It is impossible to capture the full flavor of Malawi's development strategy in a few sentences. 2/ At the risk of oversimplification, however, Malawi can be characterized as a market-oriented economy with relatively little overall price distortion, with emphasis on productivity, efficiency and self-help, accompanied by considerable government support for the private sector and extensive non-formal education and local participation programs. Government interventions affecting prices are mostly limited to certain aspects of the marketing and distribution of major crops and agricultural inputs. 3/ Import tariffs are generally modest and serve primarily a govern- ment revenue and taxing rather than a protective function. There are few quantitative trade restrictions, though some control over both imports (especially of consumer goods) and exports is exercised through parastatal export and import corporations. Foreign investment is welcomed. Domestic and foreign banks make credit accessible to most activities that meet "bankable" criteria, though the typical small farmer or craftsperson is not able to qualify. Because of continuing shortages of trained technicians, and the growth of new and specialized industries, expatriates are still employed in significant numbers by the Government; Malawianization continues, but not at the cost of efficiency. Private firms usually have no difficulty in getting approval to hire expatriate personnel. 7. The Government's development strategy has emphasized the productive sectors. Thus agriculture and supporting infrastructure (especially transporta- tion) have absorbed the lion's share of investment over the past decade. Because of this strategy and because of the Government-s acute awareness of the recurrent budget implications of expenditures in the social sectors, investments in education, health , water and housing have absorbed a relatively low share of government capital expenditures. In 1977/78, central and local government authorities spent an amount equivalent to 19 percent of budgeted expenditures or 6 percent of GDP on basic needs type activities (education, 1/ IBRD, Malawi--Employment Aspects of Economic Development (Washington, D.C.: May 1981). 2/ Much of this report is devoted to that task. The basic official guideline is still Statement of Development Policies, 1971-1980, Office of the President and Cabinest, Economic Planning Division (Zomba: Government Press, December 1971). 3/ For a fuller discussion, see IBRD, The Development of the Agricultural Sector (Washington, D.C.: May 1981).  - 3 - health, water and housing). 1/ In the past two or three years, the Government has stepped up investments in education and in health. Education and health account for most of the direct government provision of basic needs goods and services, with education broadly defined to include extensive non-formal education in such areas as agricultural extension, nutrition and health; together education and health account for over 80 percent of government outlays for basic needs. The Ministry of Community Development has an extensive program to provide potable water through large-scale self-help programs in those areas (other than Blantyre, Lilongwe and district centers) which do not have parastatal water boards. The Malawi Housing Corporation and the Capital City Development Corporation provide housing in Blantyre, Lilongwe and several other urban areas for persons at all income levels, though many of those below the poverty level live in overcrowded and unhealthy conditions. Considerable effort is made to distribute health, education and water projects and services equally between districts in order to reduce regional disparities. Administration, Self-Help and Participation 8. Major infrastructure investment in basic needs-related sectors, such as main roads, universities and central hospitals, are undertaken by the central government. Self-help district development committees (DDCs), estab- lished in 1966, are responsible for initiating all smaller-scale projects such as primary schools, health clinics, teacher and health worker housing, local roads, small bridges, wells and gravity-fed piped water systems. These committees are broadly based advisory and major decisionmaking bodies. While responsible for the completion of projects, they in practice must rely on other local and central government units for implementation. An important component of these projects is the self-help labor provided by the project beneficiaries. Such labor is usually one day each week for the period of project activity, which is concentrated in the dry season when farming activity is at its seasonal low. 9. The 24 DDCs are the nexus of a strong organizational-communication- participation system that is proving to be very successful in carrying out development projects that meet basic needs. These committees bring together central government officials, the national and local political leadership, and experts and leaders in each district. The senior district officials from central government ministries and agencies such as education, health, agricul- ture, community development, ADMARC, local government, and supplies and services are members. So too are all members of parliament from the district plus leading Malawi Congress Party (MCP) officials (e.g., the MCP district chairman, the chairman of the Women's League and the Youth League). The chairman and clerk of the local district council (the local governing body) and other local officials are also members. Many of these officials are central government civil servants, but local hereditary chiefs, school headmas- ters and other prominent local persons are also members. The district commis- 1/ Because of the role of self-help and of private organizations, such figures are an underestimate of the amount of resources (above the household level) devoted to the fulfillment of basic needs.  - 4 - sioner, appointed by the Office of the President, is chairman of the district council, and also chairman of the DDC. 10. The DDC is decentralized downward to area action groups and village action groups, headed by local chiefs and village headmen. Some of these action groups also have subcommittees for one or more individual project areas, such as school, health facilities and water. Thus, there is extensive local participation in the selection and planning of projects. Ideas may originate from any source, from a local villager, a district-level official, or the President. 11. Whatever their original source of suggestion, all self-help develop- ment projects must be considered and approved by the DDC, which is both a channel of communication and a coordinating body that reconciles the goals of the central government and national political leadership on the one hand, and of local citizens on the other. The DDC makes the community aware of the possibilities for development projects and explains any projects the central government wants to undertake or supports in the district. It is also res- ponsible to advise the central government of local needs and priorities, and to encourage complementarities and avoid duplication between national and local projects. No self-help project can be undertaken until it has been discussed and approved by the DDC (and the district council). 12. Once the DDC has chosen a project as feasible and of appropriate priority, they request funding from the development division of the Office of the President. The development division then requests comments on the project from the relevant national ministry, for example, education or health. Most ministries have ten-year national development programs, and they see if the proposal fits into that plan. These national plans include standardized construction, design staffing and standards, and guidelines to assure that projects are relatively evenly distributed between and within districts. 1/ The development division will approve a project only if the ministry or ministries that will support the project (e.g., staffing, recurrent costs) give their approval, and necessary investment funding beyond the local self-help element (mostly labor and bricks) has been identified from existing external aid or other sources. Projects may have to be tailored to available resources, or priority given to types of projects for which external aid is available. 13. The Ministry of Community Development staff in each district is also charged to make villagers aware of opportunities for self-help projects in their area, for offering suggestions about project priorities, and for helping villagers plan their presentation of requests to the DDC. Malawi Congress Party officials are also important sources of suggestions to villagers and to the DDC. The influence of the central Government is limited by the necessity 1/ The Ministry of Education guideline calls for each elementary school to serve a radius of three miles unless population densities warrant greater proximity, and Ministry of Health guidelines provide for health clinics to serve 50,000 people, with a clinic or health post within five miles of each village.  - 5 - of support by the concerned villagers and local action committees, since projects cannot be successfully completed without the self-help labor of the intended beneficiaries. If more than one village will participate, different parts of the work are divided as equitably as possible between the villages. Without popular community support, most projects would not get done. For some water projects, for example, villagers may have to walk as much as ten miles one-way to perform some phase of the project; villagers near the work site but who will not benefit from the project do not contribute labor. The development division, Office of the President, also assists each DDC by maintaining a building team of skilled craftsmen in each district to help supervise and maintain the quality of construction, providing technical officers to check that projects conform to standards, and supplying a vehicle and trucks. 14. Self-help projects have also generated considerable support from both donor government and from voluntary groups, including religious organ- izations. Such external voluntary agencies are particularly important in the health and gravity-fed rural water schemes, and work closely with the govern- ment ministries and other external agencies such as UNICEF. II. EDUCATION 15. From a basic needs perspective, education is important to the extent that it helps people meet their health, nutrition and shelter (including clean water and sanitation) needs. It is an important instrument in meeting all basic needs objectives, partly through the teaching of these subjects in the school system, partly through non-formal education provided at such places as health clinics and adult homemaker classes, and partly through formal and non-formal academic, vocational and technical training that adds to economic productivity and income. From this perspective, primary education is the most important part of the formal system, since in Malawi no more than three or four per cent of the population receive any more advanced formal schooling. Female primary and non-formal education are also extremely important, since the household sector produces most of its own basic needs, and hence the knowledge of nutrition, hygiene, child care and homemaking skills of women can make a crucial difference. Also, higher-level education tends to lift people well above the poverty level, so that additional consumption on their part is not meeting basic needs but rather providing yet higher standards of living. Nevertheless, more advanced levels of education are also indirectly necessary to meeting basic needs, e.g., in training well-qualified and able teachers, agricultural extension agents, technicians and managers to speed industrial growth, etc. Thus, the greater the strength of the entire education system, the greater its direct and indirect contribution to meeting basic needs. 16. As in all developing countries, Malawi has had to make--and con- tinues to have to make--hard choices about how much of its public resources to devote to education, and to what type of education. 17. Malawi's adult literacy rate of 25 percent is somewhat above its income-predicted level for sub-Saharan countries, but below its predicted  -6- level for all developing countries (Annex 1, Chart 12). 1/ The 1976 primary school enrollment ratio of 63 percent, and the female primary school enrollment ratio of 50 percent, were also above income-predicted levels for Africa but below those for all developing countries (Annex 1, Charts 7 and 8). The secondary school enrollment ratio of 4 percent was moderately below the predicted level for African countries (Annex 1, Chart 9). 18. Malawi's formal education system consists of eight years of primary education (standards one through eight), four years of secondary education (forms I through IV), and various post-secondary and university training. Students take examinations that determine eligibility for (though not neces- sarily confer entrance into) subsequent levels of the formal education system, which culminates in the University of Malawi, at the end of the 5th, 8th, 10th and 12th years of work. 2/ Various technical training schools are available to a small proportion of those who have completed different levels of the relatively academic mainstream of the formal education system. Non-formal education aimed primarily at adults, centers on agricultural production, home crafts (health, nutrition and child care), literacy, and training of school leavers in farming and vocational trades. The central Government pays all primary school teacher salaries, and primary school teachers have recently become civil servants. The construction, equipping and maintenance of primary schools, however, are the responsibility of local governments (district councils). The central Government operates 31 of the 61 secondary schools, and these enroll 58 percent of all secondary students (the remaining 30 private schools are nearly all supported by religious organizations). Nineteen other secondary schools receive government financial aid to pay teachers' salaries. The University of Malawi is also financed by the central Government. 19. Education has long been the surest route to economic and social advancement in the civil service, private enterprise and other wage or pro- fessional employment. Demand for education, as measured by parental goals for their children, far exceeds the supply. 3/ The first academically oriented and post-primary schools were established in the northern region by Scottish missionaries in the late 19th century, and the graduates of these schools came to dominate the Malawi citizen component of the government bureaucracy and the 1/ There predicted levels are derived by simple linear regressions of each variable (e.g., adult literacy) individually against national per capita income levels for a group of more than 80 developing countries, and separately against a subsample of 30 sub-Saharan countries. These samples include all developing countries for which fairly complete sets of such indicatros are available. 2/ For a description and evaluation of the system, see World Bank Reports, Malawi - Education Sector Survey, Report No. 1781-MAI, February 23, 1978, and President's Report, Third Education Project, Report No. P-2475, May 2, 1979. 3/ UNICEF, Evaluation of the Needs of Children and Women - A Participatory Model (Draft Report; Lilongwe: June-October 1977).  -7- modern sector of the private economy.. 1/ The first government secondary school was not established until after World War II. 20. As late as 1962, only 1,700 students attended 40 classes in govern- ment schools, but another 175,000 students attended nearly 5,000 classes in schools (mostly operated by religious groups) receiving government financial assistance, and the government was estimated to be financing 80 percent of the cost (net of school fees) of education expenditure, while voluntary agencies (mostly church-related) provided 17 percent. Another 150,000 students were enrolled in nearly 6,500 classes in schools not receiving any government assistance. 