Access to Health Care: How Governance Plays a Role

By Intern Rachael Thorn

World Camp’s work focuses on helping the people of Malawi access health care. There are many challenges to health access in Malawi and issues surrounding governance are a starting point to help us understand lasting and sustainable solutions for communities. 

Malawi’s government decreases its capacity to provide fundamental services to its citizens through poor governance that would ultimately only strengthen Malawi as a whole. The 2014 report of the Corruption Perception Report ranks Malawi as 110 out of 174 (with number 1 being the country with the least amount of corruption). Its score is 33 on a scale of 0 (highly corrupt) to 100 (not at all corrupt) (Transparency International).

Corruption Perceptions Index 2014
The perceived levels of public sector corruption in 175 countries/territories around the World:

What does this have to do with access to health care? Let’s take a look at Malawi’s government. Malawi appears to have a patronage system, which means the government rewards contacts in the private sector for their support or in exchange for furthering their political advantage. Between a patronage system and the large income disparity present in Malawi, we begin to see a vicious cycle of poverty and stagnation for lower classes. As there is less room for reward in sectors like education and health, for government officials and companies, less money is put into these underfunded sectors. Largely, a system has been put in place that is beneficial for some, but not for those who depend on the state to provide fundamental public services.

The 1998 Local Government Act was an attempt to introduce a framework that diminished instances of corruption. This was implemented “to further the constitutional order based on democratic principles, accountability, transparency and participation of the people in decision making and development processes” (Commonwealth Local Government Forum). However, Malawi’s rule of law lacked the ability to enforce this accountability that would come from the democratic process, because it was proposed without outlining methods to constrain the patronage system already in place. Thus, the pedestal of democracy did not have the legs to stand on and the tradition of patronage continued to dictate the priorities of the public sector.

We must remember that it is difficult to talk about the corruption in any country because it is only the perception of corruption that it is verifiable. Thus, to quantify it, such as the Corruption Perception Report does, only tells us part of the story. It is more important to understand that the citizens perceive this corruption based on the quality of life in their daily experiences and accessibility to public services. World Bank’s “survey results suggest that users (households and businesses) regard public institutions as delivering generally inferior quality services or alternatively that none of the public institutions listed are performing exemplary public service in Malawi. The performance and the perceived honesty/integrity of institutions are highly correlated” (eldis). It may be difficult to view public institutions as reliable for many citizens after the 2013 Cashgate scandal in which over 70 people were arrested in regards to illegitimate payments from the government that were being paid to civil servants who had previously supported political players.

Why is understanding corruption in state governance important? Where do we go from here? One major form of change comes through social mobilization that comes out of education, awareness and empowerment. World Camp is working towards all of these things. We face the systemic problems everyday and have to continue to believe that they are not unchangeable. The first step in mobilization is understanding where the foundation is cracked and how that crack trickles down to affect almost every aspect of society. The first of the World Bank suggestions for moving towards progress says: 

“In fighting corruption not only must the approach be holistic, but it must also be carried and supported by all stakeholders in the society” (Governance and Corruption Diagnostic Survey in Malawi). 

Continuing support of our work to include all citizens of Malawi in having an empowered voice can lead to improved access to health care and education. Our holistic programs reflect the suggestion of the World Bank and looking towards the future, the hope instilled in our partner communities can become empowerment—and empowerment can become change. 

A Hopeful Future

HIV was first reported in Malawi in 1985. Since then, the spread of HIV has reached 10.8% of the adult population. “Malawi has a generalized HIV epidemic. HIV prevalence among persons aged 15 to 49 years has been declining steadily from 16.4% in 1999 to 11.8% in 2004 and then 10.6% in 2010.” Not only does the disease affect the adult population, but about 170,000 children also live with HIV (Malawi AIDS Response Progress Report 2015).

Photo: AVERT
An HIV prevention poster in Mzimba, Malawi.

Counsellor explaining about HIV testing and treatment on World AIDS Day, Malawi - See more at: http://www.avert.org/hiv-aids-malawi.htm#sthash.qndVapSH.dpuf

Counsellor explaining about HIV testing and treatment on World AIDS Day, Malawi - See more at: http://www.avert.org/hiv-aids-malawi.htm#sthash.qndVapSH.dpuf

Counsellor explaining about HIV testing and treatment on World AIDS Day, Malawi - See more at: http://www.avert.org/hiv-aids-malawi.htm#sthash.qndVapSH.dpuf

Increased prevention work and education over the past decade attributed to the decline in new cases. Although, Malawi’s infrastructure and economic standing make it difficult to truly erase it from epidemic status. Recent years indicate positive steps in the right direction, but prior decades of poor governance and constrictive bureaucracy left behind a lot of work to be done.

