Malawi - Human resource development strategy

Report No. 7854-MAI Malawi Human Resource Development Study April 23, 1990 Population and Human Resources Division Southern Africa Department and Population and Human Resources Department Policy, Planning and Research FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURR3CY EQUIVALENTS Currency Units - Malawi Kwacha (MK) 100 Tambala - 1 MK US$1.00 - MK 2.80 MK 1.00 = US $0.36  FOR OMCIUL USE ONLY ACRONYM ADD Agricultural Development District ADMARC Agricultural Development and Marketing Corporation AIDS Acquired Immuno-Deficiency Syndrome CBD Community-Based Distribution CCAH Chitukuko Cha Amayi M'Malawi (Women's Section of the Malawi Congress Party) CDAs Community Development Assistants CMR Child Mortality Rate Co Clinical Officers CPR Contraceptive Prevalence Rate DEMATT The Development of Malawian Traders Trust DEVPOL Statement of Development Policies DPMT Department of Personnel Management and Training EEC European Economic Community ENM Enrolled Nurse Midwives EP&D Economic Planning and Development EPI Expanded Programme of Immunization FA Field Assistant FFS Family Formation Survey (1984) FHA Farm Home Assistant FHH Female Headed Household GDP Gross Domestic Product GOM Government of Malavi HA Health Assistant HIV Human Immunodeficiency Virus HRID Human Resources Institutional Development HSA Health Surveillance Assistants HW Homecraft Workers IDA International Development Association IDRC International Development Research Centre IEC Information, Education and Communication IFAD International Fund for Agricultural Development ILO International Labor Organization IMR Infant Mortality Rate INDEFUND Investment and Development Fund ITF Industrial Training Fund JC Junior Certificate JCE Junior Certificate Examination, MA Medical Assistants MANEB Malawi National Examinations Board MCDE Malawi College of Distance Education MCE Malawi Certificate of Education MCH Maternal and Child 2ealth This document has a restricted distribution and may be used by recipients only in the performancej of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.|  MCS The Ministry of Community Services MEDI The Malawi Entrepreneurship Development Institute HIM Malawi Institute of Management MOA Ministry of Agriculture MOEC Ministry of Education and Culturt MOH Ministry of Health MOL Ministry of Labor MUSCCO The Malawi Union of Savings and Credit Cooperatives NGO Non-Governmental Organization NRC Natural Resource College NRDP National Rural Development Project NSO National Statistical Office NSSA National Sample Survey of Agriculture NUM National Union of Mineworkers ODA Overseas Development Administration PHAM Private Hospital Association of Malawi PHC Primary Health Care PHW Primary Health Workers PSLC Primary School Leaving Certificate PSLE Primary Schoel Leaving Examination READI Rural Enterprises and Agro-business Development Institutions (USAID project) RTS Rural Trade School SACA Smallholder Agricultural Credit Administration SEDOM The Small Enterprise Development Organization of Malawi SIS Small Scale and Informal Sector SME Small and Medium Scale Enterprises SRN State Registered Nurses TBA Traditional Birth Attendants TEBA The Employment Bureau of Africa TEP Temporary Employment Permit TFR Total Fertility Rate UNDP United Nations Development Fund UNICEF United Natitns Children's Fund UNIDO United Nations Industrial Development Organization UNIFEM The United Nations Development Fund for Women VHW Village Health Workers WFP World Food Programme WHO World Health Organization This study was undertaken by a team consisting of Frederick L. Goliaday (Economist and Mission Leader), Joy A. de Beyer (Labor Market Economist), Dr. John Kevany (Nutritionist--Consultant), Marlaine E. Lockheed (EducatorlSociologist), Dr. Anthony Measham (Health Specialist), and John Middleton (Educational Evaluator). The main mission visited Malawi in March, 1988; a three-day workshop was ..eld in Malawi in July 1988 at which early drafts of Chapters II to VI were discussed. We are grateful to the participants from the Ministries of Labor, Education and Culture, Community Services, Health, and Finance, DPMT, EP&D, and the Center for Social Research for their careful reading and constructive comments. The initial drafts of the report were prepared by Frederick Golladay and the final version by Joy de Beyer.  TABLE OF CONTENTS Page No. EXECUTIVE SUM)ARY ..................................... i-xviii I. CHALLENGES AND PRIORITIES ............................. ... 1-18 Introduction ........... .................................. 1 Broad Development Issues and Their Implications for Human Resource Development . . . 2 A Changing Economy .. 2 Population Growth and Policy . . 3 Agricultural Productivity and Food Security . . 4 Employment Generation .. 6 New Markets and How the Human Resource Sectors Can Contribute . ................... 7 Constraints and Strengths ..8............. Priority Actions for Developing Malawi's Human Resources ... 9 Slowing Population Growth .... 9 Reducing Nutritional Stress ......................... . 10 Improving Health .. 11 Improving Water and Sanitation . . 14 Strengthening Education ............. .............. 14 Improving the Flexibility of Vocational and Technical Education and Training . . . .16 Resource Const-aints, Choices and Linkages Across Sectors and Time.. 17 I II~1. POPLTON ............ ........ 19-32 Introduction .............................................. 19 Demographic Trends and Their Implications . . . 19 Population Projections .............................. . 21 Population Planning Ins.tutions and Capacity ... 24 Childspacing ...................... 25 Supply Problems and Constraints . . 26 Recommendations for Extending and Improving the Supply of Childspacing Services ................. 27 Financing the Childspacing Program . . 29 Issues of Demand ............ . .. ..................... 30 III. NUTRITION ............. .........*..33-50 Overview and Perspectives ................................. 33 Nutrition Status ...... 35 Nutrition Among Infants and ChLldren ................ . 35 Maternal Nutrition .............. . . 37 Biological Determinants of Nutritional Status ... 38 Achieving Nutrition Goalss Feasibility and Constraints ... 39 Land Shortage .. .. .......... . . 39 Limited Rural Income Opportunities . . . 40 Labor Constraint and Crop Mix ... 40 Situation of Women ................................... 41  Page No. Access to Health Care and Nutrition Services ......... 42 Access to Other Public Services ...................... 42 Strategies for Improving Nutritional Status ............... 43 National Nutrition Policy ............................ 43 Sectoral Programs .................................... 45 Surveillance ......................................... 45 Targetting Women and Service Delivery ................ 45 Education as a Basis for Behavioral Change ........... 47 Agricultural Credit and Income Support ............... 48 Technology Research and Development .................. 4o Direct Nutrition Support ............................. 49 Long-term Perspectives .................................... 50 IV. IMALTH ................................ ... 4...................... 51-68 Overview .................................................. 51 Key Recommendations .. 51 Key Objectives for Improving Health .. 52 The Health System .. 53 Health Conditions and Their Determinants . . 54 Overall Mortality and Morbidity . . 54 Maternal Mortality and Morbidity . . 54 Undernutrition .. 54 Halaria .............................................. 55 Under Five Mortality .. 57 AIDS ................................................. 57 Adequacy of Health Statistics . . 58 Health Sector Performance .. 59 Infrastructure .................. 59 Utilization of Health Services .. 59 Primary Health Care .. 59 Health Goals and Objectives: Feasibility and Constraints . .. ...... ....... 60 Strategies for Achieving Health Goals .62 Improving Child Survival and Development .62 Improving Maternal Health (Safe Motherhood) .64 Increasing Efficiency in the Health Sector .65 Immediate Decisions. .............. 68 V. EDUCATION.******..*. *** ... . ............................ . 69-89 Overview .................................................. 69 Structure of the Education System ............ 70 Primary Education ...................... 71 Access and Equity .. .......... 71 Quality .................... ....... .. 73 Timing of Instruction ............ 77 Some Suggestions for Innovation . ......... 79 Secondary Education ..0.......... s Access ............ 80 Quality of Secondary Education . ........... 82 Achievement ............ 83 Higher Education ............ 85 Primary Teacher Training ............ 85  Page No. Secondary Teacher Training ............................. 86 Suummary of Main Recommendations ............................. 88 VI. VOCATIOdALITECHNCAL EDUCATION AND TRANING ............... 90-103 Overview - Key Issues ....................................... 90 The Training System ......................................... 91 The Formal Vocational and Technical Education System... 91 Support for Human Resource Development Projects .... 92 The Apprenticeship Pzogram .... 93 Trades Testing .... 94 Employer Training ............... 95 Labor Market Information and Placement Mechanisms . 95 Training Goals and Objectivest Feasibility and Constraints. 95 Demand and Supply Projections . 95 Strategies for Achieving Training Goals . 99 Decentralization .. 99 Labor Market Information ..100 Enterprise Financing and Involvement . 100 Autonomous Training Agency . 101 Annex Table ......................................... 103 VII. THE EMPLOYMENT CHALLENGE FACING MALAI .104-145 Introduction ..... 104 Population Growth, Participation Rates and the Size of the Labor Force ....104 Present Deployment of the Labor Force and Prospects for Growhth ..107 The Public Sector ..109 The Private Formal Sector .109 M$igration. ... 110 Land Availability and Agriculture .111 The Small Scale/Informal Sector .117 Urbanization. . .i.z. ............. 120 Unemployment . .. . ..... 121 Trends in the Unemployment Rate .121 Unemployment Among the Young and Well-Educated .122 Policy Interventions ........ 123 Skilled Labor Shortages, Localization .124 Localization .............. .124 Skill Shortages ............................. 125 Vacancies and Turnover ................................... 126 Creeping Credentials and the Returns to Education ........ 127 Women in the Labor Market .................................... . 128 Women in the Formal Sector ..............................129 Women in Agriculture .................... . ;c.__ . .. . 130 Women in the Informal Sector .136 Credit for Women ........... 137 Wage Policy .138 The Level of Wages .138 Effectiveness of the Policy .140 Policy Implications. . 143  TABLES Page No. 1.1 Implications of Alternative Population Projections, Year 2015 . ........................................... 4 2.1 Projected Size of the Population of Halawi (in millions) ........................................ 21 2.2 Projected Age Structure of the Population of Malawi ................................................ ..... 22 2.3 Projected Numbers of Primary School Age Children and Health Service Clients . . . 23 3.1 Proportion of Childhood Deaths Association with Malnutrition ......................................... 35 3.2 Estimate of Population of Outpatient Visits Determined by Under Nutrition . .36 3.3 Dietary Adequacy (1982).. 39 4.1 Ten Leading Causes of Outpatient New Cases Malawi, 1986 ......................................... 55 4.2 Ten Leading Causes of Hospital Admission, Children Under Five, Malawi, 1986 . . 56 4.3 Ten Leading Causes of Mortality Among Inpatients Under Five, Malawi 1988 .................. 57 4.4 Ten Leading Causes of Mortality Among All Inpatients, Malawi. 1988 ................. . S8 5.1 Total Primary School Age Pupils (6-13) in Malawi by District, 1987. ............ 72 5.2 Pupil/Classroom Ratios in Urban Schools, 1987 ..73 5.3 Transition from Standard 1 to Standard 4 . .75 5.4 Average PSLC Scores by Subject and District, Malawi, 1987 ........... . ........... 76 5.5 Mean PSLC Examination Results, by Subject and Gender, 1987 ............. .77 5.6 Academic Year Versus Rainfall in Selected Districts 78 5.7 Student/Teacher Ratios in Secondary Schools, 1986/87 83 5.8 Mean JC Scores for Internal and External Candidates 84 5.9 MCE Distinctions and Credits, by Subject, 1987 ..84 5 10 Enrollments in Teacher Training Colleges, Malawi, 1987188 .......................... 86 5.11 Enrollments and Graduates of Secondary Teacher Training Programs ................... 87 5.12 Distribution of Academic Degrees for Faculty at Chancellor College, 1986/87 ........................ 88  Page No. 6.1 Industrial Training Fund Revenues and Expenditures and Technical College Enrollments, 1980/81-1985/86 (1981 Constant Kwacha) ............... 94 6.2 Projected Manpower Demand and Supply in Priority Skills Areas, 1981-1986 .98 7.1 Population Projections, Malawi 1990-2020 .105 7.2 Age- and Sex-Specific Participation Rates, 1977 Census Data ..................................... 105 7.3 Labor Force Projections by Sex and Age, 1990-2020, (thousands of persons) .................... 106 7.4 Labor Force and Structure of Employment Estimates ..... 108 7.5 Population Densities, Selected Countries, 1985 .112 7.6 Population Carrying Capacity of the Land, By District, Year: 2000 ............................. 114 7.7 Indicators of Agricultural Mechanization by Farm Size, 1980181 .116 7.8 Urbanization Levels, Selected Countries, 1985 .120 7.9 Degree of Localization by Industry, 1975 and 1983 .125 7.10 Numbers and Percentage of Women Formal Sector Wage Employees by Subsector, 1971, 1976 and 1983 ..... 129 7.11 Percentage of Female Headed Households (FHH) by Marital Status and Area, 1980/81 .130 7.12 Women Working on their Own Holdings, 1966 and 1977 131 7.13 Distribution by Cultivated Area, by Sex of Household Head, 1980-81 .132 7.14 Percentage of Women in Phalombe Participating in Credit Programs ............. 133 7.15 Average Daily Pay (Tambala) for Women and Men in Ten Flue-Cured Tobacco Estates in Kasunga District, 1984 ................................................. 136 7.16 Statutory Minimum Daily Wage Rate as at January 1, 1965-89 ................................... 138 7.17 Real Average and Minimum Wage Indices, 1974-86 (1974 = 100) ......................................... 140 ANNEXES A External Migration ..................................... 146-147 B The Agricultural Labor Market ............................. 148-153 C The Small-Scale/Informal Sector ........................... 154-160 D Wages and Salaries Policy ................................. 161-162 STATISTICAL APPENDIX ...................................... 163-167  EXECUTIVE SIM4ARY 1. This study suggests priority actions in human resource development to help the Government of Malawi (GOM) move closer to its long term development objectives as set out in the "Statement of Development Policies 1987-1996" (Devpol). The study broadens the policy dialogue between the GOM and the World Bank by taking a longer term view than is usual in human resource sector analysis and lending, and by looking across the whole range of human resource issues, from nutrition, population and health, through education and training, to the labor market. 2. Chapter one outlines the broad economic context and the important contribution that human resource development could make to a better future. The key priorities in each sector are identified, drawirg from the more detailed analysis in the following chapters. Chapter two reviews nutritional status and strategies for improvement. Chapter three makes suggestions for strengthening the health care system. Chapters four and five consider future demands on the education and training systems. Chapter six discusses the challenge of findir.g productive employment for Malawi's very rapidly growing labor force and analyses key issues relating to employment and labor force development. THE ECONOMIC AND SOCIAL DEVELOPMENT CONTEXT 3. Impressive gains have been made in human resource development since Independence, and the GOM is heading in the right direction in its human resource development strategy. However, the road ahead is still long and rough. The effects of massive efforts to improve education and hetklth have been undermined by economic setbacks since 1980 and diluted oy rapid population growth. There is a serious national problem of undernutrition, especially among small children, which has retarded progress in reducinp infant and child mortality. Many citizens do not have access to adequate food, essential health care, safe water, improved sar.itation and housing, basic education, and the opportunity for earning an adequate income. More than 70 percent of the population over 10 years of age is still illiterate. AIDS is emerging as a very serious problem. Efforts to prevent the potentially explosive spread of AIDS are just beginning. 4. Since 1980, Malawi has had to contend with adverse terms of trade movements, drought, and the disruption of external transport routes by the instability in Mozambique (from which 650,000 people have sought refuge in Malawi). GOM has responded with measures to restore macroeconomic stability and growth. A more fundamental problem is that rapid population growth (3.5 percent) is causing increasing pressure on arable land. A turning point has been reached in Malawi's economic and social development. In the past, development has relied very heavily on smallholder agriculture for the country's food supply, and on the estate sector for export growth. Agriculture will continue to dominate the economy, but there will have to be more intensive use of land and other resources, and much greater economic diversification. This suggests four key priorities: (i) slow the rate of population growth; (ii) increase agricultural productivity; (iii) facilitate employment growth; and (iv) find nexi export and import substitution opportunities.  - ii - 5. There are several obstacles to be reckoned with: First, the domestic market for manufactured goods and modern services is very small. Sec3nd, Malawi's landlocked position imposes high transport costs for imports and exports, exacerbated by regional political instability which has interrupted the shortest routes to Indian Ocean ports. These two factors reduce opportunities to exploit economies of scale and competitive pressure that could restrain prices and be a goad to efficiency. Third, Malawi does not have abundant or varied reserves of mineral or energy resources, which have provided valuable exports for other African countries. Imported fuels and raw materials must be shipped over land at high cost. 6. In facing the challenges of the future, Malawi has important strengths upon which to draw. First, the country has a stable government and competent civil service. Second, sound policies and strategies are in place, as regards both overall economic policy and the human resource sectors. Third, there is a sound infrastructure of roads, communications and electric power. Fourth, Malawian workers have earned a reputation for reliability, honesty and willingness to work. Fifth, the country has substantial potential to increase agricultural productivity. 7. Population Growth and Policy Without any change in present demographic trends, the population will grow from 8.4 million today to over 21 million by the year 2015. This will place enormous demands on Malawi's health, education and training facilities and agricultural output. The rate of population growth can be influenced by government action. Malawi has made a start: child spacing services have been introduced slowly since 1986. Much more could be done. It is urgent to act now because there is a long lag before fertility changes have an impact on population growth. The health and education systems have an important role to play in slowing population growth, through educating adults and young people about the implications of high population growth for families and society, and providing the knowledge and ready access to modern contraceptive methods that will allow families to make wise choices and to act upon them. 8. Agricultural Productivity and Food Security. There is compelling evidence that many farmers are unable to grow enough food for their families' needs. Opportunities for earning supplementary income are limited, so they are unable to make up the shortfall through purchases. Population pressure is decreasing farm size, bringing more marginal land under cultivation and forcing continuous cropping which depletes soil fertility. Maize yields have fallen over the past two decades, and will continue to fall unless use of plant nutrients and high-yielding crop varieties increases. Increased agricultural productivity and food security is critical to improvements in nutrition, and health improvements are to a large extent contingent on better nutrition. 9. Adoption of improved maize has been low, accourning for only 10 percent of the maize area, because available hybrids do not store or pound well with traditional methods, and require fertilizer. Few households have the cash to buy fertilizer, and although seasonal agricultural credit is available, the farmers clubs that have collective responsibility for loan repayment rarely admit poor farmers, who are seen as bad credit risks.  - iii - 10. Women farmers, who account for seventy percent of all smallholders, have poor access to extension advice, credit and fertilizer. A large proportion of the smallest farms are managed by women. Small farms and low yields mean poor harvests, and without a husband to help with the farm work or to earn extra income off the farm, these families are especially vulnerable to food insecurity. These smallholders may have no option but to feed their families by working for others during the peak periods of activity of planting and weeding, risking delays in completing these tasks in their own gardens that reduce yields. 11. The Ministry of Agriculture is trying to develop a more acceptable high-yielding maize variety, develop extension messages and agricultural practices that respond to the needs and constraints of resource poor households, reach a much greater proportion of farmers, especially women, with advice and credit, and target the subsidy on fertilizer better to benefit poorer farmers. Innovative proposals to assist especially vulnerable households to obtain farm inputs and supplementary food supplies are being seriously considered, and should be tried on a pilot basis. 12. Employment Prospects. The labor force will more than double between now and the year 2015. Averaging over this period, the number of new jobs needed each year will be roughly the same as the total number now employed on agricultural eatates (185,000), which is 40 percent of wage employment. GOM recognises that all sources of employment growth must be pursued; the processing of natural resources, the development of export manufacturing, expansion in the number of small-scale enterprises, and the further exploitation of import substitution opportunities". 1/ Development of small scale enterprises will be facilitated as rural incomes increase, and if additional credit and technical support are made available, and restrictions on location, activity, imports, trade by minorities, transportation services and urbanisation are relaxed. 13. New Markets and How the Human Resource Sectors Can Contribute. The realization of Malawi's potential for further economic development implies a substantial change in the structure of the economy. The modernization of agriculture must be accompanied by further development of the manufacturing and service sectors that will increase their relative importance. Industrial growth will depend on finding new markets, both export opportunities and replacement of imports in the domestic market. This will require entrepreneurial skill to seek out new market opportunities, marketing widely enough to take advantage of scale economies, reaping competitive advantages by being an early entrant into new markets, and entering markets that are being abandoned by other countries because of rising labor costs. Exploiting new opportunities will demand that producers are able to move quickly to produce new items, which r quires a highly trainable labor force which is able to acquire specific skills rapidly. 1/ Statement of Development Policies, 1987-1996, Government of Malawi, Office of the President and Cabinet.  - iv - 14. Economic transformation will impose new human resource demands. The social sectors have a vital role in helping Malawi's people to be better nourished, healthier, more educated, more skilled and more productive. In the past, it was enough for most Malawians to waster the techniques and knowledge of their parents; today, and increasingly in the future, they will need more and better quality education to enable them to seek out and seize new opportunities, evaluate options, and apply new skills and technologies. The four key priorities -- population, agricultural productivity, emplcyment, and finding new market opportunities -- are closely interlinked with human development: they are crucial for progress in the social sectors, and the social sectors have a role to play in their achievement. The demands of the economy for higher quality human resources are consistent with the Government's commitment to improve the quality of life for Malawians. Better health, nutrition, life expectancy and education are ends in themselves. RESOURCE CONSTRAINTS, CHOICES, AND LINKAGES ACROSS SECTORS AND TIME 15. The priority actions identified for each sector (listed below) are those which experience in Malawi and elsewhere indicate will be most effective in helping to reduce disease, ignorance and poverty. The list is long, and there are inadequate resources -- financial, managerial and material -- to move quickly on all fronts simultaneously. The "most likely" macroeconomic flow-of-funds scenario suggests that government expenditures may be able to grow at about 2 percent per year in real terms over the medium term. 2/ Government's stated commitment to increase the budget shares of health (from 7 to 9 percent) and education (from 11 to 15 percent) implies a slightly larger increase, but would still be significantly below the population growth rate, and well below the increase that would needed for concerted efforts in all or most of the priority areas identified. There is no easy guide to decisions about the optimal mix and timing of actions. There are two sets of considerations; the relativt costs and benefits of additional resource allocations to priority activities, and the complementarities and linkages among them. 16. There are always difficult choices to be made in allocating limited resources between and within sectors. One guide to decisions is to estimate unit costs and compare the different outputs that MK10,000 (or some other amount) could buy; e.g. the number of primary school graduates, or years of secondary school or University study, or boreholes, or users of contraceptives, or additional children fed by a supplementary feeding program, or months of malarial treatment, or babies immunized, or textbooks. There is no objective way to quantify and compare benefits; e.g. to estimate the value of the life of a child or a mother, or of learning to read and write, or of the time and energy saved by the installation of a new water point. However, at least if the trade-offs are reasonably clear, decision makers can make value judgements about relative desirabilities. 2/ Based on the analysis of the Malawi Public Expenditure Review, report 7281-MAI, February 10, 1989, and Government's Policy Framework Paper.  v 17. Another factor to weigh is the linkages between different activities and policies. There are backward linikages; that is, some things need to be done together. For example, providing additional school places will not raise enrollment rates unless families can afford to pay fees; higher enrollments will nrot improve educational attainment much unless there are teachers, blackboards and books from which to learn. New health facilities cannot operate without staff, drugs and dressings. 18. There are many linkages that generate positive externalities; that is, activities that contribute to more than one goal, and are mutually reinforcing in that improvements in one area increase the benefits from investments in other areas. For example; efforts to encourage child spacing are more effective for better educated familes, and when infant mortality is falling or low. Smaller family size can improve nutrition, maternal and child health and mortality, and increase education. Longer birth intervals reduce the maternal health risks of high fertility and reduce the mortality risk to the infants. Parents of smaller families are more likely to be able to afford to feed them adequately and to send them all to school. Nutritional improvements lead to better health, greater ability to learn, and higher income earning capacity. Good nutrition increases resistance to disease. Well nourished, healthy children are likely to have better attendance and to learn more in school than hungry, sickly ones, and to be less likely to fail or to drop out. Well educated workers are easier and cheaper to train for specific jobs. Healthier workers are more productive, and can grow morp food and generate higher incomes, which in turn can lead to improvements in nutrition, health and education. Gains in education can also lower infant, maternal and child mortality, improve health and nutrition and reduce desired family size. Better informed parents, especially mothers, are better able to protect the nutrition and health of children. More educated farmers in Malawi have been found to have higher yields since they take advantage of extension services, advice and credit. 19. There are linkages across generations that cause the benefits of investments in human resource development and the costs of neglect to multiply over time: educated, well-nourished, healthy parents are more likely to have educated, well fed, healthy children. Children who do not complete a basic education are likely to remain illiterate all their lives, which will make participation in a modern changing economy difficult for them, and have negative consequences for the welfare of their families. The costs of delaying social sector investments are high. The results of these investments cannot be judged only in the short-term, they also benefit future generations. KEY ISSUES AND RECOMMENDATIONS FOR HUMAN RESOURCE DEVELOPMENT Slowing Population Growth 20. Paragraph 7 has commented on the need to extend the present child spacing services. Four sets of actions are recommended (some of which are planned or have begun):  - vi - o enable rAore health workers to deliver child spacing services by phasing and accelerating training, first giving short training and allowing delivery of non-clinical contraceptives (such as condoms, spermicides and oral contraceptives), and later training health workers in clinical methods as well; o implement Government's plans to use commercial and community-based distribution networks for contraceptives to increase acessibility and availability; o broaden the criteria for use of various contraceptive methods, since the present stringent age ana parity restrictions on use of some methods are inappropriate given that the mortality risks of pregnancy far outweigh the health risks of contraception, even of injectables and tubal ligations; o strengthen the management structure, staffing and information system of the childspacing program; and o increase awareness of the problems associated with high fertility and of the health benefits of child spacing by delivering more education and information through schools, the media, workshops and seminars, health workers, the planned nongovernmental family welfare association, and political, community and church leaders. Nutrition 21. Current Situation. Undernutrition is widespread; the 1980/81 National Sample Survey of Agriculture (NSSA) revealed chronic malnutrition among 56.5 percent of children under five, distributed fairly evenly throughout the country. Male children of weaning age (12-23 months) in the pre-harvest season in the Southern region are the highest risk sub-group. Malnutrition is caused by food shortage, compounded in the case of small children by the low energy density of porridge which requires that they be fed 6-8 times/day instead of the usual 2 or 3 meals. 22. Malnutrition exacerbates the high levels of infant, child and maternal mortality and morbidity. It may be a direct or contributory cause of nearly half of all hospital visits and 60 percent of hospital deaths among children under five years of age. The problem of low nutritional intake is compounded by the extraordinary demands for dietary energy that are created by a high incidence of febrile diseases and by exceptionally high energy outputs, especially among women. The heavy burdens of malaria, respiratory infections and diarrheal diseases increase caloric demands significantly. In addition, gastroenteric infections reduce absorption of nutrients from the diet. Low levels of mechanization in farming and food preparation further exacerbate nutritional demands. 23. Use of maternal and child health and nutritional services is high, although attendance at under-five clinics falls sharply after immiunization at 9 months, just at the critical nutritional period of weaning, because of domestic responsibilities, child care and distance to the clinics.  - vii - 24. Access to other public services is less satisfactory; 16 percent of smallholders receive agricultural credit for fertilizer and improved seed, but 70 percent have virtually no contact with the extension staff; small sample surveys have found that agricultural and community service extension services targetted to women reach no more than 25 percent; nearly 50 percent of households must travel 2-8 km (taking 1 - 3 hours) to an improved water supply and one third of households must travel this distance to obtain fuelwood. Available data show that the poorest are least likely to benefit from these other services. 25. Priorities for Action. Malnutrition in Malawi is primarily a consequence of poverty and secondarily of education and behavior. Until poverty and serious food insecurity are alleviated, little progress can be expected in reducing malnutrition and associated diseases through other means. Government recognises this and, assisted by the donor community, is developing surveillance systems and policies and programs to address food security, nutrition and poverty, based on sound analysis. 26. Focusing specifically on nutritional improvements, a number of key areas and actions require particular emphasis: o There is justification for increasing the resources allocated to nutritional programs, if necessary by reallocating part of the health budget. o The infant growth monitoring system and supplementary feeding program must be maintained and expanded. Steps to encourage community health networks increasingly to take responsibility for this should be continued. o Existing specific nutritional supplement programs (e.g. provision of iron, folic acid and vitamin A to target groups and iodine deficiency control measures) should be continued and program coverage expanded. O New options, ideas and pilot proposals for providing agriculture credit and inputs, and income support to target groups should be pursued. Programs and specific services for women need to be integrated at the local level in order to avoid duplication and improve efficiency; consultation with smallholders (especially women) would help determine how best to do this. Agricultural extension services could be targetted better to women; the Ministry of Community Services' extension services could be strengthened. o The provision of health and social services on commercial estates requires strengthening, Legal minimum standards and tax relief for capital costs of improved housing, sanitation, etc. were recommended in Zimbabwe to achieve this. O Educational efforts need to be intensified and made consistent across sectors and services, including health, agriculture, community services, and the education system. A large effort is required to coordinate all the different agencies.  - viii - o Messages must be simple, consistent, and economically and culturally appropriate, ann should inclup e advice on growing (including o intercropping), storageu prepiration and nutritional value of food crops in addition to maize. o More and better information on breastfeeding and weaning practices should be delivered through health and other services, public media and comuunity networks to reach a very large audience of women in Malawi. o The most important priorities for research and technology development are high-yielding varieties of food crops that store and process well; labor- and energy-saving agricultural tools and food proccssing technology; improved low-cost transportation; low-cost technology for environmental health such as vector control and sanitation. Research and experimentation results from other countries should be investigated and adapted. Health 27. The Government has done a very creditable job of providing basic health services to the country's citizens despite severely constrained financial resources. There is a good network of district and central hospitals that provide basic referral services, and the balance of infrastructure among primary, secondary and tertiary levels is about right. The Private Hospital Association of Malawi nicely complements government efforts. The Ministry of Health estimates that about 80 percent of the population lives within eight kilometers of a modern health facility. Utilization is high: immunization is over 80 percent, children under five average almost four contacts per year with the health system, and 85 percent of pregnant women have at least one antenatal examination. Shortages of drugs and materials occur occasionally, but most health facilities have basic supplies in stock most of the time. There are some weaknesses: the scarcity of transport compromises access to health care, especially for patients with severe injuries and obstetric emergencies; there are shortages of doctors, registered nurses and medical assistants; many patients bypass lower level facilities, worsening congestion in central hospitals; and the system cannot meet the demand for child-spacing services. 28. Despite high utilization of the relatively good health services, health conditions in Malawi are very poor. Life expectancy at birth is approximately 49 years; among the lowest in the world. Under-five mortality is at least 25 percent; malaria and widespread undernutrition appear to be the key explanatory factors and interact to reinforce each other. Reducing under-five mortality would go a long way toward improving overall life expectancy in Malawi. Maternal mortality is ab"-".; 170 peL 100,000 live births, and ten times as many women suffer permonent disability as a result of pregnancy or birth complications. The loss of a mother is a major tragedy for her family, the community and for economic development. The prospects are good for a substantial reduction in maternal deaths in Malawi. 29. The leading diseases in Malawi are malaria (by a huge margin), nutritional deficiencies, respiratory infections, symptoms referable to the  - ix - abdomen and gastrointestinal tract, skin conditions, other diarrheal diseases, inflammatory eye diseases and traumatic conditions. The number of cases of AIDS reported by hospitals had reached 7,160 by November _v89, and the extent of HIV appears to be substantial. The potentially explosive spread of AIDS makes prevention of transmission an urgent priority. 30. Although the health sector is a key determinant of health conditions, equally if not more important are efforts to alleviate poverty especially the resultant undernutrition, and to raise education levels, particularly for women. Mothers with primary education tend to have healthier and better nourished children, lower fertility and higher productivity. 31. Priorities for Action. Improving child survival is critical to lowering overall mortality and increasing life expectancy; child survival and health will affect the quality and quantity of the human resource base and of human welfare twenty-five years from now. o Top priority should be given to control of malaria, which is the leading cause of admissions and death among hospital in-patients. o Actions to prevent HIV transmission which occurs through sexual contact, the use of contaminated blood and perinatal infection deserve very high priority. High seropositivity rates among pregnant women bode ill for the rate of perinatal transmission and resultant infant mortality; prevention requires that HIV-positive women avoid pregnancy. o Further investments in water supply, sanitation, and hygiene education should be undertaken in order to control water-related disease including diarrhea. O A community-based system for presumptive treatment of malaria (for example, using traditional birth attendants) deserves serious consideration. It could be effective and low-cost. o Child spacing is probably the most cost-effective approach to lowering infant mortality. The recommendations listed earlier to slow the population growth rate are relevant. 32. In order to make mothernood safer, save women's lives and prevent disability caused by pregnancy: o An epidemiological study should be done to establish the levels and causes of mortality and morbidity among specific population groups, especially those delivering at home. o High risk women should be identified as early as possible in pregnancy and good community level antenatal care provided (such as in community-built maternity villages near to health centers) complemented by a well-functioning 'alarm' ard transport system to ensure good access to obstetrical *-are at first-referral level.  o Child spacing services are especially relevant to the large number of women for whom pregnancy carries a high risk of complications or death; this includes women at the extremes of the childbearing period (under 18 or over 35 years of age), whose children would be born less than two years apart, or of high parity (over five children). 33. The community health program being organized through primary health care committees has good potential to improve access to health services for people living in isolated rural communities, especially through improvements in sanitation, water supply, midwifery, and first aid, notably presumptive malaria treatment. o A careful look at national and other country experience to date would be a useful guide to further development of community-based primary health care. 34. Four areas in particular offer promising avenues for increasing health sector efficiency: o improvements in the alarm and transport system for emergencies along with more consistent deliveries of drugs and other supplies to health centers and district hospitals and bypass fees will encourage patients not to bypass low level facilities and help decongest central hospitals; o the distribution and management of drugs, other supplies and transport could be strengthened by introducing more systematic and rigorous controls and monitoring, and would yield significant savings. o There is some (limited) potential for increa.ing cost recovery by instituting charges for curative services, especially at higher level services and for unreferred cases. Preventive services such as EPI and child-spacing, and the poorest patients could be exempted from charges. o Additional detailed data is needed to inform manpower development and staffing decisions. A comprehensive manpower study is needed, and should be periodically updated. In-service training could be more systematic. Reducing the shortage of physicians will be very expensive and can only occur gradually as resources permit; through force of necessity Malawi has developed a model health system whose backbone is made up of medical assistants and enrolled nurse- midwives, which other resource-constrained countries would do well to emulate. Water and Sanitation 35. Malawi has a highly regarded gravity-fed rural water program serving about one million people, and being extended to cover 750,000 more. Further water supply schemes will have to rely primarily on groundwater, which will be higher cost. About 70 percent of rural households still lack access to safe drinking water and 42 percent have no facility for the sanitary disposal of excreta. Improvement could have a dramatic impact on  - xi - health by reducing diarrheal disease and infection, which in turn would improve nutrition, since illness reduces the ability of the body to absorb nutrients. Also, carrying water over long distances saps energy and time of women and children, which could be devoted instead to crop cultivation, child care, education, or other activities. 36. The control of fecally transmitted diseases should continue to be pursued vigorously through o persistent education, including men, who could be reached through the Malawi Congress Party and other community leaders, o expanding safe drinkinga water supplies as rapidly as funds permit. o encouraging construction and use of simple latrines, and o allocating more funds for maintenance and repair of pipes - a very small user fee could assist, and Donors could be encouraged to provide additional funds for maintenance activities. Education 37. Malawi's education system is generally well-functioning and of reasonable quality at the upper levels. Despite rapid expansior during the last 25 years, coverage remains very low. The 1.023 million children enrolled in primary school include only 43 percent of the 6-13 age group; the 26,000 formal secondary school students amount to 4.5 percent enrollment. Another 24,000 students are enrolled in the lower quality Malawi College of Distance Education, a low-cost "second chance' secondary school system. The University enrolls about 2,000 students. 38. Achieving GOM's ambitious goals for expansion of the education system by 1995 will require an increase in investment resources and the recurrent budget beyond the planned increase in education's budget share from 11 to 15 percent (which will still be below levels in other African countries). There is a great need to expand the coverage of the system especially at the primary level, but maintaining and improving the qualitj of the system is even more important. Many children who begin school do not attain lasting literacy and numeracy. Dropout and repetition rates in primary school are very high, and more teaching materials a i improved teaching methods are necessary. Many classrooms are grossly overcrowded, and the average pupil:teacher ratio is 63:1, but over 100:1 in some areas. Boys out-perform girls in almost all subjects in the Primary School leaving Examination, although the reasons are unknown. 39. The school year runs from early October through July, which seems suboptimal: it includes the whole rainy season (Nov/Dec through March) which is also the time of peak agricultural activity, the "hungry season' before the harvest when many families have exhausted their food supplies, end the worst time for malarial attacks. Although MOEC argues that the present school calendar has the advantages of allowing practical lessons in agriculture and avoiding the coldest month, this study recommends that:  - xii - o MOEC reconsider changing the timing of the school year to avoid the wettest months, as this would (i) reduce disruption of learning by heavy rain, (ii) leave children free to help on family farms during the peak agricultural period, (iii) minimize the part of the school year that coincides with the pre-harvest 'hungry season", and (iv) make it easier for parents to buy uniforms and pay fees by starting the school year at harvest time, when cash becomes available in rural households. 