TABLE OF CONTENTS
LIST OF ABBREVIATIONS………………………………………………………………….i
A
INTRODUCTION AND BACKGROUND .................................................... 1
B.
PROCESS ESTABLISHED FOR THE END-DECADE REVIEW ................. 3
C.
ACTION AT THE NATIONAL AND INTERNATIONAL LEVELS ................... 4
D
SPECIFIC ACTIONS FOR CHILD SURVIVAL, PROTECTION AND
DEVELOPMENT..................................................................................... 6
E
LESSONS LEARNT............................................................................... 19
F
FUTURE ACTION ................................................................................. 21
RECOMMENDATIONS FOR FUTURE ACTION .............................................. 23
LIST OF ABBREVIATIONS
AFP
AIDS
ANC
ARI
BES
BFHI
BHS
BIHP
BMHI
CBM
CCAM
CHAM
CHAPS
CCA
CPR
CRC
CRU
CSA
DPT
ECC-SGD
ECD
EHP
EPI
FPRHS
GAVI
HIV
HRC
IMCI
IMR
IPRSP
KAPHS
MDHS
MIC
MIHS
MKAPHS
MMR
MNHP
MOGYCS
MOH&P
MSIS
MTCT
NACP
NALP
NCHS
NEC
Acute Flaccid Paralysis
Acquired Immune Deficiency Syndrome
Ante-natal Clinic
Acute Respiratory Infection
Basic Education Statistics
Baby Friendly Hospital Initiative
Basic Health Statistics
Baseline Information Survey for the Malawi National Health Plan (2000-2004)
Bakili Muluzi Health Initiative
Community-based management
Chitukuko Cha Amayi M’Malawi
Christian Hospitals Association of Malawi
Community Health Partnerships
Common Country Assessment
Contraceptive Prevalence Rate
Convention on the Rights of the Child
Child Rights Unit
Child sex abuse
Diphtheria/Pertussis/Tetanus vaccine
Early Childhood Care for Survival, Growth and Development
Early Childhood Development
Essential Health Package
Expanded Programme of Immunisation
Family Planning and Reproductive Health Survey
Global Alliance for Vaccines and Immunisation
Human Immuno-deficiency Virus
Human Rights Commission
Integrated Management of Childhood Illnesses
Infant Mortality Rate
Interim Poverty Reduction Strategy Paper
Knowledge, Attitude and Practice in Health Survey
Malawi Demographic and Health Survey
Malnutrition-infection complex
Malawi Integrated Household Survey
Malawi Knowledge, Attitude and Practice in Health Survey
Maternal Mortality Ratio
Malawi National Health Plan 1999-2004
Ministry of Gender, Youth and Community Services
Ministry of Health and Population
Malawi Social Indicators Survey
Mother-to-Child Transmission (of HIV)
National AIDS Control Programme
National Adult Literacy Programme
National Centre for Health Statistics (US)
National Economic Council
i
NECDP
NNT
NPAC
NPAW
NPP
ODA
ORT
PRSP
RHBS
SITAN
SMI
TBA
U5MR
UNHCR
UNICEF
WHO
WSC
National Early Childhood Development Policy
Neo-natal tetanus
National Programme of Action for the Survival, Protection and Development of
Children in the 1990s
National Platform of Action (Follow-up to the 4th World Conference on
Women)
National Population Policy
Official Development Assistance
Oral Rehydration Therapy
Poverty Reduction Strategy Paper
Reproductive Health Baseline Survey
Situation Analysis of Women and Children
Safe Motherhood Initiative
Traditional Birth Attendant
Under-5 Mortality Rate
United Nations High Commission for Refugees
United Nations Children Fund
World Health Organisation
World Summit for Children
ii
A
INTRODUCTION AND BACKGROUND
1.
At the World Summit for Children held in New York in September 1990,
Malawi was represented by a delegation led by the Minister of External Affairs.
The delegation included representatives from the Ministry of Health, the
Ministry of Education and the CCAM (Chitikuko Cha Amayi M'Malawi), of the
Department of Women in the Office of the President. This high level delegation
reflected the importance Malawi attached to issues relating to children and
demonstrated the extent of commitment for the follow-up actions that could
be expected from the country.
2.
Malawi was a party to the World Declaration on the Survival, Protection
and Development of Children and the Plan of Action for its implementation
during the 1990s adopted at the World Summit. In January 1991 it signed
the Declaration without reservations. At the same time it ratified without
reservations the 1989 Convention on the Rights of the Child (CRC) that the
Summit had endorsed.
National Plan of Action
3.
Following the Summit, and in line with section 34 of its Plan of Action
urging governments to prepare national programmes of action to implement
the goals of the Summit, Malawi undertook the formulation of its own Action
Plan. The responsibility of preparing the plan was entrusted to the newly
created Ministry of Women and Children Affairs and Community Services
(MOWCACS). The Ministry developed the National Programme of Action for
the Survival, Protection and Development of Children in the 1990s (NPAC) in
collaboration with several line ministries including the Ministries of Health,
Education, Agriculture and Finance and the Department of Economic
Planning and Development in the Office of the President. Some donor
agencies and NGOs were also involved in the formulation of the Plan.
4.
The NPAC was approved in 1993. A Women and Children’s Department
was created in the MOWCACS and entrusted with the mandate of
coordinating the implementation of the NPAC. The Head of State urged all
relevant government agencies to pursue with maximum diligence and
dedication the objectives of the Plan which he described as "a struggle for the
future of our nation" (NPAC, p.2). Coordination and monitoring of the
implementation of the Plan has remained the responsibility of the Ministry
which is now called the Ministry of Gender, Youth and Community Services
(MOGYCS).
Mid-decade Review
5.
A mid-decade review was conducted in October/November 1995. A
Multiple Indicator Cluster Survey (MICS) was undertaken by the National
Statistical Office (NSO) to collect updated information on indicators needed to
measure what progress the country had made towards reaching the end-of1
decade goals. The Survey gathered information from 6,206 households
throughout the country on child mortality and morbidity, immunisation,
nutrition, micronutrient supplementation, breast feeding, education, and
access to water and sanitation facilities. Its findings were presented to the
donors Consultative Group meeting in the United Kingdom in December 1995
and disseminated widely as the Malawi Social Indicators Survey, 1995 (MSIS).
6.
The mid-decade review concluded that overall, "the state of children has
not changed much in the past few years", (MSIS, p.103). This could be
attributed to rapid population growth, the HIV/AIDS pandemic and a
deepening economic crisis during the change from one-party rule to
multiparty democracy. There was little improvement in the rates of infant and
child mortality and malnutrition among under-5s. Although immunisation
levels had been sustained at considerably high rates in most years there was
some decline in 1995. There was no increase in access to safe water and
hygienic sanitation facilities.
On the positive side, the review showed
significant improvements in breast feeding and the use of home-made ORT
solutions for the treatment of diarrhoea. A remarkable increase was noted in
primary school enrolment following the introduction of free primary education
in 1995.
Convention on the Rights of the Child (CRC)
7.
Under Article 44 of the CRC, state parties had undertaken to submit to
the Committee on the Rights of the Child, established under Article 43 of the
CRC, periodic reports on progress made on the fulfilment of children's rights.
Countries undertook to submit a report within two years of the Convention's
ratification and every five years thereafter. Malawi's initial report was
therefore due by 1993. However, in view of the political uncertainties
culminating in the change from one-party rule to multiparty democracy in
1994, submission of Malawi's initial report was delayed. The initial report on
implementation of the CRC was submitted to the Committee on the Rights of
the Child in 1999. It usually takes nine to ten months after submission for a
report to be tabled before the Committee and Malawi’s Report is scheduled to
be considered in January 2001.
8.
On the basis of a review of legal and policy measures put in place to
give effect to the provisions of the CRC, the Initial Report highlighted the
following major issues:
-
Malawi's Constitution and national laws do not comply with the CRC's
definition of a child as every individual under eighteen years of age, nor
do they uniformly define a child. The Constitution defines children as
persons under 16 years while different age limits are found in various
laws relating to sexual consent, employment and judicial procedures.
-
The Constitution provides for protection against discrimination.
However, in reality it does exist – especially against girls. For example,
2
a girl’s education is not considered important and is sacrificed for early
marriage. A number of traditional rites harmful to girls, such as being
forced to have sex as part of an initiation ceremony, are still practiced.
-
Provisions of the Children and Young Persons Act, which recognises the