HIV prevention and access to antiretroviral drugs are the focuses to curbing the spread of the disease. Initiatives currently implemented include: expanding voluntary HIV testing and counseling (HCT/ VCT), prevention of mother-to-child transmission services, condom promotion and distribution, voluntary medical male circumcision (VMMC), blood safety measures, mass media campaigns, and life skills education (LSE) for young people (AVERT).

Many non-governmental organizations (NGOs) collect high volumes of data in their hands-on work to identify the most common causes of transmission and the most affected demographics. Organizations such as the World Bank, the Global Fund, the World Health Organization, the President's Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on HIV and AIDS (UNAIDS) have all taken an active role in funding and planning to decrease incidence and increase awareness in Malawi (AVERT).

Photo: AVERT
Counselor explaining HIV testing and treatment on World AIDS Day, Malawi.

UNAIDS, specifically, leads the way in analyzing target goals to catalyze initiative to eliminate HIV/AIDS. Their plan for 2015 has been very successful. The target goal for 2015, as set out in the Millennium Development Goal 6 of 2000, has been surpassed. This year, UNAIDS “celebrates the milestone achievement of 15 million people on antiretroviral treatment—an accomplishment deemed impossible when the MDGs were established 15 years ago… [Worldwide,] new HIV infections have fallen by 35% and AIDS-related deaths by 41%” (UNAIDS).

Malawi’s steadily improving situation reflects the larger global picture, but meeting goals requires working within localized communities. Greater awareness and education will lead to a better perspective on HIV prevention in Malawi. For example, many adults do not get tested, but simply assume they are living with HIV because of its prevalence. Unsafe sex is justified by choosing partners based on their societal status or perceived cleanliness. Even if precautions are taken, condom use and safe sex practices are rarely being implemented on a consistent basis. Education, access to testing sites, and decreased stigmatization of testing will be key factors in the next five years in continuing to improve the state of Malawi’s HIV epidemic.

Looking to the future, UNAIDS’s highlights its target goals for 2020, “90% of people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression” (UNAIDS 90-90-90).

By World Camp Intern Rachael Thorn

Greetings from Camp Hope!

After years of writing about Camp Hope and working to make it possible each summer, I had my first chance to visit yesterday. The experience was as moving and fun as I could have ever imagined. The campers, like all groups of Malawian children I’ve gotten to hang out with, were sweet, excited to meet a new person, and super energetic. I was invited to eat at a different table for every meal, but I barely sat down before the kids were eagerly asking, “What’s your name?”

Camp Hope is a camp that serves specifically youth living with HIV. These children, so considerate and adorable, are all facing a tremendous life-long challenge. Camp offers our newly-disclosed to youth a chance to come to terms with their diagnosis, learn more about their disease, and bond with other children facing similar difficulties. It’s jam-packed with fun activities, but also designed to provide campers with knowledge and skills they will need to care for themselves throughout their lives.
One of the absolute highlights of my visit was meal time. Campers are clustered into Color Groups that sit together at meals and participate in activities together. During meals campers chant songs, break out into dance and celebrate each other’s achievements from the day. Two campers from each Color Group are recognized at every meal, sung to the front by the whole Camp – enthusiastic hands pounding out a rhythm on the tables. Mentors (think Camp Counselors) recognize the success of these campers: Describing their positive contribution, Labeling the attributes this speaks to, and Praising the camper for this behavior.

I was so happy to find that my visit fell on Day 5 of Camp which features Stage Night in the evening. Stage Night is a talent show that really lays clear what a supportive, nurturing environment Camp is. Each Color Group spent much of the day preparing a presentation to share with the rest of Camp. The presentations showcased the campers’ talents while also emphasizing the importance of Camp Hope to our youth. My favorite moments were when campers recited poems they had written about Camp, or the importance of adhering to your HIV drug regimen.

Both World Camp Intern, Zoey Ponder, and I will be visiting Camp again next week. We can’t wait. We’ll be back with more updates for sure!

