REPORT ON UPDATE OF HEALTH ASSESSMENT
UNFPA, UNICEF, UNAIDS, MINISTRY OF HEALTH AND WHO
MALAWI SEPTEMBER 2002
2
Introduction
A rapid health assessment was conducted by WHO in collaboration with MoHP and
partners in April 2002. The main findings of that assessment became the guiding principles
for the design of the health projects outlined in the Consolidated Appeal that was launched in
June 2002.
The health information and indicators reflected in the appeal have to be updated
regularly as part of the planned activities, hence the need for this reassessment exercise that
was carried out during the month of September 2002.
Objectives
The general objective of the reassessment was to continue to determine the impact of the
humanitarian crisis on the people of Malawi, especially on the most vulnerable groups:
children under 5, women and people living with HIV/AIDS (PLWH), with special emphasis on
significant changes since the month of June.
The specific objectives can be described as:
 To assess if the access to preventive services by the vulnerable people was being
jeopardized by the crisis;
 To assess the excess burden of disease the crisis has put on the PLWH;
 To assess the impact at the community level by measuring mortality.
Study design
The health facilities and communities to be visited are the same chosen for the first health
assessment and are included in the group of districts reported by WFP as most vulnerable.
In the seven districts that had been visited five months ago the same villages were selected
for the community-based data. In the three new districts newly classified by WFP as
vulnerable the communities were chosen by the local District Health Management Team
(DHMT).
Data was collected at two different levels (strata): secondary data from the HMIS, the EPI
division and the National TB Control Programme and primary direct data from the community
level through household interviews.
Sample size
For the institution-based secondary data it was agreed that districts would be included whole.
For the community-based survey it was agreed that 20% of all households should be
interviewed in each community. A total of 40 villages and 1079 households (5932 people)
were interviewed.
Study area
The ten selected districts were: Salima, Thyolo, Ntcheu, Blantyre, Dezda, Mchingi, Mzimba,
Dowa, Kasungu and Karonga. The list of villages visited within each district can be found in
Annex 1.
Participating agencies
UNFPA, UNAIDS, UNICEF, WHO and Ministry of Health and Population (MoHP).
3
Material and methods
The assessment will collect secondary information from health facilities and central level. The
data to be collected from the health facilities was:
 First visit to antenatal services/month
 Number of children receiving DPT3/pentavalent vaccine/month
 Number of new admissions to the tuberculosis treatment program/month
Based on the guidelines given by the UN Regional Southern Africa Co-ordination Office the
periods to be compared will be March to May 2002 versus June to August 2002.
Mortality (crude mortality rate, CMR and CMR in under 5) was collected at the community
level through household interviews.
Data collection forms were prepared for both the primary and secondary data.
Methodology
At district level
A letter of introduction from the Epidemiology Unit on behalf of this exercise was faxed in
advance to the District Health Office informing them of the arrival of the teams.The first step
once on the field was to visit the District Health Officer (DHO) in order to explain the purpose
of the assessment and request his support by appointing somebody from his office to
accompany and introduce the team to the communities.
At the community level
The purpose of the assessment was explained to the village headman and the Health
Surveillance Assistant responsible for the chosen village. They would provide the number of
households (see “field definitions” below) or families living in the village and together the
number of households to be visited would be predetermined (20%).
At the household level
The information collected at the household level was:
 Gender of head of household;
 Reasons for a woman to be the head (see field definitions)
 Head of household younger or older than18
 Number of people in the household
 Number of members of the household deceased since March 2002 (Easter, end of
rains)
 Age of the deceased
Field definitions



“Household”: equivalent to “family”. It is a unit normally composed by the mother and her
children. The husband may be part of it (monogamous) or not (several wives). It can also
contain grandparents, other siblings and increasingly so, orphans that used to belong to
other family units.
“Female-headed household”: When there is no male breadwinner in the family, the head
is either widowed or divorced. She is the sole provider of the family unit.
“Child-headed household”: when the head of the family is under the age of 18. Normally
the other members are not his/her offspring but siblings. No adult as provider exists.
4
Data analysis
The data was analysed using Microsoft Excel.
Findings and conclusions
The main results and conclusions from the analysis of the data are:
 The Crude Mortality Rate (CMR) remains at 1.96 deaths/10.000 population/day and the
under 5 CMR has been found to be 3.9.
 These results are not completely comparable to the CMR of 1.97 obtained in the initial
assessment because the 2 periods measured overlap by one month.
 These results are very worrying, since the period between March and October (dry) is
considered the “good season”: there is no cholera, there is less malaria, the crops are in
and there is food available. Therefore these new results should be interpreted as a
worsening of the situation and forecast a very dire upcoming rainy season in terms of
human survival. See annex 1
 The excess mortality affects similarly all ages; both the CMR and the CMR in children
under five has about doubled from the emergency threshold.
