POLICY BRIEF April 2021 Spending for Health in Malawi: Current Trends and Strategies to Improve Efficiency and Equity in Health Financing Key Messages: Malawi has made In the short term, the There is an urgent need The Malawian government remarkable progress in government and donors to make public finance could strengthen the improving maternal and should ensure that existing management work better efficiency and equity child health outcomes, financial resources in at district level in order to of its human capital but the COVID-19 the health sector are not improve the quality and investments given the pandemic could reverse reduced, while at the same effectiveness of health constrained fiscal space these gains due to its time monitoring how the service delivery in the by developing a health direct and indirect effects COVID-19 pandemic is country. financing strategy to guide on health, and its impact affecting the supply of, resource mobilization, on economic growth and and demand for, services pooling, allocation, and resource mobilization in order to mount an purchasing of health care efforts. effective response. goods and services. 02 POLICY BRIEF April 2021 Spending for Health in Malawi O ver the past two health services. Patients’ fears of social sectors could shrink rather decades, Malawi has contracting COVID-19 if they go than increase. made remarkable to health facilities has also been progress in improving maternal contributing to this trend. Even In the face of the COVID-19 and child health, as well as though a COVID-19 vaccination pandemic, Malawi needs to nutrition outcomes. Under-5 campaign was launched in the improve the efficiency of its and maternal mortality have country on March 11, 2021, the current spending in the health been reduced by more than half, direct and indirect effects of the sector while at the same time surpassing the averages for pandemic are nonetheless likely strengthening key institutions regional and peer countries. to persist for some time. so that service delivery improves. This is due in large part to Structuring spending to support government expansion of key Financing of health services in the most vulnerable and improve health and nutritional services Malawi is also likely to be human capital outcomes more across the country. In fact, affected by the COVID-19 broadly is also important. Malawi performs better than most pandemic. Additional investments To support these efforts, the low-income countries in sub- in the health system are needed World Bank recently completed Saharan Africa in terms of to prevent the further spread a Public Expenditure Review that service coverage, and of the virus and maintain the seeks to identify bottlenecks and government spending on health provision of other essential health solutions in order to improve is relatively higher than other services. This will require expenditure on human capital[2]. low-income countries. However, additional domestic and external This policy brief draws on the Malawi still lags behind on funding. However, given the health module of this review certain health and nutrition negative impact of the pandemic highlighting key gaps, and indicators particularly stunting, on economic growth and resource outlining the measures required which contributes to the country’s mobilization worldwide, to improve financing and health low Human Capital Index score expenditure on health and other service delivery in Malawi. of 0.41. This means that children born in Malawi today will only be 40 percent as productive Trends in the Volume and Composition as they could have been had of Health Expenditure they enjoyed full health and complete education. Malawi’s total spending on health and high disease burden. in per capita terms and as a share The fact that most key health The COVID-19 pandemic could of GDP is higher than other system delivery inputs - such reverse the gains in the health low-income countries. as medicines, equipment, and sector in Malawi. As of April 7, Nonetheless, total health spending ambulances - are purchased 2021, there were 33,673 per capita, estimated at US$39 outside the country, and paid confirmed cases of COVID-19 per year, is insufficient to provide in foreign currencies from in Malawi with 1,124 deaths[1]. essential health care as outlined international suppliers compounds There has also been a reduction in the country’s health benefit this problem. in the use of some key reproductive, package – the Essential Health maternal, and child health Package (EHP). This has Donor funding remains the largest services. This is mainly due to contributed to gaps in service source of funding to the health disruptions in the procurement delivery. Moreover, due to high sector, but its growth has been and distribution of medicines and inflation, public expenditure on low in recent years with other medical commodities; and health has been decreasing in households picking up this slack greater emphasis on COVID-19 real terms over the years despite (Figure 1). High dependency on as compared to other essential the country’s growing population donors to finance the health sector POLICY BRIEF April 2021 Spending for Health in Malawi 03 in Malawi poses a potential risk was uncovered; donor