Reporl No. 5648-MA Malawi Population Sector Review March 10, 1986 Population, Health and Nutrition Department Division I FOR OFFICIAL USE ONLY > | *stt * ; ,, f ,~~~~~~~~~~~~~-., ,;; ;s;C Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without brld Bank authorization. CURRENCY EQUIVALENTS US$ 1 - M.K. 1.74 M. Kwacha 1 - US$ .57 WEIGHTS AND MEASURES 1 Acre (ac) - 0.405 Hectares 1 Mile (mi) - 1.609 Kilometers GOVERNMENT OF MALAWI FISCAL YEAR April 1 to March 31 FOR OMCIAL USE ONLY ABSTRACT _ Malawi is one of the most densely populated countries in Sub-Saharan Africa. The population has increased from 4.04 million in 1966 to an estimated 7.15 million in 1985. The present growth rate is estimated to be 3.2Z per annum. Rapid growth of population is inevitable over the next few decades. Under any plausible assumption of fertility trends the population will increase by roughly 50 to 70 percent over the next 30 years. If fertility does not fall, the rate of population growth will have climbed to 4 percent by 2010-2015 implying a doubling of the population within 17 years. Slowing population growth is needed urgently if most or all of the gains in economic growth and social welfare are not to be threatened. A multi-sectoral population program is recommended, with particular emphasis on the expansion of the availability of child spacing services and the introduction of information and educational programs. I/ This report is based on the findings of a Population mission which visited Malawi in October 1984. The mission was composed of Vulimiri Jagdish (Mission leader, Public Health Specialist, Bank), Althea Hill, (Demographer, Bank), Barbara Kennedy, (Population Specialist, USAID), and Nancy Yinger (Economist, USAID). | Thu document has a restrictd distribution and may be used by recipients only in the peformance of their official dutieL Its contents may not otherwise be discloe without World Bank authorization. ABBREVIATIONS ACMO Assistant Chief Medical Officer ADD Agricultural Development Districts BER Basic Economic Report CBR Crude Birth Rate CDR Crude Death Rate CEM Country Economic Memorandum CMO Chief Medical Officer CMS Central Medical Stores CO Clinical Officer DCMO Deputy Chief Medical Officer DMO District Medical Officer DPT Diphtheria, Pertussis and Tetanus EAB Extension Aids Branch EN Enrolled Nurse EPD Economic Planning Division EPI Expanded Program of Immmuization FFS Family Formation Survey HA Health Assistant HI Health Inspector HSA Health Surveillance Assistant H USC Health Sub-Center IEC Information, Education and Comunlcatlons DIR Infant Mortality Rate IUD Intra Uterine Device KAP Knowledge, Attitudes and Practice MA Medical Assistant -CH Maternal and Child Health MOH Ministry of Health MOLG Ministry of Local Government NPDP National Physical Development Plan NRDP National Rural Development Progras NSO National Statistical Office NSSA National Sample Survey of Agriculture OPC Office of the President and Cabinet PCS Population Change Survey PHAM Private Hospitals Association of Malawi PEC Primary Healtb Center RNI Rate of Natural Increase SCO Senior Clinical Officer SRN State Registered Nurse TBA Traditional Birth Attendant TFR Total Fertility Rate UNFPA United Nations Fund for Population Activitles UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organization DEFINITIONS Contraceptive Prevalence The percentage of married women of Rate: reproductive age who are using (or whose husbands are using) any form of contracep- tion. Crude Birth Rate: The number of births per 1,000 population in a given year. Crude Death Rate: The number of deaths per 1,000 population in a given year. Dependency Ratio: The ratio of the economically dependent part of the population to the productive part, arbitrarily defined as the ratio of the young (those under 15 years of age) plus the elderly (those 65 years of age and over) to the population in the "working ages" (those fifteen to sixty-four years of age). Infant Mortality Rate: The number of deaths of infants under one year old in a given year per 1,000 live births in that year. Life Expectancy at Birth: The average number of years a newborn would live if current age-specific mortality were maintained. Life expectancy at later ages is the average number of years a person already at a given later age will live. Life expectancy at age five and above can exceed life expectancy at birth substantially if the infant mortality rate is high. Mortality: Death as a component of population change. Rate of Natural Increase: The rate at which a population is increasing (or decreasing) in a given year due to surplus (or deficit) of births over deaths. The rate of natural increase equals the crude birth rate minus the crude death rate per 100 people. It also equals the population growth rate minus emigration. Rate of Population Growth: The rate at which a population is increasing (or decreasing) in a given year due to natural increase and net migration, expressed as a percentage of the base population. Total Fertility Rate: The average number of children that would be born alive to a woman (or group of women) during her lifetime if during her child-bearing years she were to bear children at each age in accord with prevailing age-specific fertility rates. MALAWI POPULATION SECTOR REVIEW TABLE OF CONTENTS Page No. EXECUTIVE SUMMARY ...................... i - iv I. DEMOGRAPHIC BACKGROUND Population Size and Growth ............ 2 Population Distribution, Urbanization and Internal Migration .o ...... 2....g.......... u 2 External Migration ..... ...... ..... 3 Mortality ...............**......... ...... * 3 Fertility ...*.. 4 Age and Sex Structure ................................ 5 Vital Rates and Natural Increase .......................... 6 II. CONSTRUCTION AND RESULTS OF POPULATION PROJECTIONS Construction of Projections .............................. . 6 Results of Projections ................*........**** 9 III. SOCIO-ECONOMIC IMPLICATIONS OF POPULATION GROWTH Implications for Economic and Agricultural Growth ........ 13 Implications for Provision of Social Services ............ 20 IV. GOVERNMENT POLICIES AND PROGRAMS Government Policies ............ ...e ............ee 25 Present and Potential Population-related Activities ...... 25 V. ISSUES AND RECOMMENDATIONS ................. ............. 36 ANNEXES A Population Projections *.........*.... ................. 41 B - Socio-economic Data .*..............s........se .. 47 C - Key Health Statistics ........ an .. .......seeee*ee... 64 D - Outreach Programs of Ministries other than Ministry of Health ....................e.e...eee*.eee 69 E - Information, Education and Communication Activities ..... 72 NALANI POPULATION SECTOR DEVIUW EXECUTIVE SUiMIAY The Population Problem 1. Malawi's population In 1985 is estimated to be 7.15 million. The rate of natural increase is currently 3.2Z per annum. The country is already one of the most densely populated countries in Sub-Saharan Africa. Population density, 59 Inhabitants per km2 at the time of the 1977 census, may have risen to 74 per km2. External migration, important in past decades, has undoubtedly fallen and is expected to continue to diminish. The level of fertility is high. In the mid 1970., the total fertility rate (TFR) was estimated at between 7.5 and 8.0 ad Is unlikely to have changed since. Regionally the TFR is highest in the Central Region at around 8.5, lowest in the Southern Region between 7 and 7.5. The TFR in the Northern Region is close to the national average. 