principle of best interests of children, are not always followed. Children
are often tried in open courts instead of closed juvenile courts. The
prohibition on disclosing names and addresses is frequently violated by
journalists.
-
In deciding on the right to custody of the child, courts are guided by the
principle of "the welfare of the child being of paramount importance."
However, in most cases financial ability to support the child is
considered the criterion for guaranteeing welfare. Mothers usually lose
custody, and the child is deprived of the mother's care.
-
High infant and child mortality rates indicate little progress in
guaranteeing the right to survival.
Pervasive household poverty
compounds the difficulties caused by inadequate financial resources,
lack of capacity to implement health programmes, cultural practices
and the HIV/AIDS pandemic.
-
Constitutional provisions are in place to provide special treatment to
children with disabilities and protect them against discrimination.
However, there is not as yet a policy on people with disabilities, and the
majority of disabled children face problems of access to public services.
It is also not unusual for children with disabilities to be stigmatised.
-
Children are known to work to supplement family incomes. The child
labour market is dominated by domestic workers, especially girls, and
hazardous and detrimental work is performed by children on tobacco
and tea estates.
-
Reports of sexual exploitation and abuse of children have been
increasing.
Poverty and cultural practices can be identified as
contributory factors. Some child sexual abuse cases, particularly incest,
are overlooked to protect privacy and family reputation.
B.
PROCESS ESTABLISHED FOR THE END-DECADE REVIEW
9.
The End-Decade Review (EDR) process was initiated in mid-2000. The
process involved various stakeholders at the family, community, civil society,
government and international community levels. The exercise, coordinated by
the Ministry of Finance and Economic Planning, was undertaken by a joint
Government of Malawi and UNICEF Technical Working Group comprising
members from key government ministries and departments, UN agencies and
Civil Society. Save the Children Alliance as a member of the Technical
3
Working Group represented the NGOs in the review process.
The
participation of children and women was ensured through focus group
discussions and interviews. The Technical Working Group was assisted by
consultants in the collection and analysis of the most recent data available for
the indicators developed by UNICEF for the EDR.
10. The EDR drew on the findings of the 1995 mid-decade review, the midterm review of the Government of Malawi/UNICEF Country Programme of
Cooperation (1997-2001), Malawi's Initial CRC Report to the United Nations,
the United Nations Common Country Assessment (CCA), the Situation
Analysis of Children and Women in Malawi 2000 (SITAN), the Interim Poverty
Reduction Strategy Paper (IPRSP) and the Report of the Consultative Group
(CG) meeting held in May 2000. Further information was obtained from
studies conducted by NGOs, such as on Child Abuse by Save the Children
(USA). Ideally, the EDR should have been supported by a MICS to provide
end-decade data on key indicators. Since a Demographic and Health Survey
was scheduled for September 2000 and included about 90 per cent of the
required indicators, it was decided in consultation with the UNICEF Regional
Office that a separate MICS could be dispensed with. UNICEF provided
financial and technical support for the Malawi Demographic and Health
Survey (MDHS) in 2000, but results will not be available before March 2001.
Similarly, detailed results of the 1998 Population Census are not expected
before the end of the year; however, preliminary results are available now.
11. The EDR has therefore been based on four major sources of data – the
MDHS 1992; the mid-decade MICS 1995, the Malawi Knowledge, Attitude and
Practice in Health Survey (MKAPHS) 1996; and the Malawi Integrated
Household Survey (MIHS) 1998. Moreover, some additional data was available
from partial surveys conducted to provide baseline information for plans in
the health sector. The detailed results of the MDHS 2000 will be incorporated
in the end-of-the-decade "report card" which is required to be submitted by
mid-2001 as a statistical update to this report.
C.
ACTION AT THE NATIONAL AND INTERNATIONAL LEVELS
12. In addition to formulating the National Programme of Action for the
Survival, Protection and Development of Children (see paragraphs 3 and 4),
the Government of Malawi accorded a high priority to incorporating in
relevant policies and programmes measures aimed at improving the wellbeing of children in general and meeting the goals of the WSC. In 1995 the
Government formulated the Policy Framework for its Poverty Alleviation
Programme that highlighted youth and orphans as vulnerable groups. The
National Platform of Action launched in 1996 as a follow-up to the Fourth
World Conference on Women (held in Beijing), incorporated actions for
eliminating discrimination against girls. Malawi’s long-term development
perspective – Vision 2020 – identifies children as a vulnerable group.
13.
All major sectoral policies and programmes have addressed issues
4
relating to children. The National Population Policy (1994) incorporated
targets for the reduction of childhood mortality and malnutrition. The current
Education Policy made primary education free. The National Health Plan
(1999-2004) identifies child health as a priority, while the National Plan of
Action for Nutrition places special emphasis on child nutrition. Initiatives
focussing exclusively on children are the Policy Guidelines on Orphans,
Integrated Management of Childhood Illness, Expanded Programme on
Immunisation, Baby Friendly Hospital Initiative, Community Based Child
Care and the National Early Childhood Development Policy. A number of
measures have been taken to improve administration of juvenile justice, and a
Child Rights Unit was created in the Human Rights Commission in 1999.
14. Allocations to basic social services that impact most significantly on
children include basic education (including early childhood care, primary
education and adult literacy); basic health (including primary health care,
immunisation and reproductive health facilities); nutrition programmes; and
water and sanitation. A study undertaken by the Ministry of Finance in the
context of the 20/20 Initiative shows that during the period 1990/91 to
1996/97 the share of basic services in total government expenditure
fluctuated between 6.4 and 11 per cent. In 1996/97, it was 7.6 per cent, 85
per cent of which went to primary education. The share of primary education
in total government expenditure on basic social services ranged between 50
and 55 per cent until the introduction of free primary education; it increased
to 67.5 per cent in 1994/95 and further to 85 per cent in 1996/97. The
remaining expenditure on basic social services was equally divided between
health and water and sanitation.
15. Out of Official Development Assistance (ODA), the share of basic social
services has remained low, according to a Ministry of Finance and Economic
Planning study to review the 20/20 Initiative. The share of social-related
sectors like human resource development, health and social development has
been less than 25 per cent in most years. Though ODA has been channeled
to development of education, health care, particularly the immunisation
programme, only a small proportion of ODA going to social-related sectors has
supported basic social services activities.
16. The 1990s have witnessed an increase in community based initiatives
in the areas of early childhood care, orphan care, Integrated Management of
Childhood Illnesses (IMCI) and primary education. Local communities and
parents are playing an increasing role, for example, in educational
contributions with regard to sharing the cost of buildings and their
maintenance, learning materials and extra-curricular activities. More than 75
per cent of primary schools have been built with the support of local
communities, and primary school maintenance has largely been a
responsibility of communities. The role of community based management in
the water and sanitation sector has also improved.
17.
Progress towards establishing appropriate mechanisms for collection
5
and analysis of data required to monitor relevant social indicators related to
the well-being of children has up to now been inadequate. Since the MICS,
conducted as part of the mid-decade review, no attempt has been made to
collect data for the key indicators. Partial surveys, such as those aimed at
gathering baseline data for the National Health Plan, Family Planning
Services, and Prevalence of Anaemia have yielded some relevant information
relating to children. Data from the 1998 Population Census, currently being
analysed, is expected to provide information on fertility, mortality rates,