40. The Ministry of Education and Culture (MOEC) h..s begun a comprehensive program of reforms to improve educational access, quality and efficiency. Measures are being taken to reduce sharply repetition and dropout, including phasing out primary school fees in standards 1-4. Teacher training, inspection and supervision are to be improved; a new curriculum and new teaching materials are *nder development. The secondary school curriculum is also to be revised. The Malawi National Examinations Board will modify the primary and secondary level examinations to take account of curriculum changes. Doubl- shifts are being introduced in urban secondary schools to accomodate more students, and cost recovery is being rationalized. o This study is very supportive of the whole MOEC reform program, and most especially the efforts to reduce dropout and repetition rates in primary schools, and emphasises that the highest priority for the primary school system is to improve retention and quality so that children develop good literacy and numeracy skills. Good access to text and exercise books and other teaching materials seems to be the most cost-effective way of improving educational. outcomes. The quality of teaching matters, and MOEC's plans for providing better inspection and more in-service teacher training should be implemented without delay. o The revision of the curriculum and teachers' guides provides a good opportunity to introduce innovative teaching methods to improve the quality of teaching and learning, and increase the effectiveness of schools in developing in pupils the skills and abilities that will help them cope well with a changing world. Greater attention needs to be given to developing reasoning and interpretation skills, and to applications of mathematics and science. 41. The key issues at the secondary level are: (a) increasing access, through more intensive utilization of existing secondary level facilities and improvement of distance education, (b) maintaining or improving the quality, particularly of distance education, and (c) continuing to recover costs of secondary school from beneficiaries and their families. Student:teacher ratios are low at 21:1, although there is a shortage of mathematics, science and biology teachers. There are also shortages of textbooks and science equipment. o The low secondary enrollment ratio and under-utilization of teachers and facilities justify expanding access and improving ;-1ization through doubling shifting. Thie will require supplemL- ng some facilities but is much cheaper than building new school.. The acute resource constraint and urgency of other educational invest..nts  -xiii - prevents Government from being able to construct and maintain additional boarding facilities, which must be left to communities. 42. The Malawi College of Distance Education is showing good results from its efforts to improve quality, however, it is under-resourced and tries to reach too many target groups through too many modes of instruction. The night secondary schools are not functioning well, and students at home have very low examination pass rates. o MCDE should concentrate its efforts and resources where it is most successful -- that is, JC courses offered at study centers. The MOEC should maintain or increase the resources at MCDE's diEposal. 43. Primary teacher training. This report supports MOEC's decision to address the gap between the required increase in the primary level teaching force and the output capacity of the training colleges mainly through in-service training which, given adequate inputs, can achieve results comparable with pre-service training and is the most flexible and least-cost option and allows immediate deployment of trainee teachers. It is also recommended that: o the primary teaching curriculum include special professional skills such as methods for teaching very large classes, remedial and multi- grade teaching, that teaching realities and new policies will increasingly require. 44. Adult Literacy. The Ministry of Community Services is intensifying its efforts to improve literacy, especially of rural women. o The National Adult Literacy Program is an important complement to the formal education system and should be allocated adequate resources so that there are enough reading materials. Vocational and Technical Education and Training 45. Malaw; has developed a relatively small, flexible, and good quality manpower training system. This has been a remarkable achievement. The demands of the modern sector of the economy for skilled manpower have been met except for a very few highly skilled professional occupations. Most expatriate workers have been replaced (97 percent of paid positions are held by Malawian citizens; expatriates are concentrated in professional and senior managerial positions in the private sector). There are mechanisms to facilitate flexible, short-term responses to labor market conditions. O The goal for manpower training and development in the near future should be to maintain and increase the capacity of the system to adjust flexibly at the margin, so as to respond to labor market demand and needs for upgrading the work force. o Employer participation in the training system could be increased by inter alia reviving the Tri-Partite Advisory Commission and enabling it to meet at least twice annually.  - xiv - o GOM should consider establishing a quasi-autonomous national training agency, linked to the Ministry of Labor, to manage and coordinate selected components of the training system. o It should be mandatory for employers to report all vacancies and hires (with appropriate information on qualifications) through the existing Ministry of Labor labor exchange system. The capacity of this system to collect, report and analyze these data needs strengthening. o Highly centralized manpower forecasting and allocation should continue to be avoided. The separation of public and private sector training and manpower monitoring systems should be maintained. O A marginal increase in the training levy on employers would provide adequate recurrent cost support for the improvements suggested. 46. It is likely that the demand for industrial workers over the next decade will be modest, and that it will be difficult to absorb increasingly large groups of job seekers. The impact that AIDS will have on the existing labor force is unpredictable; however, it may kill significant numbers of skilled, experienced people who will not be easy to replace. The main modern sector training needs for the next decade will be: (a) to upgrade the skills of senior and middle management in government and the private sector; (b) to train relatively small numbers of highly skilled professional personnel in short supply, including medical doctors and other senior health professionals, accountants, professional engineers and engineering technicians; (c) to cope with the serious potential impact of AIDS; (d) to continue localizing posts filled by expatriates; and (e) to train the teachers needed to staff the planned expansion of schooling. An oversupply of subprofessional personnel in health and agriculture will emerge unless training resources are re-allocated. The new Malawi Institute of Management has the potential to provide strong in-country managerial training capacity which will contribute to professional development of government and private sector managerial staff. O If used creatively and flexibly, existing training capacity, as strengthened through investments already in place, should be adequate for the next decade. Further investment in training facilities should not be urndertaken. O Supply and demand for key skills in relatively short supply - such as accountants, engineers, architects and quantity surveyors need to be monitored; temporary training arrangements in conjuction with external institutions should be used to train where small numbers are needed. o In order to increase the output of Malawian accountants, the University Faculty of Accountancy needs strengthening; wages for accountancy teaching staff need to be made more comparable with private sector wages for accountants and a bonding system should be introduced for staff who benefit from fellowships to study abroad. Consideration should be given to introducing a shorter accountancy qualification.  - xv - The Employment Challenge 47. The rapid growth of Malawi's population, and hence its labor force, and the country's weakened capacity to absorb increasing numbers of new labor force entrants into the economy, presents a formidable problem. Between 1990 and 2015, Malawi's labor force is projected to grow from 3.5 million to nearly 8 million. The challenge ef creating more than 4 million new jobs during the next twenty five years appears especially daunting when compared with the present labor force structure. Currently, there are about 450,000 formal sector jobs (14 percent of the labor force) of which 185,000 are in the estate sector. An estimated 120,000 people are in the informal sector; the remaining 2.9 million workers are smallholder farmers. 48. Even if formal sector employment were to grow at an unprecedented 10 percent (it was 3.7 percent between 1977 and 1986, and 7.2 percent between 1968 and 1977), there would be jobs for only half of the new labor force entrants. A growth of 5 percent would accommodate less than 20 percent of the labor force increase. Public sector employment is likely to expand modestly at about 2 percent annually; private sector employment growth will depend on the development of new labor-intensive export-oriented and import-substituting industries, the introduction of new crops, and further processing of estate crops. Employment opportunities in other countries have declined sharply. Most recently, all Malawian workers in the South African mines have been repatriated and new recruitment stopped. This was precipitated by GOM's refusal of the mines' demand for routine HIV screening for all would-be migrants, but must be seen in the context of the mining industry's commitment to giving preference to South Africa workseekers over foreign workers. The estate sector has considerable uncultivated land; further employment expansion depends mainly on technology changes and export prices and prospects. There are already signs that smallholder agriculture cannot absorb the growing number of entrants into the labor market; the growing pressure on arable land has already been discussed. Informal sector growth is constrained by capital and credit availability, the small domestic market, licensing restrictions, limited access to foreign exchange, and inadequate entrepreneurial skills. However, there are some reasons for optimism; the cost per job tends to be lower in this sector than in the more capital-intensive formal sector; import-dependence tends to be lower; evidence from other countries indicates a high positive income-elasticity of demand for the sector's output; and the GOM, supported by several donors, has begun to establish an imaginative and effective system of support to small-scale businesses. 49. Urbanization. Malawi has been exceptional in its success in avoiding the development of urban slums; in the future resisting the migration of low income household to cities in search of economic opportunities will become increasingly difficult. Successful development implies a substantial increase over the present 11 percent urbanisation level. Higher urbanisation would facilitate informal sector expansion by making it easier for entrepreneurs to obtain access to inputs, markets and business services. 50. Unemployment. Open unemployment is a lo3S serious problem in Malawi than in most African countries. The Government estimates that about 130,000 persons are actively seeking jobs; this implies that the  - xvi - unemployment rate is about 4 percent. This figure is probably misleading in that many people who do not readily find urban employment return to the rural areas, where they may be underemployed, i.e. their productivity, earnings and/or hours of work are inadequate to generate enough income to provide for their family's basic needs. The sketchy data available suggests that unemployment is increasing and has emerged as a particular problem among educated young people; the 1987 census data will provide a clearer picture. There are thL.ee other indicators of the imbalance hetween labor supply and demand: the increase in the number of applicants for jobs widely commented on by employers; low turnover rates among most formal sector workers; and the escalation of educational standards required for jobs at each skill level and among applicants to trade schools and other vocational training. 51. Wage Policy. The GOM has had a considerable influence on both the level and structure of wages through the minimum wage and its role as wage leader. Public sector nominal wage revisions in 1977, 1980, 1986 and 1989 have not fully prevented some erosion of real wage levels and living standards of civil servants, nor ensured comparability with private sector wages for most jobs. The policy of wage restraint formulated in 1969, is generally judged to have been successful. Changes in the nominal minimum wage have been infrequent and usually modest, and the real minimum wage has seldom exceeded its 1974 level. The substantial nominal rise effective May 1, 1989, has restored the purchasing power of the minimum wage, in terms of maize, to its pre-1975 level. This rise seems well justified on welfare and distributional grounds, "efficiency wage" arguments, the small likely impact on employment, and because the high propensity to consume of low- income groups should result in large multiplier effects. 52. The relatively low wage structure has helped encourage strong and labor-intensive private sector growth and constrain urban/rural wage different .als. However, other factors have also been important, and although excessively high wage levels deter employment creation, wages below a cErtain level may do little to encourage an increase in jobs. Women in the Labor Market 53. The Fo-mal Sector. Women comprise only 15 percent of formal sect'r workers, and are concentrated in a few relatively poorly paid occupations. They are disproportionately represented among workers paid in kind, whose earnings are below average. An important reason for this relative disadvantage is women's poor access to higher education, especially in the past, their lower achievement levels at school, and their reluctance to choose science and mathematics courses. Second, employers apparently prefer to hire men for most jobs, as reflected in higher unemployment rates for girls with secondary education and by higher education cut-off points for women than men for jobs at various skill levels. On estates, women tend to be paid lower wages than men for the same tasks, and are generally relegated to lower-paying and more seasonal jobs. 54. Women smallholders. As noted above, women predominate among smallholders but have smaller plots and poorer access to extension, inputs and credit than men. This, and their low education levels, makes them less  - xvii - likely to adopt agricultural innovations. They are more likely to have inadequate labor during the peak agricultural season, more likely to hire themselves out as casual labor (ganyu) and to be caught in a cycle of impoverishment. Women have less time and opportunity to generate non-farm income because of their child-bearing and family care responsibilities, which include the time- and energy consuming tasks of collecting water and firewood. 55. Women in the Informal Sector. The Ministries of Agriculture and Community Services and several NGO's are attempting to assist women to generate income in the informal sector. Many women are eager to learn new skills, however, the assistance offered is not always very competent, is rather ad hoc, has covered very few women, and can do little about the problems of inadequate credit, small markets, difficulty of obtaining materials, poor rural transport services, and time and mobility constraints faced by most women. Few rural women would be able to support their families entirely on non-farm income, but for many this is an important element of a diversified strategy. The challenge is to identify activities that do not compete for time during the peak agricultural season. 56. Policy Recommendations for Employment Generation. The Government of Malawi recognizes the challenge facing the country and understands the broad policies that need to be followed in order to meet it as reflected in the Statement of Development Policies 1986-1995. There is no single solution. A range of measures to foster new opportunities for income generation and productivity improvements will be needed. Numerous actions to achieve small improvements will have a cumulative effect. Specific policy recommendations based on the discussion in chapter six are as follows: o A determined, effective, and wide-ranging effort to slow population growth is essential to improve Malawi's long-term economic prospects, as well as the immediate and future welfare of her people. o Policies with respect to rural-urban migration need to be revised, recognising that in the long run, successful development implies a substantially increased level of urbanisation. o Government should state clearly and demonstrate a commitment to gender impartiality in hiring and promotion. The public sector: o Malawi should continue to (i) avoid the unsustainable and imprudent practice adopted by many countries of expanding the public sector to provide employment, and (ii) maintain a small public sector that is paid well enough to have an incentive to remain in public service and put a best effort into the job. o Greater emphasis needs to be placed on expatriates' role in skill transfer and training.  - xviii - Small-scale and informal sector: o Present restrictions on small-scale entrepreneurial activities must be removed, to give this sector the best possible chance of expanding and flourishing. Specifically, urban zoning restrictions on small-scale activities should be loosened, as should restrictions on operation of minibuses. o Efforts to provide better access to credit, capital, and foreign exchange and help in teaching managerial and business skills should be intensified. In particular, credit channels that will be accessible to the poorest families - such as the new Mudzi Fund - must be developed. O Government procurement from small-scale, competitive producers, e.g. of school furniture and simple equipment and government staff housing materials, should be encouraged and facilitated. O The efforts to assist people to undertake non-agricultural income generating activities undertaken by the extension staff of the Ministries of Agriculture and Community Services require strengthening. Agriculture: o Special attention needs to be given to the additional constraints and special needs of women farmers, both through targetted Women's Programs and by the mainstream operations of the Ministry of Agriculture. O Research, development and dissemination efforts focused on simple agricultural and food-processing technology need to be intensified. Water, fuelwood and peak-season activities are priority areas.  CHAPTER ONE CHALLENGES AND PRIORITIES INTRODUCTION 1.01 As Malawi moves now from its first to its second quarter century since Independence, human resources development is more crucial than ever to its overall development strategy and prospects. While much has been achieved, much still remains to be done across the whole range of human resource issues -- in nutrition, population, health, education and training, and employment and labor market initiatives. This study, reflecting on the accomplishments to date and the challenges that lie ahead, discusses what the Government can do to move closer, and more quickly, toward its long term objectives for human resources improvement as articulated in its uStatement of Development Policies 1987 - 1996' (Devpol). 1.02 The Government has important strengths to draw on as it works toward these objectives. Sound policies and strategies are in place and being implemented, both on overall economic policy and in the human resource sectors. There is widespread recognition of the vital role of human resource development, and commitment to doing something about it. Well established traditions of stable government and a diligent and competent civil service have helped create an ensbling environment more favorable than in many other African nations. The physical infrastructure -- roads, communications, and electric power -- is well maintained. There is substantial potential to increase agricultural productivity. Malawian workers have earned a reputation for reliability, honesty, and willingness to work. 2.03 Building on these strengths, the Government has brought about impressive progress in the twenty five years since Independence in 1964. Per capita income has risen 60 percent. Infant mortality has fallen by 28 percent, from 210 to 151 deaths per thousand births. Life expectancy at birth has risen 32 percent, from 37 to 49 years. Enrollment in primary education has nearly trebled. The literacy rate has increased by more than 50 percent. At Independence, only 33 Malawians had a university education; since then, over 8,000 have graduated from the University of Malawi, and many others have earned degrees abroad. 1.04 Yet there have been disappointments too. The effects of massive efforts to expand education and health have been undermined by several economic setbacks since 1980 and have been diluted by rapid population growth. Many social indicators still need to improve dramatically, both to reduce poverty and to make possible the productivity increases needed to support the economic development the country is counting on. For example, more than 70 percent of the population over 10 are still illiterate. Many citizens still do not have access to adequate food, essential health care, safe water, improved sanitation and housing, basic education, and the opportunity for earning an adequate income. There is a serious national problem of undernutrition, especially among small children, which has  - 2 - retarded progress in reducing infant and child mortality and improving health. The incidence of HIV infection appears to be high and AIDS threatens many lives and could orphan very large numbers of children. 1.05 Considering together the progress achieved, the problems not yet solved, and the vast challenges ahead, there is a clear message that emerges. The Government is on the right road, heading in the right direction, and has come a long way in its human resource development; but the road ahead is long and is going to get much rougher. Urgent and bold measures need to be taken now to enable the country to travel that road significantly faster than in the past and with greater resilience against being thrown off by shocks and obstacles. Failure to act soon is likely to mean that progress in the future will be considerably slower than previously, and could be reversed by serious setbacks. Yet if the right things are done now, the prospects are good that conditions at the end of the nation's second quarter century will be substantially improved and in line with the Devpol objectives. 1.06 Among the actions needed, this report concludes that high priority should be given to particular areas within nutrition, health care, child spacing, education, training, and labor market services. By way of introduction to discussion of these specific priorities, the next section reviews the broader context that links human resources issues and other development issues. Then a following section outlines the report's main specific recommendations, leaving more extensive elaboration to the remaining chapters. BROAD DEVELOPMENT ISSUES AND THEIR IMPLICATIONS FOR HUMAN RESOURCE DEVELOPMENT A Changing Economy 1.07 The Economic Crises of the 1980s. Since 1980, a series of external economic shocks have weakened economic growth and retarded Malawi's social progress. The oil price increase in the late 1970s sharply raised foreign exchange expenditures for energy. The weakening of tobacco and tea prices in 1979, 1980 and 1981 slashed export earnings by nearly a third. A drought in 1981-1982 reduced farm output sharply and forced the country to import supplies of its staple food, maize, for the first time in its history. The civil war in neighboring Mozambique halted rail shipments of goods to Indian Ocean ports in 1984; this increased transport costs for imports and exports substantially. Per capita income has fallen in most years since 1980; in 1980, 1981 and 1987 total national output declined. 1.08 The Government of Malawi has responded with policies to restore macroeconomic balance and increase the resilience of the economy. A stringent program of fiscal policies has been introduced, and the exchange rate has been adjusted repeatedly in an attempt to control inflation and restore economic incentives. Prices have been decontrolled and export promotion and diversification programs have been implemented. These measures have helped restore a favorable environment for economic growth. 1.09 The crises of the last ten years have partially obscured a fundamental change in the Malawian situation that pcses a much more serious  - 3 - threat to the future than external economic factors. Until recently, Malawi's development strategy was able to rely on smallholder farmers to meet the country's food needs, and on the promotion of agricultural estates to genetate fcreign exchange and fuel the development of the emerging formal sector. Indicators of the importance of agriculture are that: 80 of the workforce are smallholder farmers; agriculture provides more than 90 percent of export earnings; and the estate sector accounts for over forty percent of formal sector employment. Now a turning point has been reached in Malawi's economic and social development. Rapid population growth is causing increasing pressure on arable land. In the smallholder sector, reductions in land holding size and yields are causing a serious and worsening problem of food insecurity. In the estate sector, export growth has faltered. A develonment strategy for the future will have to emphasize more intensive use of land and other resources. Although agriculture will continue to dominate the economy, future growth needs to be more diversified. This suggests four key priorities: (i) slow the rate of population growth; (ii) increase agricultural productivity; (iii) facilitate employment growth; and (iv) find new export markets and import- substitution opportunities. 1/ Population Growth and Policy 1.10 In the twenty-five years since Independence, the population of Malawi has more than doubled, from about 3.9 to 8.2 million persons (excluding refugees). The rate of population growth has accelerated to around 3.5 percent, among the highest in the world. Fertility is extremely high in Malawi -- women give birth to an average of 7.6 children over their lives. This fertility rate would produce a rate of population growth of about 4.7 percent a year if it were not accompanied by very high under- five mortality. As health programs bring childhood diseases under control, Malawi's population growth could accelerate even more. Without any change in present demographic trends, the population will reach 21 million during the next twenty-five years. This will place enormous demands on Malawi's health, education and training facilities and agricultural output. Between now and the year 2015, there will be nearly 18 million deliveries for the health sector to cope with. There will be nearly 5 million children of primary school age to be educated in 2015; and nearly 12 million people of working age, most of whom will need productive employment. The number of 1/ A detailed discussion of the agriculture sector is to be found in the National Rural Development Program (NRDP) Technical Issues Review, World Bank Report No. 7539-MAI, February 15, 1989; Land Policy Study, World Bank, April 24, 1987, and the Staff Appraisal Reports for the Agricultural Marketing and Estate development Project, Report No. 7401-HAI, October 31, 1988, and the Smallholder Agricultural Credit Project, Report No.6886-MAI, October 9, 1987. For a discussion of prospects and policies for promoting exports, see the Industrial Sector Memorandum, World Bank Report No. 7402- MAI, November, 1988; and the President's Report for the Industrial and Trade Policy Adjustment Program Credit, World Bank Report No. P-4778-MAI, May 25, 1988. Population issues will be analysed in the World Bank's 1990 economic report for Malawi, Growth Through Poverty Reduction, and more fully discussed in the Population Sector Study.  - 4 - people per hectare of arable land will have increased from 2.0 in 1985 to 6.1 in 2015. 1.11 Unlike regional politics and world commodity prices, the rate at which the population grovs is a policy variable which can be influenced by government action. Malawi has made a start: child spacing services have been introduced slowly since 1986. Much more could be done. The best African experience has been in Zimbabwe, where a large and successful family planning program and a lengthy process of broad-based consensus building on the need for national action on population, have helped reduce the total fertility rate from around 7 in 1981/82 to 5.7 in 1986. 1.12 Rapid population growth over the next twenty-five years is unavoidable, but Malawi can decide whether the population reaches 21.4 million by the year 2015, or 18.7 million. Table 1.1 compares projections for the year 2015 which assume that present demographic trends continue, with an alternative scenario under which more determined family planning policies are adopted now, and which gradually reduce the average total number of children born to each woman. 2/ The long lag before fertility changes have an impact on population growth makes it urgent to act now. Table 1.1 Implications of Alternative Assumptions for Population Projections in the year 2015, (millions) Present trends continue Fertility falls Population 21.41 18.71 Births 1990-2015 17.96 14.80 Children aged 6-13 4.97 4.09 Working age (12-64) 11.81 11.56 Dependency ratio 109 85 Agricultural Productivity and Food Security 1.13 By 1985, compelling evidence had accumulated that a substantial proportion of Malawians suffer from a lack of food. Population pressure has decreased farm size, brought more marginal land under cultivation and 2/ These projections are based on the preliminary results of the 1987 population census. They exclude refugees, which is tantamount to assuming that they will not remain in Malawi in the long term. They also take no account of the possible demographic impact of AIDS. The projected numbers are illustrative, and not accurate predictions.  - 5 - forced continuous cropping which depletes soil fertility. Maize yields appear to have been falling. 3/ 1.14 The 1980/81 National Sample Survey of Agriculture found that a third of land holdings were smaller than .7 hectare. A farm of .7 hectare could produce about 500 kg. of maize at the national average yield. This represents enough food for 2.5 persons -- roughly half the membership of a typical rural household. If part of the crop were sold to pay school fees or to buy other necessities, household food deficits would be even larger. Opportunities for earning supplementary income are limited. 1.15 As the population continues to grow and there is less and lese land available per person, farm size will continue to fall. Since there is little further scope for bringing additional land under cultivation, existing land must be farmed more productively. Reversing the fall in yields requires better access to plant nutrients and wider use of high- yielding food crop varieties for the majority of smallholders. Increased agricultural productivity and food securitv is critical to improvements in nutrition, and health improvements are to a large extent contingent on better nutrition. There is a need for improvement in agricultural technology, and more extension services geared to small livestock and crops other than maize, such as vegetables. 1.16 Adoption of improved maize has been low, accounting for only 10 percent of the maize area, because available hybtids have high storage- and pounding losses with traditional methods, and require fertilizer. Few households have the cash to buy fertilizer, and although seasonal agricultural credit is available, the farmers clubs have collective responsibility for loan repayment and rarely admit poor farmers who are seen as bad credit risks. Only 25 percent of farmers have access to fertilizer and only 16 percent receive credit. Women farmers have particularly poor access to extension advice, credit and fertilizer. A large proportion of the smallest farms are managed by women. Small farms and low yields mean poor harvests, and without a husband to help with the farm work or to earn extra income off the farm, these families are especially vulnerable to food insecurity. 1.17 There are other cogent reasons to pay special attention to women farmers who account for seventy percent of all smallholders. Women bear major responsibility for the nutrition and welfare of the family, especially of children. Most agricultural extension agents are men and have tended to speak to men, wrongly assuming that advice would filter its way to women. Female-headed households are especially likely to have labor shortages during the peak periods of activity of planting and weeding, when delays in completing tasks reduce yields. It is estimated that a two week delay in planting can reduce yields by 25 percent. Things are made worse for families who have run out of food by this time, and are forced to leave their own fields to work for others to feed their families. 3/ Lele et al, issues in Fertilizer policy in Africa; Lessens from Development Programs and Adjustment Lending, 1970-87, MADIA Study, world Bank, 1989.  1.18 The recent review of the National Rural Development Program (NRDP) 41 urges that the Ministry of Agriculture tap all possible sources of support and assistance for its efforts to develop a more acceptable high-yielding maize variety; develop extension messages that respond to the specific needs and constraints of resource poor households; establish more demonstration plots in farmer's own fields; increase support for leguminous intercrops, trees and shrubs that help restore soil fertility; give higher priority to soil and water conservation measures; improve the training and supervision of extension staff; and increase the subsidy element in the smallest packs of fertilizer, which are used by poorer farmers. 1.19 Proposals to assist especially vulnerable households in obtaining farm inputs and food supplies are being seriously considered, and should be tried on a pilot basis. One suggestion is to supply fertilizer in return for labor on public works programs during the dry season. The notion of fertilizer-for-work poses complex administrative problems in targetting beneficiaries, identifying and supervising appropriate works projects, and distributing the fertilizer at the appropriate time in order to minimize its leakage from the group of intended beneficiaries. Nonetheless several donors have indicated interest in such an undertaking. Since application of economic quantities of fertilizer would enable many peasant families to become self-sufficient ir. food, this proposal deserves to be tried. Employment Generation 1.20 Malawi's labor force will more than double between now and the year 2015. This is daunting, especially when the likely number of work seekers is compared to the present number of non-agricultural jobs. The active labor force is estimated to have been about 3.5 million persons in 1986, about 63 percent of the population over the age of 10 years. Most of the labor force - about 2.8 million people - were self employed farmers. There were about 430,000 modern "formal sector jobs (including the estates) and an estimated 120,000 persons working in the informal sector as petty craftsmen, traders and service workers. The average annual increase in the labor force will grow from about 120,000 to about 300,000 by the year 2015. Averaging over this period, the number of new jobs needed each year will be roughly the same as the total number now employed on agricultural estates (185,000). 1.21 There is no single solution to the employment problem. The strategy must be to pursue growth in every sector - many small gains cumulatively will make a noticeable difference. Devpol recognises that substantial increases in employment can only be achieved through 'the processing of natural resources, the development of export manufacturing, expansion in the number of small-scale enterprises, and the further exploitation of import substitution opportunities". It reports that Government will focus its efforts on creating a general policy environment that will encourage both domestic and foreign'investment. These efforts 4/ Malawi, National Rural Development Program, Technical Issues Review, February 15, 1989, World Bank Report No. 7539-MAI.  - 7 - include providing incentives to purs-e specific economic activities and developing roads, telecommunications and power. 1,22 There are considerable expectations for the development of small scale enterprises. However, the growth of this sector is severely constrained by the very small domestic market for consumer goods. The growth of commercial agriculture may be expected to improve this s_tuation; farmers are likely to want to trade some of the increase in production for consumer goods. A significant proportion of this trade and production is likely to occur in rural areas in the near term. 1.23 The intention stated in Devpol to provide additional credit and technical support to small scale enterprises should be acted upon. In addition, Government should remove as many constraints on private initiative as possible. These constraints include prohibitions against location of small businesses in residential neighborhoods, cumbersome procedures for obtaining permits to import raw materials and equipment, and restrictions on trade by minorities. Government should also reevaluate its policies toward urbanization. Malawi has been exceptional in its success in avoiding the development of urban slums; in the future resisting the migration of low income household to cities in search of economic opportunities will become increasingly difficult. Urbanization will become increasingly important as a device for encouraging creation of off-farm economic opportunities. In cities it will be easier for entrepreneurs to obtain access to supplies of inputs, markets and business services. The likelihood of new businesses succeeding is likely to be enhanced by more rapid urbanization. 1.24 The economic feasibility of small-scale, rural enterprises would be increased if transport services were improved. Restrictions on private trucking and passengers transport should be relaxed. Frequent, inexpensive transport in rural areas would permit enterprises to market their outputs over a wider areas and thus to exploit scale economies, and would make it easier to obtain supplies of inputs. Increasing the size of the input and output markets in which each enterprise operates would also increase price and quality competition. New Markets and How the Human Resource Sectors Can Contribute 1.25 Realizing Malawi's potential for further economic development implies a substantial change in the structure of Malawi's economy that will increase the relative importance of the non-agricultural sectors. The modernization of agriculture must be accompanied by further development of the manufacturing and service sectors. It will be necessary to generate higher export earnings to pay for additional amounts of ir.2orted fertilizer, to provide employment opportunities for those who cannot be accomodated on the land, and to produce the goods and services that surplus-producing farmers will want to buy. Since Malawi's domestic market is small, industrial growth will have to be spurred by new export opportunities, as well as by finding new import-substitution opportunities. 1.26 Malawi's comparative advantage in finding new market opportunities in light manufacturing and service industries must derive  from its superior human resources and from any scale economies that it might be able to exploit by marketing to other countries in the region. 1.27 Malawi should seek to reap the competitive advantages that accrue to early entrants into new markets. Early entrants have the opportunity to establish a market niche and &lso to charge initially somewhat higher prices for their goods. In order to seize this advantage a producer must continual'ly seek out new market opportunities. This requires both a capacity to identify unmet demands and an ability to rapidly establish a credible local industry. Malawi is likely to be able to profit by entering markets that are being abandoned by other countries because of rising labor costs. Possible opportunities include spires, flower seeds and essential oils. However, exploiting these opportunities will demand that producers are able to move quickly in order to produce new items. Such flexibility requires both entrepreneurial skills and a highly trainable labor force which is able to acquire specific skills rapidly. 1.28 The economic transformation of Malawi will impose new demands on the people of the country. The education sector in particular can contribute to the development of new industries and markets by enabling people to acquire new skills and to innovate. In the past, it was enough for most Malawians to master the techniques and knowledge of their parents; today, and increasingly in the future, they will need more and better quality education to enable them to seek out and seize new opportunities, evaluate options, and apply new skills and technologies. Constraints and Strengths 1.29 The challenges of the next twenty five years seem even more daunting than those of the past twenty five. Three structural disadvantages hamper economic development. First, Malawi has a very small domestic market for manufactured goods and modern services. Second, Malawi's landlocked position imposes high transport costs for imports and exports. Regional political instability has exacerbated this by interrupting the shortest routes to Indian Ocean ports. The end of the civil war in Mozambique and the completion of the Northern Corridor overland route through Tanzania will ease the transport problem, but access to international markets will remain difficult and costly. This, combined with the small domestic market, results in few opportunities to exploit economies of scale and very little competitive pressure that could restrain prices and be a goad to efficiency. Third, Malawi does not have abundant or varied reserves of mineral or energy resources, which have provided valuable exports for other African countries. Imported fuels and raw materials must be shipped over land at high cost. 1.30 However, Malawi faces the future with several important strengths. First, the country has a stable government and a competent civil service. These institutions provide a favorable environment for private sector initiatives. Second, Malawi has developed a good economic infrastructure, particularly inter-town roads, communications and electric power. Third, the Malawian people have developed exceptionally good work habits and have earned a reputation of reliability, honesty and willingness to work. Fourth, the country has substantial agricultural potential; by  introducing modern methods and crops, farm output might be increased by as much as four fold. 1.31 The four key priorities -- population, agricultural productivity, employment, and finding new market opportunities -- are closely interlinked with human development; they are crucial for progress in the social sectors, and the social sectors have a role to play in their achievement. This role is a direct one in slowing population growth, through educating adults and young people about the implications of high population growth for families and society, and providing the knowledge and ready access to modern contraceptive methods that will allow families to make wise choices and to act upon them. The social sectors have an indirect role as regards the other priorities: to develop one of Malawi's resources - her people - to be healthier, better nourished, more educated, more skilled and more productive. 1.32 The demands of the economy for higher quality human resources are consistent with the Government's commitment to improve the quality of life for Malawians. Better health, nutrition, life expectancy and education are ends in themselves. They will not only increase the adaptability and productivity of workers, but also will provide benefits in the form of greater individual capacity for appreciation and enjoyment of the world. PRIORITY ACTIONS FOR DEVELOPING MALAWI'S HUMAN RESOURCES Slowing Population Growth 1.33 Four sets of actions to extend the present child spacing services are recommended (some of which are planned or have begun). First, enable more health workers to deliver child spacing services. At present, health workers are required to complete twelve weeks of training before providing any contraceptives. The shortage of health workers has made it difficult to release many for such lengthy training. Training should be phased and accelerated, so that within months all health facilities could offer non-clinical contraceptives that require very little training, such as condoms, spermicides and oral contraceptives. Within two or three years, further training in use of clinical methods would enable the full range of modern methods to be offered at all health facilities. 1.34 Second, implement Government's plans to use commercial and community-based distribution networks for contraceptives. Multiple delivery systems will reach different groups of people, and increase acessibility and availability. 1.35 Third, broaden the criteria for use of various contraceptive methods. The risks of pregnancy for many Malawian women outweigh the small contraception health risks, even of injectables and tubal ligations. There is therefore strong justification for allowing women a wider choice of methods with less str.ngent restrictions on age and parity than are imposed currently.  - 10 - *.36 Fourth, increase awareness of the problems associated with hip fertility and of the health benefits of clhild spacin. Some workshops and seminars have been held, some discussion aired in the media, and there are plans to introduce family life education in schocls, There is scope for much more information, education, and communicatibn. The more these issues are openly and frankly discussed by health workers and political and community leaders, or the radio, in schools, newspapers, churches and villages, the more rapidly will desired family size fall and reliance on modern contraceptive methods increase. The planned nongovernmental family welfare association could play a very useful role, and deserves strong support. Reducing Nutritional Stress 1.37 The most prominent social problem now confronting Malawi is undernutrition. Throughout southern Africa, malnutrition is a problem among selected population groups (principally weaning children) which rely on maize meal as a dietary staple. Maize porridge provides relatively few dietary calories per unit volume -- about half the calories per cup of a European diet. Weaning children have small stomachs relative to their caloric demands and are unable to consume enough food to supply their needs unless fed very frequently. Moreover, thinning maize porridge with water, in order make it easier to feed to small children, further reduces its caloric density. Since many poor rural families are unable to set aside time to feed infants six or seven times a day, small children frequently do not consume sufficient nutrients. The solution to this problem is either more frequent feedings or greater reliance on higher density weaning foods. Groundnuts and edible oils provide the necessary caloric density. 1.38 The problem of low nutritional intake is compounded in Malawi by the extraordinary demands for dietary energy that are created by a high incidence of febrile diseases and by exceptionally high energy outputs, especially by women. The heavy burden of malaria, respiratory infections and diarrheal diseases increases caloric demands significantly. In addition, gastroenteric infections reduce absorption of nutrients. Low levels of mechanization in farming and food preparation further exaggerate nutritional demands. 