2/ Many of these schools formed at the approach of independence spurred a zeal for education, with primary school enrollment doubling and secondary school enrollment tripling in a period of two or three years. The quality of education in a majority of schools was very low. A large proportion of primary school students were taught by teachers only slightly better trained than themselves. 3/ Only one student in 10 then completed work in government primary schools, and in unassisted schools the number was less than one in 150. Secondary schools were largely taught by expatriates, and the country's less than 50 college-educated citizens were trained abroad. 4/ 21. Problems facing the education system at independence included improvement of the qualifictions of teachers and quality of education, reorga- nization and nationalization of the education system, modernization and Africa- nization of the curriculum to increase the focus on knowledge relevant to life in Malawi, including more technical and vocational education, and expanding secondary and tertiary education levels to meet the acute shortage of middle- and higher-level labor. These problems were compounded by an acute lack of classrooms, teaching materials and financial resources. The same problems persist today, but the achievements of the past decade and a half have been very great. 22. After independence in 1964, the central Government entered the education sector at all levels. Local governments were given major responsi- bilities in primary education, but the central government took over the burden of all primary school teacher salaries (90 percent of the recurrent primary education budget). Central government programs concentrated on the development of middle- and higher-level work force: secondary education was improved and the University of Malawi established; capital expenditures on secondary 1/ See Stephen Heyneman, "The Formal School as a Traditional Institution in an Underdeveloped Society: the Case of Northern Malawi," Paedagogica Historica, Vol. XII, No. (1972), pp. 460-472, for a description of the founding and continuing influence of these northern region missionary schools. 2/ Education for Development: Report of the Survey Team on Education in Malawi, prepared by the American Council on Education for the U.S. Agency for International Development, April 1974, Eldon Johnson, et. al. 3/ Ibid, 87 percent of primary school teachers had eight years or less of education. 4/ Ibid.  - 8 - education and the university have absorbed about three-quarters of the Ministry of Education's capital budget during the 1970s (as high as 90 percent in the early 1970s). Post-primary education accounted for more than 50 percent of recurrent expenditures in the 1977/78 Ministry of Education budget, with the University of Malawi alone accounting for 23 percent. 1/ By contrast, primary schools (Standards 1-8) accounted for more than 97 percent of enroll- ments. 2/ Teaching standards have been sharply raised, an excellent university now has a student body of 1,200, substantial curriculum reform has occurred, and the education system has been expanded to include a number of technical and vocational schools, thousands of classrooms have been constructed, dropout rates have been sharply reduced, and the efficiency of the formal education system greatly increased. 3/ 23. Malawi's educational planning calls for continuing expansion of the entire system. Increasing the numbers of qualified secondary school teachers has been identified as a critical priority, both to continue the replacement of expatriate teachers (approximately one-third of the total), and to increase secondary school enrollment. Since at 62:1 the primary school student-teacher ratio is too high, attention should be paid to increasing the supply of teachers. Expansion of the numbers of primary school classrooms, but equally importantly improving teaching materials, quality of teachers and physical facilities in primary schools, is also being accorded higher priority. 4/ Numbers of secondary, vocational and technical school and university graduates must also risesharply to meet projected labor requirements. 5/ 24. Public expenditures on education in Malawi are approximately 2.4 percent of GNP and 14-15 percent of recurrent government budget expenditures (or 17 percent including informal expenditures on education and training by agencies other than the Ministry of Education). 6/ This compares with about 4 percent of GNP and 18-25 percent of recurrent expenditures for the typical developing country. 7/ The relatively low level of capital expenditures (1.5 to 6 percent of central government capital expenditures during 1971/72 to 1978/79 reflects partly the fact that construction of and maintenance and equipping 1/ These data are from IBRD, Malawi - Education Sector Survey, op. cit., Appendix I, pp. 14-15. 2/ Ibid, Appendix V, Annexes 3-5. 3/ The fullest description of the present system is found in IBRD, Malawi - Education Sector Survey, op. cit. 4/ IBRD, President's Report, Third Education Project, op. cit. 5/ IBRD, Malawi - Education Sector Survey, op. cit., Appendix V, pp. 11-20; Education Plan of Malawi 1973-80, Ministry of Education, 1973; and IBRD, President's Report, Third Education Project, op. cit., p. 24. 6/ IBRD, Malawi - Education Sector Survey, op. cit., Appendix I, Annex 3, and Appendix VI, Annex 5. 7/ F. Stewart, S.J. Burki and P.P. Streeten, Basic Needs Overview, draft, June 15, 1979.  of primary schools are the responsibility of the local governments and are financed out of locally collected school fees, and also partly the slow rate of physical expansion. 25. Between 1962 and 1978, primary school enrollments more than doubled from 332,000 to 675,000 (with 99 percent of the increase occurring since 1970). As of 1977/78, primary school enrollment was equal to 60 percent of the population ages 6-13 years (56 percent if overage students are excluded). Between 1962 and 1978, secondary enrollment increased fivefold from 3,000 to 15,000 students. Nevertheless, of the 14-17 year old group only 4 percent were enrolled in secondary schools (Forms I-IV) in 1977/78. Enrollment has varied widely by district and region, and by sex, as shown in the following 2 tables. Table 1: PRIMARY SCHOOL ENROLLMENT RATES BY REGION AND SEX, 1975/76 Female Male Female Total as % of (% of 6-14 year old population)a/ Male Northern 98.6 70.8 84.6 71.8 Central 65.1 43.1 54.1 66.2 Southern 60.5 37.6 49.1 62.1 a/ This nine-year, rather than eight-year, span is used because of the large number of repeaters (about 17 percent) and overage students. Source: IBRD, Malawi - Education Sector Survey, Report No. 1781-MAI, February 23, 1978, Appendix VI, p. 8. Near universal male primary education has been achieved in the northern region, compared with 60 percent in the southern region. Female enrollment rates are about two-thirds as high as for males, and range from 72 percent of those of males in the north, to 62 percent in the south. By individual districts, combined male and female enrollments range from 100.4 percent of the relevant age group in Rumphi in the north, to 22.9 percent in Mangochi in the south. 26. Much the same regional and sex pattern emerged for enrollment in Form I compared to the 15-year old population, 1/ though average enrollment was only 4.6 percent of the age group. By district, the highest enrollment rate in Form I was 11.9 percent of the 15-year old population, in Rumphi, compared to only 2.2 percent in Mulanje. 2/ As shown in the following table, male enrollment rates were approximately double those of females. 1/ Comparable data were not available for all secondary enrollment. 2/ IBRD, Malawi - Education Sector Survey, Report No. 1781-MAI, February 23, 1978, Appendix VI, p. 16.  - 10 - Table 2: FORM I ENROLLMENT RATES BY SEX National Average 4.609 Male 6.125 Female 3.074 Highest District (Rumphi) Male 16.413 Female 7.915 Lowest District (Mulanje) Male 2.822 Female 1.489 Source: IBRD, Malawi - Education Sector Survey, Report No. 1781-MAI, February 23, 1978, p. 21. 27. Most of the rural primary schools observed by the mission had no furniture for students below about Standards 6 or 7. Most students sat on the floor in bare rooms without blackboards, the only visual aids were usually one or two hand-made tables of measurements or the like, and each student had only a few books and a limited supply of note paper and pencils provided by the local government from student-paid school fees. Under these conditions, the burden of education is borne almost entirely by the teacher. Unfortunately, 20 percent of primary school teachers are not qualified to teach, and another 30 percent are underqualified. 1/ A major expansion of primary teacher education is under way 2/ and the central Government is launching a program to finance primary school mathematics, English and Chichewa textbooks. 3/ The Malawi Broadcasting Corporation has several hours of daily programming for elementary and secondary schools that may partly compensate for poor quality teaching and textbook shortages, but many schools in poorer areas do not have radios. 28. Despite limitations of personnel, facilities and budgets, education is clearly making a major contribution to meeting basic needs in Malawi. Over the objections of many parents who hoped their children would receive a university education (despite the heavy odds against that), the primary school curriculum was broadened in the late 1960s to include two periods of instruc- 1/ IBRD, Malawi - Education Sector Survey, op. cit., p. 17 and Appendix I, p. 3. Underqualified teachers defined as those at the T-4 and T-5 grades, which require two years of postprimary education. These two grades are now being phased out, and efforts made to upgrade these teachers to the T-3 or higher levels. 2/ Ibid., p. 23. 3/ IBRD, President's Report, Third Education Project, op. cit., pp. 12-13.  - 11 - tion in health per week in all grade levels, 1/ two to four periods per week of home economics (girls) or handicrafts (boys), 2/ and in Standards 6 through 8, four periods of agriculture. The secondary school curriculum was expanded at the same time to include a somewhat larger proportion of similar subject matter. 3/ 29. Recent efforts to expand non-formal education by the health, community development and agriculture ministries personnel is reaching large numbers of adults, particularly mothers of young children. Such education, given at health clinics, village homemaker classes and other centers, can be most effective because it is given to adults who may feel a need for it and can immediately put it into use. Health and nutrition information, for example,is given to mothers who come to both well-baby and sick clinics with children. 4/ While no measures of before and after effectiveness are available, the impact of current programs must be substantial. Public radio is also extensively used for basic education. The health services provide both health information programs and short health announcements, tips and reminders over public radio, as well as calendars with seasonally appropriate health messages and other literature. All levels of primary and secondary education programs are also carried over public radio. In addition to several hours of morning broadcast- ing intended especially for classroom use but available to anyone with a radio, the Malawi Correspondence College (MCC) broadcasts secondary level courses to enable persons not admitted to secondary schools (Form I) to take examinations to earn the junior certificate of education (JCE) given by examination at the end of Form II. This then makes them eligible to enter various technical or other schools requiring the JCE for admission, or to enter Form III in a secondary school. While the ratio of entrants to com- pletions in MCC courses is low, about 18C persons earned their JCE this way in 1977, and about 60 of those were admitted to Form III. Many others obtain useful education from listening to MCC broadcasts and taking course examinations. 30. At least seven ministries other than the Ministry of Education conduct education and training programs. Those most directly relevant to basic needs education have already been mentioned. The Ministry of Community Development trains workers who in turn train villagers both in homecraft, nutrition, health, child care and literacy programs, and in community development and organization techniques such as how to establish a local school committee, or how to organize to obtain a self-help constructed school, clinic, water supply, road or other facility. The Ministry of Health trains paramedical personnel, health assistants, nurses and health inspectors who in turn train 1/ Periods are 30 minutes long in Standards 1 and 2, 35 minutes in Standards 3-8. 2/ Two periods per week in Standards 3-5, and four periods in Standards 6-8. 3/ See health and nutrition sector discussion for information on these programs. 4/ See health and nutrition sector discussions for information on these programs.  - 12 - villagers mostly in classes at clinics, health posts and hospitals, about health, nutrition, child care and sanitation. The health inspectors visit villages and have powers to enforce sanitary rules concerning wells, latrines, etc. The Ministry of Agriculture and Natural Resources trains farm home instructors who conduct village classes, as well as extension, veterinary, fishery and forestry personnel, many of whom work directly with groups of producers to raise productivity and income levels. The Ministry of Youth and Culture trains youths who have left school in agriculture, metalwork, carpentry and joinery, entrepreneurship and clerical work. The Ministry of Labor has apprenticeship and leadership training courses, and the Ministry of Transport and Communications and Works and Supplies trains technicians, artisans and specialists in their areas of activities. 31. Regional inequalities in educational opportunities may be lessened, and educational opportunities for persons from poverty level families may possibly be improved by regional quotas which increase the intake of students from districts and regions with the qualitatively and quantitatively weakest education systems into national secondary schools and the University of Malawi. At the same time, this has obvious costs in denying entrance to better-qualified students from other regions who may come from equally low- income families. The early establishment of quality education in the north continues to be reflected in higher levels of school enrollment (twice the national level in primary grades in Rumphi District), better qualified and more experienced teachers, and higher student average scores on national tests. Primary school enrollment ratios range from 85 percent in the northern region to 54 percent in the central and 49 percent in the southern region. The ratio of qualified teachers in the northern region is 1:54 students, compared to 1:76 and 1:86 students, respectively, in the central and southern regions. As a result of higher average test scores in the north, passing grades on nationwide examinations of students admitted to the University of Malawi and national secondary schools are somewhat more rigorous for students from the north, and least rigorous for those from the south. This has the advantage of increasing the number of qualified teachers and others with post-primary education from the areas where educational achievement has been least, and should help to raise educational levels in the more disadvantaged areas. The shift of teachers to civil service status in 1977 will also help redress the regional imbalance in teacher qualifications, as newly-qualified teachers will be assigned where the need is greatest. 