enrolment and child labour. The Demographic and Health Survey conducted
in September 2000 will provide information on a number of social indicators
needed for assessing changes in the well-being of children; that data will be
available in 2001.
18. The Summit had envisaged that the role of international cooperation
would be critical in meeting its goals for improving the well-being of children
in all countries. Following the Summit, a number of global conferences were
held during the 1990s focussing on various key development issues. These
included: the International Conference on Nutrition (1992); the United
Nations Conference on Environment and Development (1992); the World
Conference on Human Rights (1993); the International Conference on
Population and Development (1994); the World Summit for Social
Development (1995); the Fourth World Conference on Women (1995); and the
World Food Summit (1996). All conferences endorsed Summit goals falling
within their mandates. Malawi participated in all these conferences, was a
signatory to resulting agreements and in most cases formulated national
action plans. Implementation of these plans, such as the National Plan of
Action in the field of Human Rights, the National Plan of Action for Nutrition,
and the Platform of Action for Women, have all included measures for
improving the well-being of children.
D
SPECIFIC ACTIONS FOR CHILD SURVIVAL, PROTECTION AND
DEVELOPMENT
(a)
Ratification and dissemination of the CRC
19. Malawi ratified the CRC without reservations in 1991, within a year of
the World Summit for Children. Since then a number of measures have been
undertaken to publicise the CRC. Some youth associations have been
advocating for the Rights of the Child using the child to child to adult strategy
in their campaigns. The most prominent association in this respect has been
the Young Voices Movement which is currently in six districts and has formed
clubs in both primary and secondary schools to discuss issues related to
children’s rights and sensitise children as well as adults.
20. Government, NGOs and community-based organisations have also been
increasingly advocating for the rights of children using the media and local
dance and drama groups.
These activities are regularly planned on special
events such as the Day of the African Child, the International Children’s Day
6
of Broadcasting, the Universal Children’s Day and the Launch of the UNICEF
State of the World Children’s Report. Sensitisation and awareness creation
workshops have been conducted for various opinion leaders, notably
Parliamentarians in 1996 and 2000.
21. The CRC has been translated into two of the national languages,
Tumbuka and Chichewa. Vernacular versions of the CRC facilitate the
increase of public awareness of children’s rights in Malawi. All forms of the
media have played an important role in publicising the CRC. Additionally,
Parliament has instituted a Parliamentary Committee on Women and
Children (PCWC), and the Human Rights Commission (HRC) has established
a Child's Rights Unit. In 1999 the UNICEF trained 25 core trainers on CRC
who will in turn conduct series of training under the coordination of the
HRC's Child Rights Unit.
(b)
Child Health
Child mortality and morbidity
22. Infant and child mortality and morbidity rates are important indicators
of the attainment of children's rights to survival, to the highest attainable
standard of health and to facilities for the treatment of illness. Manifestations
of the non-fulfilment of these rights are expressed in high mortality rates and
low standards of health. The mid-decade review showed that infant and
under-5 mortality rates had remained virtually unchanged at respectively 134
and 211 per 1000 live births. Reliable figures for mortality are not available
after 1995 but the estimated decline in life expectancy at birth from 52 years
in 1992 to about 40 years in 1999, largely as a result of the HIV/AIDS
pandemic, suggests an increase in child mortality during the second half of
the decade.
23. A great majority of deaths among under-5s in the developing countries
are accounted for by preventable childhood diseases such as measles, polio,
tetanus, tuberculosis, whooping cough and diphtheria, against which there
are effective vaccines, and diarrhoeal diseases, pneumonia and other acute
respiratory tract infections that can be prevented or effectively treated.
Malawi has continued to take concerted action to maintain high levels of
immunisation.
Efforts to reduce the incidence of the three diseases
contributing most to childhood mortality – malaria, diarrhoea and acute
respiratory infections (ARI) – have included strengthening of basic health
services and improving home management of these illnesses.
Immunisation
24. Malawi's immunisation strategy has aimed at fully immunising children
against the six Extended Programme of Immunisation (EPI) diseases before
attaining the age of 12 months and ensuring that all women of childbearing
age receive at least two doses of tetanus toxoid. Success has been achieved in
sustaining high levels of routine infant immunisation coverage for all
7
childhood antigens, but tetanus toxoid coverage for women has remained low.
Coverage rates for individual antigens have been maintained at reasonably
high levels (70-85%), though achievement is still below the Summit target of
90 per cent fully immunised before reaching one year. Moreover, there has
been some decline in the proportion of children being fully immunised on time
i.e., before reaching their first birthday. A comprehensive review conducted by
the EPI Unit in 1999 noted "a decreasing trend in polio,
Diphtheria/Pertussis/Tetanus vaccine (DPT) and Tetanus Toxoid Vaccine
(TTV) coverages."
25. Polio immunisation coverage has been maintained at well over 80 per
cent in most years. No polio case has been reported to date since 1991 and
Malawi is drawing close to achieving WHO "polio-free certification" status
which depends on at least 1 Acute Flaccid Paralysis (AFP) case reported per
100,000 under-15 population. AFP Surveillance in Malawi has improved
remarkably and this year to date (January-October 2000) more than the
minimum required number of AFP cases have been reported: 83 cases as
against the required minimum of 50 on the basis of an estimated under-15
population of about 5 million.
26. With improving tetanus toxoid (TTV2) coverage of pregnant women,
cases of Neo-Natal Tetanus (NNT) declined from 391 in 1985 to 99 in 1990. In
1999 only 6 cases were reported. Malawi is now classified by WHO as one of
the countries in the eliminating phase of tetanus and complete elimination of
neonatal tetanus is expected to be achieved by 2005.
27. A decline in measles cases from 38,347 in 1990 to 4,120 in 1996
achieved through increased immunisation coverage was reversed by sporadic
outbreaks in 1997 when 10,845 cases were reported. In response, a
"Catching-up Measles Immunisation Campaign Week" was undertaken in
October 1998 under which all children between the ages of 9 months and
below 15 years, irrespective of their previous immunisation record, were given
the measles vaccination. The results were remarkable and in 1999 only 152
measles cases were recorded, a reduction by 98.5 per cent. Furthermore,
between January and July 2000, only 134 cases of measles have been
reported. Malawi has thus achieved the Summit target reduction of 95 per
cent in measles cases and deaths resulting therefrom among the under-5
population.
28. Overall, Malawi's immunisation record has been a success story and
the sustained fairly high coverage has been taken into consideration by the
GAVI (Global Alliance for Vaccines and Immunisation) Secretariat in selecting
Malawi for the introduction of new vaccines such as the combined
DPT+Hepatitis B and Haemophilius Influenzae (type B).
Common childhood diseases
29. Malaria, diarrhoea and acute respiratory infections (ARI) have
continued to be the three main causes of mortality among Malawian children.
8
These are the main causes of out-patient attendance and in-patient
admissions.
30. Accurate statistics are not available on the incidence of malaria, but it
is known to be the major cause of mortality and morbidity in children under5. Information relating to the knowledge of the link between mosquito-bite
and malaria and adoption of preventive practices among the population shows
that less than half the women reported knowing that malaria was caused by a
mosquito bite. The level of knowledge of causation was higher in urban areas
and positively correlated to the level of educational attainment. Lack of
knowledge combined with widespread poverty has severely restricted the use
of prophylaxis, mosquito repellents and insecticides. The Government has
continued efforts at controlling malaria through the National Malaria Control
Programme and it is expected that efforts will be intensified under the Roll
Back Malaria (RBM) initiative which involves community groups and schools
to increase the use of vector control tools and bed-nets.
31. The National Mortality, Morbidity and Treatment Survey carried out in