 The most vulnerable districts in terms of morbidity and mortality are Karonga, Mchingi,
Salima and Dezda.
 The number of new TB cases diagnosed and admitted into the TB program has more
than doubled between the first and the second quarter of the year 2002.TB cases can be
used as a measure of underlying HIV/AIDS in the community since over 80% of all new
TB cases in Malawi show HIV co-infection. The remarkable increase shows that the
humanitarian crisis has put an extra burden on PLWH, specially women. See annex 2
 In the most vulnerable districts above mentioned the attendance rate to antenatal
services has declined markedly since June; this leads to 2 worrisome conclusions: access
to services is declining in the worst affected districts, and of course the fact that more
women may be at risk of unplanned pregnancies. See annex 2
 A very similar picture is seen from the access and utilization of EPI programs. See Annex
2.
Recommendations
These are the main recommendations:






WHO as the lead agency in the health sector must strive to convince donors to support
the areas of action proposed in the consolidated appeal that have never been acted upon;
The functional implementation of an integrated disease surveillance system is a priority,
especially in the most vulnerable districts.
Epidemic preparedness (especially for cholera) must be implemented during the coming 2
months (before the next “cholera season”).
Health coordination among all partners must be reinforced and better synergy should be
achieved among the various, abundant and sometimes simultaneous assessment
exercises.
The indicators chosen for this reassessment were limited in order to provide essential
information quickly for immediate dissemination and action. Nevertheless the results are
sufficient to show a worrying picture of the health situation in Malawi. A more in-depth
survey should be carried out by the interested agencies. That survey should include data
on factors relating to the spread of HIV/AIDS.
The community-based mortality survey should be repeated in 6 months’ time.
5
ANNEX 1 VILLAGES VISITED IN EACH DISTRICT
# HH
# F HH
# people
# under 5
# deaths
# deaths U5
CMR
CMRU5
SALIMA
79
12
376
95
11
8
1.63
4.68
Ndovu
30
8
132
28
6
4
2.53
7.94
Chikunda
12
1
57
18
1
1
0.97
3.09
Kanvanjilou
17
1
91
22
2
1
1.22
2.53
Wirize
20
2
96
27
2
2
1.16
4.12
THYOLO
85
5
566
75
4
2
0.39
1.48
Warani
28
0
300
38
2
1
0.37
1.46
Jeremiya
9
0
40
4
0
0
0.00
0.00
Mpenda
33
1
162
24
1
1
0.34
2.31
Lisiyano
15
4
64
9
1
0
0.87
0.00
NTCHEU
115
38
604
101
17
1
1.56
0.55
Chitsulu
24
10
118
22
5
1
2.35
2.53
Kalumba
26
10
158
30
5
0
1.76
0.00
Dzaole
45
15
226
31
1
0
0.25
0.00
Ben Chinseu
20
3
102
18
6
0
3.27
0.00
BLANTYRE
110
22
548
96
3
3
0.30
1.74
Jiya
37
11
197
32
0
0
0.00
0.00
Kamtukule
43
7
209
40
1
1
0.27
1.39
Kadikira
24
3
118
20
2
2
0.94
5.56
Mlongoti
6
1
24
4
0
0
0.00
0.00
DEZDA
142
38
724
157
36
15
2.76
5.31
Tembwe
31
1
176
33
2
1
0.63
1.68
Mtachire
14
3
93
27
6
0
3.58
0.00
Mtawanga*
46
17
253
52
11
9
2.42
9.62
Kamgunda
51
17
202
45
17
5
4.68
6.17
MCHINGI
70
18
408
75
18
8
2.45
5.93
Kaluza
22
8
120
26
8
1
3.70
2.14
Filimoni
14
4
70
12
4
3
3.17
13.89
Tongole
12
3
72
13
1
1
0.77
4.27
Mtondo
22
3
146
24
5
3
1.90
6.94
105
27
556
85
11
6
1.10
3.92
Chikondowanga
40
11
187
38
2
1
0.59
1.46
Simeon Mvula
25
10
152
19
2
1
0.73
2.92
MZIMBA
Kacherera Soko
9
2
54
6
4
3
4.12
27.78
Ndabambe Gausi
31
4
163
22
3
1
1.02
2.53
DOWA
74
15
465
95
22
5
2.63
2.92
Ntsilu
21
4
129
24
1
0
0.43
0.00
Kantepa
12
3
100
26
12
2
6.67
4.27
Misi
36
8
205
42
7
1
1.90
1.32
5
0
31
3
2
2
3.58
37.04
Mbota
KASUNGU
102
14
606
122
21
7
1.93
3.19
Chiwera
40
5
244
54
10
2
2.28
2.06
Kasinjeni
26
1
179
29
6
4
1.86
7.66
Chikwiya
20
0
100
22
3
1
1.67
2.53
Kaninga
16
8
83
17
2
0
1.34
0.00
197
55
1079
244
66
25
3.40
5.69
Mwakalomba
40
7
204
48
4
3
1.09
3.47
Maxwell
27
8
121
26
21
8
9.64
17.09
Chimalabantu
86
27
496
120
17
5
1.90
2.31
KARONGA
6
Yalero*
44
13
258
50
24
9
5.17
10.00
TOTAL
1079
244
5932
1145
209
80
1.96
3.88
* 1 child-and-female-headed household found in the village
An average of 22.6% of households are female-headed
The average size of HH is 5.5 persons, oscillating between 4.8 in Salima and 6.7 in Thyolo
The worst affected districts are Karonga, Mchingi and Dezda, followed by Kasungu, Salima and Dowa.