32. Two broad conclusions that may be made about education from a basic needs perspective in Malawi are: (a) that a rather inclusive formal and non-formal education system is now in place, and that a structure exists for utilizing most opportunities for basic needs education both inside and outside the formal eduction system, and (b) more resources are needed to expand the various formal and non-formal education systems so that they reach more of the population. While secondary and university education now absorb about half the recurrent budget for education, though they serve only about 3 percent of the total formal education system enrollment, that is a smaller share of the budget than in many developing countries. On the other hand, the physical facilities for secondary and university education are much more comparable to those of developed countries than are the facilities for primary level educa- tion. While it is true that the quality of the primary level teaching is more important than the physical facilities, textbooks, visual aids, desks  - 13 - and chairs do matter and do make the average teacher more effective. Poorly- trained teachers, lack of textbooks and other materials and equipment also contribute to the high dropout rates and high rates of repetition, which result in major inefficiencies and can mean little of educational value is gained by students. 33. More resources are needed at the primary level both to reach those not now attending school and to upgrade the quality of education of those who are. About 65 percent of children enter Standard 1 (the first year of the school system). Of 1,000 students entering Standard 1, however, only 560 will enter Standard 2 the following year. Another 233 will repeat Standard 1 the follow- ing year, and the remaining 207 will drop out of school. Of the original 1,000, only 91 will proceed to Standard 8 without repetition, but another 203 will eventually reach Standard 8 after having repeated or dropped out one or more years. 1/ 34. Of those who complete their primary education, about 75 percent pass the Primary School Leavers Examination, but there are spaces for only about 10 percent of those passing the exam to enter secondary school. Some may enter vocational or technical training schools, although many of these have raised their admission standards in recent years to require a JCE obtained by examination after completion of Form II. Most of those who complete Standard 8 enter private business, military or government service, or return to farming. The continuing shortages of trained labor suggests that more of these youths are needed to continue on to more advanced studies to help overcome the shortages of primary and secondary school teachers as well as technicians and managers (though some school-leavers will achieve these latter positions). III. HEALTH 35. As education is a means for achieving other basic needs, health is a major objective for nutrition, water, sanitation and housing activities as well as more narrowly defined health sector activities. Health status and life expectancy in Malawi, adjusted for national per capita income, are about average for sub-Saharan Africa though generally below least-squares predicted values for a worldwide developing country sample of health and per capita income values (see Annex 1, Charts 1-4). Malawi's estimated life expectancy at birth of 46 years is about what would be expected in view of its $140 per capita income in 1977, on the basis of comparison with other sub-Saharan countries, but is below the predicted life expectancy at that income level for the sample of all developing countries. 2/ The infant mortality rate, at 142 per thousand, is nearly 20 percent higher than would be predicted from the African 1/ IBRD, Malawi - Education Sector Survey, op. cit. 2/ The source of data for these comparisons lists 46 years for Malawi, which is an update from estimates cited elsewhere in this paper of 43 years.  - 14 - sample, and 40 percent higher than in the all-developing country sample. Malawi's child (aged 1-4) death rate of 27 per 1,000, however, again approximates the predicted and median values for sub-Saharan Africa. The lack of any family planning program is reflected in Malawi's crude birth rate of 52 live births per 1,000 population, which is the highest rate in the African sample, though Niger and Liberia have the same rate. 1/ 36. By measures of health-producing inputs, average annual calorie availabilities of 103 percent of requirements are substantially higher than would be predicted by either the African or worldwide comparator groups, and is higher than in any other African sample countries except the Ivory Coast and Madagascar (Annex 1, Chart 5). That 33 percent of the population had access to safe water in 1975 placed Malawi above the income-predicted value for the African and all-developing country samples (Annex 1, Chart 6). By 1980, it is estimated that 55 percent of Malawi's population had access to sate water supplies. Malawi had the third highest number of person per physician of countries in the African sample (Annex 1, Chart 10), and about 2.5 times as many per physician as would be predicted by the all-developing country sample. However, the population per nurse in Malawi was only about one-half as high as predicted by the all-developing country sample (Annex 1, Chart 11). These contrasting results reflect Malawi's heavy dependence on nursing and other professional and paramedical staff to compensate for the small number of fully-trained doctors. 37. Because of limited budget resources, health planning during the first five years of independence was limited primarily to trying to maintain the quality of existing curative facilities and to expanding medical training to increase numbers of Malawian medical personnel. The modern health system was first introduced by foreign missionaries, and religious groups (foreign and Malawian) today account for about 40 percent of health care; more than 80 percent of medical doctors are expatriates. From about 1969 the beginnings of what is now called the Primary Health Care System began to take form, and plans for such a system were spelled out in the 15-year Health Plan for 1973-1988. The last several years have seen a growing government commitment to improvement of health standards, with increased budget allocations and plans for considerable expansion in training of health personnel (see table 10, following para. 61). 38. Use of health facilities is also rising. As many as three-fourths of those suffering from illnesses now go to a health facility for treatment. About 70 percent of pregnant women attend a prenatal clinic at least once, and these average 3.5 follow-up visits. One-third of reported live births now take place in some type medical or maternity facility. An estimated 90 percent of the population is reached by one or more health education programs 1/ The Malawi Population Change Survey, February 1970-January 1972, estimated the unadjusted crude birth rate of 50.5, and the adjusted rate as 54.  - 15 - (e.g., the under-five clinics). 1/ The health care, preventive health care and health education programs, and health-related water supply, nutrition and other programs are expected to result in substantial improvements in health conditions in the next five years. Mortality and Morbidity 39. Vital statistics registration is not mandatory in Malawi, and many births and deaths go unrecorded. These and other measures of population change are estimated by census data and special surveys by the National Statistical Office. The only data on diseases and causes of death are those maintained by hospitals and other medical facilities. Thus the proportion of disease among the entire population may vary substantially from data for outpatients and inpatients, and data on deaths in medical facilities would reflect only a small and probably select portion of total deaths. Nevertheless, the data on patients give at least broad indications of the relative incidence of diseases considered serious enough to seek modern medical help (which may occur before or after consulting traditional healers). 40. The largest sample of data on diseases is for outpatients, and is broken down by patients under 5 years of age and those 5 or older (table 3). Among the nearly 3 million patients under 5 years of age treated in 1976, some 754,000 or 25 percent of the total, had malaria as their primary disease. Some 588,000 or 20 percent were suffering from pneumonia or other respiratory system diseases. Another 20 percent were treated for diarrhea (12.2 percent) or other abdominal or gastrointestinal symptoms (7.7 percent). The other 35 percent of under-5 patients were treated, in descending order of numbers of cases, for eye inflammations, skin conditions, measles, traumatic conditions (injuries), nutritional deficiencies and hookworms and other worm infestations. Among outpatients 5 years of age or older, malaria, respiratory ailments and diarrheal and abdominal-gastrointestinal symptoms were also the most prevalent diseases. These accounted for only 49 percent of illnesses among this older age group (as compared with 65 percent for those under 5), however, who naturally suffered more from diseases associated with older age groups (such as cancer, tumors, cardiovascular diseases). 1/ M. C. Jinazali, "Population in Malawi," in Health for All, Report of the National Seminar on Primary Health Care, Lilongwe, October 30 - November 3, 1978.  Table 3: NUMBER AND PERCENTAGE DISTRIBUTION OF OUTPATIENTS BY DISEASE AND AGE GROUP, 1976 Number of Cases (thousands) Percentage Under Over Under Over 5 Years 5 ';ears 5 Years 5 Years Malaria 754 800 25.5 15.2 Respiratory system 588 730 19.9 13.9 Diarrheal diseases 362 270 12.2 5.1 Abdcmen and gastro-intestinal tract 228 380 7.7 7.2 Eye inflammacions 213 187 7.2 3.6 Skin conditions 182 275 6.2 5.2 Measles 132 37 4.4 0.7 Tr.umatic con6itions (injuries') 110 318 3.7 6.0 .Nutriticnal deficiencies 56 77 1.9 1.5 Hookworm and cther helminthiasis 51 126 1.7 2.4 Other 280 2,0 60 9.5 39.2 Total 2,956 5,260 100.0 100.0 Source: Statistical Reference Tables for the Ministry of Health, Lilongwe, June 1978, table 12D.  - 17 - 41. Data on disease by age group for outpatients also shows 295,000 outpatients cases per 100,000 population aged 0 to 4 years in 1976, and 101,000 cases per 100,000 population aged 5 years and above, 1/ or an overall rate of 2.9 outpatient illnesses per child under 5 years of age and one per person among those 5 years of age or older. Also on a per 100,000 of popu- lation basis, children under 5 years of age had 15.7 times as many cases of measles, 5.9 times as many cases of diarrheal diseases, 5.0 times as many cases of inflammatory diseases of the eye, and 4.1 times as many cases of malaria, as the rest of the population. Among the next several most common outpatient illnesses, children under 5 years accounted for 3.5 times as many cases of respiratory system symptoms per 100,000 of population, 2.9 times as many skin conditions, and 2.6 times as many abdominal and gastrointestinal tract symptoms other than diarrhea. 42. Disease rates among inpatients reflect a higher proportion of life-threatening conditions. Infectious and parasitic diseases acounted for 32.5 percent of all inpatients seen and 45 percent of inpatient deaths (table 4). Three diseases accounted for 36 percent of inpatient deaths from all causes and for 79 percent of inpatient deaths from infectious and parasitic diseases: measles (42 percent), malaria (21 percent) and enteritis and other diarrheal diseases (16 percent) (table 5). The other leading causes of death were pneumonia and other respiratory system diseases (14 percent), and endo- crine, nutrition and metabolic diseases (10.5 percent). Complications of pregnancy and child-birth accounted for 28 percent of inpatient illnesses and 1.6 percent of deaths.  Table 4: DISTRIBUTION OF INPATIENTS BY DISEASE GROUP AND CAUSE OF DEATH, 1977 Percent Percent of Patients of Deaths I Infective and Darasitic diseases 32.5 45.1 II Neoplasms 0.9 3.2 III Endocrine, nutritional and metabolic diseases 3.3 10.5 IV Diseases of blood and blood forming organs 4.2 6.4 V Mental disorders 1.2 0.3 VI Diseases of nervtous systema and sense organs 2.3 2.8 VII Diseases of circulatroy system. 1.0 2.5 VIII Diseases of respiratory system 9.0 14.0 IX Diseases of digestive system 2.1 2.1 X Diseases of genito-uiinary system 2.8 1.2 XI Deliveries and complications?of pregrancy, childbirth and puerperium 27.8 1.6 XII Diseases of the skin and subscutaneous tissue 3.0 0.0 XIII Diseases of musculoskeletal system and connective tissue 1.0 0.3 XIV Other diseases A.7 6.7 XV Accidents etc. J..J TOTAL 0.0 100.0 Source: Statintical Reference Table for MinistrX of Health, Lilongwe, June 1978, tables 16 and 17.  Table 5: DISTRIBUTION OF INPATIENTS BY INFECTIVE AND PARASITIC DISEASES, 1977 Inpatients Deaths Tnumber) (%) (number) (%.) Malaria 27,571 36.5 775 20.9 Measles 20,517 27.2 1,547 41.6 Enteritis other diarrheal diseases 11,473 15.2 591 15.9 Schistosomiasis, hookw-orm, other helminthiases 6,665 8.8 19 0.5 Tuberculosis 4,170 5.5 340 9.1 Venereal disease 1,177 1.6 11 0.3 Whooping cough 700 .0.9 29 0.8 Bacillary dysentery and aimiobiasis 591 0.8 22 0.6 Infectious hepatitis 478 0.6 46 1.2 Tetanus 419 0.6 190 5.1 Typhoid, paratyphoid, other salmonella 279 0.4 23 0.6 Other 1.418 123 3.3 TOTAL 75,458 .100.0 3,716 100.0 Source: Statistical Reference Tables for Ministry of Health, Lilongwe, June 1978, table 13.  - 20 - 43. Data by cause of death are not available by age group. Death rates by age group, however, estimate that infant deaths are 142 per 1,000 live births. 1/ Of non-infant deaths, 50.7 percent of those reported occur during ages 1-4. 2/ Measles, the leading cause of death from infection, is primarily a disease of childhood. Diarrheal diseases also affect most severely those under about 5 and 6 years of age, after which body resistances substan- tially reduce their incidence. Using Ministry of Health data on deaths by age group and estimated population figures, both for 1971-72, it appears that the death rate among children aged 5 to 9 was about 13 per 1,000, and 66 per 1,000 among children aged 1 to 4. Health Characteristics of the Urban and Rural Populations 44. Death and illness are much more likely to strike rural than urban dwellers in Malawi. As shown in table 6, accor1ing to the 1970-72 Population Change Survey, the crude death rate in urban areas is 12.7 per 1,000 persons, but 28.2 per 1,000 in rural areas,. Infant mortality, defined as the death rate of live-born children before they complete their first year of life, is 74 in urban areas but 151 in rural areas. Life expectancy at birth in rural areas is 40.3 years, but 42.4 years for all of Malawi, or about 61 years for urban areas. Contrary to developed countries, the crude birth rate in Malawi is higher in urban than in rural areas, 57.3 per 1,000 in urban vs. 49.8 per 1,000 in rural areas. 3/ The national crude birth rate is 50.5 unadjusted, one of the highest in the world. 4/ 1/ 1972 Population Change Survey. Most experts believe this figure is on the low side. 2/ For males, 58.1 percent of non-infant deaths occur at ages 1-4, and for females 43.5 percent. 3/ M. C. Jinazali, "Population in Malawi," Annex 9, in Health for All, Report of the National Seminar on Primary Health Care, Lilongwe, October 30-November 3, 1978. 4/ The adjusted rate from the 1970-72 Population Change Survey is 54 per 1,000 population. The updated sample in Annex 1 estimates 52 per 1,000 for Malawi.  Table 6: SELECTED RURAL AND URBAN POPULATION STATISTICS Rural Urban Malawi Ratio of Males to Females a/ 0.87 1.22 0.90 Crude Birth Rates a/b/ 49.80 57.30 50.50 Births per 1,000 Females Aged 25-29 a/ 291.00 332.00 296.00 Percent of Births in Hospitals, Clinics or Dispensaries 30.00 75.00 34.50 Crude Death Rates c/ 28.20 12.70 26.50 Infant Mortality Rates d/ 15.00 74.00 142.00 Life Expectancy at Birth in Years 40.30 61.00 42.40 a/ From 1970-72 Population Change Survey. bI Number of live births per 1,000 population. c/ Number of deaths per 1,000 population. d/ Death rate of live born children under one year of age per 1,000 live births. These figures are believed to be underestimates. Source: M.C. Jinazali, "Population in Malawi," Annex 9 in Health for All, Report of the National Seminar on Primary Health Care, Lilongwe, October 30- November 3 1978.  - 22 - 45. In urban areas, 75 percent of all reported live births occurred in hospitals, clinics or dispensaries, while the figure for rural areas was only 29.7 percent. The percentage of live births which occurred in the home of the mother were 22 percent and 69 percent for urban and rural areas respectively. 1/ Determinants of Health Status 46. The very substantial differences in urban and rural mortality rates reflect many factors. Most important would appear to be the quality of drink- ing water and nutrition levels (see paras. 