Life Expectancy
Year Life Expectancy (F) Life Expectancy (M) Country World Ranking
1960 38.5 37.4 157
1970 41.6 40.1 160
1980 45.8 43.9 160
1990 50.0 47.3 164
2000 47.1 45.0 172
2010 51.5 51.5 179
2013 61.1 58.1 168
2015 62.7 58.7 196

Data source (1960 - 2013) WHO, (2015) CIA World Factbook.

Leading Causes of Death
Cause of Death No. of Deaths (x 10,000) % of Total Deaths
HIV / AIDS 4.08 29.3
Influenza / Pneumonia 1.30   9.3
Malaria 0.95   6.8
Stroke 0.86   6.2
Diarrhoea Related 0.69   4.9
Premature Birth 0.50   3.6
Coronary Heart 0.50   3.6
Birth Trauma 0.46   3.3
Maternal Conditions 0.34   2.4
Malnutrition 0.33   2.4
Road Accidents 0.26   1.9
Congenital Anomolies 0.26   1.9
Liver Disease 0.21   1.5
Other Injuries 0.20   1.4
Cervical Cancer 0.18   1.3
Diabetes Mellitus 0.17   1.2
Oesophagus Cancer 0.16   1.2
Meningitis 0.15   1.1

In terms of Age-Standardized Death Rate, Malawi ranks in the top 10 worldwide for death rates associated with these leading causes of death: HIV / AIDS, Cervical Cancer, Maternal Conditions and Cancer of the Oesophagus.

HIV / AIDS

Life expectancy in Malawi increased until ~1989 when progress in this indicator was reversed due to the impact of the HIV / AIDS pandemic. The first case of AIDS in Malawi was diagnosed in 1985 and much of the 1990’s saw decreasing life expectancy as the HIV prevalence increased. Even today HIV / AIDS is by far the leading cause of death in Malawi. Expansion of Anti-Retroviral Treatment has enabled the HIV+ population live longer and live better. As observed elsewhere young females are more susceptible to HIV.

Despite the drop in HIV prevalence, the increase in population and success in expanding the coverage of ART therapy means that the number of people living with AIDS remains high. As such the demand on resources within the health delivery system is significant.

In line with UNAIDS goals Malawi is working towards the virtual elimination of vertical transmission of HIV. Malawi’s plan adopts a 4–prong approach to achieving this goal:

  • Reduce number of pregnancies (and therefore opportunities for MTCT) through expansion of family planning activities.
  • Reduce or eliminate HIV transmission (=> stop mothers getting HIV in first place) with a focus on youth and adolescents.
  • Identify & treat HIV+ expectant mothers such that babies are free of HIV (increasing coverage Option B+, scaling-up pediatric HIV with focus on EID and supply-chain management of HIV related commodities).
  • Care for people living with HIV and their children.

With regards to the 3rd prong of this approach, in mid-2011 Malawi instituted Option B+ (a lifelong commitment to providing ART (TDF+3TC+EFV) to all HIV+ women regardless of clinical or immunological stage. The cascade of care by which HIV+ expectant mothers are identified and treated is as follows:

  • At ANC the expectant mother is given counseling and is offered an HIV antibody test. The mother has to opt-out of this test. The results are available within 15 minutes of the test being administered.
  • Should the mother be identified as being seropositive she is immediately offered Option B+. Should the mother be identified as being seronegative, repeat testing should occur at least once prior to actual delivery of the child.
  • The mother should continue to take ART throughout the breast-feeding period and ideally for the rest of her life.
  • A child born to an HIV+ mother should receive NVP within 72 hours of birth.
  • A child born to an HIV+ mother should receive a DNA-PCR test 6 weeks after birth and then antibody test at 12 and 24 months.
  • Any child identified as being HIV infected during these tests is prescribed Option B+.

If the approach was executed flawlessly the risk of vertical transmission would be reduced from ~30% to less than 2%. However challenges exist all along the cascade of care. Unfortunately these challenges mean that those already disadvantaged (the poor, uneducated and those living in remote rural areas) are most likely to be further disadvantaged.