Risky Business: Malawi's Youth and Tobacco

In the past decade, Malawi has become one of the worlds five largest tobacco producers. (Aljazeera) As a result of Malawi’s high-nicotine, low-cost tobacco, many major cigarette brands are including Malawian tobacco in their blend. More than 90% of Malawi’s tobacco is bought by U.S.-based leaf buyers Universal Corporation and Alliance One International. These companies resell to tobacco firms, amongst these firms are such big names as Phillip Morris (Marlboro) and British American Tobacco (Lucky Strike) (The Guardian). Malawian tobacco can be found in the blend of nearly every cigarette smoked in the west. 

At first glance the industry may seem good for Malawi, being that it is one of the least developed nations in the world, ranking 153 of 169 countries in the human development index. (Aljazeera) Unfortunately, however, the tobacco industry has done little to improve the situation for Malawians and much to improve the payout for the large western companies that purchase the incredibly cheap “green gold”. The price of this tobacco is kept low for big business in a multitude of ways. There are low tariffs on unmanufactured tobacco imports and a low labor cost. The labor cost is often kept so low by employing child laborers.  

Photo: The Guardian

Though the minimum age to work in Malawi is officially 14, it is common to see children as young as five picking tobacco alongside their parents. It is estimated that 20% of children aged 5-14 in Malawi are working. (Bureau of International Labor Affairs) Many of these children drop out of school to work in tobacco farms and other industry and are unable to return to school or only able to attend school sporadically. Child laborers are especially susceptible to work-related injury and illness. When working with tobacco, large amounts of nicotine can be absorbed through the skin causing nicotine poisoning, an incredibly common ailment amongst child tobacco workers. Large tobacco industries claim not to support farms that employ child laborers, but often do little to actually prevent child labor. In addition, the legal framework to prevent child labor in Malawi is weak. 

The most effective method thus far for preventing child labor is pressure on the companies that purchase the tobacco, in turn putting pressure on the government as well as farms. Other groups suggest improving the school system to attract children and families to enroll and stay in school. This is problematic, however, since many families need the children to work in order to support the family. An improved education, though valuable, would not immediately help support the family. The main groups making headway within the farming system and the government are small NGO’s and other grassroots programs that support both the children and the family. Still, with tobacco sales comprising 70% of Malawi’s income and Malawi being one of the most child labor-intensive economies in the world, it is unlikely much will change as long as companies can keep the tobacco cheap.

This blog was written by Zoey Ponder

Free Secondary Education in Malawi?

Talk of Malawi’s 2014 presidential election has fostered significant debate regarding the state of education in Malawi, specifically, the United Democratic Front’s proposition to provide free secondary education for Malawi’s youth. Malawi’s current education system is comprised of a primary system consisting of eight grades, while secondary and university systems have four years of curriculum each. In an opinion column for the Nyasa Times, writer Steve Sharra provided what he sees as the pros and cons of this proposal and the potential of the education system to develop a more prosperous Malawi.

Currently, Malawi has a free primary education system which is beneficial but has had its fair share of flaws and shortcomings. Subsequently, opponents of this free secondary education system look to the history of the primary education system, and worry that past mistakes will be repeated. In 2010 the World Bank published a study on the education system in Malawi and found that compared to other Sub Saharan African (SSA) countries, Malawi performs worse in post-primary levels and technical, entrepreneurial, vocational education and training. Malawi’s Southern African Consortium for Monitoring Education Quality (SACMEQ) scores in Mathematics and English reading are among the lowest. Dropout rates are high and lead to a 35 percent completion rate for students within the system. As of 2010, the primary education system requires 23 years to produce one Standard 8 graduate, instead of eight years with an ideal internal efficiency. The retention rate in secondary education is much better, with very few dropouts within the cycle. (World Bank)

Having a sufficient number of teachers as well as ensuring they are adequately qualified through their own education and training is a significant issue. The ratio of student to trained teacher hovers at 88:1. When only looking at urban schools, however, the student-teacher ratio (STR) drops to 46:1

In addition to the lack of physical resources to maintain a thriving education system, opponents also worry about the implications of further dependency on donors for Malawi’s economy and ability to thrive and be competitive on a global scale. The cost of providing more free education is beyond the financial means of Malawi’s budget and an argument is made that investing in other areas of national development could produce benefits within a shorter time frame.