70-80). The greater availability of health facilities in urban areas, higher average education levels and greater access to health education, and higher income levels that reduce the likelihood of malnutrition, are other probable factors. Thus, the solution to these high mortality rates is not just in providing more curative health facilities and personnel, but also in environmental efforts (e.g., water and sanitation), control of communicable diseases through immunization and vector control programs (e.g., malaria, schistosomiasis (bilharzia)) through improved nutrition, and through education about personal, family and village health maintenance. All of these programs need to be pursued, with particular emphasis on health education. The Government is taking action in all of these areas, including especially the expansion of the Primary Health Care Program to provide health facilities to the entire population. These facilities include considerable health education and preventive work, such as under-five clinics for immunization and health monitoring, nutrition education and rehabilitation units, prenatal and maternal-child health clinics. Health education is also provided in the primary schools and by community development and agriculture ministry instructors in village and regional level home management/homecraft courses, such as food and nutrition, child care, sewing, health and sanitation, home improvement, vegetable growing and poultry keep- ing. The Ministry of Community Development is working to provide piped gravity-fed potable water where feasible, and potable well water in other areas. The environmental health staff supervise the installation of drinking wells and test samples for water quality, advise on methods of waste disposal and the location of latrines, conduct surveys and organize programs for control of such vectors as mosquitoes, flies and rats, and inspect food supplies, preparation, handling and storage. Primary Health Care Program 47. The Primary Health Care Program is a community centered and sup- ported type of health care program that has been developed and recommended by WHO and others as the only feasible way to bring health services to an entire population in developing countries where budget resources and per capita income levels are severe constraints to modern western medicine. The Malawi model was recommended by a 1971 WHO team that studied the health situ- ation and prepared a report "National Health Plan for Malawi," which covered the period 1973 to 1988. The plan, which has been accepted by the Government and is now being implemented within resource and other limits, calls for a primary health care center, staffed by a clinical officer (who in Malawi, 1/ Ibid.  - 23 - performs the functions of a medical doctor), a registered nurse, and other personnel, 1/ serving a population of 50,000. In addition to the primary health care center itself, there would be four subcenters serving as dispensary and maternity units, including normal deliveries, and as a base for health education and mobile clinics. Each subcenter would serve 10,000 people, with the primary center serving the 10,000 persons closest to it. Each subcenter would be staffed by one medical assistant, one enrolled nurse/midwife, and hospital servants. Each subcenter and the primary center would also have four health posts under its supervision, each serving 2,000 people (and the subcenter the remaining 2,000). Each health post would be staffed by a maternal-child health assistant who would deliver basic preventive care, first-aid and simple treatment. 48. The primary health care concept is more an evolution rather than a revolution in health care in Malawi. Mission hospital centers and government "rural hospitals" have been long served in rural areas in Malawi, and most of the presently operating primary health care centers were formerly such mission or government facilities. The number of hospitals, primary health care, maternity and dispensary units and beds in 1968, 1974 and 1977 are shown in table 7. 1/ A medical assistant, a health inspector, two enrolled nurses/midwives, a laboratory assistant, a driver and servants.  - 24 - Table 7: MFDICAL INSTITUTIONS AND NUMBERS OF BEDS, 1977, 1974 AND 1968 Number of Units Number of Beds lecemDer - December Type of Institution 1977 1974 1968 1977 1974 1968 All Institutions 535 463 274 9,617 9,053 6,593 Ministry of Health Total 199 156 133 4,584 4,337 3,267 Central Hospital 2 1 1 912 571 450 General Hospitals ]. 2 2 322 547 544 District Hospitals 21 21 20 2.070 2,225. 1,616 Rural Hospitals 1/ 2/ 15 14 13 479 477 334 Specialized llospitals - 2 2 2 316 316 273 Dispensaries/Maternities 138 116 95 485 201 50 Military Total 3 2 1 22 22 19 Hospital 1 2 1 22 22 19 Sub-Centers 2 - - Mission Total 134 125 92 4,320 4,157 3,015 Hospitals -/ 20 46 43 2,4'14 3,477 2,51.8 Primary Health Centers 14 - - 601 - 3 Maternity and Dispensary Units 68 47 24 1,100 466 730 Maternity Units 4/ 5 5 3 29 57 7 Specialized Hospitals - 5 4 4 143 129 _ Dispensaries 21 23 18 33 28 District Countil Total 93 78 42 632 483 234 Diapensaries and/or Maternities 93 78 42 632 483 234 Private Total -/ 106 102 6 59 54 58 Hospital 1 1 3,. 26 26 52 Dispensaries and/or Maternities 105 101 3 33- 28 6 1/ Now designated primary health centers. 2/ One leprosarium and one psychiatric hospital 3/ Includes some maternity hospitals as well as primary health care centers prior.to. 1977. 4/ Leprosaria 5/ Includes those units run by other government departments and by agriculture and industrial enterpriEcs. 6/ Lujeri Hospital. Source: Ministry of Health.  - 25 - 49. The major agricultural land development schemes have also contained similar local health clinics (subcenters) to improve health in the project areas. Thus the adoption of the primary health care program as a national program is primarily an extension of health concerns to all locations even as the National Rural Development Project is an extension of the land development projects to a national scale. As an example of health care prior to the implementaton of the primary health care system, in 1972 there were 223,000 first-time attendances at under-five clinics and more than one million total child attendances, an increase of nearly 40 percent from the previous year. Between 1973 and 1978, the number of static and mobile under-5 clinics rose from 542 to 841. First visits by infants in 1978 numbered 338,000, indicating that most infants make at least an initial visit to an under-5 clinic. Total visits for infants (i.e., under one year of age) were 884,000, and for all infants and children under 5 were more than 2 million. 50. As shown in the following table, the number of primary health care centers in operation in 1978 was nearly half as many as required to provide the envisioned ratio of one center for every 50,000 of population, and the number of subcenters was 87 percent of the number required by the population. Health posts, however, have received a low priority and only about 2 percent of requirements have actually been established. The number of health units required in 1978 is estimated on the basis of a population of 5.5 million, and in 1988 on a population of 6.5 million. Table 8: BASIC HEALTH UNITS Required Actual No. in 1988 in 1978 in 1978 Primary Health Centers 130 110 49 Health Subcenters 520 440 385 Health Posts 2,080 1,760 41 Source: Health for All, Report of the National Seminar on Primary Health Care, Lilongwe, October 30-November 3, 1978. Supporting Hospitals 51. The primary health care system is in turn supported by an existing structure of two central hospitals (Queen Elizabeth's in Blantyre and Kamuzu in Lilongwe), a general hospital (Zomba) and 21 district hospitals, plus 20 mission hospitals associated in the Private Hospital Association of Malawi (PHAM). The central hospitals have a large number of specialists, including 35 of Malawi's 116 medical doctors, and extensive equipment. The general hospital is completely staffed and equipped. Each district hospital is the nucleus of the medical and health services at the district level. Each is located in a district capital and there are 21 of them plus the 3 central  - 26 - and general hospitals, or one in each district capital. Each district hospital is in charge of a medical officer (M.D.) or a senior clinical officer who is responsible for curative and preventive services within the district. 52. These district hospitals are the referral units for the primary health care units, and the central and general hospitals are the referral units for district hospitals. The central and general hospitals also conduct outreach activities and serve as district hospitals, supervising primary health care centers, conducting static and mobile clinics including under- five, prenatal, maternal-child health and nutrition and rehabilitation units. 53. PHAM represents 15 different Protestant and Catholic religious denominations. Each of the 20 PHAM hospitals has at least 2 medical doctors and appropriate nursing and support staff. In practice, the Govern- ment and PRAM health facilities are operated in an integrated fashion, with the Government relying on PHAM facilities to service their established areas. In addition to hospitals, PHAM facilities include 27 primary health care centers (out of a national total of 49), 87 health subcenters, 4 leprosy centers and 13 training schools. The PHAM units are also actively engaged in public health activities such as under-5 clinics (about 400 of the 841 operating in 1978), and mobile health units. The Government pays part of the salaries and other operating costs of PHAM facilities, and PHAM in turn participates in and supports the government program, including serving as a conduit for support by overseas religious organizations. 54. Central, general and district hospitals are important for the support they give to the primary health care system, as well as for the numbers of patients they handle. They treat cases referred to them by the primary health care units and also train health personnel from these units. Supervision of and support for primary health center personnel is provided partly by visiting staff from the referral hospitals and partly from the Ministry of Health medical staff. This lessens the burden on the local health unit personnel, who are not equipped to handle certain types of health problems, maintains the confidence of the local populations that they will receive adequate professional treatment by visiting their local health units, and continuously upgrades the experience and knowledge of local health unit staff. 55. As the primary health care units grow in number and patient loads, so do the number of hospital referrals. Therefore, these need to expand in capacity as the periphery system grows. Queen Elizabeth's hospital treated 610,000 outpatients during 1972, of whom 135,000 were under 5 years of age. In that year, a separate outpatient department building for children was con- structed to handle the growing case load. In 1978, Queen Elizabeth's treated more than one million outpatients. Currently (mid-1979), the number of inpatients averages 800 to 900 per day though the number of beds is only 585. In the infant and children's wards this is usually handled by having 2 to 3 small patients per bed. In the adult wards, it is usually handled by bedding the excess patients on the floor. Large numbers of children contract measles 2 weeks after entering Queen Elizabeth's, since measles cases are  - 27 - placed in one corner of the large pediatrics wards, which has 80 beds but typically 120 inpatients at one time. The operating theaters handled 2,400 operations in 1963, and 8,000 in 1978. According to the rule-of-thumb that there should be one operating theater for each one hundred patients, the hospital should have 9 theaters, rather than the present 4. The operating theaters are in almost constant use, and therefore some undesirable chances of non-sterile conditions must be taken. Furthermore, a 250-bed maternity unit is now under construction. Other facilities greatly in need of expansion and improvement include those of housing and maintenance of patient records and the medical library. 56. Kamuzu Central Hospital, though it opened only in June 1977, is also overcrowded. With 340 beds and 3 surgical theaters, the number of in- patients averages between 400 to 500, and occasionally reaches 600. There are an additional 206 maternity beds and one operating theater at the asso- ciated older "Bottom Hospital" in Lilongwe. Medical Personnel 57. The key bottleneck, because it has the longest lead time and is the most expensive to overcome, is that of medical personnel. Though mission hospitals started training Malawian medical and health assistants 50-60 years ago, there was no domestic training of senior staff such as doctors and registered nurses prior to independence. The major emphasis of the Five-Year Health Plan (1965-69) was on health work force development. The training of registered nurses started in 1965 with the opening of the Kamuzu School of Nursing at Queen Elizabeth's Central Hospital. The Polytechnic also started training health inspectors in the same year. Today 17 hospitals and schools train clinical officers, registered and enrolled nurses, medical assistants, midwives, health inspectors, and health, dental, laboratory and pharmacy assistants. Training of medical doctors, dentists, pharmacists, specialized nursing and other medical personnel is still done abroad. There are still only 20 Malawian medical doctors in the country, compared with 13 in 1973. Out of 60 medical and dental students studying abroad in 1974, only a few have returned. Eight M.D.s but no dentists were in training abroad in 1978. Clinical officers, formerly given three years training in France, but now being trained domestically, are performing virtually the same functions as M.D.s, including surgery. Dental assistants working with dentists also fill teeth and do other routine dental work. 58. Numbers of medical and paramedical personnel in Malawi are shown in table 9. In the four years between December 1973 and April 1978, the number of medical doctors rose from 106 to 116, but the number of clinical officers rose from 49 to 79. The number of medical assistants rose very little because their training was discontinued for several years in conjunction with in- creases in the number of clinical officer trainees, but growing demand and shortages have resulted in reopening of medical assistant training. By far the largest increases have taken place in the numbers of enrolled nurses, medical and nursing aides, health assistants and homecraft workers.  - 28 - 59. The annual number of entrants into selected health personnel domes- tic training courses in 1974 and in 1979/80, the length of training and the entrance requirements are shown in table 10. The first class of domestically- trained clinical officers will graduate in 1980, with 32 of the original 40 entrants expected to graduate. 1/ These graduates will be the key personnel of primary health care centers. The number of registered nurse trainee entrants will double in October 1979 when the first class enters the newly- constructed facilities at Kamuzu Hospital in Lilongwe. The annual rate of new enrolled nurse trainees will also increase (to 120) in the fall of 1979, as will the annual number of medical assistant trainees when their school is shifted to Queen Elizabeth's Central Hospital in 1980. 