The process and where it breaks down and the potential impact to vertical transmission can be depicted as follows:

Females 15 - 49 years of age are targeted with HIV Education and Family Planning Instruction

As a result, of every 1000 females of child-bearing age who become pregnant:


930 attend ANC at least once

The mothers-to-be who don't attend do so through lack of education or resources or distance from nearest ANC.

70 unseen mothers deliver 1.7 HIV+ babies

744 receive HIV test / counseling

Not all ANCs have HTC capability, space for testing and counseling. Staff shortages and lack of test kits are also occasional problems.

186 untested mothers deliver 4.5 HIV+ babies

55/60 HIV+ mothers start Option B+

Ineffective counseling, fear of lack of confidentiality or husband issues and concern around side effects mean some HIV+ mothers to be do not accept ART.

5 untreated mothers deliver 1.5 HIV+ babies

47/55 HIV+ mothers stay on Option B+

Transport distance / cost, stigma and lack of male involvement are contributing factors to HIV+ mothers not continuing with ART.

8 HIV+ mothers stopping ART have 2.4 HIV+ babies

46 HIV free babies delivered

Option B+ ART is 98% successful

47 HIV+ mothers on ART have 1 HIV+ baby

The relationships above assume the probability of untreated vertical transmission to be 30% and the number of seropositive women to be 8%.

"False" negative (either through contraction of HIV in few weeks prior to test, post-test contraction of HIV or testing error) tests are another source of risk to the prevention of vertical transmission. A second test during pregnancy is advised but often this doesn't happen for numerous reasons (only 1 ANC visit, second test is declined etc.)

The challenges do not stop with birth. A HIV+ mother can still pass on the virus through her breast-milk, so following the ART regimen through this period is essential. Quickly identifying babies who do contract HIV ( EID) is literally a matter of life or death for them. Left untreated 30% will die in their first year while after two years half of them will be dead. The HIV antibody test cannot be used with infants, up the age of 18 months, since antibodies from the mother will be present in their blood. Diagnosis of HIV status of young infants requires the specialized DNA PCR test to be run on a blood sample and only 8 sites in the country able to execute this test. There are over 600 sites able to take and prepare the DBS for testing. Getting the blood samples to the testing laboratories is a logistical challenge and on average it takes 5 weeks form sample taken to result available and in many cases much longer. Managing to retain contact with the mother – child pair is an organizational challenge and up to 30% of HIV exposed children are lost to care within a year of their birth. Mothers who give birth in the absence of a trained birth attendant and in rural areas only exacerbate the challenge.

New applications of technology (UAVs / drones) could be a solution but in a situation where the government struggles to pay its employees, where there are insufficient funds for fuel to visit or even for airtime to phone HIV+ mothers who are behind with their ART therapy it seems somewhat unlikely in the absence of external funding that progress here will be rapid. Challenges with respect to getting technological capability into more than 600 sites would seem significant. To put these challenges in context ~10% of attendees at an ANC in a City Health Center during a 3 month period did not get blood pressure measured due to a lack of charged batteries for the blood pressure tester.

Influenza / Pneumonia

Pneumonia is a leading cause of death in children less than five years of age. In sub-Saharan Africa, child pneumonia deaths account for approximately 15% + of under-five mortality. The incidence of pneumonia and the case-fatality rate are highest among infants and decline with increasing age. Children exposed to or infected with HIV and / or malnourished suffer higher mortality rates. Latterly progress in addressing underweight children has reversed and even prior to the floods of 2015 and drought of 2016 the number of moderately or severely underweight children had risen to 1 out 6.

Recent studies have suggested that tuberculosis is important in the development acute childhood pneumonia and have recommended more research in this area. Although Malawi's tuberculosis statistics have been improving, rising poverty and hunger are major risk to the continuation of this progress. Work is also being carried to assess the impact of smoke from open fires (such as those used in cooking by much of the population) on the development of pneumonia.