2. The following table suimarizes the projected size and growth of the population of Malawi over the next 30 years. Rapid population growth is all but inevitable over the next few decades. If fertility remains constant, the population will grow from 7.15 million in 1985 to 11.95 million in 2000 and to 21.31 million by 2015. If there is accelerated decline in fertility, the population will grow to 10.63 million in 2000 and 13.29 million in 2015. By 2000 an accelerated fertility decline could reduce population increase by 121, and within 30 years from now, a fall in fertility would cut the population increase by a quarter to a third. MALAWI: POPULATION PROJECrIONS 1985-2015 Ratio of Population !p'ulation to Base 1985 (In illions) Population in 1985 2000 2015 2000 2015 A. Constant Fertility 7.15 11.95 21.31 167 298 B. Standard Decline 7.15 11.44 17.09 160 239 C. Accelerated Decline 7.15 10.63 13.29 149 186 Implications for Economic and Agricultural Growth 3. There is tremendous potential for Halawi's population to grow with the prospect of a 50 to 70X increase in size over the coming 15 years, and a doubling or tripling within the next 30 years. Such massive and rapid population growth will have significant socio-economic consequences. During the 1970s economic growth averaged 6.8Z annually while the population growth rate during the same period was 2.8 to 2.9Z. This resulted in a continued increase in per capita Income. Between 1979 and 1983 annual growth in GDP has failed to match population growth, with a consequent slight decline in average income. Mach of the economic growth is due to estate agriculture and smallholder agriculture. Continued rapid - ii - growth in agriculture is essential to provide food for the growing population. However, the growth of the agriculture sector is constrained by shortage of land. All agricultural land in Malawi will have to be brought under cultivation to support the population within the next 30 years if fertility does not fall. By 2015 there will be a land deficit of 13X with constant fertility. The effect on nutritional intake is already being felt. There is evidence that suggests that current domestic food production falls significantly short of required levels. At present this deficit may be as much as 15%. The following table shows the land required to support the population at present nutritional levels and land productivity under three fertility assumptions. Land Needed to Support Percent of Total Land Fertility Assumption Population {kmZ) Resources* Required for Cultivation 2000 2015 2000 2015 Constant Fertility 24,054 42,888 63 113 (deficit) Standard Decline 23,018 34,389 61 91 Accelerated Decline 21,259 26,749 56 71 *Not including land under estate cultivation in 1985. Implications for Social Services 4. If fertility remains constant, the implications are staggering for primary education expenditures. To achieve current enrollment targets for primary education, annual costs will rise from 24.4 million Kwacha in 1985 to 68.2 million Kwacha in 2000 and to 159.3 million in 2015 (a 552% increase). With accelerated fertility decline, annual costs will rise from 24.4 million Kwacha in 1985 to 61.2 million Kwacha in 2000 and to 66.1 million Kwacha in 2015 (a 170% increase). Thus rapid fertility decline could result in annual savings of 93 million Kwacha by 2015. Similarly, a decline in fertility could cut annual secondary education expenditure within 30 years by 17% if moderate, and by 43% if rapid fertility decline occurs. The need for Maternal and Child Health Services will also increase substantially. If no fertility decline occurs, the number of children under 5 years of age will increase by 70% in 15 years and will more than triple within 30 years to 4.5 million. Reduction in fertility will not only reduce health costs, but enable the country to increase the quality and scope of the health services. Government Policies and Programs 5. Although the Government of Malawi has only very recently begun to focus on the economic consequences of rapid population growth, it has - iii - recognized the link between family planning and maternal and child health (MCH) much longer. The Government in 1982 decided to include child spacing services as part of its MCH program. Although Malawi society still has a positive view of the value of large numbers of children, the introduction of child spacing services has revealed an unexpectedly high level of demand. The Government is taking steps to respond, while leaving individual couples the right to have as many children as desired. This policy deserves support; there is sufficient unmet demand for child spacing, and services should be readily available to those couples who wish to use them. 6. Less than two years old, the child spacing program should be considered a pilot effort, small in scale but clearly sufficiently well run to merit expansion. Currently, child spacing services are available only at three major hospitals; a 350% increase in users at one facility _ alone within one year, however, is considered encouraging. To permit wider dissemination, attention must be paid to increasing facilities which offer services, to providing a reliable supply of contraceptives, and to improving various support procedures. This will necessitate strengthening and expansion of the MCH program. 7. In view of the continuing demand for child spacing services, the Ministry of Health (MOH) has developed a second Child Spacing Plan of Action for 1986-88, which would establish goals for training, education, services and research. Although still a working document, the Plan represents convincing evidence of the Government's commitment to providing families with access to child spacing services. However, given that MOH is already overburdened with many other responsibilities, the Plan would need to take into account other ministries, private and local government health providers and the pharmaceutical sector, all of which could contribute both to the promotion and supply of child spacing activities. Issues and Recommendations 8. Two major recommendations are made for the immediate future. The first is that the&Government establish a formal capacity for population policy formulation and planning. The second is that the MCH program and its child spacing component be further developed and strengthened. For planning it is recommended tile Government establish a population planning capacity in the Economic Planning Division, Office of the President and Cabinet, to develop a multi-sectoral population program. Population related activities should be initially started in priority ministries, such as Education, Community Services, Agriculture and the Information Department of the Office of the President and Cabinet. In parallel, a series of seminars should be held to discuss the implications of population growth involving decision makers and community leaders. Meantime, the MOH should turn its attention to refining and expanding the Child Spacing Program for incorporation into the five-year National Health Plan currently under preparation. Particular attention should be paid to the following issues: (i) manpower and training, to ensure that health workers receive appropriate training and that village level health personnel become involved; (ii) logistics, to determine the most