1991 revealed that each under-5 child could be expected to suffer 5 to 6
episodes of diarrhoea each year, (quoted in MSIS, p.37).
While no
comparative figures for later years are available, information on the incidence
and management of diarrhoea provided by surveys indicates a reduction in
the incidence of diarrhoea among the under-5s. Also, there has been
improvement in management practices. Variations in knowledge and practice
pertaining to diarrhoea management were found to be significant for the level
of education of the mother or caretaker. The narrowing of the differences
after 1992 reflects an increase in the spread of knowledge pertaining to
diarrhoea management that may also explain the observed reduction in
incidence. Improvements in home-based management practices can further
reduce the incidence of diarrhoea.
32. Assessment of trends over the decade in the incidence of (ARI) is
hampered by non-availability of data for most years; the only figures available
are for 1993, 1995 and 1996. Cases of pneumonia out-patient diagnoses per
1,000 population of under-5s increased from 118 in 1993, to 138 in 1995 to
166 in 1996. Additional information available for 1992 and 1996 from surveys
on the incidence of ARI and the response of the caretakers in seeking
treatment indicates no marked change in either the prevalence of ARI or the
use of health facilities.
33. The Government has put in place a number of policy measures aimed
at improving the health status of the population in general and children in
particular. The current National Health Plan (1999-2004) seeks to halve the
average number of episodes of diarrhoea per child through increasing health
education and awareness and improving the supply and distribution of ORS.
It also aims at integrating all ARI activities into the Integrated Management of
Childhood Illness (IMCI), planned to cover all districts by 2004. The Essential
Health Package (EHP) focuses on preventive and curative health services and
the Bakili Muluzi Health Initiative (BMHI) focuses on making selected basic
9
drugs available and free (within EHP).
HIV/AIDS
34. The growing HIV/AIDS pandemic has a serious impact on child
mortality and morbidity. Children are at risk of getting infected during the
mother’s pregnancy, delivery or breast feeding. The HIV prevalence rate in the
age groups (15-49) is currently estimated at 16.4 per cent. Sentinel surveys
have reported much higher rates of 30 per cent among women attending ante
natal clinics. About 25-30 per cent of HIV positive mothers give birth to
babies who are infected. In addition, some infants are likely to be infected
after birth as a result of breast feeding, and the majority of HIV positive
infants die before reaching age 5. During their short life span they are prone
to repeated bouts of illness. Generally children of HIV positive mothers receive
less care due to the ill health and subsequent loss of their mothers.
35. The Government of Malawi is fully committed to implementing
programmes to reduce the devastating impact of HIV/AIDS on national
development. It is being increasingly recognised that making progress in this
area is fundamental to the national poverty reduction and growth strategy. In
October 1999 it launched the National Response to HIV/AIDS, followed by the
Strategic Framework for HIV/AIDS in January 2000. The multi-sectoral
Strategic Framework for HIV/AIDS was developed following detailed
consultations at community and national levels. The National Strategic
Framework was discussed at a Round Table Resource Mobilisation
Conference in March 2000.
Water and sanitation
36. Availability of clean water and safe sanitation is a major factor affecting
the health status of the population in general and of children in particular. In
Malawi, access to safe water is defined as the existence of a safe source of
drinking water within 500 metres walking distance one way. For adequate
sanitation, the convenient distance is defined as 100 metres from the
household to the facility. During the period 1992-1998 access to safe
drinking water remained virtually unchanged with about 90 per cent of urban
population and less than 50 per cent of rural population having access to a
safe source. In the case of sanitation facilities too there was very little change.
Less than 5 per cent of the population have access to a sanitary means of
excreta disposal if traditional pit latrines are excluded. Coverage increases to
70 per cent if traditional pit latrines are included. Waterborne sewage
facilities are available to only 16 per cent of the urban population.
(c)
Food and nutrition
Malnutrition
37.
Malnutrition
has
been
widespread
10
among
Malawian
children.
Underweight prevalence is almost 30 per cent among the 6-59 months old
and has remained more or less constant during the decade. Prevalence of
severely under-weight conditions increased slightly over 1992-1998 from 9 to
11 per cent. Stunting also increased, affecting more than half the 6-59
months old population. One-third of the child population is severely stunted.
Though less than 10 per cent of the children are wasted, the incidence
increased during the decade. The proportion of severely wasted in 1998 was
3.6 per cent, more than double that in 1992. There is no significant
difference in the incidence of malnutrition between girls and boys. The overall
incidence of both underweight and stunting is higher in rural areas, but a
higher proportion of urban children are wasted. Generally, the level of a
mother's education is found to be negatively correlated to child malnutrition:
the higher the educational attainment of the mother, the lower the prevalence
of malnutrition. This could be explained by the impact of education on the
mother's knowledge of child care and better feeding practices.
38. It is a fallacy that overall household food insufficiency and insecurity is
the basic cause of the poor nutritional status of children. Poor nutrition
among children largely stems from inadequate feeding and care practices.
Improvement in the nutritional status of children in Malawi is hindered by a
number of factors. These include poor feeding practices such as stopping
exclusive breastfeeding earlier than the recommended six months and
introducing food that is prepared for adults into the diet of children only a few
months old. Other constraints include: lack of knowledge of an appropriate
diet for children and not considering children’s nutritional needs as a priority;
poor household hygiene practices that result in food contamination; poor
healthcare management that leads to frequent illness in children such as
malaria and diarrhoea; infrequent feeding of infants and toddlers; lack of time
for mothers to spend on their children as they walk long distances to fetch
water and firewood; an inadequate supply of food and scarcity of fuel which
decreases the frequency of children eating.
Micronutrient deficiencies
39. The general protein energy malnutrition has been accompanied by
micronutrient deficiencies. Incidence of iron deficiency chronic anaemia
among children under-5 is high. The Ministry of Health and Population
estimates anaemia prevalence in children under-5 at 71 to 90 per cent.
Prevalence of moderate-severe anaemia (haemoglobin levels below 100g/L) is
estimated at 50 to 64 per cent. To overcome this problem, the National Plan
of Action for Prevention and Control of Anaemia aims at providing
iron/folate/micronutrients supplements every six months to 50 per cent of
pre-school children by the year 2004.
40. Substantial progress has been achieved in reducing iodine deficiency
disorders from 66 per cent before 1990 to 17.5 per cent in 1998. Legislation
for salt iodisation in Malawi was enacted in 1995 and is expected to lead to a
gradual elimination of iodine deficiency disorders.
11
41. Vitamin A deficiencies have been substantially reduced by concerted
government action aimed at increasing supplementation through the
immunisation programme. Vitamin A supplementation was incorporated in
the 1996 National Immunisation Day (NID) with the polio vaccine. In 1998, it
was combined with the measles vaccination programme. In 1999 Vitamin A
supplementation was combined with the measles immunisation in the urban
areas. In each campaign the target group was children 9-59 months old and
very high coverages were achieved.
Breast feeding
42. The recommended best practice is for babies to be breast fed exclusively
until six months and then with complementary foods well into the second
year. This practice has not been widely followed in Malawi. To encourage
breastfeeding the Government of Malawi started implementing in 1993 the
"Baby Friendly Hospital Initiative (BFHI)" which aims at promoting breast
feeding through counselling mothers and to provide an enabling environment
at the health facilities. The number of health facilities certified under BFHI
increased from 1 in 1995 to 13 at the end of the decade. Provisions have also
been made for counselling mothers on the risks of mother-to-child