Malaria

Malaria is a persistent cause of mortality impacting most significantly children under the age of 5 and expectant mothers. It is spread by the female Anopheles mosquito. In Malawi and sub-Saharan Africa the predominant malaria parasite is Plasmodium Falciparum which is responsible for almost every death. It can cause severe malaria through its rapid multiplication within the blood. The infected parasites clog small blood vessels and if this occurs in the brain, cerebral malaria, a potentially fatal complication, results.

Transmission is greatest in the rainy season (Nov to Apr). The Lakeshore and the Lower-Shire Valley are the areas most prone to transmission. Activities such as improved malaria control, distribution of ITNs, improved diagnostice testing and treatment options (Artemisinin based combination therapy) have contributed to the general drop in mortality rate for children under five years of age fell by 36 percent between 2004 and 2014.

Worldwide the risks to continuing progress in reducing the malaria caused mortality rate are the appearance of insecticide resistant Anopheles mosquitos and anti-malarial resistant Plasmodium parasites. An increasing number of reports of insecticide resistance and the rise of multiple insecticide resistant vectors pose challenges to vector control and to the benefits from insecticide treated bed-nets. Plasmodium Falciparum resistance to Artemisinin has been reported in South-East Asia and would be a major public health issue should it migrate to sub-Saharan Africa.

Malawi's continuing fight against malaria include the following activities:

  • Ongoing distribution of ITNs to pregnant women and children under 1 year at ANCs or maternity
  • Localized (high burden areas) Indoor Residual Spraying
  • Improved case management
  • Use of intermittent preventative treatment in pregnancy
  • Capacity Building in Helath System
  • Motivating behavioural change through communications
Health Care System

Malawi operates a tertiary healthcare system. The top tier consist of the Central Hospitals (Kamuzu - Lilongwe, Mzuzu, Queen Elizabeth - Blantyre and Zomba). Below them are the District Hospitals located in each of Malawi's 28 districts. Note: Mzimba districts is divided into Mzimba North and South. Mzuzu Health Centre functions effectively as District Hospital for Mzimba North but remains resourced as a Health Centre. The front-line primary care facilities which carry the main load are urban and primary health centres, rural and community hospitals. These are often unstaffed and always under resourced. Getting effective health care into rural communities is a major issue. CHAM operate hospitals, community hospitals and health centres which charge a small fee and as a result are often significantly underutilized in comparison to the Government facilities. CHAM also run 10 Training Colleges which are responsible for the education of the majority of mid-level Health Professionals.

Through 2006 - 2013 Malawi succeeded in meeting the goal of the Abuja Declaration (2000) of having Health Expenditure as % of Government Expenditure >15%. The deluge of 2014-2015 and the following period of drought together with reduced donor funding of the government budget have however seriously challenged the nation's finances and all district hospitals are experiencing reduced funding and non-availability of essential drugs.

A sustained effort in recent years in executing a Nurse/Midwife Training Operational Plan and driven by international aid (CDC, PEPFAR, USAID, UNFPA, GAIA , Melinda & Bill Gates Foundation) as well as National Bank of Malawi has seen the number of nurse / midwifes increase from 3 per 10,0000 in 2010 to 6 per 10,000 in 2015 (data source NONM). In comparison Australia, UK and US have ~ 100 per 10,000 while countries such as Belgium, Denmark, Iceland, Ireland and Switzerland have >150 per 10,000. (Data source World Bank). This resulted in effective vacancy rate being reduced from 76% to 60%. Although as is evident a significant number of vacancies remain the government has been unable to fund positions for the 2015 cohort of graduating NMTs. That a significant number of trained graduates are unable to exercise their skills in a country that is so short of these skills is tragic.

At 0.3 doctors per 10,000 population (2013) Malawi has one of the lowest doctor:patient ratios in the world.

In 2000 a WHO report rated Malawi's Health Care System 185 out of 190 in the world. Despite government investment the system remains disorganized, disfunctional and short of resources (essential drugs, equipment, materials, staff etc.). In common with many Malawian organizations management and adminstration skills are lacking.

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