support to opportunity to improve the public of making health financing the health sector has mainly been financial management (PFM) unsustainable, which could cause through vertical programs and system in the country. On the disruptions in health service projects. For the FY2017/18, about other hand, households have delivery. Since the ‘Cashgate’ 74 percent of donor funding to the significantly increased their scandal in 2013, where health sector was off-budget. This spending on health as compared misappropriation of donor funds negates the five principles on aid to growth in donor and government amounting to around US$32 million effectiveness* and is a missed spending (see Figure 1). Figure 1: Composition of Total Current Health Expenditure, FY2006/07 – FY2017/18 Source: Authors’ construction from Malawi National Health Accounts (MOHP, 2020) [3] 80% 14% Households and Employers/ 70% 12% Donors and Government 60% 10% Local NGOs 50% 8% 40% 6% 30% 4% 20% 10% 2% 0 0 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Donors Government Households Employers/Local NGOs Resource Allocation and Predictability of Funding All three main financiers of health disease burden in the country – for personnel emoluments, leading care in Malawi (donors, example, the growing prevalence to low expenditure on drugs government, and households) of non-communicable diseases – and medical supplies, and other focus their spending on the main and aligning funding to the top recurrent transactions (ORT). causes of disability-adjusted life causes of DALYs is an important At 16 percent, Malawi’s share years (DALYs), but priorities differ. strategy for reducing the overall of public spending on drugs is Government and household funding burden of disease in the country. lower compared to the share are more aligned to the order of spent by other African countries. priority of the disease burden than In line with the national health Consequently, the current level donor funding. This suggests that policy, which prioritizes primary of funding only caters for about although health spending in Malawi health care, the bulk of financial a six-month supply of drugs. is broadly linked to the disease resources are spent at district Results from the Harmonised burden, the order of prioritization is level, but there are issues with Health Facility Assessment (HHFA) aligned to the preferences or the way spending is distributed. shows that, on average, health interests of the financiers. Adapting More than half of total public funds facilities countrywide had only 38 to the changing nature of the in the health sector are spent on percent of the essential medicines 04 POLICY BRIEF April 2021 Spending for Health in Malawi 0.011 Karonga 0.004 Figure 2: Chitipa Number of Doctors per 1,000 Population, FY2018/19 Source: Authors’ calculations based on government data 0.022 Rumphi Mzimba North 0.012 0.024 Nkhatabay Likoma Mzimba South 0.015 Nkhotakota 0.005 Kasungu 0.013 Ntchisi 0.009 0.008 Dowa Mchinji 0.017 Salima 0.012 Lilongwe 0.005 Dedza 0.007 Mangochi 0.005 Ntcheu Doctor density 0.004 Machinga 0.005 Balaka <0.005 per 1,000 0.007 0.012 0.005 - 0.010 per 1,000 Neno Zomba 0.008 Mwanza 0.005 0.029 Phalombe Blantyre 0.010 - 0.015 per 1,000 0.008 0.006 Chiradzulu 0.010 Mulanje 0.005 Thyolo 0.015 - 0.020 per 1,000 Chikwawa >0.020 per 1,000 0.020 Nsanje Lakes POLICY BRIEF April 2021 Spending for Health in Malawi 05 they should have, and no health 25 percent are able to diagnose cost-effectiveness, and equity. facility had all 24 essential and treat co-morbidities like However, this formula is not being medicines at the time of the malaria with anaemia, and used, and distribution of public survey[4]. diarrhoea with severe funds to districts is based on dehydration[4]. Finally, while the historical precedence. Despite the relatively high share of public spending on Specifically, the amount allocated expenditure on personnel infrastructure development in the to each district annually is based emoluments in the health sector health sector increased from a low on the previous year’s allocation, in Malawi, there is still a critical of 5 percent in FY2014/15 to a which increases (or decreases) shortage 10,000 of clinical health high of 16 percent in FY2015/16, 50 in line with the available budget. workers while the existing only half of required infrastructure This approach perpetuates Public Per capita Spending (MK) infrastructure is dilapidated. is available. In addition, general inequities and explains the wide 8,000 40 U5 Children Stunted (%) The World Health Organization service readiness is estimated variations across districts between recommends one doctor per at 60 percent[4]. per capita public health spending 1,000 people, 6,000a ratio that none of and health outcomes (see Figures 30 the country’s 28 districts currently Malawi has developed four 3 and 4). Moreover, the formula come close to (see Figure 2). needs-based formulas for only focuses on the allocation of 4,000 Moreover, the distribution of distributing financial resources government funds, and financial20 doctors varies by district, with from the center to the districts, resources for drugs and ORT. most doctors in the country which aim to achieve efficiency These constitute