efficient agency and - Iv - systems for supplying contraceptives; (iII) establishment of a network of child spacing delivery points; and (iv) development of a comprehensive IEC strategy and program, taking into account that this program should be the nucleus of a future organization for coordinating population activities In various ministries outside MOH. MALAWI: POPULATION SECTOR REVIEW 1. DEMOGRAPHIC BACKGROUND1/ Sources and Quality of Demographic Data 1.01 Sources of demographic data for Malawi are limited, but their quality has in general been reasonably good. Two censuses have been held in the post World War II period, the first in August, 1966 and the second in September, 1977. The 1966 census collected information on occupation and education; there were no questions on mortality and fertility, but households were asked about household members absent abroad. The 1977 census, in addition to questions on occupation and education, collected data on marital status, fertility and mortality, and also on whether household members had ever worked abroad, but no Information on absent migrants was sought. All results have been fully published for both studies. The field work and coverage of both censuses appear to have been good, with the degree of undercount considered to have been no more than a few percent in eitlher. The data on absent migrants from 1966 are broadly consistent with information on Malawians enumerated in contemporary censuses in nearby countries and appear to be fairly reliable. The demographic data from 1977 have proved to be of good quality and are the major source of recent fertility and mortality estimates at national, regional and urban/rural levels. Unfortunately, tabulations at the district level were not included in the tabulation program, and therefore no results are available for districts. Preparations for the next census In 1987 have already begun. 1.02 In addition to census data, a national demographic survey, the Malawi Population Change Survey (PCS), was held between 1970 and 1972; a second national survey in 1982; and a third, the Family Formation Survey (FFS) in 1984. The results of the PCS, which had a sample size of 31,000 persons, have been fully published and have yielded valuable information on earlier mortality and fertility levels both at the national level and for urban and rural populations. The 1982 survey, with a sample of 94,000 households and 500,000 persons, has not yet been fully processed and tabulated. It is said to have encountered some problems with the field work. The FFS, carried out in che context of the current Bank Realth Project, was designed to collect very detailed data on fertility and child mortality, including determinants of both, at national, regional and urban/rural level. The general sample size was 12,000 households, and more detailed questionnaires were administered to 6,400 households. National Statistical Office (NSO) staff consider that the design and field work were excellent, and preliminar) results from hand tabulation of reported births and deaths during the year previoue to the survey look plausible and consistent with estimates from earlier data. Data processing is at present underway, and with assistance from the AID-funded Demographic Data for Development project, tabulations are expected to be ready by the fall of 1985. 1/ For a more detailed account of the demography of Malawi, see the Basic Economic Report of February 1982, and 'The Demography of Malawi": Althea Hill, 1985, PHN Technical Note. -2- Population Size and Growth 1.03 The population of Nalawl was enumerated as 5.55 million in September, 1977. It had increased by 37 percent since 1966, when the enumerated population was 4.04 million, thus implying an average annual rate of intercensal growth of 2.9 percent. This is close to the estimated rate of natural increase of around 2.8 to 2.9 percent, siith return migration between the censuses possibly also making some slight contribution. Trends since 1977 cannot be fully known until the FFS results become available and the next census (which is scheduled'for 1987) is held. However, it is reasonable to suppose that mortality has declined further, while fertility has remained constant and hence that natural increase and population growth rates have risen higher. Both Bank and NSO projections put current population size at about 7 million, with a current growth rate of 3.2 percent. Population Distribution, Urbanization and Internal Migration 1.04 Malawi is one of the most densely populated countries in Sub-Saharan Africa, equalled or surpassed only by Rwanda, Burundi, Nigeria and Uganda. The national density according to the 1977 census was 59 inhabitants per km2, and this may now have risen to 74 per km2. There is considerable variation within the country, however, with 1977 regional densities ranging from 24 in Northern Region, to 60 in Central Region, to 87 in Southern Region, and district densities varying from 11 to 230 persons per km2. There are two areas of very heavy settlement, one in the Shire highlands of Southern Region (with 1977 densities of 137 to 230) and the other in the southern part of the Central Region, where 1977 densities ranged from 53 to 114. Northern Region and the northern part of Central Region are uniformly sparsely settled, with 1977 densities all under 30 persons per km2. 1.05 The level of urbanization in Malawi is low by any standard. If an urban locality is defined as a locality with a minimum of 2000 inhabitants, 8.5 percent of the population in 1977 lived in urban areas, and only 5 perrent in 1966. The urban growth rate has been high, however, averaging 7.6 percent between 1966 and 1977, and the NSO has projected the current urban population to be about 12 percent of the total population. Three quarters of all urban dwellers in 1977 lived in the four main towns, Blantyre (219,000), Lilongwe (99,000), Zomba (24,000) and Mzuzu (16,000), with nearly half in Blantyre alone. However, the intercensal growth rates of these towns were very different. Blantyre and Mzuzu grew steadily but not spectacularly at annual 6.3 percent and 5.8 percent rates respectively. Zomba's growth rate of only 1.9 percent was actually less than the likely natural increase, implying net outmigration. By contrast Lilongwe, the new capital, experienced explosive population growth of 14.7 percent, quintupling in size between 1966 and 1977. Since 1977 the distribution of urban population between towns may thus have changed significantly, with the share of Lilongwe in part'cular increasing substantially. 