Karonga has 28% of female-headed households
Dezda has 27% of female-headed households
Ntcheu has 33% of female-headed households
ANNEX 2
7
Number of First ANC Visits by District and Month (March-August, 2002)
District
Karonga
Dedza
Dowa
Kasungu
Mchinji
Ntcheu
Salima
Mzimba
Blantyre
Thyolo
Total
March
April
379
2,832
805
1,444
2,836
2,168
899
1,207
2,481
983
16,034
May
350
1,372
1,785
1,975
3,040
1,480
1,291
1,301
2,498
2,459
17,551
412
1,081
1,162
1,713
2,658
1,306
1,114
1,297
2,550
2,050
15,343
June
380
973
977
1,702
4,050
1,275
1,130
1,360
2,244
2,350
16,441
July
August
425
910
1,086
1,754
3,869
1,200
1,195
1,250
2,210
2,390
16,289
389
895
834
1,769
4,140
1,160
1,250
1,300
2,299
2,040
16,076
Total
2,335
8,063
6,649
10,357
20,593
8,589
6,879
7,715
14,282
12,272
97,734
Number of <1 Children who received DPT-Hep B+ Hib 3 by District and Month.
(March-September, 2002)
District
Target Pop March April
May
June July
Aug
Sept
Total
Karonga
10,716
127
357
469
437
419
410
430 2,649
Dedza
22,284
327
989 1,387 1,699 1,787 1,837 1,985 10,011
Dowa
22,320
313
717 1,019 1,375 1,450 1,569 1,689 8,132
Kasungu
27,312
621 1,430 1,709 1,777 1,850 1,903 2,090 8,669
Mchinji
17,388
368
988 1,085 1,252 1,468 1,623 1,858 8,274
Ntcheu
18,768 1,050 1,251 1,710 2,076 2,155 2,460 2,790 12,442
Salima
17,112
288
884
883
698
607
589
570 4,231
Mzimba
24,409 1,839 2,040 2,300 1,990 2,340 2,440 2,350 13,460
Blantyre
43,428 1,711 1,149 3,771 2,701 3,260 3,757 4,060 18,698
Thyolo
23,364 1,297 1,926 2,000 2,068 2,136 2,199 2,345 12,674
Total
227,101
7,941 11,731 16,333 16,073 17,472 18,787 20,167 99,240
New Cases of TB* by District and Quarter (Jan-June, 2002
8
District
Karonga
Dedza
Dowa
Kasungu
Mchinji
Ntcheu
Salima
Mzimba
Blantyre
Thyolo
Total
First Quarter
Second Quarter
Male
Female
Total
Male
Female
Total
19
14
33
31
32
63
61
75
136
77
94
171
37
29
66
52
36
88
77
73
150
93
54
147
49
62
111
56
53
109
38
46
84
56
51
107
42
53
95
64
70
134
68
63
131
150
179
329
499
434
933
522
543
1,065
109
139
248
140
157
297
999
988
1,987
1,241
1,269
2,510
(%) M (%) F
63
26
41
21
14
47
52
121
5
28
24
129
25
24
-26
-15
11
32
184
25
13
28
* This includes all cases of TB (smear +ves, smear -ve but with clinical diagnosis and
extrapulmonary TB)
9
New cases of TB by district and quarter
1,200
1,000
800
First Quarter
600
Second Quarter
400
200
0
Karong
Dedza
a
Dowa
Kasung
Mchinji Ntcheu Salima Mzimba Blantyre Thyolo
u
First Quarter
33
136
66
150
111
84
95
131
933
248
Second Quarter
63
171
88
147
109
107
134
329
1,065
297
Comparative quarterly increases by gender and district
350
300
250
200
Female
150
Male
100
50
0
Karonga
Dedza
Dowa
Kasungu
Mchinji
Ntcheu
Salima
Mzimba
Blantyre
Thyolo
-50
10