Malawi - Health Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 4 3 4 2 -MAI STAFF APPRAISAL REPORT REPUBLIC OF MALAWI HEALTH PROJECT March 24, 1983 Population, Health and Nutrition Department 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 authorizationi.  CURRENCY EQUIVALENTS Currency Unit = Malawi Kwacha (K) SDR-1.00 = US'1.0995 (Feb. 28, 1983) US$1.00 = K1.10 K1.00 = US$0.91 METRIC EQUIVALENTS 1 metre = 39.37 inches 1 kilometer = 0.62 miles 1 sq. kilometer = 0.39 sq. miles ACRONYMS CMS - Central Medical Stores EDF - European Development Fund FUA - Fund Units of Account (African Development Bank) IBRD - International Bank for Reconstruction and Rural Development IDA - International Development Association IMF - International Monetary Fund IUD - Intra-Uterine Device MCH - Maternal and Child Health MOR - Ministry of Health MOWS - Ministry of Works and Supplies PHAM - Private Hospitals Association of Malawi PHC - Primary Health Care UNDP - United Nations Development Programme UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Children's Fund WHO - World Health Organization GOVERNMENT FISCAL YEAR April 1- March 31 This report is based on the findings of an Appraisal Mission comprising Messrs. H.M. Jones, V. Jagdish, V. Kumar and D.M. de Ferranti (IDA) and F.H.H. Walker (consultant) which visited Malawi in July 1982. Mr. E.M. Schebeck participated in concluding discussions.  FOR OFFICIAL USE ONLY REPUBLIC OF MALAWI DEFINITIONS Crude Birth Rate Number of births per 1,000 population in a given year. Crude Death Rate Number of deaths per 1,000 population in a given year. Rate of Natural Increase Rate at which a population is increasing (or decreasing) in a given year due to a surplus (or deficit) of births over deaths, expressed as a percentage of the base population. Fertility Actual reproductive performance of an indivi- dual, a couple, a group, or a population. Total Fertility Rate Average number of children that would be born alive to a woman (or group of women) during her lifetime if she were to pass through her childbearing years conforming to the age- specific fertility rates of a given year. Incidence Number of cases of a given disease which come into being during a specified period of time, that is the frequency of events, usually ex- pressed as the numbr of cases per specified unit (e.g., 1,000) population. Infant Mortality Rate Number of deaths of infants under one year of age *in a given year per 1,000 live births in that year. Child Mortality Rate Number of deaths in children one to four years of age per 1,000 children one year of age in a given year. Life Expectancy at Birth Average number of years an infant will live if the current age-specific mortality trends prevailing at the time of birth were to con- tinue. 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.  I~~~  REPUBLIC OF MALAWI BASIC DATA General Area (including lake) 118,500 sq.km. Area (land only) 94,300 sq.km. Population (1981) 6.1 million GNP Per Caput (1981) US$200 Annual Growth Rate of Population (1966-77) 2.9 % Health Birth Rate/1000 population (1977) 52 Death Rate/1000 population (1977) 27 Infant Mortality Rate/1OO live births (1975) 190 Total Fertility Rate 7.5 Life Expectancy (years) (1970-75) Males 40.5 Females 41.8 Population 14 years and younger (1977) 46 % Doctor/Population Ratio (1980) 1:43,262 Nurse/Population Ratio (1980) 1:4,245 Hospital Bed/Population Ratio 1:840 Central Government Expenditures on Health as Percentage of Total Government Expen- ditures (FY 1980-81): - Capital - - Recurrent 3.9 % - Total 3.9 % Percentage of Births Supervised (1979) about 40 % Percentage of Pregnant Women Receiving Antenatal Care (1979) about 66 %   REPUBLIC OF MALAWI FIRST HEALTH PROJECT Table of Contents Page No. I. SOCIO-ECONOMIC BACKGROUND 1 A. Geographical and Socio-Economic Situation 1 B. Demographic Situation 2 II. THE HEALTH SECTOR 2 A. Health Status 2 B. Health and Population Policy and Planning 4 C. Administration, Staffing and Major Programs 5 D. Financing and Costs of Health Services 10 E. Bank Group Involvement in Health and Population 11 F. External Assistance 12 G. Problems and Directions 13 III. THE PROJECT 14 A. Concept, Design and Objectives 14 B. Summary Project Description 15 C. Detailed Project Description 17 IV. PROJECT COSTS AND FINANCING 27 A. Costs 27 B. Financing 27 C. Procurement 29 D. Disbursements 32 E. Accounts and Audit 32 V. PROJECT IMPLEMENTATION 33 A. Organization and Management 33 B. Monitoring and Reporting 33 VI. PROJECT BENEFITS, JUSTIFICATION AND RISKS 34 VII. ASSURANCES AND RECOMMENDATIONS 37  Table of Contents (Continued) ANNEXES 1 Consultant Services: Summary Terms of Reference 2 Summary of Primary Health Care Strategy and Program TABLES 1 Ten Leading Causes of Morbidity of First Visit Out-Patients (All Facilities) 1978 and 1979 2 Eleven Leading Causes of Mortality of All In-Patients of All Ages, 1978 and 1979 3 Administration of Health Sub-Centers, Maternities and Dispensaries 4 Distribution of Expenditure in the Health Sector 1980/81 5 MOH Share of Government Expenditure on Revenue Account 6 Percentage Distribution of MOH Revenue Account 7 Estimated Costs by Component and Year 8 Estimated Costs by Expenditure Category and Year 9 Estimated Costs by Expenditure Category and Component 10 Disbursement Schedule CHARTS 1 Organization of the Ministry of Health 2 Implementation Chart - Adminis.tration and Planning Component 3 Implementation Chart - Community Health Sciences Unit 4 Implementation Chart - Pharmaceutical Procurement and Distribution 5 Implementation Chart - Primary Health Care 6 Implementation Chart - Child Spacing MAP IBRD 16734 - Malawi, Showing Location of Project Districts SELECTED DOCUMENTS AVAILABLE IN THE PROJECT FILE - Report of a Mission to Malawi to Review Existing Laboratory Ser- vices and to Make Recommendations for the Setting up of a Central Public Health Laboratory, WHO, March 1981 - Feasibility Study for the Foundation of a Medical School in Malawi, WHO/UNDP, September 1981 - Health Sector Review, IBRD, November 1981 - The Demography of Malawi, IBRD, December 1981 - Guidelines for the Development of Primary Health Care, WHO/UNICEF, January 1982 - Plan of Work and Implementation of Primary Health Care in Malawi, Ministry of Health, July 1982 - The Pharmaceutical System in Malawi, IBRD, August 1982 - Malawi Child Spacing Plan, Ministry of Health, January 1983  I. SOCIO-ECONOMIC BACKGROUND A. Geographical and Socio-Economic Situation 1.01 With a land area of 94,300 sq.km. and a further 24,200 sq.km. covering part of Lake Malawi Malawi is a relatively small country, about the size of Liberia. Administratively, Malawi is divided into three regions each of which is sub-divided into districts. 24 in total. It lies within the tropics (between 90 and 170 south latitude), but the varied topography associated with its position along part of the Great Rift Valley produces wide bio-climatic variations. Much of the Northern Region consists of plateaux from 1,200 to over 2,200 metres high with annual average temperatures varying from only 14WC to 18