1.06 Between 1966 and 1977 rural-to-urban moves made up about 35 to 45 percent of all internal migration. Other important migration atxeams were into areas of commercial agricultural development or new agricultural settlements (such as the north and east of Central Region) and out of areas with population pressure on limited land resources (such as the Shire highlands) or lacking in general economic development (such as most of Northern Region). As a net result of these movements, Northern Region had experienced a continuing net outflow from before 1966 up to 1977, while Southern had developed a smaller net outflow between the censuses; Central Region, by contrast, had attracted an Increasing net inflow from before 1966 up to 1977. Trends since 1977 will not be known till the next census is leld, but the movement into Central Region, at least, is likely to have continued. External Migration 1.07 Though an appreciable stream of imnigrants into Malawi from Mozambique existed earlier this century, a much more important flow for many decades has been of labour migrants out of Malawi to the more developed economies of South Africa, Zimbabwe and Zambia. In 1966, households reported 266,000 relatives working abroad, of which half were in Zimbabwe, a quarter in South Africa, and most of the remainder in Zambia. After the government's withdrawal of Malawian labour from South African mines in 1974, the numbers of migrants to South Africa undoubtedly fell, and even following the later resumption, contract labour may now number less than 20,000 men. Nothing, however, is known of recent trends in emigration to Zimbabwe or Zambia, though it is reasonable to suppose a decline in both cases. Since no relevant data were gathered in the 1977 census, more up-to-date information will have to await the next census. Outflows are expected to continue to diminish in the future because of dwindling labour demand in the host countries, which currently all have rapidly growing domestic labour forces and generally unfavourable markets for minerals. Mortality 1.08 The level of mortality in Malawi from the 1950s to the mid 1970s was exceptionally high by any standard, and declined only very slowly during this period. According to Bank estimates, life expectancy stood at only 37 years in the late 1950s, then rose to 39 years by the mid-1960s and to 41 years by the early 1970s. These low levels of life expectancy are due primarily to extremely heavy mortality in childhood. Even in the early 1970s, the national infant mortality rate (IMB) was as high as 190, with 36 percent of all children dying before reaching their fifth birthday. Childhood mortality as severe as this was exceptional in any part of contemporary Africa, or elsewhere in the world, and was quite unparalleled in Eastern Africa.2/ By contrast, adult mortality appears to be unremarkable by Eastern African standards. 2/ Though there are indications that similarly high mortality is also found in -those parts of Zambia and Tanzania (possibly even Mozambique) that border on Malawi. 1.09 The causes of this anomaloumly high mortality in childhood are not known, although it is hoped that the FFS data may shed come light on them when available. What Is known of patterns of differentials in mortality provides few clues. Childhood mortality in substantially higher in Central Region than in Northern or Southern Reglon, with 38 percent of Central children dying in their first five years of life in 1970-75 versus 29 percent of Northern and 31 percent of Southern children; but levels In all regions are still very high by East African, and Indeed even by West African, standards. Adult mortality, by contrast, varies very little between regions. Urban childhood mortality is very much lower than rural, with 22Z of urban children failing to survive their first five years in 1970-75 versus 34Z of rural children; this is normal In Africa and elsewhere and no doubt reflects the better social services and greater concentration of educated and prosparous families in the towns. Unfortunately, detailed tabulations from the 1977 census of childhood mortality by education and marital status of mother (the first of which factors, at least, is usually an important determinant of mortality level) were not included in the tabulation program, nor were tabulations by district, which might shed some light on environmental or cultural factors. 1.10 Trends in mortality since the early 1970s cannot be established until the FFS data, and possibly also the 1982 survey data, are available. However, it seems likely that the improvements in education and health services, particularly immunization levels, plus general economic growth, will have produced some further decline. Applying standard Bank methodology for projecting mortality decline, current life expectancy in Malawi is estimated at around 44 years, with an IMR of around 160 and about 30Z of children dying before their fifth birthday. The NSO estimate, based on somewhat different methodology, is similar, with a life expectancy of 43 years. These estimates will, of course, be revised once FFS data are available.3/ Fertility 1.11 The level of fertility in Malawi is high. The total fertility rate (TFR) was estimated at between 7.5 and 8.0 for the mid 1970s, and probably had changed little in previous years. Though fertility is high everywhere, there is marked variation by region, with the TFR in Central Region highest at around 8.5, lowest in Southern Region between 7 and 7.5, and Northern Region falling in between with a TFR close to the national average. Urban fertility is somewhat lower than rural fertility, though the difference is not very great; the urban TFR can be put at about 7.5 compared to a rural TFR similar to the national level of 7.5 to 8.0. Such a level of fertility is at the high end of the range even for East 3/ Preliminary figures from a manual tabulation of FFS data on reported deaths during the year before the survey are broadly consistent with these estimates. The reported DIR for 1983/84 was 152, with the highest rate in Central Province (169), the lowest in Southern (138) and Northern falling in between (158). Africa, with higher national TFRs found only in Kenya, Rwanda and (until recently) in Zimbabwe. It is hlgher than any national TFR in West Africa. Elsewhere in the world, this level of fertility Is paralleled only in a few Middle Eastern countries. 1.12 Little is known of the determinants of fertility in Malawi, although it is hoped the FFS data will prove enlightening on this topic. However, all the information that is available at present indicates an environment favourable to high fertility. Female marriage is early, stable, universal and mainly monogamous. In 1977, half of all women were married by the age of 17 years; 98 percent of all women aged.25-29 years had been married; only 9 percent of women in their early 309 were divorced or separated, and another 2 percent widowed; and not more than a fifth of all men over 40 reported more than one wife. There is little variation by region in these marriage patterns, except that Southern Region had a noticeably higher incidence of marital breakdown (12 percent of women aged 30-34 divorced or separated, versus 3 and 5 percent in Northern and Central respectively); there are also significant regional differences in the prevalence of polygamy, which is highest in Northern (one quarter to one third of men over 40 polygamists), lowest in Southern (10-15 percent) and Central (20-25 percent). Childbearing also begins early; in 1977 half of all women in all regions had borne at least one child by the age of 18 to 19 years. The incidence of sterility was extremely low everywhere, with less than 5 percent of women of all ages over 30 years reporting no live births; however the level of sterility was somewhat higher in Southern Region (4-5 percent) than in Northern (3-4 percent) or Central (2.5-3.5 percent). The practice of modern methods of birth control has up to now been negligible everywhere in Malawi. Almost nothing is known of other crucial determinants of child spacing such as breastfeeding patterns and the practice of post-partum abstinence or other traditional methods of birth control. Detailed data on socio-economic determinants of