transmission of HIV/AIDS as a result of breast feeding.
43. Information available indicates considerable improvement in breast
feeding practices during 1992-1995. The proportion of infants exclusively
breast fed up to age 4 months increased more than three times. The timely
complementary feeding rate, that is, the percentage of infants 6-9 months old
receiving breast milk and complementary food, increased from 78% in 1992 to
94% in 1995. The continued breast feeding rate, that is, children receiving
breast milk up to the end of their second year, went up from 56 to nearly 70
per cent.
(d)
Role of women, maternal health and family planning
Maternal mortality
44. The maternal mortality ratio (MMR) is 620 per 100,000 live births
according to the MDHS of 1992. Partial surveys since 1992 have indicated
that MMR has remained high. This can be explained by the poor health and
nutritional status of women, the lack of quality obstetric care during
pregnancy and delivery, and inadequate access to contraception which leaves
women open to the risk of too frequent, too early and too many pregnancies.
Women's nutrition
45. The general health and nutritional status of women in Malawi is low.
Three surveys of anaemia prevalence among antenatal women conducted
during the decade showed prevalence rates of 70 per cent in 1991, 56.2 per
cent in 1993 and 62.3 per cent in 1997. In addition, a few studies have been
carried out based on partial surveys.
On the basis of all available
12
information, the Ministry of Health and Population undertook a situation
analysis of anaemia in 1998 concluding that prevalence rates of anaemia
among antenatal women ranged between 54 to 92 per cent. Prevalence of
moderate-severe anaemia ranged between 34 to 60 per cent.
The
Government's response has been the National Plan of Action for the
Prevention and Control of Anaemia 1999-2004 aimed at reducing anaemia
through measures such as supplementation, food fortification, and dietary
diversification and modification.
Obstetric care
46. Central hospitals, district hospital and some mission hospitals provide
comprehensive essential obstetric care; basic essential obstetric care is
provided by health centres, maternity units and some mission hospitals. By
1999 Malawi exceeded the WHO minimum target of one facility per 500,000
population for the former and 4 per 500,000 population for the latter.
However, the proportion of deliveries attended by skilled health personnel has
remained unchanged over the decade at about 55 per cent of all births.
Information for 1992 showed that 90% of women aged 15-49 attended an
antenatal clinic at least once. This was often in the early stages of pregnancy.
Fertility regulation
47. The MDHS showed that nearly 25 per cent of birth intervals are less
than two years and 60 per cent less than the three years recommended by the
WHO. About 60 per cent of females had had at least one pregnancy by age 19
years.
While over 90 per cent of the population have knowledge of
contraceptive practices, the contraceptive prevalence rate (CPR) was 22 per
cent in 1996. A partial survey found that 94% of married women of 15-49
years know of at least one contraceptive option, and 33% practised some form
of contraception in 1999.
(e)
Role of the family
Parental guidance and responsibility
48. There is no specific policy guaranteeing parental guidance to children
because parental guidance is deeply rooted in Malawi's culture and is taken
for granted. However, in the recent past, cases of lack of parental guidance
have been surfacing particularly in urban areas. There are few family welfare
programmes that are provided by both Government and NGOs, including
family counselling services. National legislation does not recognise joint
primary responsibility of both parents for raising the child as it places the
responsibility on the head of a family for providing food, clothing and shelter
for a child below 14 years under his or her care. There is no countrywide
policy and programme on parental responsibility and the government does not
render direct financial assistance to parents or guardians in the execution of
their responsibilities to children under their care. It is only under special
13
circumstances that government provides a foster care allowance of K 200 (less
than US $3) per child per month to families that are caring for foster children.
Separation from parents
49. Under Malawian law a child can be separated from either or both
parents if the parents are legally separated or divorced; if he or she is a victim
of indecent assault by one or both parents; if a custodial sentence has been
imposed on either or both parents; or if the child has to be committed to an
institution. In custody cases, courts apply the principle of "the welfare of the
child as being of paramount interest" which usually goes in favour of the
father who is the one found more often to be financially better placed to take
care of the child. The mother is granted the right of visitation but this right is
limited by the whims of the husband and/or his relatives.
50. There has been much reluctance to talk about sexual abuse within
families, but increased reporting in the media and public discussions are
beginning to break this silence. With the growing awareness of human rights
and citizens’ responsibilities in Malawi, various instances of child abuse are
being publicised, criticised and acted upon. In the case of indecent assault by
a parent, a child is sometimes sent to be cared for by relatives or placed in an
institution for care and protection. There is no legal provision that addresses
the issue of such children maintaining contact with the parents under such
circumstances although social welfare officers encourage parents to visit the
children.
Alternative care
51. The Policy Guidelines for the Care of Orphans in Malawi (1991)
recognises three types of alternative care for children deprived of a family
environment: extended family system; foster care; and institutional care. The
extended family system is deeply rooted in Malawian culture and hence the
most preferred of the three options. A foster care scheme operates and social
workers place and supervise children in foster care, ensuring reunification of
foster children with blood relatives when they are found. Foster parents are
paid a fostering allowance. Institutional care is considered a last resort for
children for whom the first two options are not available. In 1996 the
Government launched an orphan care programme which aims at ensuring
that orphans are able to grow up in a caring environment.
(f)
Basic education and literacy
Early learning
52. Pre-school education is now available in all districts and access to early
childhood education was estimated at 26.6 per cent in 1999, an increase from
1 per cent in 1990. There is no officially endorsed record of the total number
of pre-school centres but coverage is higher in urban than in rural areas.
14
Poor communities are expected to manage and sustain pre-school
community-based day care centres by meeting the monthly honoraria of
instructors and providing daily packed meals for the children who attend.
During periods of acute food shortage, therefore, day care centres either
experience low attendance or temporarily close down. The Government
adopted a National Early Childhood Development Policy (NECDP) in 1998
aimed at developing and promoting a comprehensive and multi-disciplinary
approach to the welfare and development of young children, introducing early
childhood education as part of basic formal education.
Primary education
53. In 1994 the Government introduced free primary education. As a
consequence enrolment shot up to 3.2 million in 1994/95, an increase of 50
per cent over the previous year; gross and net enrolment ratios increased to
respectively 134 and 95.7 per cent. Intake tapered off somewhat, and total
enrolment remained at about 2.88 million for the rest of the decade. The net
intake ratio for boys increased to 75.8 per cent in 1995 from 61.1 per cent in
1990, but then declined gradually to 25.5 per cent in 1997. The survival rate
to Standard 5 for boys and girls declined respectively from 68.9 and 55.6 per
cent in 1990 to 45.2 and 43.6 per cent in 1997. Survival rates to Standard 8
that stood at 85 per cent and 69 per cent respectively for boys and girls in
1990 dropped to less than 25 per cent. On average only 23 per cent of a
cohort completes an eight year primary cycle.
54. The sudden increase in enrolment following the introduction of free
primary education put severe pressure on school facilities. The
pupil/classroom ratio rose to 140 while the pupil/qualified teacher ratio went
up to 108:1 from 80:1 in 1990. Government efforts towards building more
classrooms and training teachers have contributed significantly towards
improving facilities. The Malawi Integrated In-Service Teacher Education
Programme (MIITEP) and the Malawi School Support Systems Programme
(MSSP) were launched to meet the increased requirements of qualified
teachers and the pupil/qualified teacher ratio has improved to 74:1.