a very small 2,000 10 working in Blantyre, which has and equity objectives. Its latest portion of the overall resource 0.029 doctors per 1,000 people, formula, developed in 2019, envelope in the health sector. compared to Machinga 0 and includes data on population size, 0 Chitipa districts, which have just disease burden and coverage Mangochi Neno Mchinji Dedza Ntcheu Ntchisi Dowa Mzimba Machinga Lilongwe Mulanje Zomba Kasungu Thyolo Salima Blantyre Chiradzulu Nkhotakota Chitipa Balaka Chikwawa Nkhata-Bay Rumphi Nsanje Phalombe Mwanza Karonga Likoma Figure 3: 0.004 doctors per 1,000 people. rates, unit costs of treatment, and The quality of health care is also cost variations across districts[5]. Public Per Capita Expenditure by District vs Stunting Among poor, with only 75 percent of It is also aligned to the country’s Children Under 5 (U5) health workers able to diagnose health benefit package, the EHP , and treat common conditions which aims to advance the Per Capita Spending - FY2018/19 Stunting such as pneumonia, while only principles of health maximization, 10,000 50 Public Per capita Spending (MK) 8,000 40 U5 Children Stunted (%) 6,000 30 4,000 20 2,000 10 0 0 Mangochi Neno Mchinji Dedza Ntcheu Ntchisi Dowa Mzimba Machinga Lilongwe Mulanje Zomba Kasungu Thyolo Salima Blantyre Chiradzulu Nkhotakota Chitipa Balaka Chikwawa Nkhata-Bay Rumphi Nsanje Phalombe Mwanza Karonga Likoma Per Capita Spending - FY2018/19 Stunting P 2,000 20 06 POLICY BRIEF April 2021 Spending for Health in Malawi 0 0 y Bl ulu um a D a Ka gu Th a be a kw a at a re za Zo je Li dza ra hi N e N a je a i Ka phi a Sa u Li lo C a M -Ba ji ot a o M his aw k ng ng t kh lim w m tip b in he b ow en C ko n C oc ty an yo la n om an dz m m ng sa ko ch su ro hi tc e an hi a Ba tc a N g ul D zi w ac al lo an M N M M R M hi hi Ph kh N N Figure 4: Per Capita Spending - FY2018/19 Public Per Capita Expenditure by District vs Under 5 Mortality Rate (U5MR) U5MR Source for Figures 3 and 4: Authors’ calculations from government data and Malawi Demographic and Health Survey, 2015-2016. U5MR=Under-5 mortality rate. 10,000 140 120 8,000 Public Per capita Spending (MK) 100 U5MR per 1,000 live births 6,000 80 60 4,000 40 2,000 20 0 0 y Bl ulu um a ka Ka gu Th a be a kw a at a re za Zo je Li dza ra i N e N a al e a i Ka phi M ba Sa u Li lo C a M -Ba ji ot a o h M his aw ng ng t kh lim w m Ph anj tip in he b ow en C ko n C oc ty yo la n om an dz m m ng sa ko ch su ro hi tc e an hi a Ba tc a N g ul D zi w D ac lo an M N M M R hi hi kh N N Per Capita Spending - FY2018/19 U5MR Spending is also not aligned to Donor funds are often released due to numerous reporting the budget. This could be due to late, and their absorption is low requirements. weaknesses in domestic resource mobilization at the national level, and gaps in health services Efficiency and Value for Money planning. Regular expenditure below and above the budget There are various points in the available health services and raises questions about its health system where resources outputs into better health credibility, as well as its usefulness could be lost or wasted. Figure 5 outcomes. This section analyzes as a planning and resource illustrates these pathways each of these in turn. allocation tool in the health sector. including: i) inefficiencies during the allocation of funds and/or Pathway 1: There is room to improve the purchasing of key health system Purchasing of Key predictability of donor funding. inputs such as recurrent transfers, Health System Inputs Identifying and resolving human resources, drugs, and inefficiencies in the allocation and physical infrastructure; ii) A major cause of inefficiencies in use of donor funds is critically technical inefficiencies in the health sector relates to important because donor funding transforming available inputs into Malawi’s weak PFM system, which is the largest source of financing quality health services and has made it difficult to deliver for the health sector in Malawi. outputs; and iii) issues translating health services at government POLICY BRIEF April 2021 Spending for Health in Malawi 07 Financing Inputs Production of Improved Health Services and Outcomes Total current » health 1 Recurrent » transfers 2 Outputs 3 » Health status expenditure Service » per capita » Human packages » Patient resources for maternal, satisfaction Drugs and » child health, » Risk protection medical and nutrition supplies » Outpatient » Medical and inpatient equipment admissions and physical » Universal infrastructure Health Coverage index Health Access » and Quality Figure 5: index Pathways for Potential Inefficiencies in the Health Sector. Source: Adapted from Hafez (2020)[6] hospitals and health centers. budgetary releases to districts to fragmentation of planning Effective management of public are not usually communicated and budgeting, delivery, and expenditures on health is essential to health providers leading to monitoring and evaluation systems to increasing coverage and poor accountability. in the health sector. For instance, achieving better health outcomes in addition to the government in Africa[7]. In Malawi, PFM is Planning and budgeting system, there are multiple characterized by inadequate processes are in place at district