fertility, such as female education and employment, are also lacking. Trends in fertility since the mid 1970s are not known; however it seems unlikely that there has been any change, since no pertinent changes in key determinants are known to have as yet occurred.4/ Age and Sex Structure 1.13 The very high fertility and very high child mortality of Malawi, coupled with longstanding emigration of adult males, have combined to produce a population structure that is deficient in males and only moderately youthful by the standards of other high fertility countries in East Africa. In 1977, the overall sex ratio was 93, up slightly from 90 in 1966 because of some net return migration after 1974, but still revealing a substantial deficit of adult males. About 45Z of the population was under 15 years of age; this proportion was slightly inflated by the deficit of 4/ Preliminary FFS data on births in the past year confirm a continuing high fertility level, with the reported crude birth rate (CBR) at 57 (almost equally high in Northern and Central, at 60 and 59 respectively, but lower in Southern, at 56). -6- adults. With a projected decline in mortality from the early 1970s onward (particularly in childhood mortality), the population is projected to have become still more youthful. The proportion of children under 15 is now estimated at aboue 47%, with the elderly of 65 years and over making up only 3.5%, and women of reproductive age about 17Z. The dependency ratio is consequently now about 104 dependents per 100 working-age population, a very high value by world, and even African, standards. Vital Rates and Natural Increase 1.14 The CBR and crude death rate (CDR) have both been distorted by the unbalanced age and sex structure resulting from male emigration. Normally the levels of fertility and mortality estimated above for the early 1970s would be expected to produce a CBR of around 53, a CDR of around 24 and hence a rate of natural increase (RNI) of 2.8 to 2.9 percent. Because of the effect of migration, however, (which inflates the CBR by reducing the non-childbearing segment of the population and also the CDR by reducing the numbers in the lower mortality adult age groups), the rates were actually closer to 56 and 27 respectively. These compensating effects, however, produced an only slightly higher RNI of around 2.9 percent. This is similar to the actual intercensal rate of growth of 2.86 percent between 1966 and 1977, as would be expected given the very minor decrease in mortality over the period. Since the mid-1970s, the RNI is projected to have risen as a result of the projected decline in mortality, and is currently estimated at around 3.2 percent.5/ II. CONSTRUCTION AND RESULTS OF POPULATION PROJECTIONS Construction of Projections 2.01 In order to explore the socio-economic implications of population growth, a set of three population projections for the period 1975-2015 was constructed for Malawi. "/ For all, the base used was the enumerated population from the 1977 census. The age distribution, though irregular, was not smoothed because of the impossibility of allowing adequately for the distorting effects of migration; though this results in minor irregularities later in the projections, it has no significant effect on the broad picture of population trends discussed here. Only one assumption was made about mortality trends, that of a sustained decline from 1975 onwards, following the standard Bank methodology for projecting mortality 5/ Preliminary FFS results on vital events reported for the year previous to the survey are broadly in line with these estimates, with a reported CBR of 57, a CDR of 23 and consequently a rate of natural increase of 3.4 percent. 6/ These are very similar to the set presented in the 1981 Country Economic Memorandum (CEM) but not identical, since the projection methodology used in the Bank has changed in recent years. decline.7/ Life expectancy is projected to rise from the base level of 41 years indthe early 1970s to 44 years by 1980-85 and thence to 55 years by 2010-15, thirty years from now. Variations in mortality assumptions within any plausible range would have only a minor impact on population growth. The NSO, for example, used both "fast' and "slow" mortality declines in their projections (the fast producing a life expectancy of 54 years around 2000, and the slow 49 years), but the resulting difference in population size by 2000 was less than 4 percent. Only one assumption is made about migration trends also, that of a steady decline from a net outflow of 20,000 migrants during the period 1975-80 to zero by 1995. The net effect on growth is, in fact, negligible at all periods of the projection, since the crude migration rate is always less than .01 percent, even before 2000. 2.02 A base value for the TFR of 7.75 was chosen (the midpoint of the range 7.5-8.0 given previously). Again, this is similar to the NSO estimate, which is 7.6 and is based on an average of a range of estimates. Three assumptions were made about future trends in fertility. The first is of no change in fertility during the projection period, with the TFR remaining at 7.75 throughout. This is not necessarily considered the most realistic assumption, but is certainly a possible scenario, and in any case provides a benchmark against which to measure the effects of any reduction in fertility. The second assumption is of a gradual decline in fertility beginning after 1990, with replacement level fertility not reached until 2040 (55 years from now) and the TFR dropping to around 4 by 2010-15. This path follows normal Bank methodology for projecting fertility decline; it represents the possible evolution of fertility in response to the normal processes of socio-economic development, including some provision of child spacing services through government health facilities, but no major crash government program aimed at fertility reduction. The third assumption is of a much steeper decline in fertility, still beginning after 1990, but achieving replacement level fertility by 2015, (30 years from now) with the TFR falling to 2.8 at that time. This path is based on the fertility declines achieved in the past by countries with successful large-scale national family planning programs; it is again not necessarily considered a realistic assumption, but illustrates the maximum scale of fertility decline that could be expected in Malawi over the next 30 years, if the government were to pursue vigorous family planning policies and programs. All these fertility, mortality and migration assumptions are set out in Table 1. 