1.39 Dealing with the nutrition problems is an urgent priority. The key direct, short-term intervention is to increase the coverage of supplementary feeding programs. The Ministry of Health already operates a program of growth monitoring and food sul)plementation for under-fives, the most vulnerable group. Unfortunately this program reaches a minority of those who are presumed to be in need; ough estimates are that this program covers only about a fifth of the population. Moreover, food supplementation programs provide only emergency support for severely malnourished children and do not address the root causes of undernutrition. An alarming proportion of children who are admitted to clinical feeding programs are readmitt^d within six weeks of discharge because the problem of food insecurity remains for the household. Nonetheless these programs serve the valuable function of keeping children alive while more durable solutions are being sought. More resources should be devoted to nutrition programs, if necessary, by reallocating part of the health budget; 10 to 20 percent would not be excessive.  - 11 - 1.40 Several actions could be taken to improve the efficiency of food consumption and to reduce food requirements. Adoption of higher density weaning foods would help to eliminate malnutritior among infants. Mechanicai shelling and milling of maize could save women an energy expenditure of about 350 calories per day -- the equiv-lent of 50 kg. of maize a year. Development ari. use of mechanical ridging and weeding devices would have a similar effect. Reducing the prevalence of febrile diseases could have a large impact on nutritional requirements. 1.41 The urgency of increas.ng agricultural yields has been discussed earlier. Improvement in smallholder food security is the key to the nutrition problem. The Government and World Bank are working together on a strategy for improving food security, which emphasises productivity improvements in the smallholder sector, especially of resource poor farmers; strengthening the surveillance systems for food availability and nutritional monitoring; and better management of the strategic grain reserve. 5/ 1.42 Food security improvements also require increases in household cash incomes. In the intermediate term the most appealing option for increasing food supplies at the household level is to enable peasant farmers to grow a small amount of a high value cash crop. One tenth of a hectare of burley tobacco would provide a very large increase in income, at present prices. Even with continuing shrinkage of farm sizes, most peasant families would then be able to meet subsistence requirements for a decade or more into the future. Over the longer term the prospects for the tobacco market are less certain. A number of other crops including spices, seeds, and luxury vegetables also merit consideration. Improving Health '.43 The Government has done a very creditable job of providing basic health services to the country's citizens despite severely constrained financial resources. There is a network of district and central hospitals that provide basic referral services. The Ministry of Health estimates that about 80 percent of the population lives within eight kilometers of a modern health facility. While shortages of drugs and materials occur from time to time, most health facilities have basic supplies in stock most of the time. The scarcity of transport compromises access to health care, especially for patients with severe injuries and obstetric emergencies. 1.44 Devpol reports targets for 1995 of reducing under-five and maternal mortality by a third. There is a carefully considered development plan for the health sector. Primary health care is to be expanded by mobilizing a variety of sectors and community resources. The range and quality of maternal and child health services are to be upgraded, with particular stress on priority diseases, child spacing and nutrition. Child spacing services are to be strengthened by providing training to additional health personnel and by orienting community members to the concept of child 5/ A Food Security mission took place in October/November 1988, and a report is under preparation.  - 12 - spacing. Additional health centers are to be created, principally by upgrading existing rural dispensaries. Health Surveillance Assistants are to be introduced into villages to promote local responsibility for basic health services. The basic thospital network is to be upgraded and expanded modestly. Most of the capital investment program for hospitals is to be devoted to updating mechanical and electrical equipment and improving patient flow. Programs to prevent and control important diseases are to be reinforced. Reforms in the Ministry of Health are planned which will improve management of the sector. Finally, Devpol reports that the Ministry of Health will reinforce its efforts to promote latrine construction as part of its campaign to improve saritation. Specific priority actions recommended by this study are outlined below. 1.45 The coverage and effectiveness of maternal health services need to be increased. Malawi's high maternal mortality rate might be significantly reduced if the average age at first birth were increased from the present 19 years to about 22 years and if birth intervals were increased. The median period between births in Malawi is 32 months which is long enough in most environments to ensure full recovery of the mother. 6/ However, in Malawi poor nutritional status during pregnancy and lactation commouly result in mothers being nutritionally stressed. Poor maternal nutritional status results in a high incidence of low birth weight and greater maternal risks. (Low birth weight is also attributable in part to prematurity precipitated by malaria.) A more effective child spacing program could significantly reduce maternal mortality. Efforts should be made to manage more carefully the pregnancies of women who are at high risk of complications of child birth. These include women of high parity, those who are at the extremes of child bearing age, and those with a history of complications. Women who are especially likely to encounter problems should be encouraged to move to a maternity village near the district or regional hospital for the final month of the pregnancy in order to be close to essential emergency services. 1.46 The immunization program should be expanded further and made an integral part of the operations of the Ministry of Health rather than a special, extra-budgetary activity. The network for the delivery of immunization should also be considered for the distribution of micronutrients such as vitamin A and iron. 1.47 Government should continue to strengthen its programs to control communicable diseases and to reduce the impact of malaria in particular. Distribution of drugs for treatment of severe cases of malaria through community health workers should be tested and evaluated. A very high incidence of malaria and of other communicable diseases persists. The Ministry of Health reports that the average citizen suffers 4.8 acute episodes of malaria a year, many of which are disabling. Other diseases such as respiratory and gastrointestinal infections also exact a substantial toll. Thus, especially during the rainy season (which is also the peak period of agricultural activity) considerable time is lost due to disease. 6/ Family Formation Survey, Volume II, p. 21, 1984, MOH.  - 13 - 1.48 The Government of Malawi should act swiftly to contain the tbreat of Acquired Immune Deficiency Syndrome (AIDS). A serious and wide education campaign should be mounted to en';ure that people are aware of the disease and how it is transmitted. The hospital blood sutpply should be carefully guarded to avoid its becoming contaminated. Whenever possible people who are likely to require a transfusion of blood should be encouraged to bank their own blood in advance. The use of human blood should be avoided whenever possible. Condoms should be made widely available among groups that are likely to sexually active and thus at high risk of transmitting the disease. 1.49 The Ministry of Health should develop a policy for the clinical management of AIDS patients. In order to ensure that terminal cases do not absorb a disproportionate share of health care resources, criteria for the management and discharge of patients should be agreed. Facilities including church groups, traditional healers, and community support groups outside the health care system should be encouraged to provide support and care for victims. 1.50 Access to health services for people living in isolated rural communities could be improved by developing the community health program. This scheme is based upon the tenets of primary health care. It seeks to mobilize community resources to improve sanitation, water supply, midwifery, and first aid. Representatives of the various ministries of Government who are posted in rural areas would be involved also in developing and supervising these activities. Primary health care committees have been organized by Government at national, regional and district levels in order to guide and oversee these efforts. Traditional midwives are being trained to provide safe deliveries and to distribute a limited range of drugs, most notably anti-malarials. 1.51 Encouraging patients not to bypass low level facilities would improve the efficiency with which all fAcilities are utilized, and hence improve access to modern health services. The major referral hospitals in Blantyre and Lilongwe are seriously overcrowded. Many of the patients of these two institutions could be treated satisfactorily at lower level facilities. In particular, large numbers of routine births occur at St. Elizabeth's Hospital in Blantyre which could have been handled in maternity facilities at municipal health centers. Overuse of high level facilities for conditions that could be dealt with at other facilities reduces the productivity of the hospitals and peripheral facilities as well. Lower level facilities are bypassed because the alarm and transport system for emergencies is not reliable and because drugs and supplies are not delivered to health centers and district hospitals as consistently to as to central and regional hospitals. Rectifying these two problems would be a highly cost effective method for increasing the total effective capacity of the health care system. 1.52 The distribution and management of drugs, other supplies and transport could be strengthened. Malawi has made significant strides toward the goal of rationalizing the procurement and distribution of drugs and supplies. Nonetheless considerable losses continue to occur at regional and district hospitals (which serve as the distribution points for supplying rural hospitals and health centers). These losses could be  - 14 - reduced by introducing more systematic and rigorous controls over withdrawals and monitoring rates of use. The gains from controlling misappropriation of drugs and supplies could be as large as one-third of current expenditures on these items. Similarly, increasing controls over the use of transport would yield significant savings. Improving Water and Sanitation 1.53 Malawi has implemented a highly regarded rural water supply program which relies on gravity-fed supplies to pipe water to rural communities. This program now serves about one million people and investments are either under way ur planned to provide services to 750,000 more. However, the potential for gravity-fed supplies has been largely exhausted. Further gains in coverage by water supply schemes will have to rely primarily on groundwater, which will entail larger per capita investments and higher recurrent costs. About 60 percent of rural households do not have access to safe drinking water and 42 percent do not have a facility for the sanitarv disposal of excreta. 1.54 D,arrheal disease is a major cause of morbidity and mortality. Expanding access to safe drinking water could have a dramatic impact on health, especially if accompanied by improvements in sanitation and personal hygiene. Access to clean water can reduce the probability of infection which can improve nutrition, since illness reduces the ability of the body to absorb nutrients. Also, carrying water over long distances saps energy and time of women and children. which could be devoted instead to crop cultivation, child care, education, or other activities. 1.55 The control of fecally transmitted diseases should continue to be pursued vigorously. This will require persistent efforts to educate the public about personal, domestic and food hygiene. Households should be encouraged to construct and utilize simple latrines in order to isolate excreta from human contact. Most educational efforts in these areas target women and overlook men. The Malawi Congress Party and other community leaders could be an important communication channel for reaching more villagers, especially men. Safe drinking water supplies should be expanded as rapidly as funds permit. Funds for maintenance and repair of pipes has been a problem - a very small user fee could assist, and increase communities' sense of ownership and responsibility for their water supply. 71 Donors should be encouraged to provide additional funds for maintenance activities. Strengthening Education 1.56 Malawi's education system is generally well-functioning and of reasonable quality, particularly at the upper levels. However, coverage is very low - only 43 percent of children aged 6-13 are in primary school, only 4.5 percent of secondary-school aged children are in the formal secondary system, and nearly the same number are enrolled in the lower quality Malawi College of Distance Education. The dropout and repetition 7/ The University of Malawi is presently undertaking a study of "willingness to pay" for water in rural communities.  - 15 - rates in primary school are very high, so that the majority of Malawian children leave school without the four years of education generally regarded to be necessary to attain lasting literacy and numeracy. 1.57 The ambitious goals reported in Devpol for expansion of the education system by 1995 cannot be met without a significant increase in investment resources and the recurrent budget. Primary school net enrollment is planned to increase to 85 percent, the number of formal secondary school places to increase from 26,000 to 35,500, and the capacity of the Malawi College of Distance Education to double. Devpol also reports plans to expand the College of Accountancy and to increase enrollment in the University by about half over the next decade, mostly through creating a medical school (200 students) and an external diploma program (500 additional students). There is a great need to expand the coverage of the system. especially at the primary level, buc maintaining and improving the quality of the system is even more important. 1.58 The Ministry of Education and Culture (MOEC) has begun a comprehensive program of reforms to improve educational access, quality and efficiency. Measures are being taken to reduce sharply repetition and dropout. Primary school fees in standards 1-4 are to be phased out. Teacher training, inspection and supervision are to be improved; a new curriculum and new teaching materials are under development. The secondary school curriculum is also to be revised. The Malawi National Examinations Board will modify the primary and secondary level examinations to take account of curriculum changes. Double shifts are being introduced in urban secondary schools to accomodate more students, and cost recovery is being rationalized. 8/ 1.59 The highest priority for the primary school system is to improve quality so that children develop good literacy and numeracy skills. Pupils need to be retained for at least four years. Good access to text and exercise books and other teaching materials seems to be the most cost- effective way of improving educational outcomes. The quality of teaching matters, and MOEC's plans for providing better inspection and more in- service teacher training should be implemented without delay. 1.60 Dropout and repetition rates in primary schools need to be reduced. The phased abolition of fees for standards 1-4 will have a significant impact on enrollment if parent's inability to pay fees keeps many children out of school. There may be other important causes as well. First, some children may stay away from school because their labor is needed on the family farm especially between October and January. Second, the difficulties of travel during the wet season and the noise and disruption in classrooms caused by heavy rains may also contribute to poor performance and attendance during this time of year. Authorities should reexamine the advantages and disadvantages of revising the academic calendar. Third, older children may be forced from school by the need to work to supplement family income, domestic responsibilities and premarital 8/ These reforms are being assisted by the IDA First Education Sector Credit, 1767 - MAI, effective July 1987, and the Second Education Sector Credit, expected to become effective in 1990.  - 16 - pregnancy. These problems are not readily overcome by public policies; offering opportunities for part time enrollment, and readmitting girls who have withdrawn because of pregnancy may help. Fourth, relating the curriculum to future activities and improving the quality of instruction may help to maintain student interest. 1.61 The revision of the curriculum and teachers' guides provides a good opportunity to apply new insights from educational psychology and communications to improve the quality of teaching and learning, and increase the effectiveness of schools in developing in pupils the skills and abilities that will help them cope well with a changing world. The ability to assimilate new information and apply it to various situations, to think out sollutic. t_ problems, to weigh the advantages and disadvantages of alternative courses of action, and the application of mathematics and science will be important. There are methods for teaching pupils to understand better written and verbal communication; for example. having students make up conclusions to an incomplete story and then discuss them with classmates. Mathematics teaching could be improved by introducing more applications to common problems familiar to rural Malawians. Research has demonstrated that "brighter" pupils rely upon strategies to simplify arithmetic problems. For example, problems can be rearranged: add 2 to 28 rather than 28 to 2, find sub-totals of a long string of numbers to be added, regroup and factor numbers to simplify multiplication and division problems. All of these ..echniques are easily taught even to students of average capacity. Many are easily drilled as mental arithmetic problems; where teaching materials are scarce and class sizes are large, team competitions can be used to both motivate students and extend the teacher's effectiveness. 1.62 Adult Literacy. The Ministry of Community Services is intensifying its efforts to improve literacy, especially of rural women, in an ambitious National Adult Litetacy Program. This is an important complement to the formal education system and should be adequately resourced so that there are enough reading books and supplementary reading materials. Improving the Flexibility of Vocational and Technical Education and Trainina 1.63 Devpol advocates expansion of vocational and technical education over the next decade, on the assumption that this will be necessary to meet the increased demand for skilled workers that is expected to accompany future economic growth. The analyses presented in this report suggest that the capacity of the current training system is adequate to meet foreseeable demand without significant capital investment or expansion. 1.64 The flexibility of the system can be improved through better labor market information and stronger employer participation. More efficient utilization of training capacity could be achieved through the establishment of a small quasi-autonomous training agency to manage the technical colleges, to coordinate the efforts of the institutions providing training support for small-scale businesses, and to improve the labor market information system. A marginal increase in the training levy on employers should provide adequate recurrent cost support.  - 17 - RESOURCE CONSTRAINTS, CHOICES, AND LINKAGES ACROSS SECTORS AND TIME 1.65 The priority actions identified for each sector are those which experience in Malawi and elsewhere indicate will be most effective in helping to reduce disease, ignorance and poverty. The list is long, and there are inadequate resources -- financial, managerial and material -- to move quickly on all fronts simultaneously. The "most likely" macroeconomic flow-of-funds scenario suggests that government expenditures may be able to grow at about 2 percent per year in real terms over in the medium term. 9/ Government's stated commitment to increase the budget shares of health (from 7 to 9 percent) and education (from 11 to 15 percent) implies a slightly larger increase, but would still be significantly below the population growth rate, and well below the increase that would needed for concerted efforts in all or most of the priority areas identified. There is no easy guide to decisions about the optimal mix and timing of actions. There are two sets of considerations; the relative costs and benefits of additional resource allocations to priority activities, and the complementarities and linkages among them. 1.66 There are always difficult choices to be made in allocating limited resources between and within sectors. One guide to decisions is to estimate unit costs and compare the different outputs that MK10,000 (or some other amount) could buy; e.g. the number of primary school graduates, or years of secondary school or University study, or boreholes, or users of contraceptives, or additional children fed by a supplementary feeding program, or months of malarial treatment, or babies immunized, or textbooks. There is no objective way to quantify and compare benefits; e.g. to estimate the value of the life of a child or a mother, or of learning to read and write, or of the time and energy saved by the installation of a new water point. Aowever, at least if the trade-offs are reasonably clear, decision makers can make value judgements about relative desirabilities. 1.67 Another factor to weigh is the linkages between different activities and policies. There are backward linkages; that is, some things need to be done together. For example, providing additional school places will not raise enrollment rates unless families can afford to pay fees; higher enrollments will not improve educational attainment much unless there are teachers, blackboards and books from which to learn. New health facilities cannot operate without staff, drugs and dressings. 1.68 There are many linkages that generate positive externalities; that is, activities that contribute to more than one goal, and are mutually reinforcing in that improvements in one area increase the benefits from investments in other areas. For example; efforts to encourage child spacing are more effective for better educated familes, and when infant mortality is falling or low. Smaller family size can improve nutrition, maternal and child health and mortality, and increase education. Longer birth intervals reduce the maternal health risks of high fertility and reduce the mortality risk to the in,ants. Parents of smaller families are more likely to be able to afford to feed them adequately and to send them all to school. Nutritional improvements lead to better health, greater 9/ Based on the analysis of the Malawi Public Expenditure Review, report 7281-MAI, February 10, 1989, and Government's Policy Framework Paper.  - 18 - ability to learn, and higher income earning capacity. Good nutrition increases resistance to disease. Well nourished, healthy children are likely to have better attendance and to learn more in school than hungry, sickly ones, and to be less likely to fail or to drop out. Well educated workers are easier and cheaper to train for specific jobs. Healthier workers are more productive, and can grow more food and generate higher incomes, which in turn can lead to improvements in nutrition, health and education. Gains in education can also lower infant, maternal and child mortality, improve health and nutrition and reduce desired family size. Better informed parents, especially mothers, are better able to protect the nutrition and health of children. 1.69 There __e '_1inkgeE -ee gnerations that cause the benefits of investments in human resource development and the costs of neglect to multiply over time: educated, well-nourished, healthy parents are more likely to have educated, well fed, healthy children. Children who do not complete a basic education are likely to remain illiterate all their lives, which will make participation in a modern changing economy difficult for them, and have negative consequences for the welfare of their families. The costs of delaying social sector investments are high. The results of these investments cannot be judged only in the short-term, they also benefit future generations. 1.70 It takes decades to effect significant changes in the delivery of social services and improve the quality of the country's human resources. Many of the inputs into the process are time-consuming to undertake. Strengthening programs may require many contributiry activities tc be modified and improved, which tales time to design and implement. Reforms and changes are often resisted by persons who have been trained and have operated under previous systems; time is required to integrate new ideas and methods. It will take at least a generation to alter substantially the average qualifications and capacities of the work force. These considerations reinforce the notion that human resource development is best viewed in a long-term perspective.  - 19 - CHAPTER TWO POPULATION INTRODUCTION 2.01 This chapter describes demographic trends in Malawi, and looks at the main socio-economic implications of those trends. Population- related policies, institutions and activities are reviewed briefly, issues related to the child-spacing program are raised, and recommendations made for its future development. This chapter has been summarized from the draft M wiPopjaton Sector Study, which will be published during 1990. 2.02 Malawi faces one of the most urgent problems of rapid population growth in Africa today. The country's single major natural resource -- agricultural land -- is under severe pressure from the high population growth of recent decades, which has doubled population numbers since independence 25 years ago. Already about 60 percent of smallholder farms are smaller than one hectare -- the minimum required to feed a family at current levels of agricultural technology. The expansion of cultivation into marginal lands forced by population growth has reduced fallow periods and led to deforestation and degradation of soils in many areas. Industry and the formal employment sector cannot grow fast enough over the next few decades to absorb the rapidly swelling labor force (see chapter 7). Limited government budgets and low household incomes cannot hope to cover the huge increase in needs for education and health care that will be generated by the fast growing and youthful population of Malawi. 2.03 The government of Malawi is aware of these serious population issues and deserves much credit for its rapid and effective actions to date. Impressive progress has been achieved during the past five years. A national child-spacing program was begun in 1983 and endorsed by a resolution of the Malawi Congress Party at its September 1987 convention. Several national seminars and workshops have been held to discuss population and development, the most recent being the workshop for Permanent Secretaries in October 1989. In 1989, the establishment of a National Family Welfare Association and the introduction of family life education in school curricula were approved. However, much remains to be done, and done urgently. 2.04 This report endorses Malawi's general approach and directions in population issues, and recognizes that the major needs discussed in this chapter have already been identified within the country, together with preliminary steps and strategies to address them. Still, government will need to move quickly and effectively over the next few years to maintain and accelerate current momentum in the development of population programs. Substantial increases in funding and manpower will be required. DEMOGRAPHIC TRENDS AND THEIR IMPLICATIONS 2.05 Demographic trends have been estimated using data from the three census's of 1966, 1977, and 1987 (for the latter, only population totals are available so far) and three demographic surveys -- the 1970-72  - 20 - Population Change Survey, the 1982 National Demographic Survey and the 1984 Family Formation Survey (FFS). 2.06 Malawi has approximately doubled its population since Independence, from just under 4 million, to around 8.2 million now (1990) excluding refugees. Adjusting for refugee numbers, government estimates the current population growth rate at around 3.3 percent; the Bank's own estimate is slightly higher at around 3.5 percent. Even a 3.3 percent growth rate would cause the Malawian population to double again within two decades to reach over 15 million. 2.07 Mortality ir M^l2wi from the 1950s to the mid 1970s was exceptionally high by any standard, and declined only very slowly during that time. This was especially true of childhood mortality, which was unparalleled in Eastern Africa. Evidence from the 1982 and 1984 surveys suggest that childhood mortality began a marked decline from the mid 1970s: the IMR fell to under 170 in the late 1970s, and the proportion of children dying before 5 years of age fell to 29 percent (though these are still relatively high). Extrapolation of this decline through the 1980s would imply for 1990 an IMR of under 150 and about one quarter of children dead before age 5. Gender and urban/rural differentials in mortality have the usual patterns -- lower female mortality resulting in about 2 years greater life expectancy, and a strong urban advantage and faster decline. Overall, childhood mortality is highest in Central Region and lowest in Northern Region, with extremely high levels in the heart of Central Region and in the extreme south. 2.08 Fertility is very high throughout Malawi, at a national total fertility rate (TFR) of 7.6 births per woman. There is not much variation by region and district or between urban and rural areas, and no evid,nce of any trend in fertility over the past 2 decades at least. The factors which contribute to this high fertility are: early, stable, universal marriage, childbearing beginning early (on average by 18 or 19). extremely low incidence of sterility, short post partum amenorrhea (an average of 18 months) and shorter abstinence (an average 6 months). There is little variation in these factors by educational level or urban/rural residence of women. Knowledge and use of childspacing methods is increasing, but still low: 27 percent of women and 35 percent of men in the reproductive ages reported knowledge of a childspacing method (modern and/or traditional) in the 1984 FFS, when the childspacing program was just beginning. Only about 7 percent of women aged 15-49 years were actually using any childspacing method, and only 1 percent a modern method; abstinence was the most frequently used traditional method, but others included ineffective techniques such as strings and herbs. Use of modern childspacing methods is estimated now to have reached around 3 percent; this is impressive in relative terms, but much greater increases will be needed for a significant effect on fertility. 2.09 Age and Sex Structure Malawi's very high fertility, high but declining childhood mortality, and long standing, though declining, emigration of adult males, have combined to produce a population structure with an overall male deficit and increasingly large proportions of children. In 1987 there were 95 males per 100 females, an estimated 48  - 21 - percent of the population was under 15, and a very high dependency ratio of 103 dependents per 100 adults of working age. Population Prolections 2.10 Three illustrative and policy-based population projections help explore the implications of these demographic trends and characteristics. Refugees are excluded on the assumption that they will not remain permanently in the country. The baseline is the 1985 Gover-ment population projection "Constant Fertility, Fast Mortality Decline" variant, adjusted to refer to mid-year, 1985. Net migration was assumed to be insignificant after 1985. In the absence of adequate data, no attempt has been made to incorporate the potential demographic effects of AIDS. 2.11 All 3 projection scenarios assume a continued decline in mortality which would cause life expectancy to rise to 59 years by 2015-20 and the proportion of children dying under 5 years of age to fall to 12 percent. Three fertility scenarios were employed. The first is of constant fertility at a TFR of 7.6 throughout the projection period. Recent progress in the childspacing program suggests that this is not realistic; however it serves both as a baseline against which to measure the impact of fertility change and an illustration of what could happen if the childspacing program stalled or was abandoned. The second scenario is of a moderate fertility decline, beginning after 1995 and reaching replacement-level fertility by the year 2045. The TFR falls to 6.7 by 2000-05 and to 4.0 by 2015-20. Corresponding contraceptive prevalence rates (CPRs) among all women aged 15-49 years, calculated from the well- known Bongaarts formula, are 15 and 50 percent respectively. This scenario assumes a moderately strong childspacing program, and steady progress in socio-economic development. The third scenario is of a rapid fertility decline which begins after 1995 and reaches replacement-level fertility by the year 2020, or within 30 years. The TFR drops to 4.5 by 2000-05 and to 2.4 by 2015-20. Corresponding CPRa are 44 and 71 percent respectively. This scenario is perhaps unrealistic, but provides an upper limit for the speed with which population growth can be reduced, and a minimum population size to be expected for Malawi in the future. Table 2.1 Projected Size of the Population of Malawi* (in millions) 1990 2005 2015 2030 Doubling time (yrs) at 2015-20 growth rate Constant Fertility 8.38 14.48 21.41 39.97 17 Moderate Fertility Decline 8.38 14.03 18.71 25.69 30 Rapid Fertility Decline 8.38 12.80 15.10 18.37 50 Not including refugees 2.12 Full results and more details of these projections are given in the forthcoming Population Sector Study, Fable 2.1 summarizes. Population growth will be substantial even under the most optimistic scenario. The  - 22 - population will expand by at least 50 percent over the next 15 years, and double over the next 25 years, to reach over 15 million well within the lifetimes of today's Malawian children. The worst case scenario would see the population exceed 21 million by 2015, and almost doubling again to nearly 40 million 15 years after that, by 2030. 2.13 Fertility trends have a huge influence over population trends in the longer term. Even by 2005, only 10 years after the projected beginning of fertility decline, a rapid fall could reduce population numbers by 12 percent from those expected under constant fertility. By 2015, a moderate fertility decline would reduce expected population size by 13 percent, while a rapid decline would cut it by 30 percent. The longer term effect would be even more dramatic, cutting potential further doubling time after 2015 from only 17 years to 30 or even 50 years. 2.14 Fertility trends are the most important determinant of age structure (Table 2.2). The constant fertility scenario would result in a dependency ratio of nearly 11 dependents for every 10 adults of working age, reflecting an age structure in which 50 percent of the population would be under 15 years. Falls in fertility, however, would cut the proportion of children dramatically, to 32-42 percent within 25 years, and reduce the dependency ratio to between 3.6 and 8.5 dependents per 10 adults of working age. Low dependency burdens provide opportunities for increased rates of savings and investment, and greater family well-being. Table 2.2 Projected Age Structure of the Population of Malawi* 1990 2015 Percentage Population Aged Under 15 Years Constant Fertility 48 50 Moderate Fertility Decline 48 43 Rapid Fertility Decline 48 32 Percentage Elderlv Aged 65 and Constant Fertility 3 2 Moderate Fertility Decline 3 3 Rapid Fertility Decline 3 3 Dependency Ratio** Constant Fertility 103 109 Moderate Fertility Decline 103 85 Rapid Fertility Decline 103 55 Not including refugees ** defined as the number aged under 15 years and 65 years or over divided by the number aged 16-64 years, per 100 persons aged 16-64 years. 2.15 The implications of alternative population trends for land scarcity and employment are examined in chapter seven, and show that unless fertility and population growth are sharply reduced, unemployment,  - 23 - landlessness, poverty and malnutrition will increase to very serious levels during the next twenty-five years. The ultimate solution to the problem of acute population pressure on land in Halawi must of course be found principally in improving the productivity of land and labor. Improved education coverage will facilitate technological change, and more education for girls especially is strongly correlated with smaller desired and actual family size, and better family well-being. Rapid population growth intensifies the needed pace of technological change, but it may hamper progress through the accompanying degradation of soils and increase in poverty. Thus reduction of population growth will play a vital supportive role in gaining more time and less desperate urgency for technological development. 2.16 Rapid population growth in Halawi will bring about enormous increases in the need and demand for health care and education. Without any decline in fertility, the number of children of primary school age (6- 13 years) will more than double from nearly 2 million to close to 5 million. A moderate fertility decline would mean nearly one million fewer children in 2015, and rapid fertility decline would mean an increase of less than 40 percent, to 2.6 million. The slower the rate of population increase, the better the chances of increasing enrolment rates from their present very low level. With no change in fertility, & 3-4 percent annual increase in the number of primary school places would be needed just to maintain enrolment rates. High population growth rates also place a heavy burden on maternal and child care services. Constant fertility will more than double the number of deliveries per year to about 1.1 million by 2015; a moderate fertility decline would mean a much smaller increase to .65 million per year, while a rapid fertility decline would result in fewer deliveries per year in 2015 than in 1990. The number of under five children is also highly sensitive to fertility rates and would increase from 1.1 million in 1990 to 4.4 million without any change in fertility, to just under 3 million with a moderate decline, and to about 1.5 million with a rapid decline. Table 2.3 Projected Numbers of Primary School Age Children and Health Service Clients (millions) Children aged Average annual Potential no. 6-13 years No. of Deliveries of MCH Clients* 1990 2015 1990 2015 1990 2015 Constant Fertility 1.91 4.97 0.45 1.10 2.11 5.53 Moderate Decline 1.91 4.09 0.45 0.65 2.11 3.59 Rapid Decline 1.91 2.63 0.45 0.36 2.11 1.93 * Children under 5 years plus deliveries 2.17 The impact of rapid population growth on social services would be most crucial for the poorest families in Halawi. These families tend to  - 24 - live furthest away from schools and health facilities, so are most affected if lack of funding forces cuts in coverage, service quality or expansion. Since their incomes are lowest, they also suffer most if fees are increased to supplement inadequate government funding of education and health. Yet at the same time, their educational, health and nutritional levels are worst, and their dependence on good and cheap or free government services the greatest. 2.18 To sum up, therefore, rapid population growth has been, is and will be damaging to the socio-economic development of Malawi. Most importantly, it has already created acute and harmful pressure on natural resources, chiefly land, and if continued without relief will limit the time available for implementation of the substantial technological changes needed desperately to raise the productivity of agricultural land and labor, in particular in poor households. Rapid population growth also creates acute pressure on employment markets, produces heavy dependency burdens on workers, and leads to explosive demand and need for expensive social services such as education and health. Malawi therefore needs to work urgently towards the earliest and fastest fertility decline that is achievable, in order to safeguard natural resources, stretch out the time available for technological advancement, and cut dependency burdens both at the individual or family level and at the level of national social services. In all these ways, the reduction of population growth through fertility decline will make a crucial and indispensable contribution to the alleviation of poverty and acceleration of socio-economic development in Malawi. POPULATION PLANNING INSTITUTIONS AND CAPACITY 2.19 Malawi has begun to integrate population issues in development planning and programs. A Population Planning Unit with a well-designed work plan has been set up in the Economic Planning and Development (EP&D) unit within the Office of the President and Cabinet, supported by UNFPA. An adequate population data base is being provided by the NSO through regular population censuses and intercensal and other demographic surveys. Analytical capacity for assessing population trends and linkages with development has been strengthened by the Demographic Unit at the University of Malawi, and another analytical tool will be provided by the USAID-funded RAPID III project to be set up within EPD, in conjunction with NSO and the Demographic Unit. It will now be necessary to build on this sound foundation so that attention to population concerns becomes permanently integrated in Malawi's development planning. This would require only modest incremental funding. 2.20 The Population Planning Unit needs to made a permanent part of EP&D, and regular contacts and collaborative links need to be developed with sectoral planners, especially in agriculture, transport, physical development, health, education and energy, and also with District Commissioner's offices and District Development Committees. Masters-level training in population and development should be offered to four to six staff from the Population Planning Unit and sectoral planning units. The proposed University of Malawi's master's degree in population and development would be suitable and relatively low-cost.  - 25 - 2.22 Population data must continue to be collected, processed and analyzed regularly, to maintairn a steady flow of up-to-date and useful population data. Processing, analysis and publication of the 1987 census data should continue to be given the highest priorit7 and support. The Population report also recommends that the intercensal National Demographic Survey be held on schedule in 1992 and that development of a nation-wid- vital registration system be planned and initiated. Demographic data will need to be analysed within the context of the data to be collecLed In the NSSA and national household budget surveys. CHILDSPACING 2.23 Malawi's childspacing program has grown rapidly since its inception in 1982. Childspacing services are offered free at 168 health facilities (30 percent of all facilities). Reported numbers of new clients have risen spectacularly from 3,205 in 1984 to 27,630 in 1988 (the true figure is much higher but there are no reports from over half the facilities) and about 3 percent of married women of reproductive age use modern contraceptives. These are real achievements for a very young program. 2.24 Nevertheless, it is clear that a huge challenge lies ahead in raising use of modern contraceptives to a level consistent with good maternal and child health and national and family welfare. There are problems regarding both supply and demand: the program cannot satisfy the present demand for childspacing services. and there is still widespread ignorance about correct contraception usage to maximize maternal and child health and family welfare, and some remaining misunderstanding and resistance to the concept of modern contraceptive use for health purposes. A major, wide-reaching and sustained effort in information, education, and communication is needed to stimulate demand for childspacing services. On the supply side, service coverage and quality need to be expanded rapidly to satisfy the current excess demand in most parts of the country, let alone to meet the full needs of the country now and in the future. Childspacing services are still not available in many health facilities, and there is no community outreach system yet. There are serious resource constraints and important technical issues regarding training, method mix and channels for delivery of childspacing services to be faced. 2.25 An ambitious five-year plan for increasing the range and scope of the childspacing program has been launched. Training of trainers and service providers is continuing, social marketing of contraceptives is being explored and a community outreach system is being set up, research into knowledge, attitudes and practices is planned, education, information and communication activities are being expanded, and a monitoring and evaluation system is being developed. 2.26 Role of the private sector Government has recently given permission for the establishment of a national Family Welfare Council, which will be able to assist the program in valuable ways, by helping to mobilize additional donor resources, testing new delivery mechanisms, research, advocacy, and providing childspacing services in areas not covered by MOH or PHAM. There is still much more potential for the private  - 26 - and communication activities are being expanded, and a monitoring and evaluation system is being developed. 2.26 Role of the private sector Government has recently given permission for the establishment of a National Family Welfare Association, which will be able to assist the program in valuable ways, by helping to mobilize additional donor resources, testing new delivery mechanisms, research, advocacy, and providing childspacing services in areas not covered by MOH or PILAM. There is still much more potential for the private sector to contribute to improving and expanding Malawi's childspacing services. More employers, including estate owners should be encouraged by government to set up health services - including childspacing - for their employees. Private doctors and nurses could play a very useful role particularly in the urban areas. Supply Problems and Constraints 2.27 Despite remarkable progress over the last few years, there are four major constr&ints on expansion of the childspacing program: (a) too few facilities and too few staff are able to offer childspacing services; (b) the lack of an outreach network in either health or childspacing; (c) bottlene'- s in childspacing training; and (d) deficiencies in contracept: commodity supply, program information and management. 2.28 Most families in Malawi do not yet have easy access to child- spacing services through the fixed-facility health care network. The network of facilities is thinly-stretched in many parts of the country and there is an overall scarcity of health personnel, due to budgetary constraints on hiring. More than two-thirds of the country's nurses are still not trained in child-spacing, so about 70 percent of the country's health facilities cannot offer childspacing services. Facilities that do offer childspacing services often have inadequate space and equipment for childspacing consultations. 2.29 The lack of an outreach capability in the health care system is well recognized by MOH as a major constraint upon childspacing program expansion, and strategies for creating a community-based distribution (CBD) system to supplement and extend fixed facility services are under consideration at present. There are many ways in which a CBD system could be organized and operated in Malawi, and many existing networks which could be brought into partnership with MOH, e.g. the Ministry of Community Services and Ministry of Agriculture extension services, the CCAM, the Malawi Young Pioneers, and the TBAs. It is necessary to try out different systems to determine their workability and cost-effectiveness. 