Proponents of a completely free education system acknowledge past failures in the education system but see these as a resource to create a better system. “Knowing where things went wrong ought to mean knowing how to do things differently next time,” says Sharra. For example, when free primary education was implemented, little to no consideration was made to how an influx of students would affect secondary education and its ability to accommodate such an increase in enrollment. If secondary education becomes free as well, the same mistake cannot be made at the University level.

Other considerations for a fully free education system would include a detailed list of what physical infrastructure needs to be created, how this will affect federal budget, where to get money to supplement the national budget for education, and a targeted plan for application until full-scale implementation is viable. Another important consideration is providing programs for those who are beyond secondary school age, but have not yet completed secondary level requirements.

Providing for education is a direct investment in the future of Malawi and affects economic activity for individuals as well as the nation. Education has the potential to strengthen human capital, and aid Malawians in thinking critically in a world of economic crises and high unemployment to find new and innovative responses to problems. There is much to consider though, including infrastructure, capacity, and economic feasibility.

Additional reference: US Embassy in Malawi

Happy International Women's Day!!

In honor of International Women’s Day, we thought we would look at how women in Malawi are striving to improve their situation. From a female president to local mothers working to support area youths, Malawian women shape their communities and are increasingly fighting for more rights and better livelihoods. 

For many women living in Malawi, the appointment of Joyce Banda as president has been an exciting indicator of change to come in the next few years for women in Malawi. More than ever, the country’s women are striving to achieve greater access to education, healthcare, opportunity and human rights. Historically, women have suffered an unequal status in society. Joyce Banda’s pledge to strive for women’s empowerment and rights reflects her own past that mirrors the situation of many women in Malawi. Banda was able to escape an abusive marriage and move on to a new life, job, and marriage, but she realizes that many women do not have access to the same opportunities as she.

“Two years later I got married again to my husband who was a high court judge in Malawi. For the next two, three years I moved from zero to hero: I was running the largest business owned by a woman in Malawi, in industrial garment manufacturing. But when I looked back his fingerprint was all over: if I wanted training, he paid; if I wanted a loan, he came with me. Because of his status in society everything was easy for me, so I had succeeded but I had succeeded because I was privileged. And that's when it began to worry me. I began to think about those that were in my situation that were not able to walk out of an abusive marriage, or maybe those that did not know where to go, that were in a single headed marriage, or widows.”

Women all over Malawi suffer similar conditions every day. But in realizing their shared situation, women have been rising up to improve their personal conditions and access to assistance.

As seen in this article, Malawi’s women have recently been standing up for improved healthcare and their rights concerning HIV/AIDS. For instance, the main antiretroviral (ARV), a drug taken to prevent the onset of HIV after one is infected with it, provided by the Malawian government is D4T. However, D4T contains harmful chemicals that results in physical disfiguration and even eventual death. Malawian women have been campaigning against the provision of these drugs and demanding more effective treatments.

In a separate event, a health clinic in the town of Chipoka was closed because it did not have sufficient staff to remain open. HIV-positive patients seeking ARVs on a Thursday were told they could not get them until Tuesday. Female activists, knowing this could be detrimental for the HIV-positive individuals, protested and spoke with officials, and managed to have the clinic reopened 7 days a week as originally intended. (Note: Taking ARVs sporadically or inconsistently can lead to drug resistance, rendering a particular drug or drug cocktail useless.)

“We are going to challenge the government to make a policy to ensure a sustainable ART [antiretroviral treatment] regimen regardless of whether donors are here or not. And we also need the government to make sure that [HIV] positive women have their own resources like savings loans and fertilizers [for farming]. It’s our responsibility to fight for these things,” stressed rights activist Ms. Sibongile Chibwe

In other parts of Malawi, many women’s groups and mothers’ groups have been coming together to monitor the enrollment of girls in school, as well as their attendance and retention. These groups realize that increasing education for girls will in turn decrease the poverty rates in a society – raising the overall productivity of that community. UNICEF published a short piece on a Mothers’ Group that has helped coax girls back to school at Mnjolo Primary School. There are many cases such as this in which these groups have been successful in increasing enrollment by providing things that very poor families cannot afford for school, like uniforms.

There is growing hope for the women of Malawi as they rise up to change their own conditions. In taking this stance, women are empowering themselves and making the first steps of changing century old attitudes, habits, and situations that have deprived women everywhere. Today we salute these women and hope to be able to support them in their efforts.