Increasing the number of teachers has been an uphill task in view of the high
attrition rate estimated at 11 per cent per annum. The relatively poor terms
and conditions of teachers have resulted in a poorly motivated teaching force.
Attrition is further aggravated as a result of HIV/AIDS related morbidity and
mortality.
Adult literacy
55. The National Adult Literacy Programme (NALP) is aimed at reducing
adult illiteracy. The government’s efforts have focussed on recruiting and
training adult literacy instructors, producing teaching and learning materials
and enhancing participation. However, the adult literacy rate (population aged
15 years and over that is literate) has declined from 50 per cent in 1990 to 42
per cent in 1999. For males it increased marginally from 66 to 67 per cent
but declined substantially for females from 44 to 33 per cent. As a result the
15
literacy gender parity index worsened from 0.66 to 0.50.
(g)
Children in especially difficult circumstances
56. The following categories of children have been identified as being in
especially difficult circumstances:
-
Street children
Orphans
Child workers
Children in conflict with the law
Children with a disability
Refugee children
Street children
57. A study in 1999 estimated the number of street children at 2,000 in the
main cities of Lilongwe, Blantyre and Mzuzu. Some of these children have
homes and families but spend their days in the streets, begging or scavenging.
Others have no homes and families and have to spend their nights on the
streets. A situation analysis of child abuse undertaken by the National Task
Force on Children and Violence (NTCV) showed that street children are
vulnerable to sexual abuse. The Government assists street children through
the Department of Social Welfare within the Ministry of Gender, Youth and
Community Services. There are limited resources for addressing the problems
of these children. Social welfare groups and civic and religious organisations
that focus attention on the plight of street children are severely constrained
by lack of resources.
Orphans
58. No comprehensive enumeration of the orphan population has been
conducted. Estimates vary, with some stating that the orphan population
was as high as one million by the end of the decade. HIV/AIDS-related
mortality added considerably to the number of orphans during the decade. In
1990 there were an estimated 24,000 AIDS orphans; by the end of the decade
the figure had gone up to 390,000. An AIDS orphan is defined as an under15 whose mother or both parents died due to AIDS. In 1991 the Government
organised a National Consultation on Children orphaned by AIDS which
produced policy guidelines for the care of orphans and created the National
Task Force on Orphans (NTFO). The Government’s Orphan Care Community
Based Child Programme is aimed at assisting other needy children as well as
orphans.
The support provided has been grossly inadequate and the
condition of orphans is made worse by extreme poverty and the erosion of
extended families. However, the government and people of Malawi have been
praised for their humane and exemplary treatment of orphans in spite of the
meagre resources to address a problem of such magnitude. The Government
policy is to discourage the creation of orphanages and instead to keep
orphaned children in their extended families.
16
Child workers
59. It is estimated that about half of the population aged between 10 to 15
years engage in paid work or unpaid domestic help. Malawi is a signatory to
all ILO Conventions pertaining to the abolition of child labour. National
legislation has been enacted to regulate the minimum age of employment for
children. However, due to widespread poverty enforcement of the laws is
difficult as children need to work to supplement household income.
Moreover, increasing mortality and morbidity due to the growing HIV/AIDS
pandemic, intensifies the need for children to earn a living. Orphans are the
major contributors of child labour. The child labour market is dominated by
domestic workers, especially girls. Children also continue to be employed in
hazardous and detrimental work in tobacco and tea estates.
Children in conflict with the law
60. The Children and Young Persons Act provides for the procedures to be
followed when dealing with juvenile offenders. The Act guarantees privacy and
requires that the parents or guardians should be in attendance when the case
is heard. However, the provisions of the Act are rarely followed and young
offenders are treated virtually as adults. Only two reformatory centres exist
for detaining juveniles, and juveniles are not always placed in these special
centres – consequently they end up in adult jails. An International Seminar
on Juvenile Justice in Malawi in November 1999 focussed attention on
various issues pertaining to juvenile justice and since then there has been
growing awareness of the need for change. A Juvenile Justice Forum was
formed by NGOs, government institutions, community and church leaders.
The Forum seeks to contribute to the protection of the rights of children in
conflict with the law and to promote a culture of human rights in Malawi
through the establishment of a fair and humane juvenile justice system.
The Forum has actively lobbied to ensure that all cases are screened and pretrial diversion and directives given to police for the provision of police cells for
children in order to ensure separation of children from adults.
Children wit disabilities
61. No data is available with respect to children with a disability. Most of
these children are taken care of by the family or receive community care, but
some organisations, such as Cheshire Homes, provide care for disabled
children. Government has shown an increasing awareness of problems
relating to child disability. It is evident that due to HIV/AIDS, the capabilities
of extended families and community based rehabilitation programmes have
been considerably diminished. The Government has established an Office of
the Minister Responsible for Disabled Persons within the Office of the
President which is currently developing a national policy for people with
disabilities.
17
Refugee children
62. The outbreak of civil war in neighbouring Mozambique in 1986 saw a
large influx of refugees into Malawi. By 1992, Malawi had over a million
refugees, the largest refugee population in Africa. In 1989 Malawi enacted the
Refugee Act 1989, which gave effect to the 1951 Geneva Convention and the
1967 Protocol relating to the status of refugees, as well as the OAU
Convention of 1969 governing specific aspects of refugee problems in Africa.
The Malawian refugee legislation guaranteed all fundamental rights to
refugees.
63. With the assistance of UNHCR, the Government of Malawi provided
facilities of health, education and water and sanitation to the child refugee
population for about a decade until most were repatriated by 1994. The
refugee population dwindled during the second half of the decade but picked
up towards the end of the decade. There is one camp in Dzaleka (Dowa
district) where the current refugee population exceeds three thousand and
includes about 600 children of primary school age. The Government
continues to provide them the basic services: health care including
immunisations, special feeding programme for malnourished children, and
basic education including pre-school facilities.
Child abuse
64. Children in especially difficult circumstances are at risk of suffering
abuse, including sexual abuse. Cases of child abuse, particularly child sex
abuse (CSA), have been increasingly reported. A situation analysis of child
abuse in Malawi, conducted recently by the National Taskforce on Children
and Violence, shows that unprotected children such as orphans, street
children and child labourers are more likely to experience abuse. All forms
of child abuse, particularly sexual abuse, are extremely degrading and have
far reaching and detrimental impacts on a child's personality. A number of
problems arise in the control of child sexual abuse: children and adults have
difficulties in communicating about CSA; and silence precludes any
protection for children subjected to incest or other forms of abuse. The
police, the courts and the media have been known to treat victims with little
consideration of their privacy. There are no judges or magistrates who
specialise in cases involving children.
(h)
Alleviation of poverty and revitalisation of economic growth
65. To be able to meet and sustain the goals for long-term child survival,
protection and development, Malawi needs to establish a sound economic
base and alleviate widespread poverty which affects more than 60 per cent of
the population. The Malawi Integrated Household Survey 1998 showed that
while the prevalence of poverty was 65 per cent in the total population, 70 per
cent of children aged 5-14 years lived in poor families. Poverty affects
children more and poverty reduction must start with children. Poverty
18
reduction strategies must focus on improving basic social services: primary