2.30 Several bottlenecks are slowing training in childspacing and holding back the whole program: - there is still no childspacing in pre-service training of registered nurses, mainly because the School of Nursing is reluctant to move forward; - in-service childspacing training of enrolled nurse/midwives is hampered by inadequate training facilities and staff shortages which make it difficult to release trainers and trainees from their posts;  - 27 - 2.31 Supplies of contraceptive commodities have been erratic, causing periodic shortages which have severely undermined the effectiveness and impact of the childspacing program. In part, this was because demand in the early years of the childspacing program grew far faster than had been envisioned, but in addition, the program has not responded quickly or flexibly enough. Poor recordkeeping has made it difficult to monitor and forecast demand for commodities, and orders for new supplies have not been adjusted on the basis of use and demand. The recordkeeping system is grossly defective, with multiple, overloaded and uncoordin4ted clinic forms, cards and registers. The contraceptive method mix is not well matched to client preference; for example, health personnel feel that Depo Provera would be used more widely in preference to the pill if it was not usually in short supply. MOH is well aware of these logistical weaknesses, and is making improvements. Much remains to be done however, especially to simplify the recordkeeping and reporting systems so as to streamline collection and analysis of necessary information and to provide feedback to the field. Recommendations for Extending and Improving the Supply of Childspacing Services 2.32 A number of specific actions are recommended to address these key constraints on the provision of childspacing services: o The MOH/PHAM network needs to be augmented by other channels of health and childspacing service delivery, such as the new national Family Welfare Council, the private sector, commercial marketing of contraceptives and community-based distribution of condoms and re-supply of oral contraceptives. These initiatives deserve high priority. Multiple delivery systems will enable different groups to be reached and will increase accessibility and availability of childspacing methods. o MOH needs to move quickly to test alternative outreach systems in pilot projects in one or two communities in order to determine the best system to use on a national basis. O Private estates and companies who do not at present provide health services to their employees could be pressed to set up such services, with strong emphasis placed on PHC, MCH and childspacing services. 2.33 The number of MOH/PHAM service points offering childspacing needs to be increased. O Condoms and spermicides, which have the advantage of being non-clinical methods, could be supplied quickly to all health facilities. This would increase access to these methods, and, in the case of condoms, contribute to the prevention of HIV infection. o An accelerated training program for enrolled nurse/midwives and medical assistants will be required to increase the availability of methods requiring clinical supervision, such as oral contraceptives and intra-uterine devices (IUDs) (and see para 2.35).  - 28 - o Condoms and spermicides, which have the advantage of being non-clinical methods, could be supplied quickly to all health facilities. This would increase access to these methods, and, in the case of condoms, contribute to the prevention of HIV infection. o An accelerated training program for enrolled nurse/midwives and medical assistants will be required to increase the availability of methods requiring clinical supervision. such as oral contraceptives and intra-uterine devices (IUDs) (and see para 2.35). 2.34 Another means of strengthening childspacing services and thereby improving child and maternal health is by broadening the criteria for the use of various methods. This is justified by the very favorable benefit/risk ratio for contraceptive methods in Malawi, given the high rate of maternal mortality. For example, it might be useful to consider allowing the use of injectables by women other than those over age 35 and parity five and above. Injectables are approved by WHO and the International Planned Parenthood Federation and can be used safely and effectively by women of younger age and lower parity. Similarly, risk factors for pregnancy complications, for example, higL blood pressure among women of high parity, provide a strong medical justification for tubal ligation in women interested in this procedure. PHAM's proposal to improve access and quality of surgical contraception in collaboration with the Association for Voluntary Surgical Contraception (AVSC) deserves support. 2.35 In order to speed up training in childspacing, o childspacing training should be a firm requirement or all medical and para-medical pre-service training without exception, discussions will need to be held with the School of Nut:ring and the Catholic training centers to ensure their compliance; o the present content and design of childspacing training courses should be reviewed, with a view to reducing their length and tailoring them more precisely to the needs and capabilities of each level of health staff; accompanying specialization of training of trainers, and workload of training centers, could also be considered. 2.36 Deficiencies in logistics/commodities and information and management capabilities are well-recognized in MOH, and steps are already being taken to remedy the situation. o Action to ensure plentiful, timely and reliable childspacing supplies is a high priority and must get urgent attention. O At present, there is only one staff person at the MOH central level to manage the childspacing program alone. As the progr-n expands and develops, it will be essential to strengthen its management structure, staffing and information systems. O A simple but effective system for collection and use of routine program statistics needs to be developed and installed as a matter of urgency.  - 29 - Financing the Childspacing Program 2.37 No estimates have been made to date for unit costs of, or expenditure on, childspacing service delivery. To do so, it would be necessary to determine the amount of time spent on childspacing by health staff (who have many other duties), and the costs of childspacing training for health staff. At present, clinics still seem to operate at rather low levels of capacity utilization; the Child Spacing Report for 1988 reports 32,000 new acceptors and 50,00J revisits, which would work out at about 485 client contracts per clinics in 1988, or 2 contacts per clinic per working day. Thus unit costs are probably still high, and would be expected to fall as childspacing use increases. 2.38 However even if unit costs fall to unusually low levels, large budgetary allocations will be needed to enable childspacing use to grow as fast as is likely and desirable. For example, the target contraceptive prevalence rate of 10 percent by 1992 set in the National Child Spacing Program Five-Year Plan would imply about 160,000 users in 1992. Even at very low unit costs per user - say US$10 (US$20 is more typical of developing country childspacing programs) the needed annual expenditure on childspacing would be MK 4.0 million in 1992 (1988/87 prices), which is roughly equal to the estimated total primary health care budget (including childspacing) for 1987. It will be necessary, therefore, to make careful explicit provision for the childspacing program in forecasting and planning future health financing needs. 2.39 Since most Malawian families could not afford more than a small fraction of the costs of childspacing, a three-pronged financing strategy is proposed. First, program design and management mustly strongly emphasize low-cost, cost-efficient and cost-effective ways of delivering childspacing services (and associated IEC activities), since resources will be limited even under the most favorable conditions. 2.40 Second, ways need to be sought to tap resources from non-MOH sources to their fullest extent, such as other government agencies, NGOs, donors, the private sector, and - to the extent feasible - users. For example, personnel from other Ministries, particularly those engaged in rural extension work could be used in the childspacing program. PHAM's role could be widened and strengthened, which would _.ntail some recovery of costs from clients. Private estates and companies should be pressed to provide, or help to finance (through such mechanisms as health insurance or HKO schemes) HCH services that include childspacing. An aggressive effort should be mounted to attract more funding from bilateral and multi-lateral donors. A donors' group could be formed to coordinate fund-raising efforts. 2.41 Third, the government may wish to consider increasing the budgetary allocation specifically to expand childspacing services. This implies shifting resources out of government programs in other sectors, but would be justified by the costs to government of not achieving rapid growth in contraceptive prevalence -- the savings on education and health budgets alone resulting from fewer births would soon balance, and later greatly outweigh the cost of providing childspacing services; crude estimates indicate that every kwacha spent on childspacing would save 2 to 5 kwacha  - 30 - on schooling and MCH care over the following 10 years. Government investment now in the childspacing program is financially prudent for the longer term. Issues of Demand 2.42 There is substantial open demand for modern contraception in Malawi, and a very receptive attitude to consideration and discussion of childspacing. In the 1984 Family Formation Survey, 16 percent of women aged 15 to 49 said that they wanted no more children. (The proportion was higher the older the woman and the more children she had.) Forty-three percent of all non-pregnant women aged 15-49 years wanted to delay the next birth and 8 percent were uncertain. Only 31 percent of non-pregnant women wanted another baby right away. Thus at least 60 percent of all women in the reproductive ages wished to regulate their fertility, either to delay the next conception or to stop child bearing altogether. However, less than one-third of women knew of any childspacing method, and only 6 percent knew of a modern method. 2.43 The basic concept of regulating births to maximize family health and welfare seems to be well understood and accepted in Malawi. Even among men, who in Sub-Saharan Africa are usually more resistent than women to using contraceptives, the FFS found in 1984 that two thirds would like their wives to use childspacing methods and about 70 percent would like to use a method themselves either now (31 percent) or in the future (38 percent). These levels of approval were even higher among the men under 30 years or with secondary schooling or more. 2.44 Clearly, many Malawian families need much more information about contraceptives, where to get them, and how to protect the health of mothers and children by spacing and timing births so to avoid pregnancies that are too early or too late in the mother's life (before 20 years of age or after 35), too close together (there should be at least 2 years between successive pregnancies, i.e. 3 years between births), or too many. The MOH will need to strengthen the Health Education Unit and to work with other Ministries to provide more information to health care provider and the general public. The agricultural extension system in particular is widely spread and effective, and the Ministry of Community Services extension network is much smaller but reaches large numbers of rural communities. In addition there are women's and youth organizations, programs and projects that are natural partners to the health system in health and childspacing IEC efforts. However, strong efforts to mobilize and train such networks have not yet been made and will require careful planning and additional hard-to-find funding. 2.45 A multi-sectoral, coordinated strategy for building support and demand for childspacing is lacking and needs to be developed. Several activities in IEC (information, education and communication) are underway, including introducing Family Life Education in schools, media coverage, and seminars, but there is much duplication of effort and excessive reliance on expensive and often unnecessary outside technical assistance. Donors should collaborate more, and better coordinate their assistance in childspacing IEC. A strong lead organization within Government is needed  - 31 - to plan and coordinate IEC efforts. MOH's Health Education Unit is logically the body best fitted to do this, but needs more staff and other resources and greater seniority and autonomy within MOH to be able to do this well. 2.46 Malawi could rely much more on local talent, expertise and experience (including that of neighboring countries) in developing and delivering childspacing IEC and make less use of expensive outside technical assistance; it is suggested that MOH review some of the technical consultancies already planned. 2.47 The childspacing program in Malawi, like other health programs, has rightly focused its educational efforts to date mainly on interpersonal communication, particularly between health workers and clients. In the future, however, if the program is to attract and retain a wider clientele more use will need to be made of mass media chanr.els, in addition to continued and strengthened interpersonal communication. Malawi has an effective radio network, abundant local talent in materials production, and some excellent IEC units in other agencies, notably the Extension Aids Bureau of the Ministry of Agriculture and the Department of Media Services and Public Information, which have good production and dissemination facilities for film and print media. More use could be made of these outlets for health and childspacing messages. 2.48 Some constraints and problems need attention: many families cannot afford radios and batteries; access to films is constrained by very high film processing costs and underutilized distribution systems (such as touring vans); low literacy rates, high printing and paper costs and the tendency to opt for unnecessarily high quality printed materials rather than a much greater volume of materials of lower quality reduces the availability of printed materials for the population at large and health workers. Some of these problems could be addressed: o compromising a little on print and paper quality would allow a much greater volume of print materials to be produced; o production and processing costs in film and print media should be reviewed with a view to finding creative ways of lowering costs; o consideration should be given to reviving the program begun in the late 19608 to provide community radios, and solar-powered radios or batteries should "e investigated 1/; o efforts should be made t2 increase the dissemination of films by increasing the numbers of trips made and films shown per mobile van; o the talented and popular MOH band/drama team should be used more intensively, making more field trips per year, the technical content of their materials needs to be strengthened, and their field trips should be linked to systematic training of health/community workers 1/ The Ministry of Education is looking into this for school radios.  - 32 - and community leaders in the use of song and drama for delivering development messages. 2.49 Other options for building additional support for the childspacing program (some of which are already being pursued) are: (a) more workshops and seminars and media coverage of the health benefits of childspacing, perhaps based on Malawian data from the Family Formation Study. These efforts could be aimed at key constituencies -- political leaders, influential males, women's groups, doctors and other key health personnel, the press and religious groups; (b) strengthen the childspacing content of health personnel basic training programs, especially medical assistants, enrolled nurse-midwives, and accelerate the in-service training of health personnel; (c) teach Family Life Education in schools, even in the lower grade, and include human reproduction; (d) organize study tours for key government officials to visit the family planning programs in such places as Zimbabwe, Kenya, Indonesia. The focus of such visit should be broader than family planning in order to provide a view of how other countries have dealt with the difficult questions of population policy and family planning program development; and (e) invite outside experts to participate in national workshops and training courses. 2.50 There is great potential and need to build additional popular, long-term support for the childspacing program. The 'safe motherhood' approach -- promoting childspacing on health grounds to avoid pregnancies that place mothers and their children at risk -- has been used with success in many countries in the world, and would do much to lower child and maternal mortality and morbidity in Malawi.  - 33 - CHAPTR THilR NUTRITION 3.01 This chapter reviews current nutrition status, and examines the factors that contribute to severe malnutrition. Next it identifies the constraints to achieving nutrition goals and assesses the feasibility of overcoming the problems. The final section presents and evaluates strategies for achieving national goals for improving nutrition. OVERVIEW AND PERSPECTIVES 3.02 There is widespread malnutrition, particularly among children, in the lower socio-economic strata of rural Malawi. This contributes to the high rates of infant and child mortality and morbidity and to high maternal mortality. Many families throughout the country regularly experience food shortages during the pre-harvest period of January to March. The problem of household food insecurity is in part the result of high fertility rates which are causing a decrease in access to land, combined with inadequate agricultural inputs and practices. This is exacerbated by a decrease in out-migration and the addition of about 860,000 refugees. Consequent pressure on agricultural land combined with the expansion of the estate sector has reduced farm size of many smallholders to an insufficient level to meet the food needs of the average family, given present technology. 3.03 Food deficits are made up as far as possible by cash purchases or transfers. Cash for food and for essential household needs is generated by employment on larger landholdings or estates where minimum and sub-minimum wages are paid. Competing needs for agricultural labor results in the postponement of activities on families' own farms, further decreasing yields and reducing household food security. Alternative opportunities for off-farm employment at reasonable wages and other income generating activities remain inadequate in scope and remuneration. 3.04 These problems are compounded in the case of female-headed households (FHH) which now constitute almost a third of landholdings. Many women who do not receive regular remittances or transfers have to work off-farm for minimal wages in addition to carrying out their own production and domestic tasks. In these circumstances, child care must be delegated to young children or to grandparents, who may not be competent to assume such responsibilities. The combination of insufficient food and inadequate care constitutes a major health hazard to children, particularly during the weaning period. 3.05 These problems have been recognized for some time and special rural development programs have been applied to resolve them. However, these agricultural and community development initiatives have generally failed to reach those with greatest need. Access to credit and advisory services to improve the productivity of very small landholders and poorer female-headed households is limited.  - 34 - 3.06 It is likely that land holdings of a major proportion of the population will decline further in size until they become grossly insufficient to meet subsistence needs. Under such conditions, smallholders will progressively abandon, or be forced off, customary land and be obliged to look for wage employment. Wage levels for unskilled labor are insufficient to ensure minimal living standards, particularly where less than the minimum wage is paid to women. Expansion of the rural labor pool is likely to depress wages further. Decreased access to land, low wages and increased female employment will exacerbate existing problems of food security and child care. Consequently, infant and child mortality may remain high or worsen, as has occurred elsewhere under similar conditions. As child survival is further compromised, fertility declines may also be slowed. Migration to urban areas must accelerate under these circumstances and the rural poor will accumulate in the periphery of towns and cities, facing the same problems that have occurred elsewhere in Africa. I. appropriate modifications in macro-economic policies and sectoral programs are not introduced, Malawi will, in the longer term, undergo transformation into a semi-urbanized society with increasing rural poverty and expanding under-served and underemployed peri-urban populations. 3.07 Under these conditions, food supply, diet and child care will continue to deteriorate. As the rural poor move from subsistence farming to a cash economy they will become more dependent on local food markets for supplies. If agricultural production continues to move towards cash cropping, particularly non-food crops, food prices will rise and the range of foodstuffs available will become dependent on commercial distribution systems. This implies changes in dietary patterns as consumers are obliged to adapt traditional preferences to changes in the availability of food supplies. Greater knowledge of nutritional principles will be required to respond to such changes and new techniques of preparation and conservation needed to ensure efficient use of less familiar foods. This will occur in the context of decreasing time for maternalidomestic activities as female employment rises. Breast feeding patterns are likely to be adversely affected for the same reasons and will require reinforcement. In addition to such behavioral changes, some form of income support for poor households will be required to achieve and maintain household food security. 3.08 There are several fronts on which to wage the battle against malnutrition over the next few years. Chronic household food insecurity and seasonal hunger can be combatted by increasing food production by subsistence farmers and by expanding employment opportunities for those with too little land to produce enough food for their families and for those who are landless. In the shorter term, more widespread coverage of growth monitoring of under-fives and supplementary feeding programs is needed. Child care, weaning and feeding practices should be improved to ensure that dietary .ntakes are adequate for infants and small children. The present deficiencies reflect the extraordinary demands on the time of women, especially in female headed households. These women must not only serve as mothers and wives but also work long hours on their farm plots or as laborers. These production activities conflict with the need to provide very frequent feedings of the local weaning foods. Adoption of higher density weaning foods, and introduction of affordable labor-saving  - 35 - technology for household and agricultural tasks could have a significant effect. NUTRITION STATUS Nutrition among Infants and Children 3.09 Undernutrition plays an important part in infant and child mortality in Malawi which is among the worst in the world (see para 4.13). A large proportion of hospital deaths among children is attributed to diseases that usually are not fatal in adequately nourished persons. 3.10 The proportion of under-five mortality attributable to malnutrition has not been estimated for Africa, but results from work carried out by Puffer and Serrano 5/ in Latin America can be used to give a rough indication of the proportion of child mortality attributable to underlying malnutrition. There is no evidence that the same conditions operate in Africa, or indeed in Malawi, but the exercise is nonetheless instructive. These computations suggest that in 1982 malnutrition may have been a direct or contributory cause in 60 percent of the hospital deaths among children under five years of age diagnosed as having one of the six main diseases. Table 3.1 Proportion and Number of Childhood Deaths Associated with Malnutrition. 1982 Z Attributable Number attributable Deaths to malnutrition to malnutrition 1. Measles 975 62 604 2. Pneumonia 786 32 252 3. Nutritional deficiencies 673 100 673 4. Malaria 611 61 376 5. Anemia 549 47 258 6. Diarrheal diseases 504 61 307 Total 4098 60 2466 3.11 Also drawing upon the Puffer and Serrano findings, one can examine the role of nutrition in outpatient data. Table 3.2 presents the percentages of total visits attributed to each of the nine leading diagnoses actually or potentially related to malnutrition. These nine conditions represent 89.8 percent of the outpatient load for children under 5/ Puffer, R., and Serrano, C., 1973 Patterns of Mortality in Childhood, PAHO Sc. Pub. No. 262, Washington D.C.  - 36 - five, which totaled 4.31 million visits in 1982. Applying an attribution rate of 47 percent, as estimated by Puffer and Serrano for overall mortality, would result in a total of 2.26 million visits that might have been caused to some extent by poor nutritional status. Table 3.2 Estimate of Proportion of Outpatient Visits Related to Under Nutrition Disease Z Visits 1. Malaria 35.6 2. Respiratory infection 19.8 3. Diarrheal disease 8.7 4. Infectious diseases of the eye 7.9 5. Skin diseases 5.7 6. Abdominal and gastro-4ntestinal symptoms 5.2 7. Measles 2.3 8. Nutritional deficiency diseases 2.2 9. Intestinal parasites 1.6 3.12 The most reliable information on the prevalence of childhood malnutrition is derived from data collected by the National Sample Survey of Agriculture (NSSA) conducted in 1980/81 6/. Measurements of weight and height for children under five years were collected in two rounds -- in August 1980 and March 1981 -- in order to capture conditions after and before harvest, respectively. Height for age indicates chronic or past episodes of malnutrition. Weight/height indicates acute or current malnutrition independent of any chronic effects. 3.13 The results of this investigation reveal a high prevalence of chronic malnutrition distributed fairly evenly throughout the country. The overall rate was 56.5 percent in both rounds; rates by district ranged from 64 percent in Salima to 49.5 percent in Ngabu ADD. Corresponding rates for Kenya and Zimbabwe were 37 percent and 28 percent, respectively. The distribution of chronic malnutrition by sex showed an overall rate for males of 59 percent and for females of 53 percent. The prevalence of acute malnutrition, in most cases superimposed on chronic malnutrition, was 1.6 percent in the first round (post-harvest) and 2.8 percent in the second (pre-harvest). It was most prevalent in the pre-harvest season in Blantyre (5.5 percent) and least prevalent in Karonga ADD (1.0 percent). The peak age range was 12-23 months, with a pre-harvest rate for males of 9.9 percent and for females of 6 percent. Male children reaching the second year of life (weaning) in the pre-harvest season in the Southern region represent the highest risk sub-group. 6/ National Statistics Office, National Sample Survey of Agriculture, 1980/81, Government Printer, Zomba  - 37 - 3.14 A survey carried out in the Lower Shire Valley in 1983 revealed an overall prevalence of Vitamin A deficiency of around 4 percent, with 3.5 percent prevalence of blindness due to vitamin A deficiency in the second year of life and 7 percent in the fifth year. A survey of iodine deficiency disease conducted the same year found a goitre prevalence of between 30 - 75 percent in six of ten pre-selected districts (Ntcheu, Dedza, Rumphi, Mzimba, Chitipa and Mchinji). One of the most severely affected districts (Ntcheu) had 1 percent prevalence of cretinism 7/. Maternal Malnutrition 3.15 Maternal nutrition is more difficult to evaluate than infant and childhood nutrition. Studies carried between 1973 and 1982 revealed that the average weight/height of rural Malawian women was below 90 percent of the average for young US women, but that wealthy urban women exceeded that norm 8/. Seasonal undernutrition appears to be a serious problem. A small sample of women showed a mean body weight difference over a five-month period before and after the harvest season of 4.2 kg. 9/ This finding should not be interpreted as reflecting all of Malawi, however, because the sample was small. Several health centers in the Central and Southern regions visited by the World Bank mission reported that antenatal care activities during the pre-harvest season (advice and food) were directed toward avoiding weight loss during pregnancy. The frequency of low birth weight is reported to be around 20 percent. 10/ Malaria and young maternal age are two probable leading causes of premature birth. Births occurring prior to maternal maturation, when maternal and fetal nutrition are at particular risk, are frequent; 2 births/1000 women aged 10 - 14 years and 168/1000 aged 15 - 19. 11/ However, the maternity record card in current use in health clinics does not categorize birth weight by gestational age. Relatively long average intervals between pregnancies (27 months in women 15 - 19 years and significantly longer in older women), should allow women to restore nutritional reserves depleted by reproduction and lactation, but do not seem adequate. The prevalence of unqualified anemia has been reported to be between 15 - 25 percent in pregnant women. 12/ 7/ Ministry of Health, 1988, Food Hygiene and Nutrition Section: Plan of Activities, 1988-1992, Lilongwe 8/ Government of Malawi/UNICEF, 1987, the Situation of Women and Children in Halawi, Lilongwe 9/ Beckerson, S.A., 1983 Seasonal Labour Allocation, Food Supply and Nutrition in Subsistence and Semi-subsistence Farming Households in Malawi, unpublished M.Sc. Thesis, University of Guelph 10/ Government of Malawi/UNICEF, 1987, the Situation of Women and Children in Malawi, Lilongwe 11/ National Statistical Office, 1984. 12/ Ministry of Health, 1988, the National Health Plan: 1986-1995, Lilongwe  - 38 - BIOLOGICAL DETERMINANTS OF NUTRITIONAL STATUS 3.16 Nutritional status is determined biologically primarily by dietary intake of energy and nutrients, and their expenditure on growth and development, immunocompetence, productivity and reproduction. The basic diet for Malawi is simple and is derived from a limited range of foods (fewer than 10 items) for the majority of the low-income rural population. The principal source of energy is carbohydrate derived from a predominant staple, which varies from region to region depending on ecological conditions. The most widely consumed staple is maize. (Maize so thoroughly dominates the diet that the terms food and hunger are widely equated with its availability.) Maize was introduced into the country about a century ago and has progressively displaced the traditional staples of millet, sorghum and cassava. These traditional staples are less vulnerable to drought and, in the case of millet and sorghum, are of higher nutritional value. They are, however, more difficult to prepare and less palatable. 3.17 Maize is consumed principally as a porridge (nsima) made from steamed maize flour extracted at about 60 percent of the whole grain. The extraction rate varies according to household supply. During periods of food scarcity households extract a higher proportion of the grain. The porridge is served at varying consistencies - thin for children/thick for adults. It is iccompanied by relish which provides additional protein and essential micronutrients. The composition of the relish depends upon the region and the income level of the household. The relish used by the poor during the pre-harvest period typically is made mainly from pumpkin leaves; wealthier households add pulses such as ground-nuts and beans, and meat or fish. Adults in rural families usually consume two major meals a day (mid-day and evening). Additional, smaller meals or snacks are provided to children in inverse proportion to their age. The energy and nutrient content of the diet in optimal circumstances is excellent despite heavy reliance on a single, refined staple. 3.18 The principal reason for malnutrition is an absolute deficiency of dietary energy arising from staple shortage. This is compounded in the case of small children by the low energy density of porridge (1 kcal/gram) compared with more complete diets (2 kcal/gram). The small size of children's stomachs at weaning requires that they be fed low density food 6-8 times/day. This implies that a great deal of time must be devoted to child care if weaning children are to be adequately nourished. 3.19 Under conditions of economic stress, particularly in the pre-harvest period, the quantity and quality of the relish deteriorates which restricts the nutritional value of food intakes. Meal frequency is also reduced, at the same time extraction rates increased, thus further decreasing the caloric density of the diet. Portion size is adjusted so that the needs of productive adults are met as a priority. The biological effect of economic stress and food insecurity is insufficient energy to meet basic metabolic needs, resist infection, sustain growth and development in children, and permit efficient productivity and reproduction in adults. As soon as energy needs are met, however, dietary quality becomes a critical constraint as suggested by the distribution of clinical  - 39 - malnutrition categories (kwashiorkor 30 - 50 percent). However, under present conditions in Malawi, the hierarchy of dietary constraints is -- energy, protein, iron, retinol and iodine; the latter two vary by region. 3.20 In a small study of dietary adequacy within families in one area, Chimwaze 13/ identified the following distribution of energy shortfalls: Table 3.3 Dietary Adequacy (1982) Biological Category 2 Fulfillment of Energy Needs 1 - 4 years old 46 5 - 9 years old 57 10 - 14 yr. boys 62 10 - 14 yr. girls 68 Adult males 92 Adult females 92 Pregnant/lactating 74 3.21 It is evident that pre-school children suffer the greatest deficit under prevailing adaptations to food scarcity and thus are most vulnerable to additional environmental hazards (infectious agents). This in turn contributes to excessive morbidity and mortality in this age group. ACHIEVING NUTRITION GOALS: FEASIBILITY AND CONSTRAINTS Land Shortage 3.22 The rural population is now estimated to be growing at an annual rate of over 3 percent. This growth is increasing competition for arable land, particularly in the South, where density is around 70 inhabitants per square kilometer compared with the national level of 40. This situation has been exacerbated by the progressive incorporation of customary land into the estate sector. Estate holdings as a percentage of cultivable land have increased from about 2 percent in 1960 to about 16.5 percent in 1984, thereby reducing the land traditionally available for small holdings. The National Sample Survey of Agriculture (NSSA) showed that the average size of smallholder plots declined from 1.54 hectare in 1968/69 to 1.16 hectare in 1980/81, while household size remained constant at 4.5 persons. The same survey revealed that at the national level about 55 percent of smallholders had plot_ less than 1 hectare and 24 percent had plots of less than 0.5 hectare in 1980/81. The situation was most serious in the South, where 74 percent of households in Blantyre and 69 percent of households in 13/ Chimwaze, B.H., 1982, Food and Nutrition in Malawi. Unpublished Ph.D. thesis. University of London  - 40 - Livonde ADD had plots of less than 1 hectare. As Malawi's population continues to grow, pressures on arable land will continue to mount. 3.23 Households with less than 1 hectare cannot meet their annual food requirements employing traditional crops, inputs and practices. At present plots of between 0.99 - 0.5 hectare are estimated to yield about 75 percent of household food requirements while plots of less than 0.5 hectare yield only 27 percent of requirements 14/. This implies that the majority of rural households have to supplement their food supply through transfers or cash purchases. The NSSA found that 69 percent of households had exhausted their store of food crops by March (pre-harvest). The survey provided no information on the capacity of these households to purchase supplementary supplies. Limited Rural Income Opportunities 3.24 Opportunities for off-farm employment are limited mainly to work on estates or larger smallholder farms. Wage rates are low; payment by smallholders is often in low value food items, and estate wages are generally restricted to the legal minimum. Women are frequently paid less; junior female labor is usually paid half of the minimum wage. Before being raised from MKO.77 (less than US 30 cents/day) to MK1.74 (US 66 cents) in May 1989, the minimum wage was not enough for a worker to purchase the 90 kg. of maize per month that is required in order to feed the average family of 2 adults and 3 children (see chapter seven, para 7.85). 3.25 Efforts to promote rural industry and expand opportunities for off-farm employment have been limited. Low rural income levels, the dearth of credit and transport difficulties restrict the potential for generating additional income through such activities as petty trade, beer-brewing, food processing and handicrafts (see chapter seven). 3.26 Families who run out of food long before the next harvest must take whatever rural employment is available; these opportunities coincide with peak demands for labor on subsistence plots during periods of soil preparation, planting, weeding and harvesting. If these critical activities are postponed, lower yields result. It is estimated that a delay of 2 weeks in planting maize results in a reduction in yield of as much as 25 percent. This adverse effect on household food security (and on child care) is particularly serious in households headed by young women who do not have another adult or older child available to assist with either housework or farm tasks. Labor Constraint and Crop Mix 3.27 Producing cash crops such as cotton and tobacco requires more labor than growing food crops; thus, households that produce cash crops typically have less time available for household tasks, including child care and feeding. In a small comparative survey, households engaged in 14/ Msukwa, L., 1984, Agriculture and Nutrition, Conferences Malawi - An Alternative Pattern of Development. Center for African Studies, Edinburgh University.  - 41 - tobacco production were found to have poorer child feeding patterns and higher rates of malnutrition than subsistence households 15/. Studies in other African countries have found that children's nutrition often suffers if households switch from food crops to cash crops and the income from crop sales is not controlled by the woman, who takes major responsibility for feeding the family. Analysis of NSSA data showed that nutritional status of children in households where rice, millet, sorghum and pulses were grown was significantly better (p<.05) than in households growing tobacco and groundnuts (regarded as a cash crop). 16/ Situation of Women 3.28 Women make a major contribution to agriculture in Malawi. About 70 percent of full-time farmers in the country are women. They spend, on average, as much time in agricultural work as men and, in addition, perform their domestic and child-care activities. Some 30 percent of households are headed by women; 70 percent of these women are not currently married. Male migration patterns, both external and internal, contribute to the prevalence of female-headed households (FHH). The average size of plots operated by female-headed households is smaller than those farmed by male- headed households (0.91 hectare vs. 1.16 hectare). However, not all female-headed households are dependent solely on women's earnings; some receive substantial cash remittances and food transfers from absent husband and from other family members. 3.29 Despite their central role in agriculture, women have not participated significantly in Government programs to improve agricultural productivity. In 1980/81, only 15 percent of women farmers received extension advice; less than 5 percent maintained contact with the extension service on a regular basis 17/. Few women participate in agricultural credit programs although this has improved markedly this decade. Only 5 percent of borrowers were women in one ADD surveyed in 1981/82. In 1985/86 women represented 19 percent of the membership in the farmers clubs, through which credit is normally channelled 18/. This percentage increased to 25 percent in 1986/87, and 29 percent in 1987/88 and 1988/89. 3.30 Despite these disadvantages, the NSSA revealed that chronic malnutrition was marginally less prevalent in female- than in male-headed households (51 percent vs. 55 percent), possibly because women household 15/ Beckerson, S.A., 1983 Seasonal Labor Allocation, Food Supply and Nutrition in Subsistence and Semi-subsistence Farming Households in Malawi. Unpublished M.Sc. Thesis, University of Guelph 16/ Center for Social Research, 1986 Nutritional Problems of Malawi; Situation Analysis. University of Malawi, Zomba 17/ National Statistics Office, National Sample Survey of Agriculture, 1980/81, Government Printer, Zomba 18/ Ministry of Agriculture.  - 42 - heads have more control over the use of resources. 19/ Nevertheless, there is consensus &mong those studying social conditions in rural populations that FHHs without access to additicnal income or transfers suffer dire poverty and have high rates of malnutrition and ill-health. They are clearly a group which should be specifically targeted for activities designed to improve economic and health conditions in rural areas. Access to Health and Nutrition Services 3.31 A recent sample survey conducted by MOH in collaboration with UNICEF (unpublished) indicated that use of maternal and child health services is high. About 95 percent of the households surveyed had growth charts available, though not all growth charts had recorded measurements of weight regularly. Around 60 percent of children attended under-five clinics but the proportion fell sharply following the administration of vaccination at 9 months. Domestic responsibilities, child care and distance to the clinics were cited by mothers as the principal reasons for not attending. The timing of the drop off is serious because the succeeding 6-9 months coincides with the critical nutritional period of weaning when children are at greatest health and nutrition risk. Use of World Food Programme (WFP) rations has been relatively satisfactory where feeding programs have been established. Sixty percent of children and 80 percent of pregnant and lactating mothers attend, according to lovernment and WFP estimates. Health service staff report, however, that average period of attendance at nutrition clinics is for 4 - 6 weeks, after which mothers fail to return for reasons of distance and time. 3.32 Information on the use of health and nutrition services on estates is not available. In 1983 it was reported that only 43 out of more than 1,100 estates had dispensaries; however many of these estates are very small and rely on government facilities. Facilities offering health and nutrition services provide simple diagnostic and curative care for workers and dependents. Preventive and other health services have to be obtained from government health facilities, which are often situated at a considerable distance from the work site; therefore attendance implies a considerable sacrifice of earnings. Access to Other Public Services 3.33 Access by peasant households to other public services is less satisfactory. The poorest are least likely to benefit from these other services. For example, smallholders cultivating less than 1 hectare constitute 55 percent of farming households in Halawi, yet in Kasungu ADD, they represented only 6 percent of membership in farmers clubs -- a 19/ This finding is corroborated in a study of 200 households in southern Zomba District by Pauline Peters and Guillermo Herrera of the Harvard Institute for International Development: "Cash Cropping, Food Security and Nutrition: The Effects of Agricultural Commercialization Among Smallholders in Malawi", June 1989.  - 43 - requirement for agricultural credit. 201 Only 14 percent of smallholders with less than 0.5 hectare and 18 percent with 0.5-1 hectare receive any extension services compared with 40-50 percent of landholders with 2 hectares or more. In a survey of child care practices, less than 25 percent of households sampled had received a visit from a homecraft worker or farm home assistant in the previous month. 21/ 3.34 Distance is critical in determining access to facilities and services in rural Malawi, where transportation may be scarce and/or costly. The NSSA survey showed that 48.5 percent of households must travel 2-8 km to an improved water supply, 34 percent of households must travel this distance to obtain fuelwood. However, 80 percent of households live within 8 km of an under-5 clinic and 82 percent of an ADMARC center where low-cost staples may be obtained to meet seasonal shortages. A round trip to a point 2-8 km from home is estimated to take between 1 and 3 hours. STRATEGIES FOR IMPROVING NUTRITIONAL STATUS 3.35 Any strategy to attack the twin problems of household food insecurity and inadequate child care will have to be developed within a specific policy framework addressing the future of marginal subsistence farmers and the rural poor. Malnutrition in Malawi is primarily a consequence of poverty and only secondarily of education and behavior. Until poverty and serious food insecurity are alleviated, little progress can be expected in reducing malnutrition and associated diseases through other means. Not until food supplies are adequate, or only marginally deficient, can education and domestic skills improve the use of available food and thus contribute to health status. National Nutrition Policy 3.36 There is no explicit food and nutrition policy in Malawi at present. However, the basis for one was developed in some detail by an Interministerial Symposium on Nutrition and Development for Principal Secretaries held in 1986. That meeting identified land tenure systems, production technology, population policy, income generating activities and distribution of mothers' time as topics requiring attention. A Food Security and Nutrition Unit has since been established within Economic Planning and Development (EP&D). The unit is responsible for maintaining nutrition surveillance, identifying nutrition priorities and developing a national nutuition policy. 3.37 The National Health Plan identifies nutritional deficiency as one of five conditions (with pneumonia, malaria, measles and diarrheal disease) which together account for over one third of all deaths. It concludes that 20/ International Fund for Agricultural Development (IFAD), 1986. Malawi Rural Credit and Farm Club Development. IFAD Reconnaissance Mission Report No. 0017-MW. 21/ Kilembe, P.S., 1985, Child Raising Practices Study, Center for Social Research, University of Malawi, Zomba.  - 44 - malnutrition is a major cause of preventable mortality. 22/ It identifies seasonal food shortage as the principal problem. It also cites inadequate breast feeding supplements and poor intra-household distribution of food as contributing factors to nutritional deficiency. Integrating nutritional activities into family services and introducing relevant child feeding options are specific objectives of the short-term plan to strengthen maternal and child care. The strengthening of programs to control iodine deficiency disease and vitamin A deficiency are other stated priorities. 3.38 One of the first steps toward resolving the problem of malnutrition will be to measure or estimate the magnitude of the food insecurity problem and to define the sub-groups of the population most seriously affected. 