Inequality and health in Malawi 2011 – an analytical study identifying trends over 19 years
George Chapotera1 and Cameron Bowie2
1: Department of Planning, MOH
2: Department of Community Health, College of Medicine, University of Malawi, Blantyre, Malawi.
Prepared for the Technical Working Group on health equity
Ministry of Health and SWAp partners
Malawi is the eleventh poorest country in the world according to UNDP (HDR2010). Health affects poverty and poverty affects health. This paper considers the contribution inequity of health care plays to the health status in Malawi over 19 years from 1992 to the present time.. Methods
Published data prepared by the World Bank and the Malawi Integrated Household Surveys are augmented by analysis of Demographic and Health and Multiple Indicator Cluster Surveys including the latest DHS 2010 survey. Inequalities are identified and quantified using asset scores, wealth quintiles and the equality index – a measure of inequality. Results
There has been a substantial and enduring improvement in the levels of equality for indicators of health status and the use of health services. Where access is universal, such as EPI, antenatal care and the treatment of pneumonia, the indicators are highly equitable. Where access is improving but not yet universal for services such as skilled birth attendance, family planning and bed net usage the equality indices demonstrate some progress has occurred but show room for further improvement. Underlying determinants offer a mixed picture – some show more inequality such as with fertility and women’s empowerment and some more equality, such as orphan-hood. Conclusions
Poverty in all its facets is a key underlying cause of ill health in Malawi. Recent efforts to improve access to health care through the Essential Health Package have tended to reduce inequalities. Patience and persistence appears to be having an effect on many of the underlying determinants of health of the poor.
Health affects poverty and poverty affects health. For Malawi which is the second poorest country in the world the effect of poverty on health is likely to be huge. Not only is life expectancy short (51 years at birth for women and 49 for men), but ill health is common and health services are overstretched and short of funds. Poverty limits an individual’s ability to respond to events, such as famine or a serious illness in the family. Lack of income is one limiting factor; lack of education, political freedom, ability to buy and sell goods and land tenure traditions are other limiting factors. Malawi has political freedom, an open market system, a land tenure tradition which encourages subsistence farming, and many uneducated people. Illiteracy is common (38% in women and 21% in men (DHS2010)  and food insecurity perennial without fertilizer subsidy. A number of authorities such as the United Nations Development Programme (UNDP) and the World Bank have published country specific data and analyses of health related aspects of poverty. Local data are also available. These can be used to assess the effect of poverty on health. Reducing poverty to increase capabilities will increase freedom, which can be considered the ultimate goal of poverty reduction strategies. Remedies would seem to lie in a mixed bag of initiatives across a broad range of human endeavours – political, social, health, economic, security and education. But which remedies will have the most impact on health? This paper brings together relevant information pertinent to an assessment of how poverty relates to health in Malawi. It seeks to identify the poverty reduction interventions most likely to improve the health of Malawians. It has very practical application. Analysing inequalities in health and health care is key to designing and implementation of evidence based polices for reducing them. This study will therefore...
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