7/ For details see Vu: -World Population Projections: Short- and Long-term Projections By Age and Sex with Related Demographic Statistics-: World Bank, 1984. -8- TABLE 1 World Bank Projections of Fertility, Mortality and Migration 1975- 1980- 1985- 1990- 1995- 2000- 2005- 2010- 1980 1985 1990 1995 2000 2005 2010 2015 Mortality Assumption Life Expectancy 42.5 44.1 45.8 47.6 49.4 51.3 53.2 55.1 (in years) Migration Assumption Total Number of Net Migrants -20000 -20000 -12000 -6000 0 0 0 0 Fertility Assumptions A:Constant Fertility TFR 7.75 7.75 7.75 7.75 7.75 7.75 7.75 7.75 B:Standard Decline TFR 7.75 7.75 7.75 7.48 6.89 6.22 5.46 4.59 C:Accelerated Decline TFR 7.75 7.75 7.75 6.06 4.74 3.71 2.90 2.63 2.03 For comparison, the assumptions embodied in the set of projections recently produced by the NSO are shown in Table 2. - 9 - TABLE 2 NSO: Projections of Fertility, Mortality and Migration 1977-82 1982-87 1987-92 1992-97 1997-2002 Mortality Assumptions 1/ Slow Decline: ea 40.9 43.0 45.1 47.2 49.4 2/ Fast Decline: e° 43.1 44.5 47.5 50.7 53.8 Migration Assumption Total Number of Net Migrants 0 0 0 0 0 Fertility Assumptions 1/ Constant Fertility: TFR 7.60 7.60 7.60 7.60 7.60 2/ Slow Decline: TFR 7.60 7.60 7.41 7.03 6.46 3/ Fast Decline: TFR 7.60 7.60 7.22 6.46 5.32 Differences between the NSO and Bank series in migration assumptions are insignificant; and in mortality assumptions are very slight, with the Bank decline close to the NSO slow decline variant. The match between the Bank standard decline and the NSO slow decline is also close, with the Bank decline a little faster, but starting from a slightly larger base. The Bank accelerated decline is however noticeably steeper than the NSO fast decline. Overall, the spread of the two sets of assumptions is comparable, given the inevitable differences in methodology; and in fact the results prove to be extremely close. The Bank projected population total for 2002 is 3 percent larger than the NSO total, both for constant fertility and for the standard/slow fertility decline, and 3 percent smaller for the accelerated/fast decline. Consequently the discussion of population growth and its implications that follow can be taken as applying equally well to the results of the projections produced by the NSO. Naturally, when the FFS results become available, a thorough revision of all demographic estimates and projections will be necessary. However, the overall picture is not likely to change significantly. Results of Projections 2.04 Detailed results from the Bank projections are given in Annex A Tables 1-6. Table 3 below summarizes the projected size and growth of the population of Malawi over the next 30 years, a period well within the lifetimes of most Malawians alive today, and of their children. Clearly - 10 - tremendous population growth is all but inevitable in Malawi over the next few decades. The population will increase by roughly 50 to 70 percent over the next 15 year. under any assumption of fertility trends, and by a minlmum of 86 percent over tho next 30 years. Indeed, if fertility does not fall, the population could as much as treble in size within that period. Malawi must therefore plan for a population of at least 10 million in the year 2000, and at least 13 million in 2015, even If an extremely rapid fertility decline were to begin immediately. TABLE 3 World Bank Population Projections 1985-2015 Population Ratio of Population to (in millions) Base 1985 Population in 1985 2000 2015 2000 2015 A: Constant Fertility 7.15 11.95 21.31 167 298 B: Standard Decline 7.15 11.44 17.09 160 239 C: Accelerated Decline 7.15 10.63 13.29 149 186 2.05 The remaining potential for growth in the population will also be substantial even by the end of the projected period, as shown in Table 4. By 2010-15, if fertility does not fall, the rate of population growth will have climbed to 4 percent, implying a further doubling of numbers, to 42 million within another 17 years. With a gradual fertility decline, annual growth would still be well over 2 percent, allowing a further doubling within 30 years. Even with the achievement of replacement fertility by 2010-15, the growth rate would still be 1.4 percent, with a potential doubling time of 50 years. 2.06 It is also clear, however, that the future course of fertility will have a very great impact on population size and growth, particularly after the next 15 years or so. Even by 2000, an accelerated fertility decline could reduce the population increase by 11 percent, and within 30 years from now a fall in fertility would cut the population growth by 20 to 40 percent, depending on its magnitude. Moreover, the potential for future growth would be radically reduced, with further doubling time stretched from only 17 years to 30 to 50 years. - 11 - TABLE 4 Projected Rates of Population Growth and Doubling Times Average Annual Rate of Doubling Time At Population Growth (percent) Rate in 2010-15 1980-85 1995-2000 2010-15 A: Constant Fertility 3.1 3.6 4.0 17 years B: Standard Decline 3.1 3.1 2.4 29 years C: Accelerated Decline 3.1 2.1 1.4 50 years 2.07 The effect of fertility trends on the future age structure of the population is even more striking. If mortality continues to decline and fertility does not also fall, the population will become more and more youthful (because mortality gains are concentrated in childhood), and dependency ratios will rise. With a fertility decline, on the other hand, the proportion of children in the population and hence the dependency burden will fall. This will be a temporary phenomenon (though lasting some decades) because if fertility remains low, the proportion of the elderly will gradually rise amd compensate for lower percentages of children. However it would provide a beneficial period of low dependency burdens for the Malawian economy in the short- to medium-term. These trends are summarized in Table 5 below. - 12 - TABLE 5 Projected Standard Dependency Ratios 1985 2000 2015 Percentage of Children Aged Under 15 in the Population A: Constant Fertility 47 48 50 B: Standard Decline 47 46 41 C: Accelerated Decline 47 42 30 Dependency Ratiol/ A: Constant Fertility 104 104 111 B: Standard Decline 104 95 78 C: Accelerated Decline 104 80 51 I/ Calculated as the ratio of numbers aged 15 years plus those aged 65 years & over to numbers aged 15-64 years. Clearly the impact of fertility trends will be enormous. Without a fertility decline half the population will be dependent children by 2015, and the overall dependency burden will rise from the current level of 104 dependents per 100 working age population to 111. A fall in fertility, however could cut the percentage of children in the population to between 30 and 40 percent within 30 years, and would reduce the dependency burden to between 50 and 80 dependents per 100 workers. 2.08 The use of conventional dependency ratios has been criticized for countries such as Malawi, where subsistence agriculture is dominant and both children and old people contribute significant amounts of labour. Accordingly the above table was also constructed using a modified dependency ratio, where only children aged under 5 were considered totally dependent, and the labor contributed by children aged 5-14 years, and the elderly aged 65 years and over was assigned a value of 15 and 50Z respectively of the labor contributed by those aged 15-64 years.8/ The results are shown in Table 6 below. 