60. Plans are also being made to train traditional birth attendants (midwives), traditional healers, and other community-selected village health workers in one to three month courses. A two week trial course in early 1978 for 15 traditional birth attendants, each of whom had their own maternity units and did five or more deliveries per month, was extremely successful. The basic concept was that the traditional birth attendant shouid manage normal labor in a safe way, but that abnormal cases and complications should be referred to hospital or primary health center staff. The syllabus included hygiene, the normal events of pregnancy and labor, the recognition of women at risk of obstetric abnormalities, the puerperium, and the new-born child. On completion of the course, they were given UNICEF midwifery boxes and useful equipment such as hurricane lamps, blankets and soap. The results have been excellent. Patients referred by these 15 women have been arriving at govern- ment and PHAM health centers in considerable numbers, ranging from prenatal patients with anemia or previous cesarian-section scars, to patients with labor complications and puerperal infections. Only one of the 15 traditional birth attendants trained could write, but a short note always accompanies these patients. Many of the participants have extended or improved their premises. All but one previously delivered their patients on the ground, but many have since had beds constructed, although this was not mentioned during the training course. 2/ Preventive Medicine 61. The high incidence of communicable disease has recently led to in- creased emphasis upon preventive health measures, particularly mass immuniza- tion, health education, vector control, and water, sanitation and housing improvement programs. The principal diseases subject to such control have been identified as malaria, schistosomiasis, diseases of childhood and infancy (including measles, gastroenteritis, respiratory infections and eye diseases), tuberculosis, leprosy, diarrheal diseases including cholera, and malnutrition. A National Malaria Control Committee was formed in February 1979, and an action program is being planned. Mosquito control programs are now being 1/ At least four more of the original entrants are expected to graduate in 1981. 2/ Description taken from Health for All, Report of National Seminar on Primary Health Care, Lilongwe, October 30-November 3, 1978, pp. 83-85.  - 29 - Table 9: MEDICAL AND PARAMEDICAL PERSONNEL IN MALAWI December April 1973 1978 Medical Officer 106 116 Senior Clinical Officer 15 23 Clinical Officer 34 56 Medical Assistants 473 525 State Registered Nurses/I{idwives 313 397 Enrolled Nurses and E.N./Midwives 706 1,040 Medical and Nursing Aides 693 1,362 Dentists 8 15 Dental Technicians 5 4 Pharmacists 18 6 Pharmaceutical Assistants 3 1 Laboratory Technicians 19 13 Laboratory Assistants 35 56 Radiographer 6 6 X-Ray Assistants 1 5 Health Inspectors 38 59 Health Educators 2 3 Health Assistants 76 165 Homecraft Workers 90 259 Source: Ministry of Health.  Table 10: ANNUAL NUMBER OF TRAINEE ENTRANTS OF SELECTED HEALTH PERSONNEL Training 1974 1979/80 Period Entry Requirements Clinical Officers 0 5r 4 years M.C.E.-/ with credits in English, math and science subjects. Registered Nurses 31 60 4 years M.C.E.-/ with credits in English and pass in science subject. Enrolle3 Iurses 13 120 3 years J.C.E.-/ including two science subjects. Medical Assi~stants 15 15 3 years J.C.E. Health Assistants 12 25 2 years J.C.E. Pharmacy Pharmacy Assistants - 15 3 years J.C.E. Laboratory Assistants 15 years J.C.E. 1/ Successful completion of Malawi Certificate Examination, after Form IV (12th grade). 1/ Successful completion of Junior Certificate Exmination, after Form IV (10th Grade). Source: Ministry of Health.  - 31 - carried out in Blantyre and Lilongwe and are expected to be gradually expanded on a national basis. Anti-malarial suppressive drugs are being distributed to children and pregnant women at under-5 and prenatal clinics. Surveys at four locations 1/ showed malaria-affected spleens among 22 percent (Sucoma) to 69 percent (Rumphi) of 5 to 9 year olds and positive blood slides among 26 percent (Rumphi) to 53 percent (Karonga) of those tested. 62. Schistosomiasis has been regarded as a serious problem only in irrigation areas, but recent studies suggest that it is much more widespread. A survey of Standard 1 pupils in Lilongwe (a non-irrigation area) revealed 50 percent had one variety, s. mansoni, and 15 percent another, s. haematobium. At the Dwangwa Sugar Scheme, the newly recruited labor force, drawn from all over the country had a 40 percent rate of infection with s. mansoni on arrival, and 35 percent had s. haematobium. A pilot project is now being set up to initiate control in the major irrigation areas, but major areas outside the irrigation scheme will probably also have to come under the same controls if incidence is to be reduced. 63. Diseases of childhood and infancy are being attacked mainly through the under-5 clinics (of which there were 861 in 1978), and prenatal clinics (of which there were 480 in 1978). These clinics provide such services as immunizations, primary health care including malarial-depressant drugs, health and nutrition education and distribution of foods, vitamins and iron. About 60 percent of children aged 0-4 visited under-5 clinics compared to about 20 percent in 1972. More than 80 percent of all children had been vaccinated against smallpox and tuberculosis in 1977, about 40 percent had been given DPT (dyptheria, pertuosis and tetanus, and 20 percent polio immuniza- tion. 2/ Children now receive 7 immunizations at under-5 clinics: smallpox, poLio, dyptheria, whooping cough, tetanus, tuberculosis and measles. Current immunization rates (mid-1979) are estimated at 40-50 percent of the under-5 population, and the target rate is 80 percent. First attendances at prenatal clinics in 1978 equalled 63 percent of the number of births, and the number of subsequent visits was 3.8 per initial visit. A mass measles immunization program begun in early 1979 seems to be reducing the incidence of measles. 64. Diarrheal diseases, including cholera, are primarily sanitation, water supply, and personal hygiene diseases. Rehydration units are maintained at the central hospitals, and rehydration techniques to prevent deaths from these diseases are taught at all clinics dealing with child care. Sixty per cent of the urban population and 30 percent of the rural population were estimated to be served by protected wells or safe piped water (gravity-fed in rural areas) in 1977, and the share of rural population so served is expected to rise to 53 percent in 1980. 3/ _I Rumphi, two sites in Karonga, and the Sucoma sugar estate in the Lower Shire Valley. 2y UNICEF, "Report on a Population-Based Study on Utilization of Health Services," 1977. 3! World Health Organization/World Bank Cooperative Programme, "Republic of Malawi Water Supply and Sewerage Sector Study," 1978.  - 32 - 65. As for other major communicable diseases, there has been no case of smallpox since 1971. The number of patients under treatment and deaths from tuberculosis appear to have peaked in 1976, and since declined. The government's leprosy control program dates from 1966. Registered cases totaled nearly 22,000 in 1977, or about 0.4 percent of the population. Attendance for treatment varies from 60 to 90 percent in different locations. Assessment of the Health Sector 66. A number of new initiatives, particularly the adoption of the primary health care system and the substantial increase in numbers of health personnel trainees, suggests an increase in government personnel and finan- cial resource availability for health care. Since 1975/76, health expenditures have been running at about 7.5 percent of central government revenue account expenditures. The amount spent in FY78 was about K 1.33 per person, and 85 percent of the total was absorbed by the curative services. Health is budgeted at 1.0 and 3.3 percent of the development budget in FY79 and FY80, amounts comparable to past shares. 67. The emphasis on expansion of the primary health care system and expansion of a number of preventive health programs (including improved water supplies), indicate that the proportion of the population whose basic health needs are being more adequately met is expanding fairly rapidly. The direc- tions of policies and programs are very much in line with recommendations of the WHO. From a basic needs viewpoint, the emphasis on improving rural health care and the goal of near universal health services (limited only by difficulties in serving sparsely populated areas) at no cost to recipients is attractive. 1/ Since shortage of budgeted funds is a major limitation (along with availability of personnel) on how fast the quantity and quality of medical service can be improved, however, it is possible that even poverty groups might be better served if small charges were made for services and drugs, thereby increasing available financial resources, with patients who could not afford to pay being served without charges. 68. The connection between the quantity and quality of post-primary education and expansion of the supply of qualified medical personnel is readily apparent. Generally the number of applicants for medical training has substantially exceeded the available places. This has not been true for some technical assistant level courses, but the problem seems to have been due to the timing of recruitment. For some paramedical training, including that for medical assistants who with inservice training can eventually qualify as clinical officers, the formal education requirements for admission to training have been raised from successful completion of the Public School Leavers Examination at the end of Standard 8 to successful completion of the Junior Certificate of Education examination at the end of Form II (tenth year 1/ PHAM hospitals charge modest fees for most services and drugs. Both are free at government facilities, though patients may choose to pay, which gives them the right to request to be treated by specific personnel and usually means a shorter wait for outpatients and less crowded wards for inpatients.  - 33 - of schooling). That is not a high level of premedical education by world standards, but the fact that only about 10 percent of those passing the Public School Leavers Examination are admitted to Form I means that the work force for selection is much smaller, and that some potentially very competent medical per sonnel are thereby barred from training. 69. Assuming that adequate financial resources are made available to carry through the preventive and primary health care programs as visualized (along with needed complementary expansions in referral hospital facilities), rates of morbidity and mortality should drop rather sharply in Malawi in the next five years. Since government health care is free and PHAM mission facil- ities accept patients who cannot pay, access to all facilities are available to even the poorest, subject to the provision that they can get to a health facility. 1/ IV. NUTRITION 70. Malnutrition in Malawi appears to be concentrated in young children (particularly those between 12 to 17 months of age, but continuing until about age 5), and at certain seasons of the year. Average annual calorie and pro- tein availabilities appear to be adequate, including a variety of vegetable protein sources such as (whole grain) maize, beans and groundnuts. "Lean season" shortages, lack of adequate breast feeding supplements and weaning foods, and poor food distribution within the family, appear to be major con- tributory causes to observed cases of malnutrition. Disease and food defi- ciencies also interact in negative synergistic fashion, and malnourished children are more likely than others to suffer from anemia and malaria para- sites. While higher food productivity and improved food storage would help, much of the problem appears to be amenable to education about nutrition and disease, the preparation of foods to retain their nutritional value, and health programs to reduce disease. 71. Issues of agricultural productivity, the incentive and taxation effects of government pricing policies, and other issues relevant to produc- tion and rural income distribution are discussed in the recent Bank report on the agricultural sector. 2/ Since nearly all smallholder production is limited to hand-tool cultivation, yields per cultivator are fairly low. Even with present productivity levels, however, measures of per capita food produc- tion suggest ample availabilities. Nutrition studies during 1970-73 showed that published crop production figures for four areas, adjusted for sales and estimated losses in storage, extraction and meal preparation, produced an estimated per capita daily consumption of nearly 4,000 calories and 100 grams of protein, with protein calories equal to 10 percent of the total. 3/ The National 1/ Patients must also provide their own food at primary health care centers and smaller units. These have facilities for patients and their families to prepare their own meals. 2/ IBRD, Malawi--The Development of the Agricultural Sector (Washington, D.C.: May 1981). 3/ Freedom from Hunger Report on Nutrition in Malawi, p. 18.  - 34 - Sample Survey of Agriculture 1968/69 reported a normal daily consumption based on the recall of food consumed in the previous 24 hours, of 2,405 calories per capita and 74 grams of protein, with protein calories equal to 12.2 percent of the total. The food balance sheet compiled by Bank staff in the recent Agricul- tural Sector Study shows per capita daily availabilities of 2,463 calories in 1975. In each case, availabilities substantially exceeded estimated per capita energy requirements of adults on an annual basis of 2,073 calories (for men the figure is 2,294 calories and for women 1,874). 1/ 72. Two measures suggest wide variation in per capita food consumption on a seasonal basis. One, a Lower Shire Valley survey in April/May (the preharvest lean season) 1970, reported 3,044 calories and 93 grams of protein per day on family-recall estimated levels of food consumption on a yearly average basis, but actual weighing of food consumed during the April/May lean season showed only 1,363 calories per day and 41.9 grams of fat. The "recall" method may well overstate actual consumption, and the weighing of food under- estimates consumption because of non-recorded snacks, but still the seasonal variation is marked. A study of childrens' weights by month over a two-year period also showed marked seasonal swings. 2/ 73. Anthropometric studies of growth of children in Malawi consistently show that infant weights and lengths through the first five months after birth are comparable to standard weights of development in other African and American studies. Few Malawian children show these or other signs of protein-calorie malnutrition in these early months. There is some increase in the numbers falling below foreign standards between the 6th to 11th month, but with a marked peak in the proportions with below-standard weights and indications of protein-calorie malnutrition during the 12th to 17th months, then there is significant recovery by age five. 3/ The interpretation given these data is that inadequate supplemental food is given to breast-fed children during the 12th to 17th month. Also, children are weaned mostly on maize porridge and other high-bulk foods, which makes it difficult for children to get adequate nourishment until they reach an older age. The difficulty is compounded by the fact that most rural families eat no more than two cooked meals a day, supplemented by snacks, and during busy preharvest and harvest seasons the demands for women to work in the fields often result in only one cooked meal per day. 1/ These requirements are based on the mean weights of males and females, between 20 and 39 years of age, the age distribution of the population, and adult activity averaged over the year. See Freedom from Hunger Report on Nutrition in Malawi, p. 17. 2/ H. J. L. Burgess, Susan Cole-King and Ann Burgess, "Nutritional Status of Children at Namitambo, Malawi," August 1972. 3/ See H. J. L. Burgess, et al, "Results and Appraisal of a Nutrition Survey in Malawi," Tropical and Geographical Medicine, Vol. 25 (1973), pp. 372- 80; H. J. L. Burgess, et al, "The Nutritional Status of Children Aged 0-5 Years in Nkhotakota, Malawi," Tropical and Geographical Medicine, Vol. 27 (1975), pp. 375-82.  - 35 - 74. Another major cause of malnutrition is the widespread preference for consumption of "fine" maize meal, with an extraction rate of perhaps 60 percent. At these rates, whether milled or repeatedly hand pounded, substantial portions of the protein, vitamin and mineral value of the grain are lost. Maize is the primary staple diet, accounting for about 80 percent of cultivated acreage, although substantial portions of that acreage are inter-planted with beans or other crops. 