financial management and compliance with guidelines, level, but they do not effectively monitoring and evaluation systems especially at government health support prioritization of activities. that are managed by donors. facilities. For example, while health Service providers at district expenditures at the district level are hospitals and health centers are Execution protocols emphasize in excess of budgeted amounts, usually not informed about the control over flexibility. Budget there are persistent delays in the amount of available funding or execution protocols at district- transfer of funds, and inter-sectoral ‘in-kind’ support for the following level government health facilities borrowing of earmarked funds also year. In addition, participation of require input-based controls of occurs. Delays in funding means service providers in planning and the line-item budget with limited that the money is not remitted as budgeting processes is marginal, opportunity for virement. As a planned, which results in monthly which weakens the prioritization result, district health management disbursements being process. Further, by using vertical teams sometimes avoid using the unpredictable. In addition, programs, donors also contribute electronic system, which weakens 08 POLICY BRIEF April 2021 Spending for Health in Malawi accountability, and contributes spend money. In fact, and as There are no comprehensive to the accumulation of arrears. highlighted in Table 1, budget financial reports covering all Non-government facilities formulation, execution, and levels of government. Financial managed by the Christian Health evaluation at CHAM facilities reporting at district level is done Association of Malawi (CHAM), is relatively better than at using Navision accounting on the other hand, receive a government facilities. Lessons software, while at central level the global budget and have greater could be learned from PFM financial management information flexibility with regards to how they at these facilities. system (FMIS) uses a different application, called Epicor. These two systems are not integrated, Table 1: making it difficult to generate Budget Formulation, Execution and Evaluation by Facility Type and Ownership comprehensive financial reports Source: Authors’ construction. across all levels of government. Moreover, donor financing is E1 = Efficiency | E2 = Equity | Q = Quality | A = Accountability generally not captured in the FMIS, which leads to partial financial reporting. Given that about 60 Health Centers percent of total health expenditure Service Delivery Measures in Malawi is provided by donors, Budget this means that a large part of Phase E1 E2 Q A health expenditure is not routinely reported. Consequently, evaluating Government D D D+ D+ the effectiveness of spending in Formulation the health sector is challenging. CHAM D D C D+ Government D+ D D D+ Pathway 2: Execution Technical Efficiency CHAM D+ C C D+ There is a direct relationship Government D D D D+ between public health expenditure Evaluation CHAM C C D C per capita and availability of clinical staff. This means that the distribution of health workers is Hospitals a key factor in how financial resources are distributed in the Service Delivery Measures public health sector in Malawi. Budget Phase Nonetheless, results show an E1 E2 Q A inverse relationship between the availability of health workers and Government D+ D C D Formulation total outpatient visits. Districts with CHAM B+ C B B lower staffing levels see more outpatients than those with higher Government C+ D D+ C+ staffing levels. This suggests that Execution some health workers are being CHAM B B A A underutilized. The other possible Government D D D C explanation is that the quality of Evaluation outpatient services is poor in CHAM A A A A districts with high staffing levels, POLICY BRIEF April 2021 Spending for Health in Malawi 09 hence the low usage. As revealed needed. Having a better mix of while remaining steady for the in previous sections, high service inputs and reconfiguring wealthiest households. Increasing expenditure on personnel the financing mechanism from an household spending on medicines emoluments, but low spending input-based to a performance- could be attributed to inadequate on medicines and other medical based financing system is critical. public spending on medicines as supplies, contributes to limited highlighted in earlier sections. access to quality and efficacious Persistent shortages of medicines medicines in the country. To Equity at government health facilities address this problem, resource prompts households to buy them allocation should be improved Ensuring equitable access to from private drug stores and so that there is optimal distribution quality health care services is pharmacies, which has a greater of financial resources across all a key priority for the Government impact on poor households. key health systems inputs. of Malawi. This is reflected in the country’s national health policy Over the years, equity of access Pathway 3: and strategic plan, which affirms to health care services for the Value for Money the country’s commitment to poor has improved. This could achieving the health-related be due to the increased