8/ Values derived from the Economic Planning Division (EPD) Manpower Budget 1984 report, which estimates that children aged 5-14 years contribute on average 15 percent of their own upkeep, and the 65+ age group on average half their own upkeep. This may overstate the value of labour contributed by these groups, if less is required for the support of children and the elderly, but can be usefully taken as a maximui estimate. - 13 - TABLE 6 Projected Modified Dependency Ratios 1985 2000 2015 Modified Dependency Ratio, A: Constant Fertility 82 83 89 B: Standard Decline 82 76 62 C: Accelerated Decline 82 64 40 The overall picture that emerges from Table 6 is essentially the same as from Table 5. The current modified dependency burden, now reduced to the equivalent of 8 dependents per 10 workers, will rise to nearly 9 dependents within 30 years if fertility does not fall. A decline in fertility, however, would cut the iependency burden to between 4 and 6 dependents by 2015. In both cases, indeed, even a gradual fall in fertility over the next 30 years would reduce the dependency burden by nearly one third, while a rapid decline would more than halve it. III. SOCIO-ECONOMIC IMPLICATIONS OF POPULATION GROWTH 3.01 There can be no doubt that very rapid population growth, of the scale to be expected if there is no change from current fertility levels, will seriously impede Malawi's efforts to develop its economy and raise the standards of living of its people. Growth of this magnitude threatens to exhaust the country's land resources before compensating intensification of land use can be developed, and hence to lower rural living standards and hinder the growth of Malawi's agriculture-based economy. At the same time it will result in massive increases in demand for food, energy and social services, together with a growing dependency burden. While in the short term substantial population growth is inevitable and must be planned for and accommodated, a reduction of population growth will be vital to Malawi's longer term prospects. Implications for Economic and Agricultural Growth 3.02 Malawi faces the prospect of a 50 to 70 percent increase in the size of its population over the coming 15 years, and a doubling or tripling within the next 30 years. It is therefore of vital importance to assess the socio-economic consequences of such massive and rapid growth, and to devise ways and means of accommodating the added numbers at an improved standard of living. Until recently the scale of population growth had not been perceived as a major developpent problem. Economic growth was averaging 6.8 percent annually during the 1970s, far outstripping the parallel population growth rate of 2.8 to 2.9 percent and resulting in a continual increase in per capita income. Over the last few years, however, conditions have changed. The average annual growth in GDP of 2.0% from - 14 - 1979 to 1984 failed to match population growth, with a consequent slight decline of 3X in average income. Even the target growth rate in CDP of 3.5 to 3.7 percent for the next 3 years, itself requiring considerable effort to achieve, will only restore per capita Income to its pre-1980 level. 3.03 Longer-term prospects are still more uncertain. The basis of sustained economic growth in Malawi in the past has been agriculture, both commercial and smsllholder, which still generates 40% of GDP. Performance in these two sectors has varied. Between Independence and 1980, production in the dynamic estate sector grew at an annual average of 15 percent In output and over 7 percent in value: smallholder production, on the other hand, though never adequately measured, appears to have grown only very slowly since Independence, after a period of higher growth (around 5 percent per annum) in the 1950s and 1960.. Malawi has a policy of food self-sufficiency which is economically rational because of the high transportation costs arising from its land-locked position. Continued rapid growth in estate agriculture and a revitalization of smallholder agriculture will thus be essential in the future to provide both cash incomes and food supplies to the growing population. One obstacle to past development in the smallholder sector, lack of favorable pricing policies, has now been largely removed. Since 1981, crop prices have been close to the export or import parity price. The resulting increase in maize prices, combined with fertilizer subsidies, good weather, and poor harvests in neighboring countries, has led to a substantial increase in maize production, the annual export of around 80,000 tons, and maize stocks now amounting to several months of total national consumption needs. Both sectors, however, face a more intractable constraint on future growth, namely shortage of land, which arises in turn from the pressure of continuing population growth. 3.04 The seriousness of potential land scarcity can be simply summarized.9/ Malawi's total land resources available for arable agriculture amount to 44,814 ki2, or 48% of total land area. Of this arable land, 20,143 km2, or 45%, were under cultivation in 1983, while 24,671 km2, or 55%, were vacant and available for the extension of cultivation. The assumption is made in the National Physical Development Plan (NPDP) projections that no changes in the smallholder sector in current levels of agricultural productivity (yields per hectare) or of food Intake will occur in the near future. On such an assumption, which is not necessarily the most realistic, but provides a base-line projection, increases in population would have to be supported through extension of cultivation (as has been largely the case in the past), and land resources would become the critical constraint. Resulting projected land reauirements for subsistence production (which in 1983 accounted for 13,529 km , or 67% of cultivated land) over the next 30 years are shown in Table 7 below (fuller details are given in Annex B). 9/ The discussion that follows is based largely on the work done by the UNCHS/UNDP team in the Department of Town and Country Planning, Office of the President and Cabinet, for the National Physical Development Plan (NPDP), with adjustments in the figures to follow the Bank's revised population projections. - 15 - TABLE 7 Projected Land Requirements for Subsistence Production assumlng unchanged Nutritional Levels and Land Productlvity Land Needed to Support Percent of Land Fertility Assumption Populatlon (kmn) Resources* Required for Cultivation 2000 2015 2000 2015 Constant Fertility 24,054 42,888 63 113(deficit) Standard Decline 23,018 34,389 61 91 Accelerated Decline 21,259 26,749 56 71 *Not including land under estate cultivation in 1985 Within the next 30 years all the reserves of agricultural land In Malawi would have to be brought under cultivation to support the population if fertility does not fall; indeed, by 2015, with constant fertility, there would be a land deficit of 13 percent. Even with a decline in fertility, 70 to 90 percent of Malawi's cultivable land (excluding estate land) would need to be in use by 2015. 3.05 In the absence of any increases in land productivity, the situation would, In fact, be even graver than these figures suggest. In the first place, it is optimistic to assume that the land still unutilized is capable of the same average productivity as land already under cultivation, since it is generally characterized by poorer soils, steeper slopes and greater problems of water supply and drainage.10/ The land requirements given above as a base-line projection should therefore be considered very much a minimum. 