23/ Policies must be formulat- to address priority needs. These policies will have to consider the future of marginal smallholders and the landless poor in the context of current strategies for agricultural development and the maintenance of national food security. The fundamental decision will be whether to encourage marginal producers to leave farming, and thus accept an increase in the size of the landless laboring class. The goal will be to ensure that these groups achieve consistent food security and are incorporated in the process of social development, particularly with respect to health, education and family well-being. Such re-formulation of policy and programs will have to address the following issues: o the minimum plot size to ensure house-old food security based on achievable increases in the use of currently available production technology (new varieties, fertilizer, biocides, etc.). In this context, the issues of land tenure systems and of the potential for cooperative farming will need to be considered; o the need for more precise targeting of priority groups in sectoral programs, by area, income levels, family composition, etc; o the need for more acceptable and flexible agricultural support packages, including credit terms, unit size of input packages, and appropriate technology and information transfer; o the need for a specific research and development effort to meet the technology needs of the minimum smallholder and his/her household; and o the potential for developing new opportunities for rural employment, including the improvement of working conditions in existing areas, such as estates and related industries, as well as the stimulation of new income generating activities. 22/ Ministry of Health, 1988 The National Health Plan: 1986-1995 Lilongwe 23/ The Government of Malawi, in partnership with donors, has begun to tackle many of the tasks listed here. Reports on food security and poverty are under preparation, changes are being introduced in sectoral ministry programs, and several specific interventions are to be tried on a pilot basis.  - 45 - Sectoral Programs 3.39 The program elements of policy implementation will involve contributions from several sectors, including agriculture, community development, education and health. Program inputs would have to address all aspects of the food system from access to arable land to the care and feeding of young children in order to ensure the planned health impact. While the elements of such comprehensive programs are numerous, most already are, or could easily be, incorporated as specific objectives in existing agency programs. Six major program areas would require development: (a) surveillance and monitoring; (b) targeting women and service delivery; (c) education as a basis for behavioral change; (d) agriculture credit and income support; (e) technology development; (f) direct nutrition support. Surveillance 3.40 The Ministry of Agriculture has a Food and Nutrition Unit which is responsible for developing policies and plans for nutrition activities implemented as part of its Food and Nutrition and Women's Programmes. The former is directed primarily toward maintaining surveillance of nutrition conditions at the district level. A pilot project has been developed in Mzuzu ADD which will be replicated soon in another district (probably Blantyre). Data are collected on food production, household food security, nutrition status (height and weight), and infectious disease incidence. Targetting Women and Service Delivery 3.41 Recognition of Women's Central Role in Development. Any reorientation of policy and programs will involve recognition of the central role of women in rural development and will make them primary, rather than incidental targets for programs to provide services and facilities. An extension of such recognition will imply the creation or strengthening of social structures by which women may acquire new skills and higher levels of control in respect of decision-making and resource allocation within the household and the community. 3.42 Several sectors already have special programs or activities which target women. The Ministry of Commumity Services (MCS) trains extension workers at Magomero College. MCS employs about 140 female Community Development Assistants who supervise 606 Homecraft Workers, who are employed by the Ministry of Local Government and NG0s to provide advice on nutrition, home management and child care to rural women's groups. The MOA Women's Program, which incorporates the pre-existing home economics program provides nutritional and agricultural advice through the Women's Program Officer in each of the 24 Agricultural Development Districts (ADDs). It is hoped to deplcy Nutrition Officers to all ADDs in the future, though no budgetary provision exists for this purpose. The program has also begun to assist groups of women to undertake agriculture-related income generating activities. KOA also deploys a female cadre of about 200 farm home assistants trained by the Natural Resources College (NRC) who work with farm wives and female household heads to improve knowledge and skills in home management, including traditional areas of food diet end child care. About 2,000 (male) extension workers provide farm management advice,  - 46 - largely to male farmers. Female extension workers need to be recruited and the existing cadre needs to be reoriented to serve women better. 3.43 Health Services The mother and child program of the Ministry of Health is integrated in the primary health care system under the supervision of regional MCH supervisors. It targets women as child care providers in respect of the full range of preventive health measures, including infectious disease control, nutrition and family planning. Such services are delivered through a network comprised of primary health centers, sub-centers and community health committees. The World Food Programme project targets mothers of malnourished children through rehabilitation units in district hospitals and nutrition clinics and ante-natal care services in health centers and outreach clinics. 3.44 This wide array of peripheral services directed to women and children provides a comprehensive infrastructure through which information and resources can be channelled to promote household food security and child care. It will be necessary to determine how different program approaches and specific services to women can be integrated at the local level in order to avoid duplication and improve efficiency. Consultation with very small landholders, especially female-headed households and with the landless poor will provide practical leads on the nature, timing and frequency of contacts and the way in which information and resources may be delivered in an integrated manner. 3.45 Services on Commercial Estates The provision of health and social services on commercial estates requires strengthening. Conditions of housing and health are regulated by the inspectorate of the Department of Labor. However, supervision is seriously constrained by inadequate transport. As a result, few estates provide sufficient services to meet basic health and welfare needs. While specific data are not available from national statistics or surveys, health service personnel consistently identify the lack of services as a problem area. 3.46 Confronted by a similar situation, the Ministry of Health in Zimbabwe organized a national workshop on Health Services in the Commercial Farming Area in 1986. That workshop proposed legal minimum standards for water supply, sanitation, refuse disposal, housing and plot size for domestic food production. It also recommended that estates provide transport for emergency cases to the nearest appropriate health unit and facilitate attendance at clinics for preventive and MCH services. The establishment of pre-school education groups was also specified. The workshop recommended tax relief for the capital costs of improvements such as water supply, sanitation and housing. Primary health care workers to be assigned to the estates were to be trained by the district health team and maintained by a community 'Levy, supported by government funding. They were to be supported through strategically located area health centers, operating outreach clinics on the estates. 241 24/ Ministry of Health, Zimbabwe, 1986, Report on a National Workshop on Health Services in the Commercial Farming Area, Harare.  - 47 - Education as a Basis for Behavioral Change 3.47 A basic element in any strategy to improve nutrition and health conditions will be education directed at promoting an understanding of the underlying causes of ill-health and malnutrition and the ways in which they may be combated. Educational messages should include information on adequate diets for pre-school children, child care and basic health practices. 3.48 Agricultural credit and advice will, as is currently the case, be delivered through the extension services of the MOA with specific orientation to the cultivation of food crops and small animals to ensure household food security. Message content needs to be revised to emphas -e practices such as intercropping. Advice on making mpost as a fertili_ r has been well received by smallholders; such an initiative could be further developed. 3.49 The MCS's intention to modify the basic and in-service training of Homecraft workers needs to be carried out so that the messages they deliver are more appropriate for the target households. Demonstrations provided to nutrition clinics by these workers also need revising in order to ensure continuity of extension messages on food security to include advice on food preparation and diet, particularly in relation to the nutritional -quirements of weaning, pregnancy and infections. 3.50 Consistency is also required with the advice and support offered by the primary health care team through its MCH clinics, nutrition clinics and rehabilitation units. This advice would focus on the basic elements of child care, the allocation of mother's time, the quality of delegated care and approaches to or iizing group care at the village level. A detailed list of nutrition e. ition is specified in the MOH Five Year Plan in relation to Objective 6 -- Nutritional Status of Mothers and Children -- to be incorporated in the training of health personnel carried out by the College of Health Science; regional and district staff involved in the training of village health committees for growth monitoring will also relay the same messages. Similar orientation and skills relating to maternal nutrition could be included in the current training program for traditional birth attendants. The current activities of the WFP should be reviewed to ensure that the selection of recipients, administration of rations and evaluation of response are geared to the same objectives; this would also apply particularly to the proposed extension of community-based nutrition services. 3.51 Finally, the health module for the primary education curriculum and teacher training programs should be reviewed and revised to ensure consistency with each other and with extension messages being delivered through other Ministries. 3.52 An extraordinary effort will be required to define and coordinate the input of all of the agencies involved in these educational progr&ms. It will require a clear expression of objectives and an explicit action plan to deliver a series of messages on household food security, diet and child care that are simple, consistent and relevant to the social, cultural and economic conditions of the target groups. In this context,  - 48 - c-- Aerable information has now been gathered on nutritional and child c conditions, and on the causal and contributory factors of childhood moroidity. A meeting of the technical staff of the relevant agencies should be convened in order to identify in specific terms the actions and educational content required for a coordinated program. The existing series of reports of government and donor agencies on these topics might be used as background material for this purpose; most of these are cited as references in this paper. The findings of such a technical review would be introduced into the training programs of the participating agencies, possibly supported by a single manual explaining the concept and processes involved. Implementation could be monitored by the same unit based on reports from agencies and direct supervision of training facilities. Agricultural Credit and Income Support 3.53 The provision of agricultural credit and inputs should be geared to the needs of target-groups, as regards the organization of clubs and eligibility for membership, the composition of packages, availability and terms of loans, and the removal of other constraints on use. A start has already been made. A credit project in Mzimba. sponsored by the Christian Service Committee, organized groups of five smallholders for medium-term credit. The group agreed to work together for three years to purchase a pair of oxen, a plow and a ridger. The credit was successfully repaid and the group continued for a total of six years during which time substantial additional funds were raised. The approach of ADMARC centers to the purchase and sale of food to the target-group households will need analysis. Specifically, the time lapse between harvest (April) and opening for the purchasing of crops (June) will need to be considered in the context of the urgency with which the target-group households require cash for debt repayment and essential expenditures. The question of how food sold and purchased can be economically transported by the one-fifth of smallholders living more that 8 km. from the center 25/ also needs to be considered. 3.54 The potential for ADMARC centers to provide an organizational network and administrative facilities for income support through targeted food stamp or distribution schemes, should be explored. Another option would be to develop a facility for crop repurchasing credit for marginal smallholders so that they could recover their crop sales during time of need at equal or subsidized prices. ADHARC centers might then provide community stor&ge together with targeted subsidies. Technology Research and Development 3.55 Action in this area needs to be directed to all aspects of the food chain in conjunction with credit and education initiatives. Specific areas of need include the development of new varieties of common food staples that have an expanded or a synchronous cultivation schedule permitting agricultural activities to be spread over a longer time span compared with the usual 90-day maize cycle. Other criteria for new 25/ National Statistics Office, National Sample Survey of Agriculture, 1980/81, Government Printer, Zomba  - 49 - varieties relate to improved storage and preparation characteristics. Storage losses for hybrid maize are acknowledged to be high compared with local maize, contributing to the low adoption of higher yielding varieties. The NSSA showed 40-50 percent of households reporting "significant" losses of storage crops from damage by rodents and beetles and 15-20 percent reporting termite damage. Almost 80 percent of households did not use any recommended storage protection method (chemicals, smoking, etc). The NRC needs to focus and intensify its research on improved home technology for storage, processing and preparation of the food crops. Consumer surveys to determine optimal design for domestic and communal food storage and processing equipment will be needed to ensure acceptance. The Department of Agricultural Research could play a major role in such developments, through its Commodity Research Program and Adaptive Research Teams operating at the ADD level. 3.56 There is a need to develop appropriate hoeing and ridging tools as well as low technology maize mills in order to conserve maternal energy. Fuel-efficient stoves and improved transportation devices for drinking water may also offer opportunities for innovation. Such institutions as the NRC and the Malawi Entrepreneurship Development Institute may need additional support and specific direction to accelerate developments in these areas. 3.57 Facilities for biotechnology development in infectious disease and fertility control do not exist in Halawi and would be uneconomical to establish. Use of international agency programs, such as the Special Program for Research and Training in Tropical Diseases of the World Bank, WHO and UNDP, is the most efficient way in which advances can be pursued in this area. At the same time, the development and deployment of low-level technology for environmental health, such as vector control and sanitation, adapted to local conditions and resources could make useful contributions to health. Another priority for health service research is the management of acute respiratory infections at the community level; these remain a major cause of under-five mortality for which there are tested management principles which could be adapted to local service conditions. Direct Nutrition Support 3.58 The main activity in this area will be universal growth monitoring for children 6-36 months by village health committees. The training of committees by the district primary health care team has already started and is expected to be applied nationally during the present Health Plan period. Such monitoring activities are currently combined with food supplementation for growth failure in the nutrition and under-five clinics operated by the primary health centers. The proposed expansion of WFP activities to bring this support down to the level of the village committees has yet to be tested on a pilot basis. 3.59 Iron and folic acid supplements are distributed routinely to all women attending antenatal services (about 60 percent coverage) and to preschool children with clinical signs of anemia. Vitamin A supplements are currently given to children with measles and unspecified conjunctivitis. The MOH has recently decided that graduated Vitamin A supplementation will be provided routinely to all children between six  - 50 - months and six years when they attend health centers for immunization; every mother delivering at a maternity facility will also receive a single dose after delivery. A plan of operation for incorporating dose administration in the EPI delivery system is currently being prepared. 3.60 Iodine deficiency disease control measures have already been initiated by the MOH using iodized salt on a regional basis supported by mass injection campaigns in the most severely affected areas (see above). 3.61 Special support for the management of HIV-positive mothers will be needed, particularly with respect to maintaining breastfeeding and immunization in accordance with WHO recommendations. 26/ LONG-TERM PERSPECTIVES 3.62 The future of nutrition and health in Malawi will depend on positions adopted by government in two critical policy areas; population and agriculture. Without substantial changes in current policy and programs, population growth will continue to force sub-division of subsistence farms and increase the numbers of landless poor; this will be exacerbated by refugee immigration. Without rapid growth in industrial employment, the consequent rise in unemployment and depression of wages will lower incomes and reduce household food security further. Further switching to cash crops without off-setting rises in food crop yields will elevate food prices and contribute additionally to household food insecurity. Acceleration of rural to urban migration will have predictable consequences for nutrition and health status. Existing male-only migration patterns will be modified as entire families become landless. Greater dependence on female wage-labor will adversely affect breastfeeding, fertility and child care. This sequence could be modified by improved agriculture productivity, more vigorous policies on fertility reduction, the reorganization of land use by subsistence farmers, increased opportunities for rural employment and improved wages, working conditions and welfare facilities in the commercial sector, particularly for women and dependent children. This prospect of continuing household food insecurity, dietary inadequacy and inadequate child care will require the extension of nutrition surveillance, the promotion of growth monitoring, targeted food or income support, health and household management education and possibly the provision of small gardens for production of micronutrient food sources in both rural and urban areas. 26/ World Health Organization, 1987. Special Program on AIDS Statements for Breast Feeding and Immunization, Nos. 87.8 and 87.11 Geneva  - 51 - CHAPTER FOUR HEALTH OVERVIEW 4.01 This chapter examines the prospects for improving health conditions in Malawi. It begins with a statement of key objectives for the health sector. This is followed by a brief review of current health conditions and their determinants, and then an overview of the performance of the health sector. Constraints to achieving health objectives are then discussed. The chapter ends with a discussion of policy and program options for consideration in the short and medium-term. The overall objective of the chapter is to provide a framework to assist Government in setting health sector policy in the broad context of its human resource development strategy for the next generation. 4.02 Health conditions in Malawi are poor. Under-five mortality is estimated to be about 25 percent and life expectancy is approximately 49 years. Maternal mortality is now about 170 per 100,000 live births. Total fertility is 7.6 births per women. Over half of Malawian children (56 percent) recently were found to be two standard deviations below expected height-for-age. The leading diseases in Malawi are malaria, respiratory infections, symptoms referable to the abdomen and gastrointestinal tract, skin conditions, other diarrheal diseases, inflammatory eye diseases and traumatic conditions. Hospitals had reported a total of 7,160 cases of AIDS as of November 1989. In view of the explosive spread of this disease, prevention of transmission is an urgent priority. Under-five mortality in Malawi is higher than in neighboring countries because of the high prevalence of under-nutrition and the high incidence of malaria. Reducing under-five mortality would go a long way toward improving overall life expectancy in Malawi. Equally if not more important to improving health, are efforts to alleviate poverty, especially the resultant under-nutrition, and to raise education levels, particularly at the primary level and for women. 4.03 The quality of primary health care is surprisingly high given resource constraints, especially shortages of personnel. Community-level health care and outreach from fixed facilities, however, need strengthening. Drug shortages occur from time to time, but in most cases health facilities have most of the bare essential drugs to cover a majority of their patients' needs. Shortages of several categories of personnel -- doctors, clinical officers, registered nurses and medical assistants -- exist. The central hospitals are congested due to widespread bypassing of lower level facilities. The health system is unable to meet the demand for child spacing services. More personnel need to be trained both in counselling and in the provision of clinical child spacing services. Key Recommendations 4.04 Malaria control deserves top priority attention in view of the very heavy burden of morbidity and mortality it causes. Further investments in water supply, sanitation and hygiene education should be  - 52 - The Ministry of Health has demonstrated the feasibility of community level presumptive treatment of malaria by traditional birth attendants (TBAs). 4.05 In order to make motherhood safer, risk factors for maternal mortality and morbidity should be established. High risk women should be identified as early as possible in pregnancy and good community level antenatal care should then be complemented by good access to obstetrical care at first-referral level, where assistance from trained personnel, cesarean section and blood transfusions are available. Child spacing services are especially relevant to the large number of women for whom an additional pregnancy carries a high risk of complications or death. 4.06 The criteria for the use of various child spacing methods should be broadened. In addition, support for the child spacing program should be developed. Child spacing should be promoted on health grounds using the simple, objective criteria of the risks of pregnancy. High child mortality results from pregnancies that occur at the extremes of the child bearing period (under 18 or over 35 years of age), are too closely spaced (less than two years apart) or are too numerous (over five). Indeed, child spacing is probably the most cost-effective approach to lowering infant mortality. Prevention of HIV transmission, including perinatal transmission, deserve top priority. Workshops and seminars should be aimed at key constituencies -- political leaders. influential males, women's groups, doctors and other key health personnel, the press and religious groups. The child spacing content of basic training programs for health personnel -- especially medical assistants and enrolled nurse-midwives -- should be strengthened and the in-service training program for health personnel should be accelerated. 4.07 Overcoming malnutrition will require efforts on several fronts. In the immediate-term growth monitoring and supplementary feeding should be continued. The weaning diet should be improved through the addition of foods with a high caloric density. In the long-run raising rural incomes and increasing the availability of food at household level will be necessary. 4.08 Three areas in particular offer promising avenues for increasing health sector efficiency -- decongestion of central hospitals, cost recovery and manpower development. KEY OBJECTIVES FOR IMPROVING HEALTH 4.09 Efforts to improve health conditions in Malawi should be organized around three principal objectives: o Improving child survival and child development. In 1977, mortality for children under age five was about 33 percent although this has declined since then, an estimated 25 percent of children still die before age 5 and roughly one-third suffer from moderate to severe malnutrition. Indeed, the extent and severity of undernutrition in children under five is among the worst in sub-Saharan Africa.  - 53 - o Lowering maternal mortality and improving maternal health. Despite the fact that four out of five pregnant women have at least one antenatal visit, and on average more than three visits, maternal mortality is a high 170 per 100,000 live births. Moreover, for every woman who dies, ten others suffer permanent disability from pregnancy-related complications. O Increasing the efficiency of the health sector. Central hospitals are currently congested while lower level facilities that could provide much of the needed primary care are underutilized. Moreover, severe shortages exist for several categories of health personnel, and these shortages are expected to get even worse by 1995 unless steps are taken. THE HEALTH SYSTEM 4.10 MOH has primary responsibility for the development of policies, strategies and programs for health care. Public health services are provided by the MOH and the Private Hospitals Association of Malawi (PHAM), made up of church-related and other private voluntary agency facilities. Local government authorities and other agencies such as the army, police, some estates and industries provide curative and preventive services for their employees. Private medical practice is limited to about 35 physicians in urban areas. There are about 18,000 traditional healers and 5,000 traditional birth attendants (TBAs) scattered throughout the country. Formal links between the MOH and traditional practitioners do not exist, although MOB provides training to TBAs. 4.11 MOH services are provided at five levels: community services, rural health centers and hospitals, district hospitals, central hospitals and special hospitals. Community level services consist of an extensive network of outreach activities through mobile clinics and the PHC program, and stress activities and interventions associated with under fives care (health education, environmental sanitation, diarrheal disease control, immunizations, pre- and post-natal care, and growth monitoring). The MOH runs 162 health centers and 19 rural hospitals which offer curative care, pre-natal, natal and post-natal care, and infant and child care. Many health centers also run nutrition clinics which provide nutrition education, food preparation demonstrations and free food supplements. There are 21 district hospitals run by the MOH which serve as referral facilities for health centers. In addition, they offer all preventive services available at the health center. The two central hospitals function as referral hospitals for their respective regions. They are also used as training facilities by various institutions. Special hospitals offer specialized services, su h as psychiatric care and inpatient care for leprosy and tuberculosis cases. There are considerable regional variations with regard to the distribution and coverage of facilities. The percentage of population within 8km of a health facility is 57, 70 and 100 for the northern, central, and southern regions respectively. 4.12 PHAM operates 20 district hospitals, 19 rural hospitals, and 97 health centers which offer similar services to MOH facilities. PHAM hospitals account for just over one-third of all admissions, and PHAM  - 54 - facilities deal with about 14 percent of all outpatient first attendances. PHlA facilities charge fees for curative services though most preventive services are free, as in MOH facilities. Cooperation between PHAM and MOH is close. HEALTH CONDITIONS AND THEIR DETERMINANTS Overall Mortality and Morbidity 4.13 Health conditions in Malawi are among the worst in the world. Life expectancy was 43 years in 1977 compared with 33 years in 1950-1955, and is now estimated at 49 years. The crude death rate declined from 30 per 1,000 to 22 per 1,000 between 1955 and 1977. The 1977 census indicated that the infant mortality rate (IMR) was 151 per 1,000 live birth3 and the child mortality rate (CMR; ages 1-4) was 40 per 1,000. Under-five mortality thus was about 33 percent. This represents a decline from an IMR of about 190/1000 and a CMR of about 140/1000 in the early 1970s 28/. Although the IMR may have fallen to around 150 by 1990, the combined infant and early childhood mortality rates for Zambia, Zimbabwe and Tanzania are still approximately 30 percent lower than those for Malawi. Infants and children under the age of five constitute about 20 percent of the population of Malawi, but these two groups account for an estimated 57 percent of all deaths. Maternal Mortality and Morbidity 4.14 There are no reliable estimates of maternal mortality in Malawi. For approximately 45 percent of women who were attended by trained personnel, the rate was 170 per 100,000 live births in 1986, according to Ministry of Health figures. The rate may well be worse for deliveries without trained assistance. Maternal mortality rates in neighboring countries are about two-thirds of this estimate, although Malawis rate is similar to rates prevailing in many other developing countries. 4.15 The loss of a mother represents a major tragedy for her family and her community and for economic development, and thus bas a much larger impact than the number of deaths implies. For every mother who dies of causes related to pregnancy, at least one child dies on average, and the survival prospects of her other children are reduced. And for every woman who dies, at least ten suffer permanent disability from the complications of pregnancy. In Malawi, the prospects are good for substantial reduction in maternal deaths. Undernutrition 4.16 Nationally representative data from 1981 and 1982 showed that over half of Malawian children (56 percent) exhibited nutritional stunting, defined as height-for-age at least two standard deviations below that expected. This survey, and several more recent ones, also indicated that about one-third of under-fives were moderately or severely malnourished 28/ Ministry of Health, 1988 The National Health Plan: 1986-1995 Lilongwe  - 55 - according to weight-for-age criteria. Most recently, the Primary Health Care Review found 31 percent and 3 percent of the representative sample of under-fives to be, re3pectively, moderately and severely malnourished on the same criteria. The extent and severity of undernutrition in children under five, places Malawi among the most severely affected countries in Sub-Saharan Africa. Malaria 4.17 The predominance of malaria in the disease burden of Malawi is evident from Table 4.1. Among the top ten leading causes of new outpatient visits, malaria accounts for almost double the number of cases from the next most common cause -- respiratory tract symptoms. Respiratory diseases, in turn, account for more than double the number of cases attributed to each of the next five most common reasons for seeking outpatient care -- symptoms referable to the abdomen and gastrointestinal tract, skin conditions, other diarrheal diseases, inflammatory eye diseases and traumatic conditions. 291 Table 4.1 Ten Leading Causes of Outpatient New Cases, Malawi 1986 Rank Rate per 1,000 Order Disease/Condition Population 1 Malaria 4,702 2 Symptoms referable to respiratory tract 2.746 3 Symptoms referable to abdomen and gastro-intestinal tract 1,082 4 Conditions of the skin 1,067 5 Other diarrheal diseases 788 6 Inflammatory diseases of the eye 773 7 Traumatic conditions 769 8 All other causes of morbidity 692 9 Venereal diseases 439 10 Symptoms referable to limbs and joints 426 Source: Ministry of Health, 1987. 4.18 Malaria is also the leading cause of hospital admission for children under age five in Malawi (see Table 4.2) and the second most common reason for admission in all age groups, after uncomplicated delivery. Table 4.2 shows that malaria, anemia, nutritional deficiencies 29/ The same patterns are evident in the latest (1988) available data for leading causes of outpatient attendances - see Statistical Appendix Tables Bl and B2.  - 56 - and infectious diseases account for almost four out of five hospital admissions among children under five. Table 4.2 Ten Leading Causes of Hospital Admission, Children Under Five, Malawi 1986 Rank Number of Percent of Cumulative Order Disease/Condition Admissions Admlssions Percent 1 Other Malaria 18,302 21 21 2 Anemia 12,158 14 35 3 Pneumonia 10,211 12 47 4 Avitaminosis, other nutri- tional deficiencies 8,779 10 57 5 Enteritis, other diarrheal diseases 7,708 9 66 6 Measles 6.999 8 74 7 Cerebral Malaria 3,069 4 78 8 Other specified and ill- defined diseases 2.550 3 81 9 Certain causes of perinatal morbidity 1,851 2 83 10 Other endocrine and metabolic disease 1,117 1 84 Source: Ministry of Health, 1987. 4.19 Ministry of Health data for 1987 show that malaria accounted for 35 percent of outpatient, cause-specific morbidity, 30 percent of inpatient morbidity and 18 percent of inpatient deaths among children under five. In 1988, malaria (19 percent) vas the most common cause of death among inpatients under five, closely followed by nutritional deficiencies (18 percent), and then pneumonia (13 percent), anemia (12 percent) and diarrhea (8 percent). 30/ Table 4.3 provides the details. Undoubtedly many of the deaths from anemia were related to malaria. Moreover, malaria and undernutrition act synergistically, even in the absence of anemia, to increase mortality in young children suffering from both conditions. In the complex downward spiral leading to a child death, the insult of repeated malarial episodes in undernourished children clearly accounts for a substantial proportion of all child deaths in Malawi. 30/ This pattern is fairly consistent over time, except that malaria accounted for a significantly higher proportion of deaths in 1988 (19 percent) than in 1986 (13 percent).  - 57 - Table 4.3 Ten Leading Causes of Mortality Among Inpatients Under Five, Malawi 1988 Rank Number of Percent of Cumulative Order Disease/Condition Deaths Deaths Percent 1 Avitaminosis, other nutritional deficiencies 1,408 18 18 2 Anemia 962 13 31 3 Pneumonia 935 12 43 4 Other Malaria 878 11 54 5 Enteritis, other diarrheal diseases 672 8 62 6 Cerebral Malaria 579 8 70 7 Measles 528 7 7' 8 Certain causes of perinatal morbidity 368 5 82 9 Other diseases of the nervous system 214 3 85 10 Ill-defined diseases 124 2 87 Source: Ministry of Health, 1989. Under Five Mortality 4.20 Tatle 4.4 illustrates further the predominance of under-five mortality in the overall picture of mortality in Malawi. When Table 4.4, shoving hospital mortality for all age groups, is compared with Table 4.3, which gives mortality only for children under age five, the four leading causes of death remain the same; nine of the ten leading causes figure on both lists. This similarity presumably also reflects a higher probability that a child will be hospitalized as well as the high incidence of malaria and other infectious diseases in those above the age of five, although data are not available to support these hypotheses. AIDS 4.21 Halawi had registered 2,586 cases of AIDS as of June 1988. Seropositivity rates of 7-11 percent have been reported among women attending astenatal clinics in major cities, and even higher rates among blood donors. Individual hospitals report sharply increasing numbers of AIDS patients. AIDS can therefore be expected to contribute importantly to infant and child mortality in the future. The overall extent of HIV infection in Malawi is not known, but appears to lie substantial, at least among the urban population. In view of the potentially explosive spread of this disease, prevention of transmission is an urgent priority.  - 58 - Table 4.4 Ten Leading Causes of Mortality Among All Inpatients, Malawi 1988 Rank Number of Percent of Cumulative Order Disease/Condition Deaths Deaths Percent 1 Avitaminosis, other & nutritional deficiencies 1,626 l.} 12 * 2 Other Malaria 1,397 11 33 3 Pneumonia 1,361 10 43 4 Anemia 1,280 10 53 5 Enteritis, other diarrheal diseases 897 7 60 6 Cerebral Malaria 759 6 66 7 Measles 617 5 71 8 TB of respiratory system 482 4 75 9 Other diseases of nervous system and sense organs 468 4 75 10 Other specified and ill- defined diseases 411 3 82 Source: Ministry of Health, 1989. Adequacy of Health Statistics 4.22 Population-based data are not available to show the extent to which Ministry of Health inpatient and outpatient statistics reflect the true incidence of disease and death in Malawi. However, both the high rate of utilization of government and NGO facilities and the views of Malawian experts suggest that the statistics provide a reasonably accurate picture of actual morbidity and mortality. (Data from Private Hospital Association of Malawi (PHAM) and other NGO facilities are routinely reported to the Ministry of Health). 4.23 Maior Determinants of Under-Five Mortality. The disparity between the high mortality rates prevailing in Malawi and its above-average health system is striking. For exarple, wh.ie an estimated one quarter of Malawian children do not survive to age five, the average child in that age group has more than four contacts a year with the health-care system. Moreover, 80 percent of under-fives have received at least one immunization, indicating at least minimal access to health services. Nor is the explanation to be found in poor quality of health care, as shown in the next section. Two main factors appear to. explain why under-five mortality in Malawi is higher than in neighboring countries: the high prevalence of undernutrition and the high incidence of malaria. Only six conditions account for over two-thirds of all under-five mortality: nutritional deficiency, malaria, measles, pneumonia, anemia and diarrheal diseases.  - 59 - 4.24 Overall Mortality Reduction. The National Health Plan of Malawi (1986-1995) provides an excellent summary of the major health priorities adopted by the country to reduce mortality. It emphasizes the fact that under-five mortality accounts for more than half of all deaths. Success in reducing under-five mortality will go a long way toward improving overall life expectancy in Malawi. But it is important to note that the health sector in general, and health services in particular, represent caly one of several key factors that determine health conditions. Equally if not more important to improve health, are efforts to alleviate poverty, especially the resultant undernutrition, and to raise education levels, particularly at the primary level and for women. 4.25 Primary Education. Primary education profoundly influences behavior related to health and nutritional status and to fertility norms. Mothers with primary education tend to have healthier and better nourished children, lower fertility and higher productivity. For all of these reasons, the human resource development strategy should accord top priority to expanding the coverage, quality and efficiency of primary education in Malawi, especially for girls. HEALTH SECTOR PERFORMANCE Infrastructure 4.26 Overall, the performance of the health sector in Malawi is excellent, given the severe resource constraints under which it operates. The physical infrastructure is made up of about 750 health facilities, for a ratio of approximately one per 10,000 population. About 80 percent of the population lives within eight kilometers of a health facility, well above average in sub-Saharan Africa. There are approximately 1.5 beds per 1,000 population. Although this is below the WHO norm of 2 beds per 1,000 it is probably adequate in view of the economic circumstances of the country. Utilization of Health Services 4.27 Utilization of health services is very high in Malawi compared to most developing countries. The average number of outpatient visits per year is two; children under five average almost four contacts a year with the health system. Four out of five children ages one to two years have received at least one immunizatior.. Almost 85 percent of pregnant women benefit from at least one antenatal examination. Hospital utilization is also quite high, with an overall 1986 rate of about 44 admissions per 1,000 population. Hospital bed occupancy in 1986 was a high 69 percent, while the average length of stay was seven days, indicating a relatively high level of efficiency. Primary Health Care 4.28 The high coverage of the Expanded Programme of Immunization (EPI) and of antenatal care indicates that the primary health care system generally is working well. Mobile outreach clinics are carried out by virtually all fixed facilities, except when vehicles or funds for fuel are  - 60 - lacking, which is perhaps one-third of the time. The use of paid community health workers was discontinued in 1986 because the system did not engender enough community participation or sense of responsibility for their own health care, and each worker was overloaded with a large number of tasks. Government decided, instead, to rely on village level volunteers for each major activity, for example, nutrition and family planning. These village level activities are just beginning in most areas. They will require substantial strengthening especially in order to reach the poorest of the poor, who tend not to visit health facilities as often as those who are better off. It is too early to say how successful the volunteers will be in carrying out specific primary health care functions. The new approach should be evaluated carefully and modified in light of early experience. 4.29 The quality of primary health care is surprisingly high given resource constraints, especially shortages of personnel. The great majority of health personnel seem to be dedicated, hard-working and competent. Many work under very difficult circumstances, especially the many medical assistants and enrolled nurse/midwives working alone. The quality of care is inevitably compromised in the case of a medical assistant seeing 200 or more patients a day, or the lone enrolled nurse/midwife who is on call virtually 24 hours a day, seven days a week. Drug shortages occur from time to time, but in most cases health facilities have most of the bare essential drugs to cover most of their patients' needs, although dosages, for example in malaria cases, are sometimes inadequate. HEALTH GOALS AND OBJECTIVES: FEASIBILITY AND CONSTRAINTS 4.30 As the preceding section indicates, on balance, Malawi has done relatively well in the health sector with very scarce resources -- 80 percent of the population lives within 8km of a facility, personnel generally are hard working and reasonably competent, utilization is high. The balance of infrastructure between primary, secondary, and tertiary levels is about right. PHAM nicely complements government efforts and provides about one third of the care outside of the traditional sector, charging modestly for its services. 4.31 Nevertheless, there are problems and constraints within the system that will make achievement of short and long-term goals more difficult. 4.32 Severe shortages exist for several categories of personnel, including doctors, registered nurses and medical assistants. In the rural areas at the primary level, the shortage of medical assistants and enrolled nurse/midwives is especially acute. According to the National Health Plan, personnel shortages will be even worse in 1995 unless both the training of health workers and the number of sanctioned posts are sharply increased. Without such steps, critical shortages of doctors, clinical officers, medical assistants, public health nurses, registered nurses and enrolled nurse/midwives will exacerbate current personnel problems. Fortunately, the country appears to have, or could develop, the capacity to train the additional personnel, with the exception of doctors. The key question,  - 61 - therefore, will be the availability of financing necessary to undertake this considerable expansion. 4.33 The system is also plagued by congestion in central hospitals caused by the widespread tendency for patients to bypass lower level facilities, which can generally provide primary health care more efficiently, and go directly to district or central hospitals without being referred. This tendency results from several factors, including shortages of personnel and drugs at lowez levels and, especially, transportation problems. Given a weak public transportation system, patients naturally tend to seek care at a higher level rather than risk having to undertake another .'ourney later, involving additional time and monetary costs. Thus, the hospitals are being overwhelmed with a workloed predominantly composed of routine cases that could be treated at the primary level. For example, the Queen Elizabeth Hospital in Blantyre handles over 13,000 deliveries a year, the vast majority of which are normal, while the combined delivery caseload of the seven urban health clinics in Blantyre city equipped for maternity care is less than a thousand. Similarly, Kazumu Central Hospital in Lilongwe is trying to cope with a very heavy outpatient workload, much of which is routine in nature and would be better dealt with at the primary level. As a result of such congestion, central and regional hospitals have great difficulty in providing the specialized, referral care only they can deliver. 4.34 Another serious constraint to achievement of health improvement objectives is the inability of the health system to meet the demand for child spacing services (see chapter two for more details). According to the 1984 Malawi Family Formation Study, 43 percent of all non-pregnant women wish to postpone their next pregnancy, and another 17 percent desire no more children. Since child spacing services were first offered in government health facilities in 1982, only enough personnel have been trained to provide these services in 168 health facilities, or about one in three. More personnel need to be trained both in counselling and in the provision of clinical services, such as insertion of intrauterine devices (IUDs). The relatively slow pace of training is in turn related to personnel shortages, making it difficult to release individuals for the length of time required for in-service training. The problem is serious in view of the substantial contribution child spacing can make to improved maternal and child health, especially in the context of high rates of maternal and child mortality. In addition, the widespread availability of condoms is important for the control of sexually transmitted diseases, including AIDS. 4.35 A population growth rate of over 3 percent a year obviously constrains overall development, complicates provision of social services, and affects human resource development in myriad ways. Malawi takes a very conservative approach to family planning and many health professionals and politicians are worried about moving too fast. Child-spacing services have been introduced slowly and cautiously over a six-year period. In Africa, as elsewhere, the general public is usually well ahead of politicians and policy makers in being ready to accept family planning services. The needed acceleration to assure availability is highly unlikely to cause problems.  - 62 - 4.36 A key planning assumption is that resources for health will, at best increase 2 percent annually in real terms over the next 15-20 yea-s -- or less than population growth. Cost recovery in government facilities would improve the picture somewhat, but not dramatically. STRATEGIES FOR ACHIEVNG HEALTH GOALS Improving Child Survival and Development 4.37 Given the very large proportion of overall mortality accounted for by deaths of children under five, progress in increasing child sur4ival obviously is critical to lowering overall mortality and increasing life expectancy in Malawi. Moreover, not only the survival but the optimal development of the children, both now and in the future, largely will dictate the quantity and quality of Halawi's human resource base in 20-25 years time. Cost-effective strategies are available to improve the survival of this most vulnerable of population subgroups. Five areas are proposed as deserving high priority: (a) improvement in nutritional status; (b) reduction of malaria mortality; (c) prevention and control of AIDS; (d) promotion of child spacing; and (e) strengthening of EPI and the control of diarrheal and respiratory diseases. Success in these areas should reduce substantially both mortality and morbidity in children under age five. It could result in a 50 percent reduction in under-five mortality over the next 10 to 20 years. 4.38 Improving Nutritional Status. Improving the nutritional status of children under five represents the single most important means of reducing infant and child mortality and improving child development. The principal actions required to achieve this improvement are covered in detail in the chapter on nutrition and will not be elaborated here. They are concerned mainly with increasing smallholder productivity and employment more generally, increasing incomes, and providing the purchasing power necessary for an adequate diet. The health sector can contribute importantly to this effort in a variety of ways. First, the already good growth monitoring effort should be maintained and expanded. Second, supplementary food should be provided to children who are not gaining weight. (Current coverage is estimated at approximately one out of five of those in need). Third, nutrition education should be strengthened, especially regarding the importance of breast feeding and correct weaning practices. Fourth, specific nutritional deficiencies such as Vitamin A, iodine and iron should be prevented or treated. And fifth, efforts to prevent and control disease should be undertaken wherever possible - for example, prevention through improved water and sanitation, and immunizations - and through prompt treatment when it can not be prevented. Examjles of high priority types of treatment include presumptive chlovoquine treatment of malaria cases and oral rehydration therapy for diar .heal disease. 4.3" Most of the efforts and resources aimed at reducing malnutrition shruld go to the multi-faceted and multi-sectoral array of policies and programs needed to address the poverty that largely underlies it. Nevertheless, the bleak overall economic prospects for Halawi and the  - 63 - inevitable massive increase in population make it highly likely that direct nutrition inputs will be needed well into the twenty-first century. 4.40 The extent, complexity and repercussions of Malawi's malnutrition provide a very strong argument for additional resources earmarked for nutrition programs. Nutrition services surely deserve a substantial share of the health budget, given the predominance of the problem, its impact, and the relatively high cost of feeding programs and micronutrient supplementation efforts. Resource allocation obviously should be based on careful calculations, but as an indication of order of magnitude, devoting 10-20 percent of the health budget to nutrition services would not be excessive. 4.41 Reducing '.alaria Mortality. Major gains in child survival in Malawi will not be possible without a concomitant, substantial reduction in malaria mortality. A 1987 Ministry of Health study and a 1985 EPI survey found that children under five had 15 and 12 episodes of fever per year, respectively. The Ministry of Health study demonstrated the feasibility of community level presumptive treatment of malaria by traditional birth attendants (TBAs) trained for two days. The cost of treating malaria in children under five through TBAs, was estimated at approximately MK11.7 million annually by year six of a phased program. A substantial part or even all of this cost could be recovered if the TBAs charged a small fee for treating cases in individuals over age five. This scheme, or a similar community-based mechanism for providing malaria treatment, deserves serious consideration if the toll among young children from this disease is to be substantially reduced. 4.42 Controlling AIDS. Although perinatal transmission of AIDS is not currently a major problem in Malawi, it is likely soon to become one in view of the 7-11 percent HIV seropositivity rate reported among pregnant women In urban areas. Perinatal transmission has the potential to increase infant mortality by large margins. For example, an HIV seropositivity rate of five percent among all pregnant women is projected to translate over time into an increase in infant mortality of 13 per 1,000 live births. Such an increase could negate much of the potential gain in child survival achieved over several years. 4.43 Government has already embarked upon a Short-Term Plan for AIDS prevention and control and is developing a medium-term plan, with technical assistance from WHO. The proEcam will focus on halting the transvission of HIV infection due to sexual contact, the use of contaminated blocd and perinatal infection. Prevention of perinatal transmission requires that HIV-positive women avoid pregnancy. Actions to prevent HIV transmission, including perinatal transmission, deserve top priority. 4.44 Spacing Child Births. Scientific studies in many countries have demonstrated that high child mortality results from pregnancies that occur at the extremes of the childbearing period (under 18 or over 35 years of age), are too closely spaced (less than two years apart) or are too numerous (over five). Indeed, child spacing is one of the most, if not the most, cost-effective approaches to lowering infant mortality. Chapter Two de^cribed the rise in the use of modern contraceptive methods in Malawi from a negligible level in the early eighties to about 3 percent of women  - 64 - of childbearing age now, and made recommendations for increasing and improving delivery of child spacing services and for building on and strengthening popular support and demand for these services. This should get the highest priority in Malawi's human resource development Strategy. 4.45 EPI and Diarrheal/Respiratory Diseases. Finally, improved child survival will depend on a continuation and expansion of effort in these areas. The 1987 Primary Health Care Review estimated that 45 percent of new mothers had received two doses of tetanus toxoid, and 40 percent of children under one were fully immunized, both good achievements. More recent surveys show much higher immunization coverage. Use of oral rehydration therapy has inwteased substantially in recent years. The EPI is preventing a substantial amount of respiratory disease and community-based efforts to treat acute respiratory infections are beginning. Each of these efforts deserves continued high priority. Improving Maternal Health (Safe Motherhood) 4.46 Ministry of Health data indicate that slightly under half of all births take place either in a health facility or at home under the supervision of a trained person, usually a TBA. The Primary Health Care Review, on the other hand, indicated that more than half of women delivered in a health facility. Whatever the exact proportion of institutionalized deliveries is, over four out of fie women have at least one antenatal visit and on average they have more than three visits, a notable achievement. Nevertheless, maternal mortality is still a high 170 per 100,000 live births. Likely reasons for the high mortality rate are poor maternal nutrition, lack of referral (or transport) for high risk cases, and an inadequate 'alarma and transport system for obstetrical emergencies. While the health system can contribute to improving maternal nutrition to some extent through nutrition education and/or food supplements plus malaria prophylaxis, this problem, like that of child undernutrition, will be resolved in the long-term mainly through actions outside of the health sector. Meanwhile, however, medical interventions are highly effective in saving women's lives and preventing disability caused by pregnancy complications. 4.47 A first step toward making motherhood safer is an epidemiological survey to establish levels and causes of mortality and morbidity among specific groups, especially among women who deliver at home. 4.48 Referral of High Risk Pregnancies. The most important risk factors for maternal mortality and morbidity are age and parity, previous obstetrical history, current health and nutritional status and socioeconomic variables. Reducing maternal mortality and morbidity in high risk cases requires that high risk women be identified as early as possible in pregnancy and that good community level antenatal care be complemented by good access to obstetrical care at first-referral level, where assistance from trained personnel, Cesarean section and blood transfusions are available. Both high risk cases and unanticipated obstetrical emergencies demand an effective system both to communicate the need for transport and to provide it promptly. (This communication and transport system is equally necessary, of course, to handle trauma cases and medical emergencies such as appendicitis.) Such a safe motherhood program is  - 65 - estimated to cost on average about US$2 per capita per annum, although a good start can be made for US$1 per annum per capita of national population. Expenditure of US$2 per capita probably is not feasible in Malawi in the short-run. Improvements nevertheless would be possible by using such approaches as the maternity village, in which women with high risk pregnancies stay at low-cost shelters near health facilities to await the onset of labor. (Such an approach would cause problems for her other children and her farm work. Possibly village development committees could arrange for child care and help with the farm.) The 'alarm' and transport system could be improved to some extent, with high benefits and cost savings compared to treatment of obstetrical cases. 4.49 Child Spacing. The unmet demand for child spacing services is especially relevant to the large number of women for whom an additional pregnancy carries a high risk of complications or death. Approximately one quarter of all women in the reproductive age group in Malawi are in this high risk group. Child spacing has the potential to reduce maternal mortality by 25 percent in societies such as Malawi. It can prevent not only xnwanted, high risk births, but also induced abortions with their high probability of death or serious complication. (Estimates are that the Queen Elizabeth Hospital in Blantyre and the Kazumu Central Hospital in Lilongwe each receive about ten cases of induced abortion daily.) Increased use of child spacing therefore can make a major contribution to preventing death and disability due to complicated pregnancies. Increasing Efficiency in the Health Sector 4.50 Three areas in narticular offer promising avenues for increasing sector efficiency: decongestion of central hospitals, manpower development and cost recovery. 4.51 Decongestion of Central Hospitals. As in many countries, Malawi's major hospitals are overcrowded with inpatients and overwhelmed by the outpatient workload, while nearby health centers have unused capacity. Thus, much of the workload of central hospitals consists of routine primary care that does not require the specialized services of a referral hospital. 4.52 Women generally prefer to deliver their babies at a facility near their home and will usually do so if three conditions are met: (a) they are encouraged to do so; (b) they ha',e confidence and trust in the community facility; and (c) they are assured of speedy transfer to a referral facility should complications ensue. Similarly, families seeking routine maternal and child health and outpatient care will use first level, community facilities provided they are adequately staffed and supplied with drugs. In Lusaka, Zambia, the Ministry of Health has in the past three years increased the number of deliveries in urban health cl_nics by over 10,000, while decreaving those at the University Teaching Hospital by a similar number, with no increase in complications and much greater client satisfaction. There appears to be great potential for efficiency gains at Malawi's large central hospitals, and perhaps also at some district hospitals, by decentralizing routine primary health care and deliveries to existing facilities.  - 66 - 4.53 The emphasis should be on replacement and rehabilitation rather than expansion of medical facilities, except to accommodate the massive population increase that is inevitable. This would mean keeping the bed/population ratio roughly where it stands now (1.5/1,000). Hospitals should be limited to a maximum of 600 beds. Investment should be used to build a better general public transportation system and an emergency transportation system. 4.54 Even if the cost of an outpatient visit at a central hospital is less than a visit at an (adequately utilized) health center, greater centralization of health care would not be justified. Evidence from around the world suggests that c4^ ient satisfaction, quality And efficiency are best served by a tiered system of facilities with a well-functioning referral system. 4.55 The disease burden of Malawi lends itself to a health service strategy based on good access to primary level facilities, which should be fully capable of providing immunizations, family planning, antenatal and delivery care, growth monitoring, oral rehydration, and treatment for malaria and acute respiratory disease, which are the key ways to reduce under five and maternal mortality. This approach has proved to be more coct-efficient than systems relying to a greater extent on doctors and hospitals. The projected increase of 2 percent in the MOH budget clearly is critical. Given the relatively high efficiency evident today and the projected population growth, this budget increase appears to be the minimum that would offer any hope of improving health services. If this increase is not possible, substantial cost recovery will be required. Better >-ill would be the budget increase, plus some cost recovery to allow greater efforts in areas such as nutrition services, EPI, safe motherhood and family planning. 4.56 Cost Recovery. Current economic circumstances and the need for increased efficiency combine to make it desirable to explore the potential for cost recovery for at least some kinds of health services. Suffice it to say here that preference should be given to instituting charges for curative services, especially at higher level facilities and for unreferred cases, and consideration should be given to exempting preventive services such as EPI and child spacing, and perhaps the poorest population groups. 4.57 Manpower Development. Malawi appears to be near the limit of health sector productivity given its current manpower levels. Efficiency gains seem likely in the large hospitals and are being sought, but are unlikely to be large at primary health centers, dispensaries and maternities unless additional personnel are provided. Population growth alone will require substantial increases in health personnel just to remain at today's efficiency level over the next 20-25 years. Strengthened and expanded efforts in malaria control, safe motherhood and child spacing, to name only three areas, will require additional human resources. In addition, quality improvement will only be possible with somewhat reduced workloads for medical officers, clinical officers, medical assistants, nurses, etcetera. Given this substantial need for additional human resources and the relatively well-developed facility infrastructure. manpower development deserves preference over additional hospital beds or health facilities. High priority attaches to building the capacity to  - 67 - train the large numbers of health personnel required to staff Malawi's health system in the face of growing population and demand. However, some rehabilitation or replacement of existing facilities inevitably will be required. It is difficult to see how this can be accomplished without resort to increased levels of cost recovery. 4.58 Manpower studies are needed urgently to inform health sector policy decisions. No systematic data are available beyond the mid-1984 estimates used in the National Health Plan. There are ongoing efforts to update the basic information regarding the number of sanctioned posts fiPied, distribution of-health personnel, etc., but more detailed information is required. A major manpower study to look at fill rates, turnover, attrition, training and salary costs, performance and projected output by category of personnel should be conducted. The study should address such key questions as (a) the number and availability of unemployed enrolled nurse-midwives; (b) work load norms for clinical officers, medical assistants and enrolled nurse-midwives; 29/ (c) patient satisfaction with the various care providers; (d) adequacy of training programs (quantity and quality of faculty, adequacy of facilities, equipment and accommodation); (e) the reportedly high student dropout rates; (f) availability of staff housing, especially in rural areas; (g) working conditions and remuneration; (h) feasibility of training the number of personnel projected in the National Health Plan. 4.59 The shortage of medical doctors in Malawi poses a very difficult dilemma. With only about one doctor per 65,000 population and just 24 Malawian doctors, the country faces a much worse situation than most other c'untries in sub-Saharan Africa. Apart from the three central hospitals, the Malawi health system depends heavily on the performance of medical assistants (MA) and enrolled nurse-midwives (ENM). The evidence is strong that both categories are in short supply. 4.60 Over the next 20 years, the main objective should be to improve the performance of personnel rather than making a major effort to change substantially the composition of the health staff. Thus, MAs and ENMs, each with three years training, should continue to form the backbone of the system, backed up, especially at the secondary and tertiary levels, by clinical officers (COs) and state registered nurses (SRNs). This is not to deny the need for additional COs and SRNs, and indeed for doctors, but to suggest that well trained and motivated MAs and ENMs are equal to the job at the critical primary level, that Malawi will not be able to afford the greater expense of more highly trained personnel, and that the incremental contribution of substantial numbers of the latter is unlikely to be substantial. 4.61 The community level organization of primary health care also requires further study. MOH was not satisfied with paid primary health workers (Ph-Ws), but no systematic evaluation of that experience or with volunteer village health workers (VHWs) is available. The current plan is to rely on village level volunteers (VHWs) specializing in different 29/ The Complement and Grading Review Report, Ministry of Health, October 1988, has gone some way on this.  - 68 - problem areas to organize education, promotion and referral activities on behalf of the village health committee. In addition, health assistants (HAs) and health surveillance assistants (HSAs) are to play a key role at the community level where they exist. There seems, however, to be lack of clarity regarding operationalizing PHC in general, and organizing community level activities in particular. These questions would benefit from a careful look at national experience to date on the basis of well-defined terms of reference. In the meantime, the performance of unpaid volunteer health workers (VHWs) has been generally unsatisfactory in most settings. This activity requires a reasonable infusion of resources, which might take the form of the HAs or HSAs and other health personnel playing a defined role with village leaders, committees and volunteers. IMMEDIATE DECISIONS 4.62 Immediate decisions and actions that will be vital to the longer range effort to improve health conditions include: (a) proceeding with plans for community-based and social marketing contraceptive distribution efforts; (b) establishing a vigorous AIDS prevention and control program; (c) moving quickly on poverty alleviation programs targeted on female-headed households and other very impoverished smallholders; and (d) not proceeding faster in establishing the medical school than funding for its recurrent costs becomes available through grants or other similar financial guarantees, so that very high priority health services are not starved of resources.  - 69 - CHAPTER FIVE EDUCATION OVERVIEW 5.01 Education is the foundation for economic and social development, and is closely tied to improvements in family health and nutrition and agricultural and industrial productivity. The success of the education system can be jidged primarily on whether it provides lasting functional literacy and numeracy for most of Malawi's children, as well as good preparation for the policy makers, managers, professionals, and skilled workers needed by the economy. Malawi is facing new challenges and changes, as the shortage of land increases the urgency of improving agricultural productivity and expanding job opportunities. To meet the challenges, Halawians will zequire the abilities to innovate and adapt, to adopt new technologies, and to acquire new skills and seek out new opportunities. The education system will help if it is able to teach people to absorb new information, formulate and evaluate alternatives, and apply knowledge to solve problems. 5.02 When Malawi became independent in 1964 it had a very small, but well-established fourdation upon which to build a national education system. Formal education had been introduced in the country very early. By 1910, nearly 85,000 students were studying in 1,050 schools. 30/ Since Independence, primary school enrollment has increased from 360,000 to more than one million - an increase of 184 percent. The number of secondary school students has increased from nearly 6,000 to over 26,000, and an additional 24,000 students are studying through the distance education system. At Independence there were only 33 Malawians with a University education; since then more than 8,000 people have graduated from the University of Malawi and many others have earned degrees abroad. 5.03 However, the expansion of education in Halawi has scarcely kept pace with population growth. Only about 43 percent of the primary school- aged group enumerated in 1987 were enrolled in primary schools. The gross enrollment ratio for secondary school is about 4.5 percent; there are secondary school places for only 11 percent of those who qualify. The University could only accept 600 of the 3,500 who applied in 1987. High dropout rates in the early years of primary school have kept literacy levels low, particularly in rural areas and among women. Although expansion of the education system and the adult literacy program administered by the Ministry of Community Services have improved the national literacy rate of the population group 10 years of age and older from 18 percent in 1977 to 27 percent in 1987, there are still millions of Malawians yet to be reached. 31/ 30/ Banda, 1982, p.1 31/ Devpol, p127 and Ministry of Education and Culture, Education Statistics Halawi 1987, Piann ng Division, 1987. MOEC calculates literacy in 1987 as 29 percent, the total number of literates is given as 1,419,794 (excluding literacy classes, but Devpol says their impact up to 1979 was 'negligable) and the 10+ population as 4,707,794. However, the preliminary census results suggest a 10+ population of about 5.217 million, which reduces the literacy rate to 27.2 percent.  - 70 - 5.04 The quality of primary education needs improving and the wasteful high dropout and repetition rates pose a serious problem. More teaching materials and improved teaching methods are needed. Some of these problems have been made worse by the 30 percent decline in real per capita spending on education over the past five years. The Government is committed to increasing the share of education in the national budget from 11 to 15 per cent over the next few years; this will still be below the allocation in most other African countries. Malawi now spends about 3 per cent of national income on education; this contrasts with about 5 per cent in neighboring Zambia and in Kenya and 7 percent in Zimbabwe. 5.05 Despite severe economic constraints, the Ministry of Education and Culture has ambitious plans for expansion, and has embarked on a program of reforms to improve the quality and efficiency of education at all levels by revising curricula, consolidating and rationalizing the examination system, increasing the amount of learning materials in primary school classrooms, and expanding distance education. Cost recovery has been increased at the secondary levels and introduced at the University. This chapter suggests further steps to improve the education system. STRU(;TURE OF THE EDUCATION SYSTEM 5.06 Malawi's education system appears well managed. The Ministry of Education and Culture is responsible for all non-private education. It operates technical colleges and the Polytechnic with the Ministry of Labor, which is responsible for coordinating training opportunities with labor market demand. In addition, the major ministries also operate vocational training units. Examinations for the formal educational system are operated by a parastatal body, the Malawi National Examinations Board. The Malawi Institution for Education has responsibility for curriculum development and for writing textbooks and teachers' guides. 5.07 The system provides open access to eight years of non-compulsory primary education, ending with the Primary School Leaver's Certificate (PSLC) examination. About 12 percent of students who are awarded the PSLC (about 7,000 persons) are admitted each year to secondary schools. 5.08 Secondary education consists of two years of junior secondary schooling after wtich the Junior Certificate of Education (JC) is awarded, and two years of senior secondary schooling, after which successful graduates receive the Malawi Certificate of Education (MCE). There are 36 government secondary schools, 24 government aided schools and 16 private schools. Unlike primary schools, secondary schools have low repeater and dropout rates. 5.09 The formal secondary schools are supplemented by the Malawi College of Distance Education (MCDE) which offers open admission to students who have been awarded the PSLC. Although MCDE is perceived by the public to be inferior to the formal secondary school system, demand is high. About 17,000 students are enrolled in 105 study centers where teachers (only trained to teach at primary level) monitor lessons and provide some guidance. An additional 2,000 students are enrolled in 17 night secondary schools where formal classes are held on a half time basis,  - 71 - and 5,000 students study at home. Students who have earn the JC through the MCDE programs are eligible for admission to senior sacondary schools, although there are places for very few. 5.10 At the tertiary level there are two year teacher training programs provided by training colleges, and four- and five-year courses of study leading to diplomas and d..grees in a number of .elds. About 2,000 students are enrolled on the four campuses of the university system. As noted above, in 1987, there were places for only 600 of the 3.500 students who qualified for admission to the university. In 1988 there were even fewer freshmen plnces because of a decline in the number of drop outs. However, a small expansion was achieved by admitting day students for the first time. The University has been very responsive to labor market opportunities and needs for graduates. Since 1983/84, enrollment in the sciences has almost doubled and enrollment in the humanities has declined by almest half. Specialized courses in agriculture and engineering have been introduced in response to amployers' requirements. The quality of instruction at the university is generally good. '.li The pre-school and adult literacy programs run by the Ministry of Community Services complement the formal education system. MCS intends to expand its small pre-school play group program, which is presently confined to urban areas, and is placing increased emphasis on the importance of early childhood education as a foundation for later learning. The MOCS sees a need for close links between schools and communities. This would help improve knowledge and skills in the community, and would provide a supportive environment for schools, which could help reduce drop-outs. 5.12 The National Adult Literacy Program (NALP) aims to cover two million adults over the decade, with priority targeting of women, out-of- work youth and young adults, and farmers. A pilot functional literacy program was carried out in 9 districts between 1981 and 1985 to develop and test the methods and effectiveness of the new program. The ambitious nation-wide adult literacy program is based on a recognition of the inadequate coverage of the school system, high drop-out rates, especially of girls, and the strong links between education and productivity in industry and on farms, and between mothers' education and the well-being of their families. PRIMARY EDUCATION Access and Equity 5.13 In 1987 primary school enrollments were 1,022,700; the total 6- 13 year old population was 1,733,738, giving a gross enrollment ratio of .59, about the same as in 1977. If the 26 percent of primary school pupils who were over 13 years old in 1987 are excluded, the net enrollment ratio, (which considers only children of primary school age, 6-13) is only 43 percent. 5.14 Regicnal disparities. Regional differences in net enrollment rates are strikingt (Table 5.1). Approximately 80 percent of the primary age group are enrolled in the northern region compared to only about 41 and 37 percent in the ^entral and southern regions respectively. In 1987, five districts enrolled 30 percent or less of the 6-13 age group, four of which were in the southern region. Net enrollment rates are also substantially  - 72 - higher in urban schools, with near 100 percent enrollments reached in the ma3jor cities of Mzuzu, Zomba and Blantyre. 32/ Net enrollment is only 36 percent in Lilongwe rural, and 50 percent in Blantyre rural. Table 5.1 Total Primary School Age Pupils (6 - 18) in Malawi by District, 1987 1987 Census Eatlated 1967 Estimated Population Population Enrollment Enroll ent District Aged C - 14 Aged 6 - 18 Aged 6-18 Rates, 6-13 Northern 259460 196859 152683 79 Chitispa -sumUI= 17815 Karonga 43199 82693 24368 76 Rumphi 2730 20663 18945 92 Nkhata Bay 38461 29099 19M92 68 dzuzu City 12226 9252 11228 :21 Mziaba 107888 81649 68444 78 Central 882405 667804 276266 41 K"sungu -7am 1U17 -gun U Nkhota Kota 48197 82691 15619 48 Ntchiel 36220 26654 11054 41 Dowa 91226 69089 29082 42 Sell" 61935 39804 13909 85 Lilongwe City 63489 48048 86885 76 LiIongwe Rural 212584 160883 57877 86 MchT m 68609 51847 21641 42 Dedza 121451 91914 25906 28 Ntcheu 108090 81802 80660 37 Southern 1149016 869576 822574 87 Mangochi -1T97 n! I2=1 if Machin a 149320 118006 81664 28 ZombaLra 112818 653 80 27634 32 Zomba Urban 11686 8848 9109 103 Chiredzulu 61202 46817 22146 48 Blantyre City 86981 65827 69176 90 lantyro Rural 75501 57189 29151 51 Mwanza 86017 27267 9242 84 Thyolo 128612 97267 38804 89 Chikwawa 94672 71647 17562 25 MulanJe 194892 147116 46600 82 NsnJe 59738 45209 9487 21 Malawi 2290881 1733738 75U894 48 Source: Malawi Population and Housing Census, 1987, Preliminary Report, Zo%a, National Statistical Office 1907 Education Statistics, Malawi. 1987, Tables 88-40, Lilongwe, MOEC Planning Division, 1987. 5.15 Rapid population growth has pushed the goal of providing school places for 85 percent of the school age (6-13) population by 1995 further from reach. In 1985, when the Education Plan was being developed, HOEC based its projections of the number of primary school-aged children on the 1977 census, and a 2.6 percent annual population growth rate. This estimated the school age population in 1987 at 1,337,818, much lower than 32/ Nct enrollment rates in cities may be exceed 100 percent because large numbers of children from rural areas may be sent to school in the cities, but not included in the denominator, the urban school-aged population.  - 73 - the 1.733,738 children actually counted in the 1987 census. 33/ A reasonable projection suggests that the primary school age group will reach 2,576,500 children by 1995. Net enrollment of 85 percent will r^quire 2,190,025 places, and nearly 40,000 teachers for a pupil/teacher ratio of 55:1. This is about 24,000 more teachers than are presently employed in primary schools, and 20,000 more teachers than were projected as needed itt the Education Plan. 5.16 There are limited resources available to expand the system by building new s hools. Existing facilities must be used as intensively and efficieitly as possible, and alternative strategies for reaching and teaching primary school age children must be considered. The MOEC is already taking steps to increase the number of places for additional children by reducing repetition and dropout. This report suggests that Government consider implementing a system of double shifts in very crowded primary schools. Quality 5.17 Key indicators of school quality are (a) physical facilities, (b) qualified teacherlpupil ratios, (c) material and non-material inputs, (d) the efficiency with which student progress through the system, and (e) the amount students in the system learn. By all five criteria, the quality of primary education in Malawi appears poor. 5.18 Physical facilities: classrooms. There are insufficient classrooms to serve the growing number of primary school pupils. It is estimated that 10 percent of classes are conducted in shelterless* classrooms. and many classes are held in seriously overcrowded conditions. In 1986/87, there were 14,559 permanent classrooms available for 1,022,765 pupils, an average of 70 pupils per classroom. In urban schools, there can be as many as 160 pupils in a classroom (Table 5.2). Overcrowding of this magnitude threatens educational quality. which means more pupils repeat and dropout, lowering achievement. The Ministry target is 55 pupils per classroom. This implies a shortfall now of 4,00C :Iassrooms; if 85 percent of school-aged children were to be accommodated in 1995, a further 18,000 classrooms would be needed. Table 5.2 Pupil/Classroom Ratios in Urban Schools, 1987 Permanent Classrooms Pupils Pupils/Class Mzuzu City 99 14419 146 Lilongwe 282 44811 160 Blantyre 524 74609 142 Zomba 129 11769 91 Source: Education Statistics, 1987 33/ The 1987 Census reports 2,290,881 children aged 5-14; approximately 76 percent of these are in the age range 6-13, giving 1,733,738.  - 74 - 5.19 Teachers. Teacher availability at the primary level has not kept pace with the expansion of enrollment. In 1986/87 the pupil-teacher ratio in primary schools was 63:1 compared with 60:1 in 1984185 and 52:1 in 1973. This ratio varies widely -- from 48:1 in Mzuzu city, to 128:1 in Mchinji and 119:1 in Dowa. Rural areas are at a decided disadvantage since they are less likely than urban areas to offer decent housir.g, and therefore have particular difficulty in attracting qualified teachers. An incentive system is needed to get communities to provide houses, so as to be able to attract competent and well qualified teachers to rural areas. Progress has been made in upgrading and replacing untrained teachers: the ratio of pupils to qualified teachers improved from 87:1 to 76:1 between 1984/85 and 1986/87. An estimated 17 percent of primary teachers are still untrained. (UNICEF has recently provided funds for upgrading a small number of untrained teachers). 5.20 Material inputs. National and survey data on primary education indicate shortcomings in material inputs. There is only one chair for every 15 pupils and one desk for every 13 pupils. A recent national survey of school quality in Standards 3, 4 and 7 found that only 3 percent of students had their own desk, while all pupils learning outdoors and half if those learning indoors were sitting on the ground or floor. The quality of textbooks needs improving. Some existing texts contain factual errors and exhibit poor instructional design. The Malawi Institute of Education (MIE) is presently revising all primary textbooks and teachers' guides, as well as the primary curriculum. Textbook availability has increased with IDA assistance. Overall, there are nearly enough basic textbooks for every child, although distribution problems have meant that some schools are seriously underprovided with books. However, due to the substantial increase in school enrollment, lack of budgetary resources for replacement, and the fact that textbooks tend to last only 3 years, continued adequacy of provision is not guaranteed. Government has agreed to an earmarked budgetary allocation of MK2 per primary school pupil for textbooks. This allocation, along with the parental contribution of MK1 per pupil annually for textbooks replacement and supplementary fee contributions for stationery is not adequate for these needs. The supply of stationary is severely limited especially in the early years of primary education. 5.21 Progression. Primary school dropout rates are high, with fewer than 23 percent of Standard 1 students progressing to Standard 8. The main reasons for this are: difficult geographic access to schools; parents being unable to pay school fees; and poor learning conditions. Transition rates for the earlier grades and trends in dropout show that fewer than half of Standard 1 students reach Standard 4 three years later; the likelihood for sustained literacy for students completing less than 4 years of schooling is poor, and these figures indicate considerable wastage. Recent improvements are evident, however. For example, although Standard 1 to Standard 4 transition rates declined to about 36 percent in the early 1980's, they have picked up sub tantially since then to over 50 percent (Table 5.3).  - 75 - Table 5.3 Transition from Standard 1 to Standard 4 Years St. 1 St. 4 Transition rate 77/78-80/81 180,525 79,132 43.8 78/79-81/82 201,745 86,714 43.0 79/80-82/83 232,975 88,411 37.9 80/81-83/84 234,814 92,127 39.2 81/82-84/85 262,361 94,009 35.8 82/83-85/86 236,476 95,664 40.5 83/84-86/87 204,200 103,741 50.8 Source: Computed from Education Statistics, Halawi, A987 5.22 Repetition. Repetition rates are particularly high in standards 1, 2 and 8, where repeaters account for 20 percent. 18 percent and 45 percent of pupils, respectively. The large class sizes in Standards 1 and 2 (over 100 in some urban schools) reduce the quality of the instruction. Standard 8 pupils repeat in the hope of improving their performance in the PSLC examination enough to gain a secondary school place. The combined effect of high rates of repeating and dropping out is that it takes more than sixteen pupil-years of instruction to produce each standard eight completer. 5.23 Achievement. The most critical indicator of school quality is achievement -- what pupils have learned in school. The national PSLC examination administered in Standard 8 could provide information regarding levels of, and changes in, achievement. However the scoring system now in use does not provide objective results that are comparable over time. Scores on the PSLC are set to provide an annual passing rate of 70 percent. Holding passing rates constant prevents assessing absolute levels of knowledge possessed by Standard 8 pupils or evaluating changes in this level of knowledge over time. However, PSLC scores can be used to examine internal variations in achievement, such as between regions or between male and female students. 5.24 (a) Regional variations. Regional differences in achievement are apparent from an examination of average English, arithmetic, Chichewa and science test scores from the 1987 primary school leaving examination taken by 101,000 students (Table 5.4). The scores reported in this table are normelized with a mean of 50. Overall, scores in the northern and central regions are higher than scores in the southern region. Of the eleven southern districts (including Blantyre rural and Blantyre urban), all have mean science scores that are below average, 90 percent have mean arithmetic scores that are below average, 40 percent have mean English scores that are below average, and 50 percent have mean Chichewa scores that are below average. In the central region, scores are higher in arithmetic, Chichewa and science, but equally poor in English. The highest average scores in the country are found in the northern region, in the district of Karonga.  - 76 - Table 5.4 Average PSLC Scores by Subject and DistrIct, Malawi 1987 District Chichewa English Math Science Northern Thittp 49.2 64.8 66.7 64.1 Krronga 51.2 57.0 60.1 63.3 Rumphi 44.8 43.2 49.2 50.2 Nkhata Bay 52.1 52.7 56.6 65.4 Mzimba 44.0 46.3 46.3 47.2 Central Xsungu 51.5 40.2 60.4 40.6 Nkhots Kota 62.1 49.9 46.9 52.4 Ntchisi 56.6 46.6 50.7 49.0 Dowa 56.0 40.8 51.6 62.7 Salima 66.8 50.2 58.7 58.1 Lilongwe City 64.8 54.0 51.5 53.6 Lilongwe Rural 66.2 49.7 51.6 51.1 Mchinji 55.9 52.6 53.3 33.2 Dedza 51.9 40.8 47.4 46.1 Ntchou 49.7 46.6 46.6 46.9 Southern nigochi 46.8 46.4 44.3 44.8 Machinga 49.4 48.6 45.9 47.7 Zomba 49.4 49.3 46.7 45.2 Chiradzulu 49.8 51.0 47.9 47.9 Blantyre City 51.6 65.2 59.5 48.9 Blantyre Rural 60.6 48.8 48.6 47.1 Mwanza 63.4 49.5 49.3 47.9 Thyolo 47.8 47.9 47 t 47.2 Chikwawa 49.9 47.5 49.5 45.9 Mulanje 60.1 49.9 49.9 40.3 Nsanje 60.1 50.4 61.6 49.2 Malawi 58.4 49.5 49.8 47.9 Source: Malawi National Examination board, 1968. Mean: 50, p-acsarli: 84 5.25 (b) Gender variations. Boys out-perform girls in all subjects other than housecraft and needlecraft, 5or which the boys are not examined (Table 5.5). The size and stability of the difference across all subjects is remarkable for two reasons. First, the gender differences are quite large; two-thirds of a stAndard deviation for science and the general paper, and one-third of a standard deviation for English and arithmetic. Only for Chichewa was the gender difference insignificant. Such differences far exceed those reported for primary school pupils elsewhere in developing countzies. Second, these gender differences are all the more surprising when the native ability of the male and female Standard 8 pupils is considered. Native ability is equally distributed between the sexes, and equal numbers of boys and girls rtart school. However, more than twice as many boys as girls remain in school through Standard 8 (62,880 boys versus 27,486 girls in 1985/86) and sit the examination. If the most able students complete primary school, then the girls - as a group - should have higher ability, since the boys include both the 27,000 "most able' and another 35,000 'slightly less able'. This should drive down the male PSLC scores. The scores of these boys, however, are significantly higher than the scores of the girls, which suggests that the primary school system in Halawi is particularly ineffective ih teaching its able girls, or is not retaining the best female pupils.  - 77 - Table 5.5 Mean PSLC Examination Results, by Subject and Gender, 1987 Subject Boys Girls English 51.7 46.1 Arithmetic 51.6 46.3 General paper 53.0 43.0 Chichewa 51.0 49.7 Agriculture 52.7 43.6 Science 52.0 42.8 Housecraft --- 50.9 Needlecraft --- 50.6 Sourcet Malawi National Examinations Board, 1988. 5.24 Examinations can be a powerful influence on teaching. The PSLE emphasizes recall of facts, and does not require pupils to analyse, synthesize or apply knowledge to new problems. A change in the nature of the examination questions, with careful explanation to teachers of the reason and aim, could have a very positive impact on teaching methods and learning achievement. Timing of instruction 5.25 Three elements of learning time ares time in which school is in session (the academic year and length of school day), class time allocated to teaching and learning activities (time on task), and student attendance. The official number of school days in Malawi compare favorably with both developed and developing countries, but in other respects, learning time in Malawi falls short of international standards, principally as a legacy of colonial policies. This study was unable to collect information on attendance. 5.26 Academic year. The timing of the school year seems suboptimal with respect to climatic and agricultural cycles which limit attendance and interfere with effective teaching and learning. The academic year for primary and secondary schools runs from early October through the end of July, with two two-week holidays separating the three terms. The result is an academic year of 195 days, compared with international standards of 180-190 days. However, about 30 percent of the 195 days fall during the wettest months of the year. which are also the peak agricultural months. Rainfall reduces student attendance and achievement in three ways. First, demands for child labor are greatest during the rainy season when crops must be weeded. Children may well be kept home to help with this agricultural work. Second, during rainy periods, flooding and mud conditions in areas lacking paved roads may make travel to school difficult, particularly for younger pur'.ls. Children may be kept at home for safety. Third, rain adversely affects the learning process. In classrooms, the noise of rain on the tin roofs interrupts instruction (virtually all schools in Malawi have tin roofs). 'Where there is no classroom, which is comon in urban schools, a rainstorm discontinues all instruction while children seek shelter in corridors or in already-crowded classrooms.  - 78 - Table 5.6 Academic Year Versus Rainfall in Selected Districts Average 10-year Rainfall, Number of 1974/75 - 1983/84, in mm. Month School Days Northa Centralb Southernc July 20 0.5 5.5 8.3 August 0 - 1.3 1.8 September 1 - - 1.0 October 21 7.7 14.0 23.8 November 21 31.5 55.8 48.9 December 9 204.9 203.1 187.2 January 20 228.1 230.2 159.8 February 21 214.9 195.0 253.7 March 22 176.5 117.8 174.3 April 11 52.5 34.1 33.8 May 22 4.8 5.1 5.3 June 22 0.1 0.1 1.3 Source: Malawi Statistical Yearbook, 1985. a/ Mzimba b/ Lilongwe c/ Mangochi 5.27 This academic year does not correspond to southern hemisphere seasonal variations. Instead, it suits a northern hemisphere agricultural calendar and appears to be a colonial legacy, possibly originally instituted to take advantage of certification examinations administered by the Cambridge Examination Syndicate. Since Malawi now operates its own National Examination Board, it is unnecessary for the school year to operate on a northern calendar. The MOEC explains that regional climactic variations make it impossible to time the school year in an optimal way for the whole country, that the present school year allows practical agriculture lessons using school gardens, and takes account of other climactic factors - heat and cold; however, these reasons do not seem to outweigh all the other considerations. MOEC intends to carry out a study to determine the optional timing of the school year. Attendance records and the factors that affect attendance will be studied. 