health care, education, nutrition programmes and water and sanitation. The
government has completed its IPRSP and instituted a Targeted Inputs
Programme (TIP) which serves as a kind of safety net for the poorest of the
poor whereby they receive a 20kg pack of maize and other seeds and fertiliser.
66. The Government's expenditure on basic social services during 1990/91
to 1996/67 constituted 6.4 to 11 per cent of annual total expenditure. In
1996/97, it was 7.6 per cent, which was far below the 20 per cent proposed
under the 20/20 Initiative. One of the main reasons for under-investment in
basic social services is the crippling external debt burden. At the end of 1999,
Malawi's stock of external debt in nominal terms was estimated to have been
US $ 2,597 million, including US $ 6.7 million in arrears. The net present
value of this debt, before the application of traditional debt relief mechanisms,
is estimated at US $ 1,479 million or about 81 per cent of GDP. Malawi's debt
to revenue ratio at end 1999 is estimated at 512 per cent.
67. With such a debt-burden scenario, Malawi could be considered eligible
for debt relief under the World Bank/IMF Heavily Indebted Poor Countries
(HIPC) Initiative. Under this Initiative a country is provided debt relief so as to
have additional resources available to strengthen social programmes,
especially in primary education and primary health. Malawi's case for HIPC
eligibility will be considered towards the end of December 2000. Preliminary
estimates indicate that assistance under the HIPC Initiative could translate
into an annual debt service reduction averaging US$ 40-50 million during the
next twenty years. The reduction would be equivalent to approximately 1.3
per cent of GDP during the first ten years and could be used to finance a 20
per cent increase in the resources devoted to health and education.
E
LESSONS LEARNT
68. Malawi's progress towards improving the well-being of children during
the 1990s varied from remarkable in some areas to stagnation in others. It is
clear that the early and full involvement of communities and stakeholders is a
pathway to success. Immunisations, for example, were very successful
because of community input. Long before a needle ever touched a child,
preparatory
consultations
were
conducted,
messages
developed,
methodologies of delivery established, and community approval secured. The
coming of a new multi-party system of government in 1994 brought
assurances of human rights and freedoms. For the first time in 30 years
problems were acknowledged and solutions were proposed. Freedom of
speech and of the press have resulted in expanding public awareness of
children’s and women’s rights. Information has been shared on society’s
constraints and possibilities. Such increased communication promises more
effective programming in the future. The recent socio-political changes have
also informed a population that is increasingly amenable to a human rights
based approach to programming.
Another lesson learned is that the
prevalence of inadequate and old data is a constraint to the development of
19
effective programmes. Some lack of progress in Malawi is due to the problems
associated with an inadequate information base. Thankfully, new and
accurate data collected in the Census of 1998 and the MDHS of 2000 will be
made public in the near future.
However, information gathering and
monitoring and evaluation will need to be conducted on an on-going, regular
basis in the future.
Enabling factors
69.
Government commitment, increasing community participation, and
donor support can be identified as the main enabling factors. Government's
commitment reflected in the formulation of the National Programme of Action
for the Survival, Protection and Development of Children as a follow-up to the
World Summit has been maintained. There has been increasing contribution
on the part of communities.
Community based initiatives have been
successful in the areas of early childhood care, orphan care, IMCI and
primary education. Local communities and parents have played an increasing
role in educational contributions with regard to sharing the cost of buildings
and their maintenance, learning materials and extra-curricular activities.
70
Donor support has helped bridge gaps in resources and played a
major role in sustaining the immunisation programme, free primary
education and enhancing awareness of the rights of the child. Improved
coordination of donor assistance has contributed to a more effective use of
external funding. This has been achieved with the introduction of the Sector
Investment Programmes (SIPs) and the Sector Wide Approach to
Programmes (SWAPs). SIPs involves a comprehensive review process of
strategies for a sector in consultation with donors and stakeholders and
reduces aid fragmentation, thereby removing a serious shortcoming of the
project approach.
SWAPs involve consultations between stakeholders,
government and donors to agree on sector reforms and joint financing
implementation arrangements – “a common basket” - for the SIP.
Investment Programmes have been developed in the education and health
sectors. The Policy Investment Framework 2000-2012 (PIF) is guiding
assistance in the education sector as a result of which the sector is already
benefiting from an orderly, coordinated and synergistic approach. In the
health sector, the National Health Plan (1999-2004) has provided a rallying
point for collaboration between government, stakeholders and donors to
transform health sector financing mechanisms to those that are based on
sector-wide resource availability projections.
Major constraints
71. Major constraints to greater progress have been: limited government
resources; household poverty; low status of women; and HIV/AIDS.
Government expenditure on basic social services, which impact most on
children, fluctuated between 6 to 11 per cent. Increases in government
20
expenditure remain constrained by a heavy debt burden. The high incidence
of household poverty, with over sixty per cent of the population living below
the poverty line, has been a major obstacle in children's access to adequate
food, education and health facilities.
Poverty has also contributed
significantly to the increase in child labour and exposure of children to abuse.
72. The welfare of children, particularly in the earlier years, is closely linked
to the care provided by the mother. However, when fathers are actively
involved in the care of their children, the chances for the child’s improved
welfare are raised drastically. The low status of women has had serious
adverse effects on care practices. A woman’s ability to provide care depends
on knowledge of appropriate child rearing and feeding practices, time
available for child care and the extent of control over available resources.
Knowledge of appropriate practices is closely linked to educational
attainment, and a low level of female literacy thus contributes to child
malnutrition. Time which women can devote to children is restricted by the
long hours women have to work in the home and in economic activities. Time
available is also compromised by the frequent pregnancies with closely spaced
children to look after.
These factors convey the importance of men’s
participation in caring for their children and the benefit their involvement can
bring to the entire family.
73. The HIV/AIDS epidemic has had a severe adverse impact at all levels.
Government departments and private institutions, including medical facilities
and schools, have experienced losses of trained personnel. Increasingly,
government resources have to be diverted from productive sectors to the care
of those living with HIV/AIDS. At the community level, the epidemic has put
an enormous strain on the community's capacity to care for orphans and the
destitute. At the household level HIV/AIDS has aggravated poverty through
loss of income earning capacity and increasing expenditures on the care of
family members suffering from HIV/AIDS. Children of affected households
are less likely to attend school and more likely to be malnourished. Upon the
death of their parents, orphans often have to work to fend for themselves.
Key issues
74. A number of challenges and key issues have emerged during the decade
in all areas affecting the well-being of children. Concerted action is required
to meet these challenges in the areas of health, education, water and
sanitation and the protection of children in especially difficult circumstances.
F
FUTURE ACTION
75.
To attain the goals of the World Summit for Children future action will
have to be focussed on addressing the key issues which have remained and
overcoming the challenges that have hampered progress. Recommendations
for future action are summarised below:
21
22
RECOMMENDATIONS FOR FUTURE ACTION
No.
World Summit Goal
Key issues
Recommendations
23
1.
Between 1990 and the
year 2000, reduction of
infant and under-5
mortality rate by one-third
or to 50 and 70 per 1000
live births respectively,
whichever is less


