Child mortality in Malawi
Authors: Kate Mandeville, Adamson Muula
Journal: The Lancet Global Health (2016)

We read with interest the study by Mercy Kanyuka and colleagues1Kanyuka M, Ndawala J, Mleme T, et al. Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study. Lancet Glob Health; 4: e201–14.Google Scholar on Malawi's achievements in Millennium Development Goal 4. The authors identified several major health-system barriers to replicating this success throughout all districts in Malawi, the foremost being low numbers of health workers. The authors point out that massive investment in the health workforce will be needed to reach the minimum densities recommended by WHO.2Campbell J Dussault G Buchan J et al.A universal truth: no health without a workforce. Forum Report, Third Global Forum on Human Resources for Health, Recife, Brazil. Global Health Workforce Alliance and World Health Organization, Geneva2013Google Scholar Unfortunately, these standards do not take into account the financial burden to the public sector associated with expansion of the health workforce. Previous investment in health-worker training in Malawi supported by development partners led to a glut of graduates across various professions in August, 2015. Yet up to now, most of these graduates have not been employed by the Malawian Government. The Malawi Government is facing fiscal constraints associated with poor economic growth, high inflation, and withdrawal of donor support and is under pressure to constrain its public sector wage bill.3International Monetary Fund2015 article IV consultation—press release; staff report; and statement by the executive director for Malawi. IMF Country Report No. 15/345. International Monetary Fund, Washington, DC2015Google Scholar Faced with uncertain prospects of employment, it is reported that at least 20 of the 51 medical graduates in last year's cohort have emigrated to Lesotho, a nearby country that is actively recruiting doctors.4Face of MalawiGovt still coy on 51 newly graduated doctors: 20 Malawian doctors employed in Lesotho.Face of Malawi. Nov 5, 2015; Google Scholar This emigration is despite recent success in retaining newly trained doctors in Malawi in the wake of historically high emigration.5Mandeville KL Ulaya G Lagarde M et al.Early career retention of Malawian medical graduates: a retrospective cohort study.Trop Med Int Health. 2014; 20: 106-114Crossref PubMed Scopus (13) Google Scholar Any further investment into expanding Malawi's health workforce needs to take into account the associated recurrent costs and long-term budget impact for the public sector. KLM is funded by The Wellcome Trust (grant number 09401), and founded and volunteers for Medic to Medic, a charity that supports medical students at the College of Medicine-University of Malawi. Child mortality in MalawiIt is encouraging to read in the Article by Mercy Kanyuka and colleagues (March, 2016)1 about Malawi's success in reducing child mortality, but I fear the authors might have missed one of the key factors contributing towards this great achievement. Specifically, that Malawi is unique in sub-Saharan Africa in having never charged user fees in public health facilities, apart from a brief experiment in 1964, which the President soon abandoned after protests by the population.2 Full-Text PDF Open AccessChild mortality in Malawi – Authors' replyWe thank Rob Yates for his letter and agree that Malawi's consistent absence of user fees in public facilities will have probably facilitated access to care and financial protection, which might have benefited health outcomes. Indeed, a recent analysis by Manthalu and colleagues1 found positive effects of user fee removal on access to antenatal and delivery services in private facilities in Malawi. An analysis by Leone and colleagues2 also found a positive effect of user fee removal on institutional deliveries in Burkina Faso and Ghana. Full-Text PDF Open Access