REPORT ON THE HEALTH REASSESSMENT by pW9tEG9T

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									    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).




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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.




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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.




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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
MZIMBA                  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
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
Mbota                    5             0               31                3               2                  2          3.58       37.04
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
KARONGA                 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




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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




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Number of First ANC Visits by District and Month (March-August, 2002)

District      March       April       May        June       July        August      Total
Karonga             379         350        412        380         425         389       2,335
Dedza             2,832       1,372      1,081        973         910         895       8,063
Dowa                805       1,785      1,162        977       1,086         834       6,649
Kasungu           1,444       1,975      1,713      1,702       1,754       1,769      10,357
Mchinji           2,836       3,040      2,658      4,050       3,869       4,140      20,593
Ntcheu            2,168       1,480      1,306      1,275       1,200       1,160       8,589
Salima              899       1,291      1,114      1,130       1,195       1,250       6,879
Mzimba            1,207       1,301      1,297      1,360       1,250       1,300       7,715
Blantyre          2,481       2,498      2,550      2,244       2,210       2,299      14,282
Thyolo              983       2,459      2,050      2,350       2,390       2,040      12,272
Total            16,034      17,551     15,343     16,441      16,289      16,076      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            First Quarter            Second Quarter              (%) M (%) F
               Male    Female     Total  Male   Female     Total
Karonga           19         14       33     31        32      63            63   129
Dedza             61         75      136     77        94     171            26    25
Dowa              37         29       66     52        36      88            41    24
Kasungu           77         73      150     93        54     147            21   -26
Mchinji           49         62      111     56        53     109            14   -15
Ntcheu            38         46       84     56        51     107            47    11
Salima            42         53       95     64        70     134            52    32
Mzimba            68         63      131    150       179     329           121   184
Blantyre         499        434      933    522       543   1,065             5    25
Thyolo           109        139      248    140       157     297            28    13
Total            999        988    1,987  1,241     1,269   2,510            24    28

* This includes all cases of TB (smear +ves, smear -ve but with clinical diagnosis and
  extrapulmonary TB)




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                                                  New cases of TB by district and quarter


            1,200


            1,000


                800

                                                                                                                                First Quarter
                600
                                                                                                                                Second Quarter

                400


                200


                  0
                        Karong                       Kasung
                               Dedza       Dowa             Mchinji Ntcheu Salima Mzimba Blantyre Thyolo
                          a                            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




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