5.28 Revising the school calendar could have several benefits: o First, scheduling vacations in the rainy season could increase the effective learning time in school considerably, by reducing the potential for rain-related disruptions of instruction. For example, assume that rains affect half the days of school during December-March (a realistic assumption). During 1987/88, schools operated a total of 72 days during this period. Rainfall would reduce the official school year of 191 days (195 minus four national holidays) to 155 days. By rearranging holidays and moving the present nine-week long vacation from the dry season to the rainy season, while retaining a 191-day school vear, the number of effective learning days would increase by 14 percent to 177 days.  - 79 - o Second, having the long vacation during the rainy season would benefit agricultural households by allowing children to be available to help on family farms during peak periods of agricultural activity. O Third, changing the school year could lessen the effect of seasonal food shortages on student achievement. A national survey of 7,000 primary school pupils found that 8 percent reported always feeling hungry at school, while 67 percent sometimes felt hungry at school. Food availability is best between harvest (April/Hay) and September. At present, school starts just as household food stocks are running out, and only the final three months of the school year are post-harvest. While changing the school year could not eliminate pre-harvest food shortages, it could mitigate the effects on learning by minimizing the part of the school year that coincides with the 'hungry season'. O Fourth, beginning the school year in March instead of October would increase parental ability to pay fees and buy uniforms, since the end of the first term would coincide w6ith the harvest, when cash is available in farm households. Thus, children of farm households would be more likely to be able to enroll in school at the outset, and to remain in school after fees are due. 5.29 Classroom learning time and time per subject. The length of the school day is short, with pupils in Standards 1-4 attending school for four hours only; pupils in Standard S attend school for five hours, and those in Standards 6-8 attend for 5.5 hours. The international standard is between 6 and 7 hours. Moreover, opportunities for learning are reduced by the large number of different subjects that are expected to be taught. For example, the present Standards 1 and 2 curricula include eleven subjects, with seven taught only two hours weekly, for a total of 37 official hours of instruction. The primary curriculum is presently being revised to reduce the number of subjects taught in Standards 1-2 from 11 to 6, and to reduce the total number of hours of official instruction from 37 to 27, which is more in line with practice. This change would permit doubling sessions ana lowering existing class sizes for Standards 1 and 2, with potential reduction of dropout and repetition at these levels. Some Suggestions for Innovation 5.30 The ongoing revision of the school curriculum is making a needed reduction in the number of subjects and updating textbooks and other teaching materials. The revision alsc provides the opportunity to increase the relevance of the school curriculum to the social and economic skills that will be needed in future; e.g. the ability to read and understand unfamiliar material and to evaluate new ideas. This report suggests that greater attention be given to interpretation and reasoning skills, and to application of mathematics and science disciplines. 5.31 Reading is far more than the recognition of printed words. Part of learning to read well is learning to interpret and expand upon written text using context, gramar, syntax and logic as well as background facts. These skills are typically acquired informally and are usually not  - 80 - explicitly taught. However, they can be taught and research indicates that students who are given opportunities to develop these skills are far better able to draw meaning from texts. 5.32 Teaching strategies for the development of %hese whigher orders skills require that pupils participate in creative learning activities that demand more initiative than present teaching methods. Clisses can be organized into small groups of eight or ten pupils who help one another to learn. For example, reading skills can be strengthened by having pupils work in small groups to make up their own endings for an incomplete story. Classmates then attempt to identify inconsistencies between the first part of the story and the proposed conclusion. This principle can also be used in sentence completion exercises. These methods have the additional advantage of relying only to a modest extent on printed material. The same devices that are used to enhance reading skills can be used to strengthen comprehension of oral comnunications. As the teacher training curriculum and teaching guides are revised, they should incorporate these innovative approaches to help teachers to apply them. 5.33 Options also exist for strengthening the mathematics curriculum by introducing more applications of mathematics concepts to common problems familiar to rural Malawians, and by building s deeper understanding of the principles of mathematics. Many methods and strategies are available to enrich mathematics instruction. Researchers have demonstrated that 'brighter* pupils rely on such strategies to simplify arithmetic problems. For example, addition problems can be rearranged so that the small number is added to the larger: 28 plus 2 is easier than 2 plus 28. Long addition problems can be broken down into a few smaller problems, then subtotals can be added to give grand totals. Similar strategies of regroupit-g and factoring can simplify multiplication and division problems. All of these techniques are easily taught even to young pupils of average ability. Many are easily drilled as mental arithmetic problems; where teaching materials are scarce and class size is large, team competitions can be used to motivate students and to extend the teacher's effectiveness. SECONDARY EDUCATION 5.34 The central issues for secondary education in Malavi are: (a) increasing access, through more intensive utilization of existing secondary level facilities and improvement of distance education, (b) maintaining or improving the quality, particularly of distance education, and (c) continuing to recover costs of secondary school from beneficiaries and their families. Access 5.35 Access to government-supported formal secondary education is largely determined by performance on the PSLC examination. Secondary school places are offered to approximately 11 percent of those passing the examination. -rhe examination's emphasis on rote learning gives an advantage to Standard eight repeaters. Private schools enroll 16 percent of all secondary students. Secondary schools are small by international standards, enrolling 200-500 students each. In principle, secondary  - 81 - education occurs in both boarding and day institutions, but in practice all day schools have locally constructed self-help, boarding facilities to accommodate students. 5.36 The low secondary enrollment ratio and under-utilization of teachers and facilities justify expanding access and improving utilization through double shifting. The HOEC intends to introduce a second shift in six urban schools, as soon as the facilities have been modified appropriately. Boarding facilities are an additional constraint on secondary school enrollments, and are crowded in many schools. The acute resource constraint and the urgency for other educational investments prevents Government from being able to construct and maintain additional bearding facilities, but if communities co-ld do so, enrollments could increase by 25 percent in many schools without creating unreasonably hiph student/teacher ratios or overcrowding teaching facilities. The Bwaila Secondary School provides a case study: Built in 1969, Bwaila enrolls 440 students in 11 classes averaging 40 students each. The school's physical plant includes 8 classrooms, 2 laboratories, 2 workshops (metal working and woodworking), 1 technical drawing room, 1 needlework room and 1 home economics room, for a total of 15 rooms. With 11 classes of students, not all 15 instructional rooms are occupied full-time. The technical drawing, needlework, and home economics rooms could be used for instruction in other subjects, providing space for 120 more students at no additional capital cost. By staggering lunch breaks and allowing one class session a day of supervised study, rather than instruction, additional student places could be created. A total of about 750 students could then be accommodated. Hostel facilities would be needed, however, as existing dormitory rooms are crowded, being designed for 10 students but presently housing 12-13 students. 5.37 Access to the final two years of secondary school is restricted by performance on the JC examination, which about 25 percent of students fail. Secondary school students have already been highly screened, and a competitive examination at this point is inappropriate. However, it does offer a good opportunity to allow highly successful students studying through MCDE to re-enter the formal system. Entry to Form III should be on the basis of merit if there are not enough places for all those who pass the JC examination. Increasing the number of secondary places in Forms III and IV should take priority over increasing places in the first two Forms until there are enough places to avoid having to turn away students who pass JC. 5.38 Distance education. In 1985186, 61,905 students passed the primary school leaving examination, but only 7,376 of them (12 percent) obtained a place in formal secondary schools of any type. The remainder either concluded their education or enrolled in distance education programs of the Halawi College of Distance Education (MCDE). In 1986/87, a total of 10,059 new students (16 percent of PSLC passers) enrolled in JC courses through the MCDE. The College's enrollment has steadily increased from 1424 students in 1965 to about 24,000 students in 1986187. 5.39 The MCDE functions as a test preparation center, providing materials for study that are self-instructional and directly geared to the various certification examinations. The main form of teaching is printed  - 82 - self-instructional lessons that cover the whole syllabus for each subject. Several lesson units ("sets") are bound together into a booklet that also contains practice self-graded exercises, and tests that are graded by MCDE. JC lessons are contained in five booklets for each of 8 subjects (a total of 40 booklets) and MCE lessons are contained in 8 booklets for each of 8 subjects (a total of 64 booklets). 5.40 The radio component of the distance learning activities seems less important than the print component. Medium wave radio programs supplement the contents of the sets and provide additional teaching of difficult or important parts of the subject. Radio and cassette players are provided at Study Centers and Night Secondary Schools, but are often out of order or batteries. For JC students, eight programs and eight repeats are broadcast weekly for Chichewa, English, geography, history, biology, mathematics and Bible knowledge; for students studying for the MCE three weekly programs and three repeats are broadcast for English, history and geography. Quality of Secondary Education 5.41 Material inputs. Preliminary results from a survey of 24 secondary schools indicate that lack of textbooks and other teaching aids is viewed as a problem by both teachers and headmasters. 34/ The problem is more acute in government-aided schools. where levels of assistance have not kept pace with textbook prices. In addition, Home Economics and Physical Science classes lacked equipment and chemicals for practical exercises &nd experiments. MCDE is unable to supply enough study booklets primarily because its printing facilities are taken over by MANEB for several months each year. 5.42 Teachers. Student/teacher ratios for secondary schools are low; for all secondary schools in 1986/87 this ratio was 21:1. However, the quality of teaching is not uniformly high. One study of secondary school teachers reports that in 1984/85, 25 percent of teachers were untrained, 40 percent were inexperienced, and 25 percent were teaching subjects for which they were not trained. Among the subjects most frequently taught by unqualified teachers were mathematics, biology, and physical science. 35/ 34/ Second interim progress report on the MANEB/IDRC Project, Secondary School Examinations (Malawi), Factors affecting performance of candidates at distinction and credit levels in five Halawi School Certificate of Education (MSCE) Examinations developed and administered by the Board, MANEB, Research and Aptitude Testing Department, November, 1987. 35/ Courteney, 1986.  _ 83 - Table 5.7 Student/Teacher Ratios in secondary Schools, 1986187 Type of school Student/teacher Government boa;ding schools 16 Government day schools 23 Aided boarding schools 21 Aided day schools 19 Private schools 19 All secondary schools 21 Source: Education Statistics, Halavi 1987, Table 71. Achievement 5.43 High selectivity and favorable student/teacher ratios in formal secondary schools should set conditions for excellence in achievement. Surveys of secondary education in Malawi and JC and MCE results suggest the contrary. The JC examination is graded normatively, while the MCE is graded on a 9 point scale, with scores of 1-2 receiving distinction%, scores of 3-6 receiving *credit', scores of 7-8 passing and a score of 9 indicating failure. To be selected for Form Ill, a student must pass JC six subjects. To be selected for the university, a student reeds a 'distinction' or *credit* in English, mathematics and science on the MCE. in 1987, fewer than 30 percent of students taking the MCE qualified for university admission. 5.44 Achievement is higher for students in regular secondary schools than for students studying through the MCDE, although MCDE results have shown a remarkable improvement in recent years. Of 10,204 students who sat JC in 1985/86, only 9.4 percent (960) passed 6 subjects at one sitting; a further 3 percent (300) passed by accumulation (that is, passing different subjects at different sittings). In 1988, 53 percent of those who sat 6 or more subjects passed. Formal secondary students' JC mean scores are higher than those of MCDE students in all subjects other than Chichewa. In some cases, the difference exceeds a full standard deviation; science and mathematics are areas of greatest difficulty for MCDE candidates. 5.45 MCDE, with assistance from the International Extension College, UK, is implementing a 3-year plan for management and quality improvement. At present, HCDE is under-resourced and tries to reach too many target groups through too many modes of instruction. MCDE should concentrate its efforts and resources where it is most successful -- that is, JC courses offered at study centers. The night secondary schools are not functioning well, and students at home have very low examination pass rates.  - 84 - Table 5.8 Mean JC Scores for Internal and External (MCDE) Candidates Subject Internal, 1987 External, 1985 Bible knowledge 54.1 40.7 Biology 51.0 23.1 Chichewa 52.5 51.4 English 49.9 35.9 Geography 62.8 35.0 History 42.1 36.3 Mathematics 42.7 26.4 Source: MANEB unpublished data and World Bank documents. 5.46 Comparable data are not available for MCE performance by subject for internal and external candidates. Pass rates for external candidates attempting the MCE have been very low, although they have improved. In 1985/86, 1063 external candidates sat the MCE (six or more subjects) and 118 passed, for a pass rate of 12 percent; by comparison in the same year, 54 percent of internal candidates passed the examination. In 1986/87, 23 percent of MCDE candidates and 65 percent of internal candidates passed. 5.47 Quality of performance on the MCE is not high, however, when scores in the range of "distinction' and 'creditw are taken into account and subject matter is considered. At the secondary level, students in regular secondary schools have been highly selected at entrance and then again mid-way through. Yet nearly 40 percent of them fail the MCE, and few receive high scores. Table 5.9 MCE Distinctions and Credits, by Subject, 1987 Subject 2 Distinction 2 Credit Agriculture 1.3 37.1 Bible knowledge 3.1 59.3 Biology 5.0 43.0 Chichewa 1.8 59.1 English 0.8 44.7 Geography 2.3 44.0 History 2.9 27.9 Mathematics 4.1 24.1 Physical science 2.4 37.0 Sourcet Malawi National Examination Board-unpublished data. 5.48 The most pronounced problems appear for mathematics, science, history and agriculture. Ponr performance in these subjects cannot be explained by the content difficulty of the tests, since the material covered is not particularly advanced by internat.Ional standards. For  - 85 - example, the three mathematics papers administered in 1987 covered arithmetic, algebra and geometry only; no trigonometry or calculus was included. Overall, the quality of the MC.E questions is high, with a substantic& proportion of questions testing cognitive skills at levels higher than recall, and with extensive use of graphic stimulus materials (tables, graphs, phocographs, drawings, etc.). 36/ The explanation probably lies mainly in the shortage of science and mathematics teachers, and of science equipment and chemicals for practical work. The University has begun an in-service mathematics and science teachers' upgrading program to respond to this problem. Production of enough science and math teachers is constrained by lack of suitable candidates from the school system. 5.49 In addition, the number of secondary subjects needs to be reduced. Curricula require updating especially in mathematics, science and agriculture. Libraries need new books and student use of the libraries needs to be an integral part of the curriculum. HIGHER EDUCATION 5.50 This section on higher education covers primary and secondary teacher training only. It does not discuss the training facilities operated by government agencies, private sectarian and non-sectarial concerns. Nor are the non-teaching courses offered at the University of Malawi discussed. There are four University campuses: Chancellor College enrolling 1023 students (including education students) in 1986/87; Bunda College of Agriculture, enrolling 404 students; Kamuzu College of Nursing, enrolling 219 students; and Polytechnic, enrolling 531 students. Primary Teacher Training 5.51 Primary teacher training is carried out in eight teacher training institutions, which enrolled about 2,730 students in 1988189. When the new colleges have a full complement, capacity will be 3,320, and 1,600-1,700 teachers will be able to graduate each year. There are different two year programs of primary teacher training for JC and MCE graduates. In addition, special programs exist for unqualified teachers and for upgrading teachers. All those who pass the examination are guaranteed teaching jobs. As a result, dropout is minimal; over 90 percent of those who enter teacher training become teachers. 5.52 The major issues are: (a) the quality of training, relevance to the reality of the primary school system, and balance between pedagogical and subject content; and (b) whether the production of primary school teachers is sufficient to meet the demand over the next two decades, and if not, how to increase output without incurring significant capital expenditures? 5.53 Quality. There is little direct evidence regarding the quality of primary school teachers, in terms of their performance on the JC or MCE, or teacher training examinations. The curriculum neglects special 361 Somerset, Factors affecting performance, 1987.  - 86 - professional skills such as methods for teaching very large classes, remedial and multi-grade teaching, that teaching realities and new policies will increasingly require. However, MOEC plans to revise the PTTC syllabus and will address this problem. 5.54 Production of teachers has not kept pace with rising enrollments. The expected future annual trained teacher output of 1,700 will not be sufficient to match estimated future enrollment growth, and to allow the phasing out of untrained teachers, and the reduction of the pupil-teacher ratio from 67:1 to a targeted 55:1. By 1990 there will be a gap of approximately 4,000 trained teachers. In order to close that gap MOEC has several options: (a) establish more new colleges at high capital and recurrent costs and with the risk of excess capacity in future; (b) expand existing colleges; (c) convert existing underutilized training facilities in technical colleges for primary teacher training, and use faculty provided through assistance programs; or (d) provide less expensive in-service training which, given adequate inputs, can achieve results comparable with pre-service training. MOEC has opted for (d), which is the most flexible and least-cost option, and expansion of one existing college. An in-service training course is being prepared, which will combine distance methods and residential training during the school vacations, and allow immediate deployment of a large number of trainee teachers. Table 5.10 Enrollments in Teacher Training Colleges, Malawi, 1987/88 Examinations College Capacity Entered Passed Blantyre 540 260 253 Domasi 540 opened 1987/88 Lilongwe 540 244 240 Hzuzu 540 248 245 Montfort 180 80 80 St. Joseph 140 58 56 Karonga 300 opened 1987/88 Kasungu 540 opened 1988/89 Secondary Teacher Training 5.55 S4condary teacher training is provided by the University of Malawi faculty of education at Chancellor College (CC), whose 486 students constituted 45 percent of CC enrollment in 1986187. The following education programs are being conducted: Chancellor College: o Diploma in Education (3 year course after MCE) o Bachelor of Education (2 year course after Dip.Ed.)  - 87 - o Diploma in Primary Education (2-year course after MCE, 2 years primary teacher training and 3 years teaching) o University Certificate in Education (UCE) (1 year course after general teaching experience) o Master of Education (1 or 2 year course of B.Ed. or general degree and UCE and 2 years' teaching experience) The Polytechnic: o Bachelor of Science (2 year course after Diploma in Engineering or Diploma in Technical Teaching and teaching experience) 5.56 The Polytechnic program is being phased out, with no new students enrolling since 1981/82. Both UCE and M.Ed. programs are small, enrolling 13 and 11 students, respectively. The largest programs are the Dip.Ed. and B.Ed. programs, which together enrolled more than 100 students in 1986187. Table 5.11 Enrollments and Graduates of Secondary Teacher Training Programs Enrollments 1986/87 __G_ Graduates Program Yrl Yr2 Yr3 Yr4 Yr5 Total 1987 Dip.Ed./B.Ed. 119 54 52 73 56 354 120 UCE 22 0 0 0 0 22 20 M. Ed. 7 5 0 0 0 12 5 B.Sci. 0 0 0 14 11 25 11 Source: Education Statistics, Malawi 1987, Tables 84 and 85 5.57 The stock of secondary teachers in 1986/87 was 1,229; in the same year, 120 graduated from the University with either the Dip.Ed or B.Ed. In future years, the projections for graduates range from 60-90 graduates per year, a production level that only meets replacement needs, estimated at 7.5 percent. 371 Projections through 1991/92 indicate a shortfall of 33 secondary school teachers overall or, if non-Malawians are to be replaced, 133 teachers. Thus, production of secondary teachers from the University will meet virtually all forseeable demand for secondary school teachers, so long as the secondary system does not expand significantly. 5.58 Quality. Quality in higher education is rarely indicated by performance on achievement tests; instead, indicators include the quality of the faculty and the facilities, and the nature of the curriculum. Since most secondr.ry teacher trair.ing takes place within Chancellor College, the quality of the education faculty, the facilities for education and the education curriculum at Chancellor ought to be key indicators. The quality of the facilities and curriculum at Chancellor College are generally good; 37/ Courtney, 1986.  - 88- additional information is needed about the education faculty specifically. The facilities at Chancellor College are relatively new and are being maintained; both University administrators and students have expressed satisfaction with the quality of the buildings. There is evidence that library resources for the University as a whole are adequate. A recent study found that, of the 252,000 books and bound periodicals owned by the University library in 1985/86, 40 percent were outdated, for a useful holding of 151,200 books and bound periodicals. 38/ According to international standards, a student body of 2,200 would require a library having 160,600 volumes. The degree to which these volumes include books and journals of relevance to education students is not known, but a recent survey indicates general satisfaction with reading materials among education majors. 5.59 In 1987, the education faculty of Chancellor College comprised 14 professors, 9 Malawian and 5 non-Kalawian; of these, 29 percent held doctorates and 46 percent held master's degrees. The percentage of doctorates was the lowest of any faculty at Chancellor College. Table 5.12 Distribution of academic degrees for faculty at Chancellor College, 1986/87 Faculty Total 2 Masters X Doctorates Education 14 64 29 Humanities 33 46 42 Law 12 42 33 Science 46 39 52 Social Science 21 16 57 Source: Higher Education in Malawi, Unesco, 1987 SUMMARY OF MAIN RECOMMENDATIONS 5.60 This study is very supportive of the MOEC goals for the education sector, and the wide-ranging reform program that is underway, most especially the efforts to reduce dropout and repetition rates in primary schools, and emphasises that the highest priority for the primary school system is to improve retention and quality so that children develop good literacy and numeracy skills. Good access to text and exercise books and other teaching materials seems to be the most cost-effective way of improving educational outcomes. The quality of teaching matters, and MOEC's plans for providing better inspection and more in-service teacher training should be implemented without delay. 5.61 It is recommended that MOEC reconsider changing the timing of the school year to avoid the wettest months, as this would (i) reduce disruption of learning by heavy rain, (ii) leave children fre; to help on family farms during the peak agricultural period, (iii) miv:imize the part of the school year that coincides with the pre-harvest 'hunbry season', and (iv) make it easier for parents to buy uniforms and pay fees by starting 38/ UNESCO, Higher Education in Malawi apparently miscalculates this as 101,000.  - 89 - the school year at harvest time, when cash becomes available in rural households. 5.62 The revision of the curriculum and teachers' guides provides a good opportunity to introduce innovative teaching methods to improve the quality of teaching and learning, and increase the effectiveness of schools in developing in pupils the skills and abilities that will help them cope well with a changing world. Greater attention needs to given to developing reasoning and interpretation skills, and to applications of mathematics and science. 5.63 Restricted access to secondary education and to formal-sector jobs which require high educational attainment have caused schools to place great emphasis on preparing pupils to pass examinations, rather than on equipping them with broad knowledge and skills which would be useful in later life. Many of those who are not selected for secondary schools see themselves as failures, with poor prospects. There is a need to counter this, to try and ensure that the majority of pupils who end their education in primary school have a positive self-image, and good literacy and numeracy that will be a firm foundation for learning new skills in later life, whether as farmers, traders, artisans or in other occupations. 5.64 At the secondary level, the low enrollment ratio and under- utilization of teachers and facilities justify expanding access and improving utilization through doubling shifting. This will require supplementing some facilities but is much cheaper than building new schools. The acute resource constraint and urgency of other educational investments prevents Government from being able to construct and maintain additional boarding facilities, which must be left to communities. 5.65 The Malawi College of Distance Education is showing good results from its efforts to improve quality, however, it is under-resourced and tries to reach too many target groups through too many modes of instruction. MCDE should concentrate its efforts and resources where it is most successful --that is, JC courses offered at study centers. The MOEC should maintain or increase the resources at MCDE's disposal, and give MCDE greater autonomy and control over resources and staffing decisions. 5.66 Primary teacher training. This report supports MOEC's decision to address the gap between the required increase in the primary level teaching force and the output capacity of the training colleges mainly through in- service training which, given adequate inputs, can achieve results comparable with pre-service training and is the most flexible and least- cost option and allows immediate deployment of trainee teachers. It is also recommended that the primary teaching curriculum include special professional skills such as methods for teaching very large classes, remedial and multi-grade teaching, that teaching realities and new policies will increasingly require. 5.67 Adult Literacy. The National Adult Literacy Program being implemented by the Ministry of Conuvnity Services is an important complement to the formal education system and should be allocated adequate resources so that there are enough reading materials.  - 90 - CHAPTER SIX VOCATIONALITECHNICAL EDUCATION AND TRAINING OVERVIEW - KEY ISSUES 6.01 This chapter provides a strategic overview of vocational and technical education and training in Malawi as part of a broader consideration of issues and directions in human resource development. It does not give detailed prescriptions for policy and investment action, but rather outlines, in broad terms, the strengths of the sub-sector and the strategic options that might best capitalize on these strengths. 6.02 Malawi has developed a relatively small, flexible, and good equality manpower training system. This has been a remarkable schievement. This system has enabled the country to meet demands of the modern sector of the economy for skilled manpower except for a very few highly skilled professional occupations. At the same time it has allowed Malawi to replace most expatriate workers. There are mechanisms to facilitate flexible, short-term responses to labor market conditions. Wisely, long-term manpower forecasting and heavily centralized planning have been avoided. 6.03 The policy goal for manpower training and development in Malawi in the near future should be to maintain and increase this capacity to respond to labor market demand and needs for upgrading the skills of the work force. If used creatively and flexibly, existing training capacity, as strengthened through investments already underway, should be adequate for the next decade. Further investment in new training facilities should not be undertaken unless there are dramatic changes in the demand for labor. The emphasis should not be on expansion, but on improvement. The current capability of the training system to adjust flexibly at the margin should be enhanced through modifications to current policies and institutional arrangements. Labor market information systems should be improved, and employer participation in training policy, system governance, and finance should be strengthened in order to increase the efficiency of existing training investment. Highly centralized manpower forecasting and allocation should be avoided. 6.04 The demand for skilled workers over the next decade will be shaped by nine factors: (a) acute population pressures (population will double from 8 million to 16 million in less than 20 years); (b) a very small modern wage sector (more than 80 percent of employment is now in subsistence farming); (c) a very small, relative and absolute share of wage employment in skilled categories (about 1/5 of total paid employment -- 80,000 positions -- might be classified as skilled); (d) modest reliance on expatriate workers (97 percent of paid positions are held by Malawi citizens; expatriates are concentrated in professional and senior managerial positions in the private sector); (e) significant wage differentials between private sector, parastatal and government employment, with steady loss of professional and technical personnel from the government; (f) low rates of economic growth due to deteriorating terms of trade and high transportation costs resulting from the closure of the Beira rail line and other factors; (g) the incidence of illness and death caused by HIV infection and AIDS among skilled workers; (h) low levels of productivity in subsistence agriculture, with negative effects on rural  - 91 - incomes, health and nutritional status; (i) little internal competition among major manufacturing firms; and (j) slow growth in paid employment, and the beginnings of "grade creep' as employers can increasingly require more advanced education and training credentials -- with the potential for an increase in educated unemployment. The net effect of these factors will be slow growth in modern sector employment and small absolute demand for trained manpower, and difficulty in absorbing an increasingly large group of job seekers in rural employment. 6.05 The training needs in the modern sector for the next decade will center on: (a) upgrading the skills of senior and middle management to improve the efficiency of government and the private sector; (b) training relatively small numbers of highly skilled professional personnel who are critical to the economv, including medical doctors and other senior health professionals, accountants, professional engineers and engineering technicians: and (c) localizing posts that continue to be filled by expatriates. At the same time an oversupply of subprofessional personnel in health and agriculture will emerge over the period unless training resources are re-allocated. In addition, very high priority needs to be given to training primary and secondary teachers in order to staff the planned expansion of schooling. 6.06 The new Malawi Institute of Management will provide professional development training to government and private sector managerial staff. The critical shortage of accountants and accounting technicians will be met partly by graduates of the College of Accountancy. Enrollme:.L is constrained by lack of dormitory space and the number of accountants produced by the College is severely limited by the length of time (8 years) required to meet UK accountancy standards. Unless training capacity is increased and/or a shorter accountancy qualification is introduced, Malawi will be compelled to continue to rely on expatriate accountants well into the next century. 6.07 The supply of professional engineers under current enrollment patterns in the Polytechnic would appear to meet at least two-thirds of the demand under various plausible as3umptions about future economic growth. The supply of engineering technicians appears adequate; the main issue will be adjusting the mix of specializations to meet evolving demand. Thus these needs can be met largely through the Polytechnic, particularly if effective linkages with employers can be forged to ensure appropriate short-term adjustments. THE TRAINING SYSTEM The Formal Vocational and Technical Education System 6.08 Malawi has developed a small vocational and technical education system in keeping with low absolute levels of demand for skilled workers. At the apex is the University of Malawi, comprised of a College of Agriculture, a Polytechnic, a Nursing College, and Chancellor's College (which provides arts and sciences education). The second tier consists of specialized non-degree training institutions: the Malawi College of Accountancy, five technical colleges, the Natural Resources College (which trains technical agricultural staff primarily for government employ.aent), the Lilongwe School of Health Sciences, 8 mission nursing schools, and a St&ff Training College that provides entry-level training and in-service  - 92 - upgrading for low and middle-level government workers. A third tier, which in effect provides "second chance' opportunities for school leavers, includes the two-year rural .kills training programs of the Malawi Young Pioneers, and vocational skills training programs of various government ministries. 6.09 The country has also developed a set of institutions designed to create employment in, and improve the productivity of, small-scale and medium scale industries and the informal sector. The Small Enterprise Development Organization of Malawi (SEDOM) provides concessionery finance and technical assistance to entrepreneurs at the smalljr end of the sector; the Investment and Development Fund (INDEFUND) provides higher levels of finance. The Malawi Union of Savings and Credit Cooperatives (MUSCCO) also provides credit. The Development of Malawian Traders Trust (DEMATT) provides technical assistance and in-service training to entrepreneurs in trade. The Malawi Entrepreneurship Development Institute (MEDI) provides advanced crafts and business training, together with start-up tools, capital and continuing technical assistance. The Rural Trade School (RTS) trains builders and metal fabricators, and places them in rural businesses with tools and a modest level of technical advice. (More details are to be found in Annex C of Chapter Seven.) Support for Human Resources Development Projects 6.10 Civil Service Employment. In response to a 1985 review of civil service employment, the government is moving to strengthen the Department of Personnel Management and Training to improve manpower planning and the coordination of both internal in-service training and external training across government. The Malawi Institute of Management, co-financed by the GOM, the UNDP and IDA, is being created. MIM will administer and coordinate government in-service training for upper-level and senior management. 6.11 USAID is supporting institutional development for a range of training institutions (including the Polytechnic) through the Human Resources Institutional Development project (HRID), as well as the SIS sector through the Rural Enterprises and Agro-business Development Institutions project (READI). The HRID project specifically addresses the need to strengthen the capacity of the training system to identify short-term manpower needs and to provide high quality training programs to meet them. This eight-year project provides US $18 million for technical assistance, fellowships and in-country training of frculty, trainers and planners/managers, and purchase of training equipment and materials. It focuses on institutions that provide post-secondary and non-degree training for professional, technical and managerial personnel in public and private sector employment. The project emphasizes in-service upgrading of mid- and upper-level technical and managerial personnel. Additional significant components will help develop the set of institutions that support the development of small scale industries and informal sector employment, and expand access of women to higher level training. A smaller component will improve manpower planning and management capacity; USAID notes that the principle problem in estimating skill demand is lack of resources for data organization and analysis 39/. The HRID project has a particularly 391 USAID, Human Resources and Institutional Development Project Paper, Lilongwe, July, 1987.  - 93 - appropriate institutional model. It is managed by an inter-ministerial Project Committee, which provides criterion-based funding in support of proposals received from training institutions and agencies. This model has the clear potential to provide support for the kinds of flexible adaptation arid quality improvement that the training system needs. 6.12 The training system has evolved with relatively little centralized manpower planning. The institutional structure has emphasized incremental adjustments to perceived labor market demand. Enrollments in technical colleges are controlled by the Ministry of Labor in line with available apprenticeship opportunities; the result has been declining enrollments as labor markets have contracted. At the advice of government, Chancellor's College, the Polytechnic and the Natural Resources College have opened and closed courses, and controlled enrollments, in line with employment possibilities. 6.13 The technical colleges and the Polytechnic combine institution-based training with formal apprenticeships of two or three years, the former leading to certification as skilled craftsmen, the latter as technicians. The Ministry of Education and Culture and the Ministry of Labor jointly administer the technical colleges. The former operates the schools and provides operating budgets and, through ODA grants, capital investments. The latter controls enrollments and finances, manages the apprenticeship component of training, and provides grants-in-aid to the colleges. With one year of intensive college workshop training (80-90 percent practical), followed by formal apprenticeship, the technical colleges operate very much like non-formal training centers. No degrees are given. National competency-based trades tests provide certification. The Apprenticeship Program 6.14 The apprenticeship program is financed in part by the Industrial Training Fund (ITF) established in 1973. It imposes assessments on both government and private employers in order to finance reimbursement of apprentice wages, grants-in-aid to the colleges and Polytechnic, and the operating costs of the Fund. The assessments are based on the number of persons employed in skilled occupations. The Fund is linked to industry and employees td-ough a tri-partite advisory council. 6.15 In comparison with most systems of this sort, the ITF and apprenticeship mechanisms are notable for adjusting both training volume and costs as employment demand varies. As shown in Table 6.1, the size of the ITF levy, expenditures and enrollments have fallen as economic growth slowed in the 1980s. 6.16 About half of ITF's budget is used to pay the wages of apprentices completing two or three year practicum following their training in the colleges. Thus, the impact of declining enrollments on costs works its way through the system over a three year period. The decline in expenditures from 1982/83 to 1985/86 reflects a steady decrease in enrollments. A similar decline is noted in revenues raised after 1981/82; the data further indicate that in recent years the fund has operated with a 10-15 percent margin and has, with the exception of 1981/82, met its costs. It thus appears that the ITF and apprenticeship mechanisms do provide flexibility in the face of fluctuating labor market demand. Further analysis along these lines is needed, particularly of the actual numbers of apprentices supported at different stages in each year in order to identify  - 94 - the unit costs of apprenticeship. Additional analysis of the in-college costs, combined with this data, would yield reliable estimates of unit costs for the complete training course. Such studies have been initiated with the Ministry of Labor and the Ministry of Education and Culture. Table 6.1 Industrial Training Fund Revenues and Expenditures and Technical College Enrollments, 1980/81-1985/86 (1981 Constant Kwacha) 1980/81 1981/82 1982/83 1983(84 1984/85 1985/86 ITF Revenues /a 457,460 518,986 607,267 587,129 534,905 472,597 ITF Expenditures 410,568 554,633 494,087 457,139 480,839 430,611 Surplus 46,892 (35,647) 113,180 129,990 54,066 41,966 Technical College 637 619 514 522 500 560 Enrollments /b /a Source: Ministry of Labor (1988) lb Source: Education Statistics Malawi 1986. Ministry of Education, December, 1986. The figures include both full time enrollees and apprentices on block release. Trades Testin8 6.17 Trades testing began on a national basis in 1956, prior to the introduction of the apprenticeship scheme. The testing service, initially designed to provide certification to artisans who had acquired skills on the job, now assesses more than 4,000 candidates annually. These include all apprentices as well as a substantial number of persons receiving training on the job. The pass rate is approximately 60 percent. The main testing center is in Blantyre. A satellite center is located on the grounds of the Lilongwe Technical College. The main center maintains records of all tested craftsmen, and issues renewable certificates to individuals. Employers can and do check with the center to verify employees' credentials. 6.18 Both written and performance tests are administered, with the latter involving completion of projects and products that are judged against standard criteria derived from a curriculum-based test syllabus. Test officers hold at least a Grade I skills certificate and some have had specialized training funded by the ILO. The Blantyre Center has an annual budget of about MK280,000, most of which is provided as a direct subsidy by the Ministry of Labor. Testing fees range from MK3 to MK7 per individual, depending on the level of the test administered. The testing operation is very professional and well-managed. It has served as a model for skills testing officials from other developing countries. However, the centers are short-staffed -- there are 19 officers, 2 or 3 of whom are in managerial positions. This causes long waiting times for tests in some trades, and makes it necessary for some staff to test in areas in which  - 95 - they are not fully trained or experienced. Staff shortages and higher priority claims on Ministry transport make it difficult for Ministry training officials to follow-up trainees and apprentices in order to get the feedback from them and their employers that is vital to being able to ensure that the needs of industry are well met. Recently-recruited testers lack training in design and administration of tests and there is a need to repeat the training workshops in trades testing techniques which were last held in 1986/87. 40/ Employer Training 6.19 Enterprises appear to provide little formal training, emphasizing on-the-job training instead. Economic constraints have led to a cut-back in training investment in recent years, including the closure of training departments in several firms. Employers instead appear to rely heavily on the publicly financed or subsidized training institutions. Enterprise financing is provided through the ITF and through some contract training and tuition payments for managerial and professional training at the Polytechnic and the College of Accountancy. The latter is notable for a very high level of cost-recovery (43 percent of recurrent costs) through fees. Labor Market Information and Placement Mechanisms 6.20 There are three mechanisuis. The government operates 24 district level employment exchanges for unskilled and semi-skilled workers, principally serving the estate sector. An Appointment Bureau provides placement and referral services nation-wide for all skilled workers, defined as those holding the lower secondary certificate (JCE) and above, including trades certificates. Both public and private employers advertise directly in the national newspaper. Many employers hire at the factory gate. The relative share of each mechanism is unknown. TRAINING GOALS AND OBJECTIVES: FEASIBILITY AND CONSTRAINTS 6.21 The economic slow down has reduced employment demand in the public and private sectors. Because the training system responds flexibly to labor market conditions, the capacity of the training system is presently under-utilized. With a few exceptions, therefore, the system is likely to be able to supply the country's needs for trained manpower, for the balance of the century, if provided with modest increases in recurrent budgets and modest investments to replace equipment. Demand and Supply Projections 6.22 Demand and supply projections for selected critical skills are shown in Table 6.2. These estimates are based on the 1987 Comprehensive Human Resources Study, conducted for the Government by the ILO and on USAID 40/ There is an ILO project in the pipeline to strengthen trades testing and industrial training in Malawi. Details are not known.  - 96 - surveys 41/. The projections for industrial employment of engineers, technicians, and skilled workers have been developed through manpower requirement forecasts, and over-optimistically assume annual economic growth of 4.0 - 4.5 percent for the period 1986-1996. In addition, the estimates assume that demand for manpower will grow at roughly the same rate as the economy. They make no allowances for shifts in capital-labor ratios, or for technological changes. Thus these figures probably overestimate demand. Project.ons for the remaining occupations are based on a baseline establishment survey and government development plans. All labor market projections assume complete localization of posts. In a number of critical professions (physicians, professional engineers, and especially accountants) these replacements constitute a large share of projected need -- see Annex I). While the source data are unclear, the projections apparently also include estimates of wastage from the current stock of employees. 6.23 The small absolute size of demand for professional skills reflects the small size of modern sector employment. Malawi has the capacity to meet most manpower needs over the next decade through existing institutions. Expansion of training capacity will not be needed. For occupations with small shortages, training should be done either abroad or on through temporary arrangements using the framework of existing institutions. The need for approximately 16 quantity surveyors, for example, could be met by establishing a temporary course, staffed by expatriates and Malawians, at the Polytechnic. The university has shown the ability to develop and offer such courses, and to close them down when demand is met. Quantitative needs for more senior managers can be addressed through university training, perhaps extended to include an Master of Business Administration course, and the strong program of continuing in-service upgrading promised by the Malawi Institute of Management. The potential for emergence of significant surpluses of sub-professional personnel exists for nurses; medical, pharmaceutical and veterir.ary assistants; and for agricultural extension staff. In these cases, training resources may need to be re-directed or reduced. Although expansioz is not needed, attention to further developing the capacity of existing itstitutions to identify changing training requirements, and to respond flexibly and quickly, will be important. 6.24 Projected demand for craftsmen is probably high, and can be met by the technical college system at current enrollment levels through the combination of journeymen (who have completed the apprenticeship) and serving apprentices. The advantages of relatively short in-center training combined with apprenticeship in meeting employment demand are apparent. Actual demand should be monitored closely to avoid the emergence of excess supplies, and to identify needed changes in the types of courses offered, permitting adjustment towards new specialties (such as electronics). The 41/ See Annex I for detailed calculations. The data have been 1rawn from: Government of Malawi, Comprehensive Human Resources Survey, Office cf the President and Cabinet, Department of Personnel Management and Training, 1988 (Discussion Draft); and Rudi Klauss and Earl Yates, Survey of Human Resources and Institutional Development, Lilongwe, USAID, December 1986.  - 97 - existing mechanisms for adjusting enrollments appear capable of doing this if labor market information services are strengthened. Formal training is complemented by informal sector apprenticeship, training on the job, and by evening classes at the Polytechnic. 6.25 The pace at which the demand for professional engineers can be met through the Polytechnic depends in part on the pace of localization. If the numbers of expatriate engineers employed in Malawi are reduced progressively, the supply of Malawian engineers may satisfy demand -- including localization -- by the mid-1990s. The supply of engineering technicians will be adequate in the near term, and may exceed demand in later years. Here again, careful monitoring of short-term employment demand is important. 6.26 The most numerically significant skills gap is for accountants. As currently configured, the College of Accountancy will not come close to meeting the demand for professional accountants, even at the lowest level of projection. Steps will need to be taken to increase the supply of (or reduce the demand for) accountants. The former can come through expansion of dormitory facilities and, perhaps, changes in the very high qualification levels that are being maintained. On the demand side, a careful look at the division of work between professional accountants and accounting technicians may permit greater use of the latter, and less of the former. External training of accountants, however, is likely to be needed, roughly on the order of magnitude irdicated in Table 6.2. Even then, some reliance on expatriates will be required. 6.27 The data on the projected demand for senior and middle level administrative and managerial personnel do not match well with conclusions of both the ILO and USAID surveys, both of which give highest priority to in-service upgrading of the current workforce. It is reasonable. therefore, to assume that the apparent gap between the supply of degree and diploma holders from the University and the projected demand is less than would appear from Table 6.2. In any case, the development of senior managerial personnel results from the combination of entry level staff with good quality college training and effective career development programs within organizations. The need for the latter has been recognized in the analysis that underlies planned civil service reforms, as well as in the establishment of the Malawi Institute of Management and the Human Resources Institutional Development Project. 6.28 Physicians are in short supply as well, and expatriates fill two-thirds of established posts. A medical school has been proposed because of the difficulty of getting Malawian doctors trained abroad to return home, the high foreign exchange costs of physician training abroad, and the difficulty of getting places in African medical schools. These are compelling reasons, but a full medical school does not seem affordable at present. The annual running costs have been estimated at MXl2 million in 1988 prices, which is equivalent to the entire recurrent Health budget. It is recommended that the medical school be developed in a phased manner, as finances permit. This year, Malawian doctors who have received formal academic instruction in the UK, will return to Malawi for their practical year, and earn a medical degree from the tTniversity of Malawi. In future years, an increasing part of medical training will be done in Malawi, and  - 98 - less abroad, until finally Halawi's economic and budgetary situation permits it to undertake the cost of full medical school. Table 6.2 Prjeocted Manpow*r Demand and Supply In Priority Skilla, 1901 and 1096 Demand Supply Estimated Ext rnal Training 1991 1998 Nesd (1991) Training Institution High Low H"Ih Low 1991 1"98 High Low Sourcs Agronomist & 46 41 201 87 Boo Bunda College of Related Sciences Agriculture. Veterinarions 14 6 28 10 14 6 Must be trained abroad. V-t. Assistsnta SO 21 140 46 200 450 Natural Rssourcss College. Extension Staff 856 162 834 868 750 1500 Natural Resources Colleg. Medical Doctora 182 18O 205 10 as 98 91 External; Medical School Proposed. Clinical Officers no no no no 170 290 Lilongws School of Health Scionces. Medical Assistant, 94 01 218 211 560 Lilongs. School of HeIth Sciences. Dentists 12 11 16 11 12 11 External. Dental Assistants 6 C 12 0o 50 1oo Lilongwe School of Health Sciences. Registered Nurses 70 56 las 106 Kamuzu and Lilongue Colleges of Nursi rq. Reg. Miwives 28 26 S0 44 Zobs liege of Nur Enrol!ed Nursos 172 126 a82 272 8 Miss.on Nursing Schools SUB-TOTALS 266 206 567 422 8400 5660 train 900 total. Pharmacist 74 74 90 90 9 6S 65 External; Nine returned 1989-91. Phorm.Assistante 5 9 21 11 40 90 Lilongwe School of H 1ith Scionces. Prof. Engineers 178 147 847 280 121 226 67 26 Polytechnic plus external training. EngJTschnicisns 245 187 560 892 2ss 64 Polytechnic. Craftsmen U487 2501 6665 5291 1260 2600 Journ-ymen} Apprenticos} curront Technical College cnroll ments. Accountants 429 882 802 511 eS 400 800 Professional (includes 17 abroad) 270 Technician - MCOA. Architects/Plannere 25 16 49 88 48 Now training abroad. Quantity Surveyors 1S 16 24 28 External. Sr.Aduinistrative A Managerial 1786 1805 8128 1911 800 1600 University of Malawi. Mid-level Admn. & Managerial 571 Se6 1287 671 5m00 10000. Secondary Schools. 6.29 It is Ldportant to get a firm commitment from other countries in the region to send medical students to Malawi. The present demand for physicians is substantial, but is a fairly temporary phenomenon.  - 99 - Localization and expansion will require the training of approximately 200 physicians by 1996. With a total of 175 medical posts, and the current annual civil service turtover rate of approximately 5 percent, Malawi's replacement needs would be about 10 physicians annually. Even if Malawi's total number of posts for doctors could be significantly increased, a me.ical school of economically viable size would need to train non- Malawians as well. 6.30 The external training needs noted in Talle 6.2 can be met with the level of external training awards typical of recent years. An average of about 600 were made each year in the period 1983-86 42;. The EEC and ODA provide fellowships for external training; the EEC also supports government in-service training. The ODA has financed rehabilitation and equipment for two government technical colleges. STRATEGIES FOR ACHIEVING TRAINING GOALS 6.31 The institutional framework for providing training includes many of the characteristics necessary for flexible short-term adjustment to changing labor market demand: strong testing and certification, enrollment controls, and financing based upon a training levy at least potentially linked to employment demand. Overly centralized management and control has been avoided. The government is now considering recommendations for a much stronger centralized manpower planning and allocation system. These recommendations should not be accepted, as they would introduce a level of rigidity that would undermine the capability of the system to make rapid marginal adjustments. But while the basic framework for training provision is sound, a number of policies to strengthen the system are indicated. The broad goals of these policy adjustments would be (1) to maintain a degree of decentralization in the system; (2) to improve the information base on which adjustment decisions are made; (3) to increase employer participation in the training system; and (4) to increase cost recovery through expanded employer financing of training and the possible introduction of training fees in selected institutions. Decentralization 6.32 An integrated national manpower planning and allocation system that cuts across both public and private sectors would reduce much of the flexibility now found in a system that separates civil service from private sector end parastatal employment. Recommendations from the Civil Service Review Commission for stronger government manpower monitoring, planning and development are sensible. However, monitoring and coordination of private sector employment and training should be maintained as a separate activity. Information from the two systems should, of course, be amalgamated periodically for overall monitoring and policy review purposes. The goal 42/ Rudi Klauss and Earl Yates, Survey of Human Resources and Institutional Development, Lilongwe, USAID, December, 1986.  - 100 - should be to let market forces determine manpower supply and allocation in the private sector, while government budgetary and establishment policy should determine manpower needs for government and para-statal organizations. Labor Market Information 6.33 Controls on enrollments in training programs depend on timely and accurate information on employment. The current Ministry of Labor exchange system has the potential to provide this information on private sector employment. However, the system is limited by the voluntary nature of registration of vacancies and hires, and by insufficient staff to aggregate, analyze and report the data. Requiring that private sector and parastatal organizations register all vacancies and give notice of all hires (with appropriate information on qualifications) would provide a comprehensive picture of the status of demand and employment; the current monthly reporting system would provide frequent updates. The Appointment Bureau would have to be expanded, and provided with additional staff; the use of micro-computers would greatly enhance efficiency. Employers could continue to recruit and hire outside the system if they so desired. A similar arrangement for government employment is well within the capabilities of the (strengthened) Department of Personnel Management and Training, as augmented by the proposed system of ministry manpower development officers. Enterprise Financing and Involvement 6.34 Employers now provide substantial contributions to the cost of training through the ITF (MK1,000,000 annually). Employers also contribute in the form of fees for professional training (notably to the College of Accountancy) and, to a lesser extent, the Polytechnic. 6.35 While employer participation in est., _shing training policy is strong on paper, linkages need to be strengthened. The Tri-Partite Apprenticeship Board has not been meeting due to staff shortages in the Ministry of Labor. Existing staff have their hands full with managing the ITF, and do not have time or transport '.o make visits to apprentices' places of employment. The Board is a very important channel of communication between the MOL and employers, and should receive high priority. Employer linkages to the Polytechnic appear weak, particularly as regards course content and size. The Polytechnic would like to revive its industry liaison committee. Participation in the technical colleges is strengthened through the Apprenticeship scheme; this may also evolve as the technician apprentice system develops. 6.36 Consideration should be given to improving collection, and perhaps increasing the size of the training levy to finance expansion of the labor market information system and to provide the resources necessary to support re-invigoration and expansion of the Apprenticeship Board functions. The Board should meet at least twice annually, to review carefully prepared documentation on the size and nature of labor market demand, the size, content and quality of training output, and the use of the ITF. A decision to strengthen the link with employers would have  -101 - implications for the staffing and organizational role of this section of the MOL. 6.37 Finally, consideration should be given to the gradual introduction of student fees for the technical colleges, given their relatively high costs and the potential for substantial earnings in paid employment. A student scholarship and loan fund could be established from the ITF to ensure equitable access for poorer students. The administration of such a fund appears well within the competence of the MOL apprenticeship scheme (with staff expansion). Autonomous Training Agency 6.38 International experience suggests that vocational and technical education and training benefits substantially from close linkages with employers, strong labor market information, high levels of autonomy to make of rapid marginal adjustments, and stable financing. The institutional model most often effective in this respect is the quasi-autonomous training agency, usually linked to a Labor Ministry. 6.39 Such an agency could be formed from the present nucleus of the Industrial Training Fund, National Apprenticeship Scheme, and Labor Exchange services. Guided by a strengthened tri-partite national governing board representing government, the parastatal and private sectors, and the SIS financing institutions, the agency could be funded by the ITF, although government might wish to provide a portion of the budget to maintain influence over agency operations. The agency could finance and operate the technical colleges, MEDI, and the Rural Trade School, as well as the labor exchange system and labor market information service for private and parastatal employment. The Polytechnic would remain part of the university, although the Agency would be able to establish close coordination through membership of the Polytechnic Principal on the Governing Board, and through Agency financing for technician apprenticeships and selected grants-in-aid to facilitate the establishment and closing of specialized courses. The principal advantages of such an entity would be to provide a focal point for broadened employer participation in the financing and operation of both labor market mechanisms and skills training. A single authority would be able to take better advantage of existing mechanisms for adjustment of training resources to meet changing demand. 6.40 The formation of such an agency would require some changes in the organizational structure of the MOL. This would require considerable internal discussion to clarify the functions, responsibilities, lines of reporting, and control over resources that the agency would have. The present problems and weaknesses of the units that would be merged would need to be addressed, so that a strong co-ordinating agency could be developed. 6.41 A strong training agency could play an important role in linking policies for technical and vocational education and training with those for other human resource sectors. For example, it will be important to assess the implications for enrollments in other post-secondary education and training institutions of the training needs for teachers. Revised  - 102 - population data and estimates of net school enrollment ratios imply a need to train large numbers of primary school teachers. This will draw heavily on the output of secondary schools and may require re-allocations of other training resources. For example, consideration could be given to using the apparent excess capacity of the Natural Resources College on a temporary basis to expand teacher training capacity. Such alternatives intensify the desirability of flexible management of the vocational training system. Notes to Table 6.2: 1. Data on 1986 actual employment, and projections for 1991 and 1996, have been taken from: Government of Malawi. Comprehensive Human Resources Survey. Office of the Presidentf and Cabinet, Department of Personnel Management and Training, 1988 (Discussion Draft). 2. Data on manpower supply have been taken from the same source, as augmented by information from: Rudi Klauss and Earl Yates. Survey of Human Resources and Institutional Development. Lilongwe: USAID, December, 1986, and from Ministry of Education statistics. 3. The projection figures are fr total jobs. Skill gaps have been calculated by subtracting current Malawi employment from projections, yielding a figure that includes full replacement of expatriates. 4. Supply figures are based on reported current output or capacity. The source of the data is shown for each institution. 5. All figures are provisional, and subject to considerable revision. They should be taken only as indicators of the relative order of magnitude of demand and supply for skills. For other assumptions, see the text of the report.  km Table 1 MMMI: Proetd ed MMW Oan d Mi SuWiy InPr lrty SkiIIs Arm. 1991 wrd 1B I9 Actual Prolections Skll Sqs GItty(oalat wo) Total Mal 1991i t 191 l9I Skill beSa Posts Vae. Expat Er. High tao N101 teo HIf lat N 1 too 1991 191 letitutImn (Save f Irfermtlon) *.. .. 0..._......_ .. _ ....._ .. ___. ................................ _ ..s.8 ....S.....a.......a......... _ ___ ..........3 ..............__. Aqansts & 364 24 1 333 373 374 534 420 4S 41 201 81 313 Wide Colep f AwIcultue (110) Related SclUe VIlerlw low 54 12 4 35 52 44 6S 48 14 6 2 10 ORte trainedaroad. Nud for itlaial vsW interIn rIww be at b Incresin ratlo of asistlds to pruefmlwmls (OtL) vet. Assistants 250 9 0 241 301 2S2 3n 21 5 0 21 140 46 M0 450 Natwal amims Collep (UIsI) Ixtenslan Staff 1419 40 1 143Q 1193 1WO 2212 1901 35S 162 34 353 150 150 Natwual ar o Collep (USAIS) Medical Doctors 161 8 114 45 In 115 250 1iS 132 130 2M5 130 39 ELxtorml. lblcal Sdrl frgtoad Clinical Qlcuas Na am m As m no n Nm tm m nm 110 290 Lilag ISuloo d Wgiui Selma (As Plv - 110) Md Assistnts; 416 23 3 395 484 Mi 1)3 901 94 91 213 211 550 LiIapsSdewo atld ith Sclrems(lLO) Denolsts 17 3 10 4 t i 22 IS 12 11 1I 11 Exturml Dtnal Assistuts 24 0 1 23 29 28 35 33 0 5 12 10 50 Q10 til e Sdol dof I ithia mbs(U tAIO) Relstered lilues 235 9 19 207 217 212 342 311 10 56 135 W8 Kmmad tII&" Cal tlap d off i re ReN Idlvaes 128 33 5 U III 113 138 132 23 25 50 44 ZedaCollap of lilw g. Irrolled Osses 12 16 9 157 929 t93 1139 ION 112 12B 382 272 I minaon mrsinl ecmis train Odof total _ Sdthotals 1143 55 33 1052 1311 1258 1619 1474 265 206 561 422 3400 5660 (lt) Plhiacists 25 0 7 15 92 92 lOS 199 74 74 0 90 9 , iderni lI. glns nS bred to rettin 191901 (IU0). Phars Assistrts 41 3 0 3t 43 41 59 49 5 9 21 11 40 8 til SdS d dollfithl Sclhsm (USAIO) aot EgrIgneers 391 65 15 256 434 403 603 495 118 147 347 239 121 225 Polidnic plu sxterunl tranilig In Wclallzntlene Iul Polvtednic outpu stlnted at 25; 21 nm brOed (110) fngin lecmnicians 819 109 35 675 920 9B2 1235 1067 245 IJ7 560 S 32 29 86 Poirtegtnic (ILO) Cuaftsae 10307 166 244 9691 13384 12391 19552 117el 347 250D e555 S2J1 1250 250D .weme baed on cmvrsisal tmts In Taelc j ColleOW 2se0 50D bPratic Acctntantms 691 46 203 442 J71 114 1244 953 429 332 m2 Sll U Prfdelel (Inshuls of rd) (Ito) 270 lednicim Maiil Col lap d Acntncy (ItO) Aechltects/Plamet 85 a 12 65 90 83 114 99 25 1I 49 33 43 No traIning brod IO11) eaaniit Saaveyors 30 a 11 11 21 21 35 34 16 16 24 23 lIwary Polytedvic oswss exta etmle sl Adilnlstrative 2195 83 852 1260 29Y 2565 4388 3111. 113S 1305 3128 1911 Q 1B0M University of alaw: MA. IeSe, BS hi AiBin, I Massages lal Olpmalotes In dain.. &asiness. emagint - fstlntas btasd m current output. Miii level Ain & 2362 131 76 2155 21;6 2141 34n 2126 571 586 12G1 5s1 Sacmduy Sd.0ols sajblotais 456 214 928 3415 51b2 5316 1810 5 1 2307 1891 4395 2482 800 168i0 . . . . . . . . . . . . . . .  - 104 - CAPTER SEVER EMPLOYMENT AND LABOR MARKETS INTRODUCTION 7.01 Between 1990 and 2020, Malawi's labor force is expected to grow from 3.2 million to almost 9 million. Currently, only a small proportion of the labor force is employed in the formal sector, and projections indicate that this sector will not be able to absorb a major portion of the expected increase over the next three decades. The vast majority of the Malawian work force are smallholder farmers, but there are already signs that agriculture cannot absorb the growing number of entrants into the labor market. The informal sectcr has limited potential as a primary source of income for the many labor force entrants who will be unable to find jobs in the formal sector or who will be unable to make a living on the land. Employment opportunities in other countries, which have been an important source of income for many Malawian families, have declined sharply. This chapter reviews the empljyment challenge facing Malawi, and offers policy options to meet those challenges. Five key labor market issues are discussed: urbanization, unemployment, skilled labor supply and localization, the position of women, and wage policy. POPULATION GROWTH, PARTICIPATION RATES AND THE SIZE OF THE LABOR FORCE 7.02 Malawi's population has been growing at 3.6 percent a year for the past 10 years, and as a result, its working-age population has increased rapidly. Between 1966 and 1977, the working-age population, defined as persons aged 10-64, grew from 2.06 million to 2.66 million, an average annual increase of about 2.6 percent. Over the next decade, it increased at an annual rate of 6.3 percent, reaching an estimated 4.86 million in 1987. The working-age population is projected to grow to 5.46 million in 1990, 7.61 million in 2000, 10.75 million in 2010, and 14.51 million in 2020 (see Table 7.1) 42/. Thus, despite an expected decline in the population growth rate, the working-age population will increase by 3.4 percent annually during the 1990s, 3.5 percent a year during the first decade of the twenty-first century, and 3.0 percent annually between 2010 and 2020. 42/ These calculations are based upon the World Bank's population projections using the 1987 census data as a base. The projection model assumes a gradual decrease in both fertility and mortality rates, and zero net migration, such that the population growth rate increases slightly from 3.35 percent between 1985 and 1990 to 3.39 between 1990 and 1995, and then slows steadily during the following five-year periods: 3.17, 2.97, 2.78, 2.49 and 2.23 between 2015 and 2020. It excludes the Mozambiquan refugees in Malawi (estimated to number 650,000 in July 1989) tantamount to assuming that they will remain outside the work force in Malawi and will eventually return home. It does not take account of the possible impact of AIDS.  - 105 - Table 7.1 Population Projections, Halawi 1990-2020 (Thousands) Age Group 1990 2000 2010 2020 10-14 1,058 1,559 2,054 2,442 15-19 870 1,196 1,823 2,227 20-24 711 1,009 1.500 1,994 25-44 1,786 2,471 3,492 5,183 45-54 501 651 897 1,294 55-64 315 421 561 785 65+ 219 302 425 584 Total 10+ 5,460 7,609 10,752 14,509 Average annual increase in population 10+ 214.9 314.3 375.7 Source: World Bank Projections, consistent with preliminary data from 1987 census. Table 7.2 Age- and Sex-Specific Participation Rates, 1977 Census Data Age Group Hales Females 10-14 17.1 15.5 15-19 36.5 43.1 20-24 75.8 60.2 25-44 93.3 67.0 45-54 94.4 72.2 55-64 92.6 69.4 65+ 81.4 54.3 Average rates for all age groups, both sexes: 10+ 63.0 15+ 71.7 7.03 The size of the labor force is determined by population size and participation rates. The 1977 census defined persons as economically active if they performed any work for remuneration in the form of wages, salary, profit, or other income; full-time students and trainees, persons either unavailable for or unwilling to work, and those who spend most of their time on domestic duties without pay were excluded. The age- and  - 106 - sex-specific participation rates for 1977 are shown in Table 7.2. They are similar to those found in other low-income African countries. 7.04 The future size of the labor force can be estimated by applying the 1977 age- and sex-specific participation rates to the population projections. Table 7.3 shows the labor force growing to 3.2 million in 1990, 4.5 million in 2000, 6.3 million in 2010, and 8.9 million in 2020. This translates into an average of 188,000 new labor force entrants each year, for whom formal- or informal-sector jobs will have to be found, or who will have to earn a living as smallholder farmers. The challenge, however, will become progressively more difficult each decade. The labor force will grow by an average of 123,000 a year between 1990 and 2000, 188,000 in the following decade, and 253,000 between 2010 and 2020. Table 7.3 Labor Force Projections by Sex and Age, 1990-2020 (Thousands of persons) 1990 2000 2010 2020 Males 10-14 90.3 133.2 175.8 209.5 15-19 157.7 218.6 332.5 407.0 20-24 265.3 380.5 566.2 754.2 25-44 781.9 1,115.9 1,607.6 2,395.9 45-54 220.9 273.4 396.5 591.9 55-64 134.3 177.8 231.5 333.4 65+ 79.0 108.3 150.6 201.9 Total 10+ 1,729.4 2,413.7 3,460.7 4,893.8 Females 10-14 82.1 120.9 159.0 188.6 15-19 188.8 257.3 393.1 479.3 20.24 217.?, 305.2 453.3 601.4 25-44 635.2 854.3 1,185.2 1,752.2 45-54 192.8 256.3 344.4 481.6 55-64 118.0 158.9 215.8 295.0 65+ 66.2 91.8 130.3 182.4 Total 10+ 1,500.4 2,004.7 2,881.1 3,980.4 Both Sexes Total 10+ 3,229.8 4,458.4 6,341.8 8,874.2 Average annual increase 122.9 188.3 253.2 Source: World Bank Projections, consistent with preliminary data from 1987 census- participation rates from 1977 census. 7.05 These projections assume constant participation rates over time. If post-primary school enrollment expands, entry into the labor force will be delayed by a few years for those able to extend their schooling. This  - 107 - will have a negligible impact on the projected labor force size, however. Increasing levels of urbanization will have only a small impact on the overall male participation rate, and despite the large differences between urban and rural female participation rates (see Statistical Appendix Table Al), the effect on the size of the labor force of even substantial urbanization is not large enough to change the overall picture. Given present urban and rural participation rates, an increase from 11 to 20 percent in the proportion of the population living in urban areas by 2020 would result in only a 3-percent difference in the size of the labor force, most of which is accounted for by 240,000 fewer economically active women. 7.06 Although lower participation rates would appear to reduce the burden on the economy of providing income-generating opportunities, they imply higher dependency ratios. The net effect on economic welfare depends on changes in productivity rates, per capita income levels, and the distributioti of income. 7.07 This paper does not explore the implications for the projected size of the labor force of different trends in fertility and mortality 43/, since the aim is not to attempt accurate predictions, but to highlight the nature of the challenge facing the Malawian economy during the coming generation. Mortality changes are likely to derive mainly from changes in infant mortality, whose impact on labor force growth is similar to that of changes in fertility. The 10-15 year time lag between birth and entry into the labor force reduces the sensitivity of medium-term labor force projections to changes in fertility. This lag makes it all the more important to take a long-term view, and to recognize the urgency of slowing the population growth rate. PRESENT DEPLOYMENT OF THE LABOR FORCE AND PROSPECTS FOR GROWTH 7.08 It is easier to predict the future growth of the labor force than of jobs. Recent trends, prospects for the future in the light of these trends, and present policies and constraints on economic growth are reviewed below. 7.09 Table 7.4 shows the structure of the labor force. (Migrants working outside Malawi are excluded, but their importance to the Malawian economy and future prospects are discussed later.) Between 1968 and 1977, the formal sector, which includes all workers in wage employment in registered enterprises, grew at 7.2 percent a year, and the proportion of the labor force in the formal sector increased from 8 percent to 12 percent. The growth of the formal sector slowed dramatically between 1977 and 1986 to 3.7 percent annually, just enough to maintain the proportion of the labor force in the sector at 12 percent. The scanty existing data do not allow an assessment of the rate at which employment has grown in the informal sector. The large increase in the estimated number of unemployed people between 1977 and 1986 suggests that smallholder agriculture could not absorb those labor force entrants who did not find formal- or 43/ See M. L. Srivastava, 1987, working Population in Malawi to the year 2002', mineo, Demographic Unit, Chancellor College, Zomba.  - 108 - informal-sector jobs. This had not been the case between 1968 and 1977. Table 7.4 Labor Force and Structure of Employment Eetimates Estimates (thousands) Annual Change (Z) 1968 1977 1986 1968-77 1977-86 Total Labor Force /a 1,059.9 2,657.3 3,548.7 2.9 3.3 Unemployment /b n.a. 46.6 191.6 - 17.0 Employment Estimates /c Total formal sector 164.6 309.0 427.8 7.2 3.7 Of which: Agriculture, forestry & fishing 44.2 155.1 185.1 15.0 2.0 Industry /d 34.5 59.8 101.8 6.3 6.1 Services /e 55.9 94.1 140.9 6.0 4.6 Unallocated 30.0 0.0 0.0 Informal Sector /f 44.9 84.3 116.7 Smallholder Agriculture and other Residual Ij 1,850.4 2,217.4 2,812.6 2.0 2.7 /a Estimated by applying 1977 labor force participation rates to population census estimates. /b The unemployment rate has been increasing. The unemployed are included in 'other residual' in 1968, since there are no data available. Data for 1977 are from the 1977 census. The figure for 1986 is estimated using 1985 data provided by the Labor Ministry, and assuming no change in the unemployment rate between 1985 and 1986. /c Formal sector figures are from NSO, Reported Employment and Earnings Annual Reports, and for 1986, as provided to the Mission by the Labor Ministry. Before 1977, only employees working in establishments with more than 20 employees were counted. The reported figures for 1968 have been revised upwards to make them comparable with data for 1977 and 1986. It was estimated that about 30,000 employees working in small establishments were not covered in the reported figures for 1968. These are shown as 'Unallocated' formal sector employees. /d Includes mining and quarrying, r nufacturing, electricity and water, and building and construction. /e Includes wholesale and retail trade, hotels and restaurants, trancport, storage and communications, financing, insurance and business services, and community, social and personal services. If Figure for 1977 from census data. Figures for 1968 and 1986 estimated assuming constant (1977) ratio of formal sector: informal sector employment. /0 'Other residual' reflects errors in estimates of other categories, and in 1968 includes the unemployed.  - 109 - 7.10 The Government of Malawi has recognized the signs of a serious imbalance between labor force growth and the expansion of economic opportunities. It is now grappling with how the situation is likely to develop over the next generation and how it should respond to the problem. One thing is clear: the formal sector is unlikely to provide jobs for the majority of new labor force entrants. Even if formal-sector employment were to grow by 10 percent a year, it would absorb only about half of the increase in the labor force between 1990 and 2020. If it grew by 5 percent annually, the formal sector would accommodate less than 20 percent of th2 increase. The following parakraphs review prospects for future employment in each major sector. The Public Sector 7.11 The public sector presently employs 20 percent of all formal sector wage employees (see Statistical Appendix Table A2). Public-sector employment expanded at an annual rate of 4 percent between 1968 and 1977 and 2.2 percent between 1977 and 1979. (The private sector grew more than twice as fast -- 9.5 percent annually between 1968 and 1977 and 4.8 percent a year between 1973 ard 1986.) Malawi's serious fiscal problems -- including the negative impact on tax receipts of the economy's recent sluggish performance and the huge influx of refugees as a result of the civil war in Mozambique -- will make significant increases in the wage bill, and therefore in public-sector employment, unaffordable, at least for the next few years. The Government's medium-term economic strategy includes a policy of wage and salary restraint and a freeze in 1988/89 on net civil service employment (except for teachers and nurses) and only slight growth thereafter. In the longer term, Malawi should continue to avoid expanding the public sector simply to provide jobs and protect public sector earnings against excessive real wage erosion. The Private Formal Sector 7.12 Malawi has a small domestic market and high transport costs because of her landlocked position and distance from the sea. Prudent policies, especially with regard to exchange-rate management, and economic and political stability have been conducive to rapid growth since Independence. Low wages relative to capital costs have resulted in a labor-intensive and hence an employment generating pattern of economic growth. The relevant issue now is whether the present structure of the economy provides a strong basis for continued growth 441. 7.13 Agro-processing accounts for much of Malawi's recent industrial growth, and is related to the expansion of the estate sector. Substantial further expansion cannot be expected because of mounting competition for arable land from subsistence producers. Statistical appendix Table A4 shows how agriculture dominates the private sector and the decline in the sector's share and contribution to the growth of employment since 1977. 44/ Issues of industrial structure and efficiency, and the formulation of strategies and policies to facilitate strong growth are the subject of the Industrial Sector Report, part of the ongoing discussion between the IBRD and Government. This paper does not deal with these issues in any detail.  - 110 - Future expansion of employment in the private formal sector will depend on the development of new export-oriented, labor-intensive industries, the introduction of new crops, and further growth in processing of tobacco and tea from the estate sector. 7.14 Malawi has been hit by several external shocks during the 1980s, which are partly responsible for the recent slow down in the growth of her economy. The terms of tradc have turned against Malawi as transport costs have. risen and export prices have declined. This has compressed imports and reduced exports, causing capacity utilization to fall substantially. Some elements of Malawi's policy response, particularly rationing of foreign exchange and increased levels of tariffs, bear some responsibility for undermining the incentive structure, efficiency, and growth of industry. 7.15 The Government's new development strategy addresses the structural and policy constraints that threaten long-term growth. The economy has begun to break out of the low-growth pattern of 1986-1988. In 1988/89, real GDP increased by 3.6 percent and GDP growth is projected to accelerate gradually to 5 percent by 1992/93 as further import liberalization results in increased industrial output and new measures are taken with respect to price liberalization, investment licensing, and monopoly protection. Higher private-sector investment in 1987-88 is expected to lead to new growth in manufacturing, particularly in textiles, food processing, footwear, and pharmaceuticals. Macroeconomic reforms and sectoral investments are expected to lead to sustained economic expansion and diversification. Transport costs will decline after the completion of the Northern Corridor Transport Project and the improvement of the transport link to Dar es Salaam. Increased promotion of exports is expected to result in new export growth. Migration 45/ 7.16 In the past, employment opportunities in South Africa, Zimbabwe, and Zambia, and to a lesser extent, in Tanzania, Mozambique, and Zaire, provided an alternative to domestic employment, often at better wages. In 1974 there were at least 250,000 Malawians working abroad -- about 10 percent of the total work force, and a similar number to those in wage employment at home. In areas with strong pressure on the land, up to 27 percent of the male labor force worked abroad. However, these opportunities have been decreasing, many migrant workers have returned home, and few can expect to find jobs outside Malawi in the future. In 1988 there were about 40,000 Malawian migrants (half in the South African mines); they accounted for just under 10 percent of Malawians in paid employment and contributed just over 1 percent of GNP. Their remittances were an important source of foreign exchange. 45/ Annex A describes policies on migration, the recruitment mechanism for workers for the South African mines and wage differentials.  - ill - 7.17 Prospects in mining employment in South Africa. Between 1980 and 1987, the number of new mine recruits from Malawi remained quite stable (although well below pre-1974 levels) in the face of effortui by the South African authorities and mining companies to stabilize mine employment and reduce reliance on foreign workers. The long term demand for labor by the mines in South Africa depends on the gold price, labor-saving changes in mining technology, and political factors that affect South Africa's export markets. Although relatively high transport costs (borne by the mines) put Malawians at a disadvantage compared to migrants from Lesotho and Botswana, Malawians might well have continued to be recruited as concern increased among managers of South African mines about the activities of the National Union of Mineworkers (NUM), from which Malawians have tended to remain aloof. However, early in 1988 blood tests were given to all mineworkers in South Africa and about 2,000 Malawians (about 10 percent), tested seropositive for the AIDs virus, and have been repatriated as their contracts ended 46/. The Malawian Government has refused to agree to the mines' demand for routine HIV testing in Malawi of would-be migrants, so recruitment has ceased and no Malawian contracts are being renewed. This decision has cost Malawi 20,000 relatively well paid jobs and considerable foreign exchange earnings. However, this may have been unavoidable in the long run, given South Africa's policy of replacing foreign workers by locals, and because of the very high unemployment rates among black South Africans. 7.18 Other countries. The other traditional destinations for Malawian migrants offer bleak prospects for the future. Zaire, Mozambique, and Tanzania have not been economically attractive destinations for at least the last decade. Malawi is presently host to about 860,000 47/ refugees from Mozambique. Zimbabwe and Zambia have their own unemployment problems, and the difficulties facing workers wishing to migrate to these countries are likely to increase. There may be some opportunities for skilled and professionally trained Malawians to find work in Botswana and the South African "homelands" at higher wages than at home, but these opportunities are likely to be open to people whose skills are also badly needed in Malawi. Moreover, there are obvious political inhibitions regarding the homelands. Land Availability and Agriculture 7.19 An estimated 37 percent of Malawi's 9.4 million hectares is arable land; nationally, that translates into an average of 0.44 hectare of cultivable land per person 48/, but in the Southern region, the average is only 0.30 hectare per person. If population growth continues to be distributed over the three regions of the country as it is now land 461 USA Center for Disease Control AIDS Weekly, April 25, 1988. 47/ As of December 1988 48/ This estimate is for 19R7, using the 1987 census population figure of 7.982 million. The Southern region has 49.6 percent of the population but only 33.7 percent of the arable land. At present, 36 percent of Malawi's land is under cultivation.  - 112 - availability in 2020 will decline to 0.18 hectare per person nationwide and to 0.12 in the Southern region 491. If the proportion of land that is classified as arable is increased to 55 percent, through development of steep, swampy and otherwise marginal lands, then the per-person average improves to 0.61 hectare in 1987 and a projected 0.25 in 2020. These densities are high compared with most (but not all) other African countries, but nowhere near the level of some small countries, such as El Salvador, Haiti, and Sri Lanka (see Table 7.5). However, none of the countries with comparable or higher population densities relies as heavily on agriculture as Halawi. If landholding patterns are taken into account, the picture is much worse; at present the estate sector controls 18 percent of the arable land 50/. There are difficult decisions to be taken about the optimal distribution and use of land, in the light of an assessment of the relative production, income generation, and labor-absorbing potential of the smallholder and estate sectors. Table 7.5 Population Densities, Selected Countries, 1985 Percent of Total Land Arable Land Persons/ Economically (Million (Million Population Arable Active Pop. hectare) hectare) hectare in Agric. Malawi 9.4 3.5 7.0 2.0 80 Costa Rica 5.1 0.6 2.6 4.3 27 El Salvador 2.1 0.7 4.8 6.8 40 1taiti 2.8 0.9 5.9 6.6 67 Sri Lanka 6.5 2.2 15.8 7.2 52 Source: FAO Production Yearbook, 1986, and World Development Report, 1987. 7.20 The increasing pressure on land is reflected in the changing size distribution of landholdings. Since 1977, the proportion of smallholder households cultivating less than 1 hectare has increased from 23 percent to 54 percent. The National Sample Survey of Agriculture (NSSA) data suggest that large landholdings (above 3 hectares) are being subdivided and more marginal land is being brought under cultivation 51/. The National 49/ These estimates are broadly consistent with U. Lele, Structural Adjustment, Agricultural Development and the Poor: Some Observations on Malawi, Dec. 1987, p.12. but take a longer horizon. 50/ Utilization is said to be low - only 14-percent of the 350,000 hectares controlled by tobacco estates in 1979/80 were under cultivation. (Oxfam, 1986, Malawi Country Review, Center for Social Research, University of Malawi, p16) 51/ IFAD Reconnaissance Mission Report: Halawi, Rural Credit and Farm Club Development, Report No. 0017-MW, April 1986.  - 113 - Physical Development Plan 1987 calculates that under present conditions, an average family (4.5 persons) needs 0.73 hectare of high-potential land, 1.66 hectare of medium-potential land, and 2.19 hectare of low-potential land in order to meet its basic subsistence needs, with no allowance for crop sales 52/. 7.21 Agricultural estates. The estate sector is a large employer and an important contributor to export earnings. In 1985 estates accounted for 68 percent of total export earnings (MK337.6 million). In 1984 there were an estimated 177,700 hired workers and 12,000 tenant farmers employed on estates 53/. Cultivation is very labor-intensive; a 1983 survey showed high labor/land ratios on estates: 1 person for every 0.32 hectare on 73 tohacco estates; 110.68 ha. on 3 tea estates; and 1/1.54 ha. on 2 sugar estates 54/. 7.22 Historically, the estate sector has paid low wages, even by African standards. Many of the tobacco estates are worked by tenants, under annually renewable agreements. Estate owners provide inputs and services, such as land preparation, on credit. The price at which the estr.te ovwer buys the crop from his tenants is fixed by the Government and has been substantially below the auction sales prices at which the owners have resold the crop. Under this system, the tenant bears the risk of crop failure or damage, but does not share in the profits associated with price rises. A small sample of tenants studied in 1985 55/ had a median net annual income of MK200-300. 7.23 Expansion in the estate sector depends on export prospects and technology changes, and, for some estates, land availability. The sector is vulnerable to international price fluctuations, especially for coffee and tea, particularly given high transport costs, which have increased further as a result of the disruption of routes through Mozambique. The growing strength of antismoking lobbies makes the long-term prospects for the tobacco market uncertain, and there are already shortages of wood for fire-cured tobacco processing (three quarters of Malawi's tobacco). However, there is a strong demand for Malawi's burley tobacco, which has an unusually low nicotine content. Prices are high and Malawi has been producing below her selling quota. 52/ This assumes yields of 15 bags/hectare for high potential land, 7 and 5 for medium and low potential land respectively, and a daily caloric intake of 2,000 per person, or 219 kg. of grain annually. 53/ See Annex B for a description of the agricultural labor market, including tenancy arrangements. 54/ National Physical Development Plan, 1987. These figures presumably refer to land under cultivation, rather than total land holdings. 55/ Vaughan and Chipande, 1986.  - 114 - Table 7.6 Population Carrying Capacity of the Land, By District, Year: 2000 High Apiei.llia, Medium ApgruiSuhwd Low