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

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

Our Inspiring Visit with a Community Based Organization in Malikha

World Camp Country Manager Michael Kumwenda, Program Coordinator Karen Clark, and Professional Capacity Building Intern Rufus Faggons ventured to meet with the leadership and members of Kasumba CBO (Community Based Organization) near Liwera Full Primary School in the Malikha Primary School Zone.

We were warmly welcomed by the staff, who had arranged nametags on our seats. They dove right into sharing with us the meat of their efforts. The Kasumba CBO membership hovers around 30 and they serve 58 villages! There are over 200 orphans living in their catchment area, but the number is increasing at an alarming rate.

The CBO has been serving the Kasumba area for five years, and when asked why each member joined, they all provided different and very personal responses. One woman’s sister-in-law was handicapped and she wanted to provide support not only for her sister-in-law, but for everyone in her area who faced physical handicaps (both women are pictured right). One man, frustrated that his children couldn’t go to school during the rainy season because the road washed out, has personally vowed to plant 1,000 trees during the year 2012 to combat deforestation and preserve his environment. Another man observed the human rights of youth being abused in his community.  He joined the CBO to learn more about child rights and use the group as a way to educate and sensitize the community to the fragility, resilience, and potential of youth. One woman noticed the growing number of orphans in her community and the fact that they weren’t getting the support they should from their extended families. She’s been at the forefront of Early Child Development Centers and Orphan Support Units in the area.

The main room in the CBO’s office. The sign reads,
“2010: HIV and AIDS Outside the Box: Living Positive with HIV and AIDS.”

So far, the CBO has realized amazing success: they have set up and sustained seven Community Based Childcare Centers, supported school drop outs and orphans through the donation of school uniforms and feeding programs, held weekly after school athletic events and tutoring sessions during the school year, handed out five wheelchairs for those with disabilities, and sensitized the community to the benefits of education and the risks of early

marriages. But there’s still a long way to go. HIV rates are rising, the Home Based Care group lacks adequate training, the CBO shares a building with all other community groups and the church, some of the husbands of the female members don’t like when they go to meetings, adult literacy is low, and funding is a large problem.

Two CBO members show a map and posters
used to log information

Despite the future struggles of Kasumba, we were struck by the members’ openness, articulation of past success and future objectives, complete commitment to positive growth and development, and passion for those living in their communities. Kasumba Community Based Organization is a forum for activists in Liwera to plan and accomplish their dreams for community improvement, and with the passion we saw this week, we have no doubt they will!

Chiyembekezo (Hope)

Heartbreak. At first glance, Malawi is heartbreak. A raw, unyieldingly vivid picture of the pains and sorrows of my heart. The landscape is barren for miles, sweeping toward a lone tree resting in solitude on its hilltop outlook. Girls tell me calmly, evenly, that an obstacle they face in achieving their goals is being raped and beaten by men. Children beg insistently for money, pencils, food, anything. Students ask innocent questions like: “If HIV is in the body, why can’t we just take it out?” that dig into me like thorns. Questions that leave me wishing it were that simple.

But then I close my eyes and open them again. And I see a changed Malawi. A Malawi that is happiness. I see Malawi for what it truly is. An earnest-faced teacher pats my hand and calls me his daughter while another shows me how to drive an ox cart community members volunteered for the purpose. Passerbies on the street always have a wave, a smile, or a thumbs-up to offer. Students run alongside our bus as we pull up to their school and crowd around the car door to greet us as we step out. Women welcome me into their homes and teach me to do chores while chattering away in a language I cannot comprehend. Standing in a dance circle under a still sky streaked with milky stars, my heart feels full and at peace.

Malawi: you have inspired me to keep on fighting on gritty step at a time. You are a hopeful country, a country with conviction and joy and dreams of a brighter future. So let us hold hands as brothers and sisters—equals—and march forward together towards that glimmering orb peaking over the horizon. Let us march together, struggle together, believe together, and keep moving forward. Forward toward that brighter future. One step at a time.

Chiyembekezo

(Hope)

Submitted by: Michelle Ju, Malawi SS2 Intern