use Although Malawi performs better Sustainable Development Goal of free health services by poor than most low-income countries in targets, and universal health households at government and sub-Saharan African in coverage†. Aligned to these CHAM health facilities. None- transforming the available health frameworks is the EHP , where theless, catastrophic health services into better child health Malawi has defined a list of priority expenditures are still prevalent outcomes, it is not as effective interventions and services through in certain areas even though when it comes to maternal health which resources are allocated. there has been some improvement outcomes. This could be attributed The government provides free EHP in financing and access to to low quality maternal health care, services at all government health health services for the poor. as documented in the 2015-16 facilities, and where there is no The proportion of households Demographic and Health Survey. government facility, CHAM health in the lowest (poorest) quintile The survey shows that while the facilities are contracted to provide incurring catastrophic health percentage of births occurring a package of selected health payments has increased in rural at a health facility or attended by services for free. areas, for example. Thus, despite a skilled provider are high in having a free health care policy Malawi, at 91 percent and 90 Though out-of-pocket expenditure and the existence of service level percent respectively, the quality on health as a share of total agreements with CHAM facilities, of antenatal and maternal delivery health expenditure has been catastrophic health expenditures services is poor[8]. Further, critical increasing consistently since are still prevalent in parts of shortages of key health systems FY2012/13, poor households Malawi. Therefore, the chances inputs (human resources, have not been affected. In fact, of rural poor households being medicines and medical supplies, there has been a decline in total exposed to financial hardships infrastructure), and poor household spending on health when accessing health care, governance and accountability, as a share of total household and being pushed into poverty, also contribute to the provision expenditure among the poorest are very likely. Furthermore, of low quality maternal health households. The increasing burden poor households continue to care in the country[4]. of out-of-pocket spending has consume more health services been borne by wealthy households. at government health facilities For service coverage to translate However, when faced with illnesses (where quality of health care into improved health outcomes, requiring medicines, the burden on is low) as compared to CHAM greater focus on quality is poorer households has increased, and private health facilities. 10 POLICY BRIEF April 2021 Spending for Health in Malawi Policy Recommendations To address the challenges outlined above, several key recommendations could be implemented in the short, medium, and long term. These interventions are provided in Table 2 below. Table 2: Policy Recommendations Intervention High Priorities: Short Term (1–3 Years) Medium to Long Term Priorities (3–5 Years) Improve Raise additional financial and material resources to prevent domestic the further spread of COVID-19, and maintain provision and external of other essential health services. At a minimum, the resource government needs to ring-fence funding for health care mobilization by ensuring that the existing level of funding to the health sector is not reduced. Improve ❱ Reprioritize government and donor spending in the health Develop and implement a health allocation sector. If need arises, spending on infrastructure could be financing strategy to guide resource and use of suspended until there are sufficient funds. mobilization, pooling, allocation, available and purchasing of health care ❱ Fully apply the revised district-level resources allocation resources goods and services. The strategy formula to both government and donor resources across needs to encompass key aspects all districts. Furthermore, considering that this formula only of the financial sustainability plan, focuses on the allocation of financial resources for drugs and contain viable strategies for and operational grants in the public sector, the Ministry promoting financial sustainability of Health and Population (MOHP) could also look closely and resilience. at the funding and distribution of human resources, infrastructure, and equipment. Focusing on the resources allocation formula alone will not lead to the desired improvements in allocative and technical efficiency. ❱ Develop a financial sustainability plan that could sustain the available government and donor funding for an additional three to five years. Improve Donors should align their funding to government systems at both predictability central and district levels to increase its effectiveness. Aligning of donor donor funding in this way is critical to improving the overall funding allocation of funds, as well as governance and accountability in the health sector. Immediate actions include: i) Developing a system for routine mapping and tracking of external funds at both central