75. Workers at nutrition rehabilitation units also stressed the damage done by consumption of soft drinks by small children. Workers constantly tell of mothers bringing in small children suffering from either marasmas (severe underweight conditions; emaciation) or kwashiorkor (bloated bellies) and the mother feeding the child a soft drink. The mothers feel they are doing something nice for their children, but the nutrition unit workers point out that one bottle costs as much as two to three eggs in the cities, and perhaps five eggs in rural areas. 76. The more severe cases of malnutrition seen at under-5 clinics or other health units are referred to nutrition rehabilitation centers or classes. The mother and child live at the centers for about four weeks. Often the first week is largely devoted to stopping diarrhea and getting the child's digestive system working normally. The mother is taught how to prepare and use whole grain flour for porridge and other foods, along with groundnut flour, mashed beans, and other nutritious foods. The mothers prepare these foods for themselves and their children, and may also be responsible for taking care of chickens and raising vegetables. At non-resident classes, the mothers bring their children every day for a month and are also taught to prepare nutritious foods. No systematic follow-up surveys of the long-run consequences of this training seem to have been made. Several workers reported that when the mothers return home, however, their husbands often insisted that they continue to use the relatively low-nutrition value "fine" flour, sometimes withholding money until their wives complied. A few husbands do come to nutrition clinics with their wives, but most men strongly resist doing so. 77. No systematic nutritional surveys are known to have been done since the early 1970s. Talking to medical personnel, it would appear that there are fewer cases of malnutrition now. This may reflect higher income levels and the benefits of nutrition and health education. Nutrition studies at the beginning of the decade found that hospital records of cause of death reported "malnutrition" as the cause of 20-25 percent of deaths among children one to four years of age, and malnutrition as a contributing factor in a considerable number of additional cases, such as "measles and malnutrition." 1/ In inter- views with staff at the Queen Elizabeth's Central Hospital in mid-1979, how- ever, they estimated that they see 15 to 20 infants and under-5 children with marasmas and 10 to 15 with kwashiorkor per month. The incidence of marasmas is much more common than is kwashiorkor, but marasmas tends to be accepted and ignored, while mothers recognize the symptoms of kwashiorkor and bring the children to health facilities. 1/ "Freedom from Hunger Campaign Report on Malnutrition in Malawi," p. 15.  - 36 - 78. Borderline malnutrition among children and mothers of child bearing age, however, is felt to be an important factor in childhood diseases and mortality. Measles often produce complications among Malawi children such as pneumonia and eye disease, as well as being a leading cause of death. Neither measles nor pneumonia usually causes death in primarily healthy and adequately nourished children. Malnutrition reduces the body's resistance to disease. With borderline malnutrition, the onset of a fever increases body metabolism. Particularly if accompanied by diarrhea, this quickly reduces stored body reserves of energy and other nutrients. Pneumonia is the most common complication leading to death from measles. Measles also drain the supply of stored vitamin A from the liver, and this may produce xerophthalmia, which in extreme cases leads to melting of the cornea and blindness. 79. Medical staffs also report substantial borderline anemia as another complication which adds to the seriousness of diseases. The nutrition surveys at the beginning of the decade reported hemoglobin levels averaging about 80 percent of standard in young children. 80. As with health, much of the malnutrition problem in Malawi appears amenable to relief through education and government preventive health programs such as immunization, improved water supply and vector control. The Govern- ment is now giving greater priority to these programs and appears to have the capacity to implement such programs effectively. The growing attendance at under-5 clinics, where cases of malnutrition can be detected early and mothers given appropriate instruction as well as supplemental foods, and children can be immunized against contagious diseases, is a most promising development. A nutrition studies unit, which will collect data and carry out studies to help guide national food and nutrition policies and programs, has recently been established at the Bunda College of Agriculture. V. SHELTER 81. Water, sanitation and housing constitute a "shelter" package which may have considerable importance to health, productivity and quality of life. Shelter must be judged on the basis of at least three attributes: its pro- vision of living space and healthful environment, its access to potable water, and its access to productive employment, by proximity or by low-cost trans- portation. Living space and healthful environment are subject to measurement, though there are considerable differences of opinion about what constitutes satisfactory levels. In addition to space per person, amounts of ventilation, number of persons sleeping per room, and separation of human and animal shelter areas are important. In urban areas, industrial air and noise pollu- tion are additional considerations. Water 82. As already noted, 70 percent of urban dwellers now have safe drinking water from piped systems, and by 1980 more than 50 percent of rural families are estimated to have access to safe water supplies from either gravity-fed piped systems, boreholes or community shallow wells. The Government has adopted the goal of safe water and  - 37 - sanitary waste disposal for the entire population by 1990. Virtually 100 percent of the population in the city of Lilongwe and two-thirds of the population of Blantyre are served by central municipal systems. In addition, 95 percent of the population of Zomba and 62 percent of the population in 31 other urban areas are served by municipal systems constructed by the Ministry of Works and Supplies. Another 19 urban areas, however, have no central water systems and people must rely on private wells, streams or other sources. 83. Between 1977 and 1980 the proportion of the rural population served by safe community water supplies is projected to increase from 30 to 53 percent. As shown in the following table, this growth has been the result of rapid expansion of all three types of rural water programs: Ministry of Community Development supported gravity-fed piped systems and protected shallow wells, and boreholes constructed and maintained by the Geological Survey Department of the Ministry of Agricultural and Natural Resources. Table 11: PRESENT AND PROJECTED RURAL WATER SUPPLY SERVICE Estimated 1977 Estimated 1980 Category Population Served Population Served Ministry of Community Development 19 Existing Gravity Supplies 252,300 270,000 15 New Gravity Supplies - 409,000 5,000 Protected Wells - 500,000 Boreholes a/ 3,700 Existing 1,000,000 1,000,000 900 New - 270,000 Private & Institutional b/ 3.2% of Total Population 170,000 184,000 Total Rural Served 1,422,300 2,633,000 (i.e., 30% of (i.e., 53% of estimated rural estimated rural population of population of 4.8 million) 5.1 million) a/ Some double counting has taken place as a number of Geological Survey Department boreholes are operating in areas also served by Ministry of Community Development supplies. b/ The 1966 population census noted that 3.2 percent of the total popula- tion was located in trading centers, estates, missions and government stations. For estimating purposes, it is assumed that the same percen- tage will remain in these locations and that they have a water supply service. Source: Updated by Government of Malawi from Republic of Malawi Water Supply and Sewerage Sector Study, Report, World Health Organization/World Bank Coordinated Programs, 1978, Vol. 1, p. 22.  - 38 - 84. The construction of self-help gravity fed systems in Malawi has generated worldwide interest. The first such project was completed in the Chingale area in 1968, and served 5,000 people in 15 villages. A pure water source is identified on a mountain slope, usually inside a forest reserve where there is no human habitation or pollution. The Government supplies the necessary pipes, building materials and hardware, but the people them- selves dig the trenches to lay the pipes. The key to the success of these projects is the involvement of the whole community and the setting up of a local committee to allocate the work between the villages and to ensure that each family does its share. The decision to undertake a project is made by the villages concerned, and the committee has the authority of the chiefs, the village headman and the people. The largest such project, Zomba East, now under construction, will serve 100,000 people through 700 taps and 300 miles of pipe. The number of people served by such systems is expected to increase from 250,000 in 1977 to nearly 700,000 by 1980, and between 2 and 3 million people (depending upon the availability of adequate water sources) by 1990. 85. The construction of protected shallow wells was begun in 1977-78 with a target of 5,000 wells to be completed by 1980. These are also con- structed on a self-help basis, with a village or community commitment, and an implementing committee, sometimes the village health committee formed earlier to combat cholera. The local committee is responsible for all the bricks (1,000), sand and labor required to construct the well under the guidance of Ministry of Community Development project staff, and to provide transport for the concrete slab to cover the well, the pump and the eight bags of cement (for construction of the brick well walls) supplied by the Government. Much of Malawi is underlain by a clay aquifer from a depth of about ten feet, and all dimensions of the well except depth are standardized. The Ministry has now developed a polyvinyl chloride pump whose only metal part is the steel flange to connect the pump to the cement well cover. These pumps are extremely durable, need only minimal maintenance which can be carried out by a member of the local committee, and cost only K 20 apiece. The entire cost to the Government of such wells is approximately K 84; each well serves about 100 people. 86. Boreholes, commonly to depths of 100 to 150 feet, but operated by a hand pump, have been the main source of safe rural water to date. These were originially constructed as the "conventional" source of safe water, but are now built only when physical features prevent the gravity or shallow-well solutions. Boreholes are much more expensive than either of the alternative types of rural water development, and are constructed by the Geological Survey Department without a self-help component. The average cost of a borehole and handpump is K 3,400 (about US$4,100), and annual maintenance requires an addi- tional K 60 (about US$72) per annum. 1/ 1/ New drilling equipment may make it possible to lower this initial cost by about one-third.  - 39 - 87. To achieve the goal of provision of universal safe water supplies by 1990, the WHO/World Bank Cooperative Project team has estimated will cost about K 42 million (US$50 million) for urban areas and K 43 to 47 million (about US$55 million) for rural areas, over and above projects underway in early 1978. 1/ Both goals appear to be well within the physical implementation capacity of the groups concerned. In rural areas, only the rate of gravity- fed systems would have to expand more rapidly than at present, and then only moderately faster. The goal for urban areas will require providing service for just over one million people, about double the number now served or to be served by projects due for completion in the next several years. As shown in the following table, these estimates assume that approximately 40 percent of urban dwellers will have house connections, another 27 percent will have plot connections outside their houses, and the remaining one-third will obtain their water from public standposts (sales point). Table 12: URBAN WATER SUPPLY SERVICE BY TYPE, 1990 Type of Urban Water Service in 1990 House Connections Plot Connections Standposts Category Population % No. % No. % No. Blantyre 510,000 40 204,000 30 153,000 30 153,000 Lilongwe 220,000 50 110,000 30 66,000 20 44,000 51 Towns 350,000 35 123,000 20 70,000 45 157,000 Total 1,080,000 40 437,000 27 289,000 33 354,000 Source: World Health Organization/World Bank Cooperative Programme, Republic of Malawi Water Supply and Sewerage Sector Study. 88. It is not possible to project the optimum distribution of the growth of rural water supplies between gravity, shallow wells and borehole systems. Table 13: RURAL WATER SUPPLY SERVICE BY TYPE, 1990 Alternate Percentages of Population Served Type of Supply I II III Gravity System 50 40 30 Shallow Well 25 30 35 Borehole 25 30 35 Source: World Health Organization/World Bank Cooperative Programme, ibid. 1/ World Health Organization/World Bank Cooperative Programme, Republic of Malawi Water Supply and Sewerage Sector Study, Vol. 1, pp. 37-43.  - 40 - The table above shows the probable ranges in the form of three alternative percentages of the population served by each type of system. Table 14 shows, for each of the three alternative percentages, the absolute numbers of people that would be served by each of the three types of rural water supply systems, along with the planned rate of annual increase in numbers of persons served by each system between 1977 and 1980, and the annual increase required between 1980 and 1990. This shows that the average number of people receiving service for the first time will have to increase by about 443,000 per year during the 1980s or about 13 percent more than the annual increase for 1977-80. Table 14: RURAL POPULATION TO BE SERVED (thousands) By 1990 By 1980 I II III Increase Increase Increase Increase Type of Supply No. Per Year No. Per Year No. Per Year No. Per Year Gravity System 679 136 3,250 257 2,600 192 1,950 127 Shallow Well 500 167 1,625 113 1,950 145 2,275 178 Borehole 900 90 1,625 73 1,950 106 2,275 138 Total 2,079 393 6,500 443 6,500 443 6,500 443 Source: World Health Organization/World Bank Cooperative Programme, ibid. 89. In urban areas, the water supply systems are self-supporting, including capital recovery, in Blantyre and Lilongwe. The small town systems operated at a small collective deficit (about K 60,000) in 1978. Expansion of urban systems to 100 percent coverage may present financial problems, however, to many poorer people who are not now served. In Blantyre, the largest of the systems, those with house connections pay K 1.25 per 1,500 gallons, which is about the amount (50 gallons per day) consumed by the average low-income family with a house connection. Homes and businesses which use larger quantities pay at an increasing marginal rate, at K 1.40 per 1,000 gallon for the next 5,000 gallons and K 1.65 per 1,000 gallons for amounts over 6,500 gallons. Some low-income areas are served by public standpost sales points, at which water is sold at 8 gallons per tambala (K 1.0 per 800 gallons). People who must carry water (e.g., from public sales points) usually consume about 6 gallons per person per day. This would entail 4 to 5 tambala per day for the typical urban family, or 10 percent or more of the pay of a low-income urban worker. Water from a connection would be only about half as expensive, but is discouraged by the full-cost connection charge (about K 80, including K 30 for the cost of the water meters). Various financing schemes to encourage house connections, such as drastically reducing the connection charge and adding surcharges (perhaps K 0.10 per 1,000 gallons) to the existing water rate, are being considered. It is generally accepted that even poor people should pay the cost of their water service in order to discourage urban population growth.  - 41 - 90. In towns served by the Ministry of Supplies and Works (urban areas other than Blantyre and Lilongwe), the charge for water from private connec- tions is only K 0.70 per 1,000 gallons. A high proportion of residents in these smaller towns cannot afford the cost of a private water connection, although they could pay the subsequent monthly charges for water consumed. Here again some method of drastically reducing the connection charge and capitalizing it over time is desirable. Public sales points could be estab- lished to serve those who cannot afford the connection charge, or who live too far from a water main to get a connection. 91. In rural areas, water is free. In the case of gravity systems and shallow wells, this policy is justified by the large self-help labor component and by extremely low maintenance charges. The per capita installation cost (exclusive of self-help labor) of gravity piped systems is about K 6.1 per person served (assuming 160 persons per tap and 6 gallons per person per day), and maintenance costs are virtually nil, generally only replacement of tap washers and occasional repairs of bursts, using materials left over from con- struction. The construction cost of shallow wells is somewhat less than K 1.0 per person served, and again maintenance costs are small. Borehole costs are considerably higher and no self-help labor is involved, so that charges would be much more acceptable to the beneficiaries. Even in these systems, however, the per capita cost is only about K 6 to K 7 for persons served (averaging 300 per borehole), and the annual per capita maintenance cost comes to only K 0.2 per person, or somewhat more than K 1.0 per family. Some charges for borehole water users might be appropriate now, and might be appropriate for other rural water in the future if purification of gravity system water becomes necessary and shallow well monitoring and treatment become more expensive. On the other hand, the amounts are sufficiently small that these costs might be supported as a charge to the central Government on behalf of rural residents, especially since the capital costs of rural water schemes are largely financed by grants and loans from foreign donors and since many urban dwellers receive much larger subsidies for housing. Sanitation 92. Waterborne sewerage systems serve only parts of Blantyre, Lilongwe and Zomba. Overall, these three systems serve about 15 percent of the total urban population. In other areas septic tanks or pit latrines are used. Within Blantyre, it is estimated that 15 percent of premises are connected to service (mostly in the high density city centers and one housing area), another 27 percent have septic tanks and 58 percent pit latrines. Projects are now underway totalling about K 3 million to expand and extend the overloaded Blantyre system and to provide sewerage for the town of Liwonde. In most other urban areas lot sizes are adequate and densities are low enough to continue to deal with human waste by means of septic tanks and pit latrines for many years to come. One problem has been inadequate numbers of septic tank cleaning services, and people have tended to build new tanks rather than clean out old ones. Municipal cleaning services with tanker vehicles are estimated to cost about K 5 to K 10 per year per tank. 1/ 1/ World Health Organization/World Bank Cooperative Program Report, op. cit., pp. 29-30.  - 42 - 93. Interest in rural sanitation greatly increased following an outbreak of cholera in Malawi (its first occurrence there) in September 1973. As a result of health education and promotion work by the Ministries of Health and Community Development, a very high proportion of rural homes now have pit latrines. Health inspectors also now check, but mostly in urban rather than in rural areas, for sanitation hazards. The effectiveness of such measures is suggested by the decline of laboratory-confirmed cholera cases from 1,870 in 1974 to 186 in 1978. Suspected deaths due to cholera have decreased from 856 to 17 in the same years. Intestinal schistosomiasis is still prevalent in irrigated agricultural areas however, and more intensive rural education efforts are required. With such an educational effort, and with an expansion in numbers of health inspectors to advise on well and latrine locations, to maintain water quality surveillance, and to monitor epidemiological data to identify problem locations, a high standard of rural sanitation and safe water supplies can be achieved using present systems. Housing 94. In rural areas and small towns, families are able to construct ade- quate housing structures with only their own labor and freely available local materials. Basic needs problems in housing have been limited primarily to those of access to safe water and sanitation. Land is free, allocated by the chiefs or village headmen. Housing in these areas has traditionally been created by building a round frame of branches or sticks which is plastered by mud and topped with a thatched roof. There has recently been a shift toward larger square houses built with sun-dried brick, with a thatched roof sup- ported by a ridge pole and frame. These houses still require no cash outlay unless they are fitted with glass windows and frames or other "extras." 95. In these circumstances, the provision of adequate shelter to meet basic needs is primarily a matter of safe water supplies plus education about the health requirements for adequate ventilation, the separation of human and animal quarters, and the safe disposal of human wastes. An additional aspect may be location, not only access to a water tap or protected well, but also to schools, health clinics, markets or other facilities. For some villages or parts of villages such access may be cut off during the rainy season by unbridged streams or rivers, or the distances may be too great. As already noted, health education since the cholera outbreak of 1973 has resulted in most rural houses now having pit latrines. Health inspectors now test water quality and check that latrines meet sanitary requirements in some areas, though primarily in and around urban centers. 96. Housing is thus a "basic need" problem in Malawi primarily for the nine percent of the population who live in urban areas, plus perhaps a small additional percentage who live on customary land in rural areas surrounding urban centers and who spend considerable time commuting daily to jobs in these centers. New urban housing since independence has basically been of four types. The smallest category consists of private commercial construction usually financed by firms through the new Building Society. Then there is a category of "permanent" housing put up by two government agencies--the Malawi Housing Corporation (MHC) and the Capital City Development Corporation  - 43 - (CCDC), the greater part of which is rented out to civil servants. The third category of urban housing is that in "traditional housing areas" (THAs), a type of site and services development. The final category of housing, in- creasing in volume in recent years and now probably the largest, is squatter and unplanned units. While the problem of shelter is therefore, or as above described, not an acute basic needs problem in the rural sector, it is a potential problem in the urban sector. While only 9 percent of the country is urban, the urban population is expanding at about 8 percent per annum. Blantyre, together with Lilongwe represent about 70 percent of the urban population with a network of six other towns recording populations over 10,000. Development programs ongoing and targeted for some of the regional secondary centers coupled with a high population growth rate of 2.9 percent are contributing to average growth rates for the smaller urban centers ranging between 6 percent and 23 percent. 97. The basic exposition of the Government's housing policy is contained in the Statement of Development Policies 1971-1980. It identifies the problems of rapid urbanization, an increase in squatting, and the shortage of funds for new housing. The Government's policy prescriptions are to concentrate resources for public housing in urban areas and to expand THA development. 98. The development of THA has been the cornerstone of Malawi's housing policy over the past decade and is implemented through a number of channels including the MHC, CCDC, the Building Society and the Ministry of Works. MHC was established in 1964 to undertake development, construction and manage- ment of houses and housing estates throughout the country on a commercial basis. It caters to the housing needs of the commercial, private, industrial and public sectors, but concentrates its resources on medium- and low-cost housing development in urban areas. Acting for the Government, MHC con- structs and manages THAs for the mass of people who cannot afford housing of permanent materials (fired bricks and concrete flooring). The CCDC plays a similar role for Lilongwe. A plot in such an area is surveyed and marked, and ranges from 432 square yards to 540 square yards. Plots are furnished with a concrete slab-covered pit latrine, roads are gravelled, and until recently water has been distributed by a kiosk system. Electricity is not provided. For a small fee, individual connections for water are provided at the request of the plotholder. Waiting lists for the THA program are a on a first-come-first-served basis. Once a plot is allocated, construction must begin within six months or the plot is reassigned to another applicant. The MHC register for plots in these areas indicates well over 17,000 applicants are waiting for plots. (Over 9,000 in Lilongwe alone.) In recent years MHC has not been able to expand its operations to keep up with demand because of lack of resources. 99. Malawi is remarkably free from the notorious squatters' housing that blights many major cities in developing countries. Nevertheless, with MHC's annual production declining, development of squatter or "unplanned" settlements is on the increase, although confined chiefly to Blantyre. About 15 percent of the housing stock in Blantyre is considered illegal, and is located mainly in one unplanned area, Ndirande, with a population of about 50,000. In Lilongwe, there is also one major unplanned area, the Kawale Market neigh- borhood, located in the old city. In contrast with squatter areas in many  - 44 - other countries, much of the housing in these areas is of brick similar to that constructed on site and services plots. The unplanned areas differ markedly from THAs in lacking utility and infrastructural services and having a much higher density of dwelling units. Several years ago, the Government began to raze a few houses in the Ndirande area to clear areas for sites and services and housing development, but that was soon halted by protests that good housing was being needlessly torn down. Current thinking is to provide these areas with roads, water and perhaps other community facilities and to enforce sanitation codes, but to tear down only the minimum necessary number of houses for the construction of roads and other infrastructure. 100. Until recently, MHC construction of permanent housing and sites and services plots (aside from construction under contract for corporations) was limited to the Blantyre, Zomba and Lilongwe areas. Now units are either under construction or being planned for a number of urban centers in more than half of Malawi's 24 districts. The largest number of completed and planned units in these new centers are located in Mzuzu, Kasungu and Balaka. While housing problems are less severe in these smaller centers, it is felt that some construction of service plots and housing is desirable in order to stimulate development of these smaller centers, disperse growth and urbaniza- tion over a number of centers, and to provide more systematically for water, sanitation and other utilities. 101. Two related problems now face Malawi's housing policy, each of which has important implications for basic needs. One is the substantial subsidy elements involved in MHC and to a lesser extent in CCDC housing and the significant variation in the amount of subsidy to different types of housing. The second is that urban housing construction has been lagging far behind demand and growth of the urban population resulting in overcrowding and long commuting times. 102. The types of MHC and CCDC constructed houses range from a small number of relatively large units designated Class A and B, to progressively smaller C, D, E and F classes. MHC owns less than two dozen A and B units, and now builds these only on order for CCDC or parastatal or business organi- zations. Class C houses have 975 to 1,163 square feet of floor space and contain three bedrooms, a living room, bathroom, kitchen, either a dining room or a carport, and servants quarters. Class D houses range from 975 to 1,018 square feet, and are comparable to Class C houses except they have no servants quarters. Class E houses are 677 to 951 square feet, and have either two or three bedrooms, living room, kitchen and bath with cold but not hot running water. These houses also have iron roofs and no ceilings to pro- vide insulation. Class F houses range in size from 534 to 664 square feet and are similar to Class E houses except that they have only one bedroom. 103. Information on lot sizes was not obtained, but they are fairly large. Class B and C houses in Lilongwe are built on 1.2 acres. MHC sites and service projects were initially on 40 foot by 100 foot plots, but the front was subsequently expanded to 50 feet and then to 60 feet. CCDC development costs have been averaging K 1,120 per acre for landscaping, including road- sides, open spaces and several trees per plot.  - 45 - 104. The basis for charging rents on permanent housing was established in 1967 according to a simple formula relating charges to size and facili- ties provided. However, the present day rents are completely out of line with construction costs with the result that new units are heavily subsidized. Some indication of the scale of subsidies is given in table 15, which reflects MHC calculations of the levels of rents being paid in 1977 and the levels that would have to be paid to cover MHC's economic costs. If the cost of land were included, which MHC estimates is at least K 4,000 per acre in Lilongwe, rents would have to be even higher. Building costs have been rising about 15 percent a year since 1977, and so are correspondingly higher than the 1977 averages in table 15. 105. In recent months, MHC has been able to collect economic rent on the few Class A and B houses. For Class C and D houses, it has been able to collect rent of up to K 210 and K 150, respectively, from private tenants. The Government, reportedly may agree to pay the same rent on houses occupied by government employees, although the government employees would presumably continue to pay only 10 percent of their salary as rent. Thus the amount of government subsidy would remain the same, but would be charged to employee compensation rather than be borne by MHC. Rents on the more modest Class E and F houses have remained the same and in fact are only about equal to the annual city council property taxes (average of 2 percent of construction costs) which is paid by MHC, on such houses. Thus, the entire capital and maintenance costs of such houses are subsidized. 106. Construction costs of CCDC are substantially higher than for MHC, reportedly because CCDC does not receive subsidies as reimbursements for certain of its construction costs as does MHC. 1/ Also, CCDC does not do construction but rather hires private contractors or MHC to prepare land and build roads, houses and other facilities. CCDC contract costs for C and B level houses in 1977/78.ranged from K 33,800 for the small C class houses to K 73,460 for Bl (cabinet minister's) housing. 2/ 1/ For example, MHC is reimbursed by the Government for use of some of its own equipment in construction. 2/ The basic building construction costs ranged from K 24,300 to K 58,000. Additional costs included professional fees (10 percent), K 4,000 per acre of land, K 1,200 per acre for landscaping of developments, and finance charges.  