Continuing high incidence of malaria,
ARI and diarrhoea.
Poor home management of illnesses.

Poor hygiene and sanitation practices.

Insufficient health facilities and distance
from health facility.
Inadequate supply of drugs.
Shortage of doctors and skilled health
personnel.
Inadequate management and monitoring
of the cold chain at district vaccination
centres.
High incidence of HIV/AIDS.




2.
Between 1990 and the
year 2000, reduction of
maternal mortality rate by
half




Limited awareness of safe maternal
practices and delayed resort to obstetric
care.
Low proportion of deliveries attended by
skilled health personnel.
Non-availability of timely and affordable
contraceptive services.
High incidence of teenage and closely
spaced pregnancies.
24












Promote use of treated bednets and equip all
health facilities to properly manage severe
malaria cases.
Extend implementation of IMCI countrywide as
envisaged in the National Health Plan.
Give priority to female education and increasing
awareness of basic hygiene in education
programmes.
Improve accessibility to health care by providing a
health facility at reasonable distance for all.
Ensure regular supply of essential drugs.
Increase training facilities for skilled health
personnel and scale down entrance requirements.
Monitor quality and coverage of health services
regularly.
Mainstream HIV/AIDS prevention/intervention
strategies in all health programmes.
Increase ANC facilities and conduct IEC campaigns
to emphasise importance of attendance.
Increase facilities and make them more accessible
to women for delivery under skilled health
personnel.
Provide all individuals, male or female, access to a
range of affordable contraceptives.
Strengthen family life education at all levels of
education, including emphasis on safe motherhood
practices.
No.
World Summit Goal
Key issues
Recommendations
25
2..
Cont..
3.
Between 1990 and the year
2000, reduction of severe
and moderate malnutrition
among under-5 children by
half

Low nutrition status of women,
particularly high incidence of chronic
anaemia.


National and household food insecurity.
Inadequate knowledge of appropriate
“care” practices.
Low rate of exclusive breastfeeding.
Low-status of women.



Test all pregnant women for haemoglobin levels
and provide iron supplementation as required.

Assist farmers with Starter Pack type initiatives
to increase and diversify food production.
Conduct sensitisation campaigns on improved
“care” practices.
Enhance efforts to promote breast feeding and
extend the BFHI to all health facilities.
Sensitise women and men on gender equality and
equity.



4.
Universal access to safe
drinking water and to
sanitary means of excreta
disposal







Poor participation and inadequate
community based management.
Low profile of hygiene education.
Poor hygiene practices at household
level.
Absence of a coherent national
sanitation policy and strategy
framework.
Inadequate environmental management
leading to water contamination and
pollution.
Ineffective training for extension
workers and communities.
Inadequate capacity for local
manufacturing of hand pumps and
spare parts.
26






Include CBM Systems for water and sanitation
activities as an integral part of the
implementation process to ensure sustainability.
Increase hygiene profile (education)
Develop as a priority an integrated water and
sanitation policy.
Put in place an effective data collection,
maintenance and updating and management
system for the sector.
Increase opportunities of appropriate training for
extension workers, especially skills training in
participatory techniques.
Provide an enabling environment for promoting
local manufacturing of hand pumps and spares.
No.
5.
World Summit Goal
By the year 2000, universal
access to basic education
and completion of primary
education by at least 80 per
cent of primary school-age
children
Key issues
Recommendations

Inadequate opportunities for early
learning, particularly in the rural areas.


Non-enrolment, low enrolment and late
enrolment at the primary level.


High dropout and repetition rates, more
so among girls.
Low retention of girls in primary school
due to pregnancy, early marriage or
fear of abuse.
Inadequate infrastructure and
widespread shortage of materials.
Short supply of trained teachers
Inappropriate curricula.







6.
Reduction of the adult
illiteracy rate (the
appropriate age group to be
determined in each country)
to at least half its 1990
level, with emphasis on
female literacy

Low response to the national adult
literacy programme, especially among
females.
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Encourage communities and organisations to
promote early learning and increase facilities for
early childhood education.
Take steps to get orphans, child workers, street
children and children with special needs into
school and complete primary or equivalent
education.
Ensure full and equal access to basic education for
girls through community schools; promote
retention, completion and achievement rates for
girls; ensure elimination of discrimination in
classrooms, textbooks, schools, home and
community.
Provide learning materials and basic furniture;
improve provision of classrooms, water and
sanitation facilities.
Increase supply of trained teachers.
Mainstream teaching about the causes, risk
factors and prevention of HIV/AIDS
in the
curriculum.
Encourage adults to attend adult literacy classes
and revise curricula to make them more relevant
and focussed to cater to adult requirements
No.
World Summit Goal
Key issues
Recommendations
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7.
Improved protection of
children in especially
difficult circumstances
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High rate of AIDS deaths put
unprecedented strain on extended
family system as care provider for
orphans.
Orphans usually deprived of
inheritance.
Increasing number of children headed
HH.
Inadequate access of street children to
basic social services.
Inadequate information on incidence of
child labour.
Child labour widely accepted both
culturally and because of economic
need.
Large-scale employers (such as tobacco
and tea estates) able to circumvent law
to hire under-aged workers.
Law enforcement authorities and
judicial officers not fully aware of
juvenile justice procedures.
Inadequate access to education for
children with a disability.
Children with disability face
stigmatisation
Inadequate knowledge of management
of child sexual abuse (CSA).
CSA of girls in school by teachers.
Insufficient consideration and
understanding on part of the police for
plight of CSA victim.
Long-drawn out and tedious judicial
process for deciding CSA cases.
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Provide assistance to families willing to offer foster
care for orphans.
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Provide mechanism to ensure orphans inherit.
Provide direct assistance to child headed
households.
Support organisations working with street
children.
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Collect statistical information to determine the
precise extent of child labour and its various
dimensions.
Conduct IEC campaigns to inform people on the
adverse impact of child labour on children’s
development, particularly education.
Enforce labour laws and regulations particularly
those relating to age of workers and nature of job.
Conduct sensitisation workshops for magistrates
and police officers on the rights of the child and
juvenile justice.
Make efforts to integrate children with disabilities
into normal schools while increasing provisions of
special education for others.
Encourage open discussion on child sexual abuse.
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Develop and enforce code of conduct for teachers.
Sensitise police officers on the need to be sensitive
to CSA cases.
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Introduce measures to speed up trial procedures
for CSA cases and sentence offenders
appropriately.
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