and district levels; ii) Aligning donor funding to the order of priority of the disease burden; and iii) Increasing the predictability of donor funding through the use of joint budgeting, disbursement, financial management, procurement, and reporting systems. … table continued next page POLICY BRIEF April 2021 Spending for Health in Malawi 11 Table 2: Policy Recommendations Intervention High Priorities: Short Term (1–3 Years) Medium to Long Term Priorities (3–5 Years) Improve ❱ Enforce use of the existing public finance management guidelines at district level. Integrating public finance accounting systems at the district and central government levels should also be prioritized in order management to improve financial reporting in the health sector. and efficiency ❱ There is a need for greater flexibility on budget execution at government health facilities. Health budgets at district level also need to be ring-fenced to avoid intergovernmental transfers when funds are disbursed to the district councils. ❱ Provide regular training and mentorship on health services planning and budgeting to authorities and service providers at district level. This could help to improve the allocation and use of resources. ❱ There is a need for consistent advocacy on evidence-based planning and application of the district-level resource allocation formula among policymakers and planners. Improve value ❱ The government should improve the quality of health care for money services at government health facilities as this is where most and equity poor people access health services. This is also the primary route towards achieving universal health coverage. ❱ Catastrophic health expenditures are still prevalent in rural areas even though there has been some improvement in financing and access to health services by the poor. Therefore, there is a need to further increase access for poor households to CHAM and private health facilities, especially in areas where there are no government health facilities. This could be achieved through the introduction of vouchers in addition to the existing service level agreements between the government and CHAM. Effective ❱ The MOHP needs to improve distribution of the available management health workforce across all districts and health facilities. of human ❱ Increasing the productivity of existing health workers resources by introducing performance-based financing (PBF) schemes. By using PBF , financing to health facilities would be distributed on the basis of outputs rather than inputs. These sorts of schemes are currently being used in Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Improve Regularly monitor how the COVID-19 pandemic is affecting planning for the supply and demand for health services, and undertake timely procurement procurement and distribution of vaccines, medicines, and other of drugs, essential medical commodities. vaccines and other medical supplies … table ends n 12 POLICY BRIEF April 2021 Spending for Health in Malawi Endnotes Image Credit Cover © Lindsay Mgbor/ In line with the Paris Declaration on Aid Effectiveness, the five principles that make aid more effective are: * Foreign, Commonwealth & ownership, accountability, alignment, harmonization, managing for results, and mutual accountability. Several Development Office donors that operate in Malawi are signatories to the Paris Declaration. For more information see https://www. oecd.org/dac/effectiveness/34428351.pdf. Used under Creative SDG 3, target 3.8 requires all countries to “achieve universal health coverage, including financial risk † Commons Attribution. protection, access to quality essential health care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” References 1. World Health Organization. Health Emergency Dashboard [Malawi]. Available from: https://covid19. who.int/region/afro/country/mw. 2. World Bank. Malawi Public Expenditure Review 2020. Washington DC; 2020. 3. Ministry of Health and Population [Malawi]. Malawi National Heath Accounts Report for Fiscal Years 2015/16–2017/18. Lilongwe: 2020. 4. Ministry of Health and Population [Malawi]. Harmonised Health Facility Assessment 2018-19. Lilongwe; 2019. 5. Twea P, Manthalu G, Mohan S. Allocating Resources to Support Universal Health Coverage: Policy Processes and Implementation in Malawi. BMJ Global Health. 2020;5:e002766. 6. Hafez, R., ed. Measuring Health System Efficiency in Low- and Middle-Income Countries: A Resource Guide. Joint Learning Network for Universal Health Coverage; 2020. 7. Kutzin J. Why Does Public Finance Matter for UHC? World Health Organization. Africa Health Economics Association Conference. Rabat; 2016. 8. National Statistical Office [Malawi] and ICF International. 2015–16 Malawi Demographic and Health Survey. Zomba/Rockville; 2017. This policy brief was produced by the World Bank’s Health, Nutrition and Population Team for Malawi with financial support from the Global Financing Facility. The team was led by Collins Chansa and Katelyn Jison Yoo. The core team included Toni Lee Kuguru, Mariam Ally, Moritz Piatti-Fünfkirchen, Collins Owen Francisco Zamawe, Patrick Hettinger, and John Borrazzo. Technical support was also provided by Carolina Kern. 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