World Health Organization
HEALTH ASSESSMENT MISSION IN MALAWI
(19 April to 10 May 2002)
1. EXECUTIVE SUMMARY
Following on Save the Children-UK’s report on the food crisis in Malawi, the InterAgency Standing Committee (IASC) during the Rome meeting of 13-14th February
decided to send a UN mission to this country to assess the severity of food crisis and its
impact. This mission took place from 7 to 12 April 2002. After meetings with partners and
donors and field visit to Blantyre and Chikwana districts in the south of the country the
mission concluded: i) the current UN mission could not be considered as an assessment
mission and was renamed as an information mission; ii) two missions are needed to
assess the humanitarian crisis in Malawi on: a) food crisis led by WFP, FAO and UNDP
and b) its impact on (Health, Nutrition, Water Sanitation and Education) led by WHO and
UNICEF.
Malawi is one of the poorest and most vulnerable countries in the southern Africa region
which also includes ( Lesotho, Mozambique, Swaziland, Zambia and Zimbabwe). These
countries were all hit by the humanitarian crisis due to the drought of 1992-1993. Malawi
is currently facing another humanitarian crisis aggravated by decreased food production
which next harvest is predicted worse than the previous one, mismanagement of
strategic food reserves and lack of funds to supply health facilities as well as to trained
health workers. Many rural households have a small amount of land for the food
production but, it is not enough land to support the family. The production capability
decreases over time as the land is often over-utilized without additional fertilisers. The
agriculture crop is commercially oriented and not diversified which contributes negatively
to the situation. The price of the main staple food, maize, continues to increase and is
expected to reach 24 Kw/kg ( $ 0,33 ). The per capita household income for the poorest
50% of population of Malawi is roughly 15-20Kw /day ( less then $1) as the minimum
salary is (1,000Kw) equivalent to $15 per month.
For the health impact, WHO Country office in collaboration with MoH conducted a rapid
assessment with technical support from AFRO/HQ from 22 April to 10 May 2002 in 10
worst affected districts out of 27 (37%) of the districts with estimated population of
5,626,232 inhabitants
2. OBJECTIVES
2.1.General objective:
 To assess the health impact of the food crisis in Malawi.
2.2. Specific objectives:
 to assess the excess burden of endemic diseases (malaria, ARI, diarrhoea,
malnutrition, etc.);
 to assess the capacity of the health system to respond to the needs;
 to assess the capacity of the health information system; and
 to assess the level of implementation of reproductive health and HIV/AIDS
programmes.
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3. MAIN FINDINGS
3.1. High mortality at community level not detected by health facilities
An assessment at community level, carried out in 1,016 households totalling 5,055
people, found 173 deaths during the period October 2001/March 2002. The Crude
Mortality Rate (CMR) is 1.9 per 10,000 per day. A verification exercise conducted by
WHO from 14-16 May on the reported deaths confirmed the same CMR, due to a
combination of malnutrition and diarrhoeal diseases and the particularly severe cholera
epidemic which the country had just experienced.
3.2. Decrease of use of health facilities
To assess the excess of burden diseases, indicators from the period of Oct 00/March 01
and Oct 01/March 02 were compared, which showed the following tendencies:

patient attendance had dropped from 40,000 to 30,000 people ( - 25% );

reported morbidity due to endemic diseases (malaria, diarrhoea, IRA and
malnutrition) decreased from 273, 034 to 231,576 cases ( - 15% );

number of deliveries at health facilities fell from 13,891 to 12,847 (- 7,6 % ), while
the maternal deaths increased from 39 to 67 (71%) in relation with the number of
deliveries