Table 15: ECONOMIC RENTS, MHC PERMANENT HOUSING (1977 averages, all figures in Kwacha) 2/ 3/ Type of 1977 Rent per Mfonth- Economic Rent per Montht by Interest Rates2' llouse Value- N1in'iwum Otnximum 6% 8% 9% 11% 4/ A 36,000 250.00 300.00- 357.70 406.16 433.06 484.76 14/ B 30,000 103.45 200.00- 294.65 335.00 356.25 400.50 C 17,600 51.05 q96.9f / 177.03 200.7C 213.16 2.,.13 4/ D 14,500 35.40 46.75-/ 146.58 166.08 176.35 197.9/4 E/4. 8,500 14.35 25.00 87.65 99.08 105.10 117.64 F/3 7,100 14.35 25.00 72.23 83;45 88.48 98.95 F/2 6,300 B.70 14.60 66.88 74.52 78.98 98.27 1/ Cost-basis to MHC, excluding value of land and reimbursed expenses. 2/ Varies depending upon floor space and inside facilities. 3/ MHC borrowing costs range up to 9-1/2 percent, and now average about 8-1/2 percent. These economic rent calculations take account of principal and interest repayment over a period of 30 years plus annual maintenance costs of 2-1/2 percent, City Council property tax rates averaging 2 percent of the value of property to cover refuse collection, maintenance of roads and other services, and 2 percent for MHC administrative costs for rent collec- tion, inspection, etc. 4/ In 1979 MHC received "economic" rents on A and B houses, and rents from private tenants of up to K 210 per month for Class C and K 150 per month for Class D houses. MHC is seeking the same economic rents on Class C and D houses from the Government. The rent schedule on E and F houses is unchanged. Government servants pay only 10 percent of their salary as rent, and the Government pays any additional amount due to MHC or CCDC. Source: Malawi Housing Corporation.  - 47 - 107. There is also a more modest subsidy on sites and services plots. As shown in table 16, MHC capital cost per sites and services plot have recently been about K 210 to K 220, to which should be added modest amounts of central staff overhead. MHC staff estimated that in mid-1979 the average cost had increased to about K 240-250 due to inflation. As indicated by the cost breakdown, nearly 90 percent of that cost was accounted for by roads and water mains. In addition to this initial capital cost, MHC has annual current costs to operate, supervise and maintain sites and services project areas. These costs averaged slightly more than K 20 per lot in 1977. The MHC estimates that by the end of 1979, with plots being developed in many new areas, proper control and maintenance would cost approximately K 30 per plot per annum. To recover an annual maintenance and operating cost of K 30 per year, and to amortize a K 240 initial capital cost over a 20-year period at 9.5 percent interest, would require a monthly plot rent of K 4.77 per month, or K 57.24 per year. As compared with the economic level of rent, rents on MHC plots now range from K 2.5 to K 16 per year, or less than MHC's annual recurrent costs for existing plots. Rents on MHC plots are in two parts: K 2 per annum land rent plus an additional charge depending upon the size and type construc- tion of structure built. This additional charge ranges from K 0.50 per annum for a traditional construction house of less than 300 square feet to K 14 per annum for a semipermanent or permanent construction house with more than 900 square feet of floor space. Since a traditional house can be built on these plots in conformance with the minimum building standards requirements for K 80 to K 100, most urban households should be able to afford existing housing and land rents, and most could even afford economic rents if financed over 20 years. 108. The amount of subsidy on sites and services projects is modest com- pared to that on government constructed housing, and superficially seems justified on the grounds that this is the housing which is presumably serving the needs of the poorest, or at least those poorer than the occupants of Government housing. The Government is now analyzing the results of a survey of the incomes of persons renting sites and service projects from MHC, and of all the persons living on such plots if different from or additional to the MHC tenant. The results of that survey are not yet available, but on the basis of a preliminary pilot test, it appears that about 90 percent of plot holders are also landlords, either renting out the entire house or renting out rooms. In some cases the plot holder rents all the rooms to about ten tenants, each of whom pays about K 5 per month. Such plot holders receive rents of K 600 per year, or more than 40 times the maximum rent of K 16 per year which MHC can collect. The re-renting of houses and number of occupants is not controlled in practice by MHC, although they have certain legal powers to do so, partly because of the severe shortage of and demand for housing. Some plot holders have also constructed more than one house per plot. MHC is trying to prevent anymore overbuilding, but does not penalize those who have already done this, again partly because of the acute shortage of urban housing.  Table 16: CONSTRUCTION COSTS PER PLOT, SELECTED SITES AND SERVICES PROJECTS (Kwacha) tNIC, 1978 MIlC, S. Lunztu, CCDC-4 E:pcnd.t.urrn average costs 1978/79, 4450 unlts 1978179 Surveyin g/ 6.4 7.75 20.77 Road Construction, including culverts 100.8 81.70 I6 1. (/ WN'ater rcticulAtion, including sales point 2/ 84.5 117.8 50.00 Pit latrines-/ 18.3 13.51 20).O0 210.0 220.82 251.77 Landscapin. 15.00 Gravelling and bitumenization of. main roads 100.00 366.77 1/ Includes block beaconing, plot staking, and tests to determine suitability for pit latrines. 2/ Includes all water mains and pipes exclusive of individual plot connections, for which extra charges are made. 3/ Includes excavation of pit and concrete slab top. 4/ CCDC says its costs are higher because it does not receive certain subsidies received by MHC. 5/ This figure for CCDC covers costs of dirt roads only. Source: MHC and CCDC.  - 49 - 109. Another aspect of the subsidy for government housing is the quality standards which determine its costs, such as construction standards, size and facilities. Per capita GNP in Malawi was about K 117 in 1977, or K 702 for a family of six. The cheapest F2 house costs MHC about K 6,300 to construct, or roughly nine times per household GNP. The rule of thumb that capital costs of housing should not exceed 2.5 times family income 1/ means that only those Malawians with income levels nearly four times the national average could afford to pay the economic cost of the financial cost to MHC of an F2 house, constructed with economies of scale, without profit to MHC, and with no charge for the land. This does not mean that Malawi should not construct F2 or more expensive houses, but it does indicate that only a small proportion of the population can afford to pay the economic cost of such houses. This suggests that most government resources should go into creating more sites and service plots. In addition, improvement of infrastructure in existing squatter areas could also bring up to minimally adequate basic needs standards housing that people have been able to afford. On the other hand, permanent housing construction of the B through F grades is needed in order to meet the needs of those who can afford it, and to hold in the govern- ment service and in the private sector Malawi's key trained work force, people who have options of emigrating to good paying jobs in other countries. Thus, the choice is not between different size and quality of housing, but of main- taining a balance, and of deciding how much subsidy should be given to what type of housing. 110. Another option that might relieve the subsidy problem would be to encourage more private construction of housing, which is a by-product of sites and services developments. Proposals to encourage private construction by offering income tax forgiveness for the value of actual or imputed rents amount, of course, to a different type of subsidy that might or might not be as expensive or effective as alternative types of subsidies. Low-cost rental housing is clearly needed, as indicated by the large numbers of renters living in overcrowded conditions on sites and services plots, and income tax subsidies might be one way to encourage more construction of suitable rental units. 111. A less perfect but interesting indicator of the shortage of urban housing is the growth of waiting lists for housing and service plots. CCDC reports that it now has a waiting list of 12,000 persons seeking either permanent housing or service plots in Lilongwe. The annual growth of MHC's waiting lists, as well as the annual numbers of MHC permanent houses and service plots are presented in table 17. This shows an MHC waiting list of 25,000 for permanent housing at the end of 1978, and of 17,000 for plots. Including CCDC's waiting list of 12,000, this is a total of 54,000 units. This is twice as large as the total stock of MHC's approximately 28,000 units, of which 9,300 are permanent housing and 18,700 are service plots. MHC achieved new highs in the number of permanent houses constructed and in-service plots completed in 1978, and for the first time the size of the waiting list for service plots did not increase. As indicated by the pilot 1/ This results in expenditures of 20-25 percent of annual income on housing if amortized over a 25-year period.  Table 17: MALAWI HOUSING CORPORATION--INCREMENTS IN NUMBERS OF AND WAITING LISTS FOR PERMANENT HOUSING AND SITES AND SERVICES PLOTS 1971 1972 1973 1974 1.975 1976 1977 1'478 Nu:;nleu o(f PerIU1rnant IouSeS 5,776 6,307 6,645 7,307 7,794 3,148 8,528 9,350 AnImal 111Ctu 1., t. 531 338 662 487 354 380 822 '.iILIu4, I.iS:~; for Perinannit Ilous3.en 7,739. 10,100 1-2,300 14,300 17,000 19,853 23,161 25,200 .A.nnri In l:.~...... tnCn~ .. 2,361 2,200 2,000 2,700 2,853 3,308 2,039 Clll.21; of Sif:e:i Servicer' Plots 5,582; 6,266 6,752 7,797 8,600 11,731 14,290 18,700 Ai:intl InCreliCoit 684 486 1,045 803 3,131 2,559 4,410 Waiting l.ist, :;ites &%Services 6,094 7,800 8,400 10,000 10,699 15,06'. 17,312 17,200 , A;nU.C1 I1nCrelneit 1,706 600 1,600 699 4,365 2,248 -112 1 Source: hl .lwi l1outing Corpqrntlon Annual- Reports, 1977 and earlier years, plus 1978 data.  - 51 - survey of service plot residents, a sizable number of these requests may come from people hoping to profit from renting out housing obtained from MHC. Because of the money to be made from renting such houses, there are most likely persons who have applied for more than one house or lot, although MHC is screening applicants to try to prevent this. Assessment of the Housing Sector 112. As mentioned above the sites and services schemes have been an important element of Malawi's housing policy. The THA development, success- fully implemented over the past decade should continue to be emphasized and expanded since this is where the need is greatest, the costs low and the implementing machinery efficient. For the Government to continue present policies of subsidizing permanent housing, is clearly unsatisfactory since it serves only a minority of those needing housing, and many of those who are the poorest live in seriously overcrowded housing and pay a private landlord substantially more for sharing one room with others than the landlord pays to MHC for his entire plot. Others of the poor live in squatter areas under probably no better conditions, although no empirical survey data are avail- able. Still others of the poor live outside urban areas but commute long distances on foot or bicycle to urban jobs. A partial and necessary solution would appear to be to sharply reduce or eliminate subsidies on urban housing in order to have more budget funds to permit MHC (and CCDC) to attempt to triple their rates of housing and service plot construction as appears to be required. The MHC Annual Report for 1977 calculates that if urban popula- tion, as predicted, grows from less than 600,000 people in 1977 to 1.9 million in the year 2000, the cumulative number of housing units required annually would be approximately 16,000, in order to replace existing obsolescent units and house the expanded population. This contrasts with record levels of 4,410 new service plots and 822 permanent houses in 1978. 113. Even if housing subsidies were to be eliminated, it might be diffi- cult for MHC and CCDC to efficiently supervise the construction of such a large building program. Elimination of subsidies, however, might also make it possible for private contractors to compete in the building and selling of houses. At present, with MHC and CCDC benefitting from free land and other government support, and with most of their units being rented out at heavily subsidized rates, private contractors have not been able to build and sell houses in competition with the Government. Private construction firms have essentially been limited to commercial and industrial construction, plus small contractors and craftsmen who have built houses on service plots or in squatter areas. 114. The most fundamental question, however, is how the Government wants to use its limited resources, and the levels of taxation it wants to impose. Housing is clearly a major problem in urban areas, especially but not solely for the poor. How much of the government budget should be allocated to water, sanitation, roads, community facilities and other housing-community amenities, who should be the recipients, and how much of the government expenditures can be recovered through charges? How should housing expenditures and subsidies  - 52 - compare with government outlays for health, education and other expenditures, and on specifically what kinds of programs to reach what target groups in the population should each of these expenditures be made? These are the questions that ultimately must be answered by the Government and people of Malawi in light of the best available information about the direct and indirect benefits of, and complementarities between, various types and levels of each category of expenditure in order to yield an efficient strategy and program.  - 53 - ANNEX I Charts for Intercountry Comparisons 1. Life Expectancy and Income per Capita, All LDCs and Africa South of Sahara 2. Crude Birth Rate and Income per Capita, All LDCs and Africa South of Sahara 3. Infant Mortality Rate and Income per Capita, All LDCs and Africa South of Sahara 4. Child Death Rate and Income per Capita, All LDCs and Africa South of Sahara 5. Calorie Intake (% of Requirements) and Income per Capita, All LDCs and Africa South of Sahara 6. Access to Safe Water and Income per Capita, All LDCs and Africa South of Sahara 7. Primary Enrollment and Income per Capita, All LDCs and Africa South of Sahara 8. Female Enrollments and Income per Capita, All LDCs and Africa South of Sahara 9. Secondary Enrollments and Income per Capita, All LDCs and Africa South of Sahara 10. Population per Physician and Income per Capita, All LDCs and Africa South of Sahara 11. Population per Nurse and Income per Capita, All LDCs and Africa South of Sahara 12. Adult Literacy and Income per Capita, All LDCs and Africa South of Sahara 13. Income Distribution (Highest 5%) and Income per Capita, All LDCs and Africa South of Sahara 14. Income Distribution (Lowest 20%) and Income per Capita, All LDCs and Africa South of Sahara 15. Table: Comparison of Basic Needs Indicators--Africa South of Sahara Ranked by per Capita Income  LIFE EXPECTRNCY AND INCOME PER CRPITR Chart 1 70,.0 Page 54 67.5 All Countries 65.0 62.5 60.0 Africa South 57.5 / of Sahara 55 .0 Uganda L) Kenya cL 52.5- // Cz - Tanzania C-a) - 310 Les, 0Ghana L 50.0 Liberia 475 Niger 47 .5 Lii_ Congo L _ X Ivory Coast 45.0 B Rwanda ~ ffi Guinea Zaire X Guinea Malawi _ fi-Somalia, Chad Si 42. 5 Niger Sierre Leone _ sX Senegal Benin -Ma'l Hauritania Madagascar Upper Volta C.A.E. 40.0 Sudan Togo X Ethiopia Cameroon 37.5 _ 35.0 LILL1 _ LJ-1LL.1 IL 1 LL1 LI L;I .0 4 00 .0 0(1. O 1200 .0 1 600 .0 2000 .0 I NLC .IIf HLPE CRF' .1 TH I ( i77 )  CRUDE BIRTH RRTE AND INCOME PER CAPITA Chart 2 Page 55 54.0 Malawi 52.0 - 3-, Niger Rwanda -X( X- )KLiberia Togo Kenya Zambia of Sahara Mauritania Nigeria s50.0 _ 3Ivory Coast Benin Li -x >< > )K Senegal f Ethiopia CC Som la' Tanzania ry 48 .0 G Ghanp Upper Volta '-' 05e-~3(Burundi __ Zaire Guinea 46.0 _ W/ X4( Congo LJi Sierre Leone D ." _ X % oMadagascar Uganda U _ Chad Sudan 44.0 - .A.E. X- \ Cameroon 42.0 X) Lesotho A \All Countries 40-0 .