high severity of cholera epidemic with 33,150 cases and 981 deaths (CFR=2,9).
3.3. Lack of capacity in record keeping
Six districts hospitals out of ten had not records of deaths occurred during the period
under study
3.4. No measles outbreak
No measles outbreak occurred during the period under study which confirms good
immunization coverage. A routine EPI campaign is planned for August.
3.5. The surveillance system is not sensitive to capture morbidity and mortality for
immediate response.
There are three co-existing information systems originating from the same source which
are not well synchronised: i) the Health Information Management System (HIMS),
(reporting quarterly) which collects data for strategic planning purposes; ii) the vertical
programme collecting data for individual action of respective programmes, (reporting
quarterly); and iii) the Integrated Diseases Surveillance (IDS) which is collecting data for
immediate action (reporting monthly).
We were informed that some districts are sending epidemiological information through
the postal system because of lack of e-mail or fax.
3.6. Very weak response capacity in terms of staff, basic equipment, transport and
communication.
Most of the health centres are functioning with one nurse, when there is a need for one
medical assistant and at least two nurses to run the Outpatient and Maternity
departments. Health facilities commonly lack delivery kits. This problem is compounded
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by the lack of skills among staff to implement specific health programmes, including
epidemiological surveillance.
The increase of 71% of maternal deaths reported by the health facilities versus the
number of deliveries confirms the weak capacity of the health system.
3.7. Low capacity of Country Office to deal with current situation
WHO Country Office supported by five National Programme Officer has insufficient
capacity in emergency management and health coordination to respond to the present
needs.
3.8. Constraints identified by health authorities and population
a) health authorities: affecting provision of basic health cares:
 shortage of personnel;
 shortage of drugs;
 lack of transport/communication
b) population: affecting health in the communities
 lack of food;
 lack of safe water;
 drugs not available at health facilities which are located far
4. CONCLUSIONS
4.1. The high CMR of 1.9 /10.000/day confirms the humanitarian crisis faced by the
community.
4.2. There is a decrease of use of health facilities due to lack of drugs, goods services
and geographical access, which is exacerbated as resources for food are considered
first priority.
4.3. IRC and WHO studies in DRC and Sierra Leone show that endemic diseases are
main killers in humanitarian crises. The Malawi scenario confirms that cholera epidemic
and malnutrition are the main causes of death.
5. RECOMMENDATIONS
5.1. Ensure that the projected amounting approximately to $ 2 940 000 are included in
the Consolidated Appeal Process framework and advocacy done both during the
regional process and at other opportunities.
Responsible actors: WR Malawi, Resource mobilization in EHA/AFRO and EH/AHQ
5.2. Reprogramming of WHO budget of areas of works for an immediate support to the
MoH on critical programmes such as epidemiological surveillance and including nutrition
etc…
Responsible actors: WR/Malawi and BFO/AFRO
5.3. Strengthen WHO Country Office by recruiting an International trained in public
health and with experience in emergencies and a Nutritionist.
Responsible actors: WR Malawi, EHA/AFRO and EHA/HQ
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5. ANNEX : Methodology
5.1. Selection of districts, health facilities, communities and households:
Ten out of 27 districts ( 37%) with estimated population of 5,600,000 out of 11,000,000
inhabitants have been selected among the most affected according to the Ministry of
Agriculture information. The selected districts are: (see table under point 5.2.3. and
Malawi map ).
In the ten districts, the assessment was conducted at the district hospital and two health
centres levels. For each health facility the two most affected communities surrounding
were visited with focus on 20% of households to assess the nutritional state and the
mortality of last six months correspondent to the second period of health facilities.
Globally, 10 district hospitals, 20 health centres and 60 communities constituted the
sample for the Health Assessment
5.2. Elaboration/discussion of forms for data collection:
Two forms were prepared. The health facilities forms collect data of two periods at health
facilities level : i)October 2000 to March 2001 and ii) October 2001 to March 2002
The community form to collect data of October 2001 to March 2002 at community level.
Both were prepared to collect information capable to respond to the three specifics
objectives above mentioned. The key indicators to assess the impact patient attendance,
morbidity, maternal mortality and Crude Mortality Rate (CMR) in the communities.
UNICEF, UNFPA, MSF Greece, Save the Children UK, Care International and Red
Cross National Society participated actively to this phase.
5.3. Team composition and time frame for data collection:
The data collection was done by 5 teams during one week (23-28th April). Each group
led by a WHO National Programme Officer (NPO) conducted the assessment in two
districts. The focal points from the Ministry of Health who jointed the teams work in the
following area: (Integrated Disease Surveillance (IDS), HIV/AIDS, Health Information
and Management Systems (HIMS), Acute Respiratory Infections (ARI) and Environment
Health
At district level, three people were requested to joint the team as well as a local
transport to support part of the team during the visit to the communities was requested.
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Team members
1. Mrs Mwale, Mrs Kandoole & Mr Tauzie
2. Dr Kalanda, Mr Bello & Zoya
3. Mr Dodoli Mr Chipeta & Mr Bomba
4. Mr Chandyanga Mr Dzumani & Mr Malewezi
5. Dr Nyirenda, Mr Khunga & Mr Nyimba
Districts and date of assessment
23-25th April
26-28th April
Zimba
Karonga
Dowa
Ntcheu
Mchinji
Dedza
Balaka
Zomba
Blantyre
Nsaje
5.4. Data entry and analysis:
The collected data were entered and analysed using Epi-Info and Excel. The indicators
of the two periods were compared to determine the possible impact of food crisis.
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