3.06 In the second place, while data on both nutritional levels and agricultural production in Malawi are scanty and inconsistent, data from recent agricultural surveys suggest that, despite recent net exports of maize and current ample maize stocks, total current domestic food production may fall substantially short of the level required to provide an average calorie intake sufficient for good health and growth (see Annex B for details). The reported shortfalls run as high as 25 or 50%. While much of this deficit may plausibly be attributed to underreporting of production, Malawi-s very severe and so far unexplained childhood mortality is a warning against dismissing it as entirely a product of poor data. Any current short fall in production, of course, implies the necessity for even more additional land in future to achieve food self-sufficiency at adequate nutritional intakes. If the current deficit were as much as 15%, for example, t1a achievement of an adequate intake by 2015 would be impossible 10/ Information from World Bank staff. - 16 - unless fertility fell. With constant fertility, the land deficit would reach 25% of what would be needed. Indeed, even with a moderate fertility decline, all land reserves would by then be exhausted. Only a rapid decline would preserve a modest reaervoir of 17% of cultivable non-estate land for future expansion. 3.07 Moreover, other competing uses of the land must be taken into consideration. If tobacco estate production were to grow at an annual rate of 2.2 percent (as projected in the recent World Bank Energy Report) without any increase in productivity per hectare, then the land requirements of tobacco estates alone would increase from a current total of 6,594km2 to 9,172km2 in 2000, and 12,758km2 in 2015, absorbing by then more than a quarter of current land reserves. Even more importantly, land requirements for forest plantations, the main source of fuel in Malawi for both household use and for tobacco curing, will increase substantially over the next 30 years. Table 8 below, based on projections in the recent World Bank and NPDP Energy Reports, shows the growth in land requirements for wood under the most optimistically low assumptions of growth in demand (for full details see Annex B). By 2015, wood plantations alone will require about half the land currently vacant if there Is no fall in fertility or if the fertility decline is only moderate. Even with an accelerated fall in fertility, just under 40% of currently vacant land will be needed for wood. TABLE 8 Projected Land Requirements for Wood Plantations Fertility Assumption Land Needed for Percent of Land Vacant Additional Wood in 1985 needed for Plantations to Cover Additional Plantations Growth in Demand (km') 2000 2015 2000 2015 Constant Fertility 6,870 13,470 29 57 Standard Decline 6,530 11,270 28 48 Accelerated Decline 6,000 8,600 26 37 3.08 Minimum land requirements for these competing uses are summarized in Table 9 below. It is evident that even on these generous assumptions population growth will create tremendous pressure on land resources in Malawi. If productivity does not rise, and fertility does not fall, almost - 17 - TABLE 9 Projected Land Requirements for all Uses Fertility Percent of Land Vacant in Percent of Land Vacant in Assumption 1985 Needed by 2000 for 1985 Needed by 2015 for Growth in: Growth in: Food* Tobacco* Food* Tobacco Prod- and All uses Prod- and** All uses uction Wood** uction Wood Constant Fertility 41 29 70 121 57 178 Standard Decline 37 28 65 85 43 133 Accelerated Decline 29 26 55 53 37 90 *Assuming no improvement in current levels of food intake. **Assuming high-yielding plantations, increased efficiency of fuel wood use on tobacco estates, and also that additional land for expansion of tobacco production will be able to produce sufficient fuel wood for the increase in production. twice the available reserves of cultivable land would be needed to support additional population within 30 years from now. Even given a moderate c'ecline i-n fertility, land reserves would meet only three quarters of the additional needs by 2015. Only a rapid fall in fertility would restrain population growth to an approximate balance with land resources, and even then reserves would be 90% exhausted within 30 years. 3.09 Another gravely worrying aspect of this problem is the effect of population growth on employment opportunities. Table 10 below shows the projected employment in the formal and urban informal sectors (based upon the EPD Manpower Budget projections) and the residual numbers of the labor force who will have to be absorbed in the smallholder agriculture sector. - 18 - mE 10 Ahwut of AE 1AXd Auail- !sis1lne able for 9b- hMrage lTd under als tme Pkaou Ainual Cakivatiro per tiam per Soal- Growth Rate Smallbsider boldr Sector SectDr Worker Wbrcer 1985 2000 2015 1985 - 2015 (ha) 1985 1/ (ha) 2015 2/ Mdbers In labor force (JD milIIlowi) CoDstant fertlity 2.527 4.216 7.260 3.5 SpOzitWASOU decin 2.527 4.216 6.864 3.3 Accelerated decline 2.527 4.216 6.302 3.1 Projected jobs in formal sector (in mIll Ios) .423 .881 1.967 5.2 Projected jobs In urban infonmi sector (in ii .204 .459 1.032 5.4 Balance regi Aymt (In mllions) Gutm fertility 1.900 2.876 4.261 2.7 .76 .59 Spntaneous dleclne 1.900 2.876 3.865 2.4 .76 .69 ACeerated eline 1.900 2.876 3.303 1.8 .76 .85 1/ Total. larxl Iudrsuteix w1tivatiox tlen from Table Ii, Amex B. 21 Asstmda that 46, 52 and 58Z respectively of laxd rescmes are devoted to tobacco and wood productin (see Table 9). The formal and urban informal sector at present only employs about a quarter of the labor force. Even on the assumption of rather rapid growth in these types of employment, they will still only absorb just over one third of the labor force in 15 years, and 50 to 60% in 30 years Lime. The remaining workers, who will increase from 1.9 million to 2.9 million by 2000 and to between 3.3 and 4.3 million by 2015, will have to be absorbed by the smallholder agricultural sector.11/ At present each worker in this sector cultivates about 76 ha for subsistence production. Yet by 2015 less than .9 ha will be avaiJlable per worker, even if all currently vacant land is brought into production. Indeed, unless there is a rapid decline in fertility, the maximum amount of land available for each worker for subsistence production will actually be less than is currently cultivated. 3.10 Evidently, the mere extension of cultivation will not long suffice to meet the needs of the growing population of Malawi under any of .1/ These figures are probably all underestimated, since the participation rate of 72Z used to estimate the labor force from the projected population of working age was derived from the 1977 census, which like any African census, underrecorded the participation of women in suallholder agriculture. - 19 _ the fertlllty assumptlons used In these projections, although a very rapid fertility decline would provlde a longer breathLng space. Moreover, the costs of bringing these huge amounts of land (often mrginal and poorly endowed) into production at a forced pace are likely to be very heavy. They would Include both dlrect Investment costs of clearing, drainage, irrigation and enrichment of the land, and also the costs of massive population resettlement schemes, given the uneven distribution of available land (see Annex B and the NPDP for more detailed regional data). Ways of lightening the pressure on scarce land resources must therefore be devised. Diversification of cash crops out of tobacco is one obvious possibility, given the uniquely heavy fuel wood requlrements of flue-cured tobacco in a context of lcreasing land scarcity. At present, tobacco production accounts for around 15 to 20% of all fuel wood consumption in Malawi. Even on the assumption of substantial improvements in efficiency of fuel wood use in estate production, tobacco would still probably account for around 10 to 15% of all consumption by 2015. Diversification could therefore make a significant contrlbution to reducing land shortages simply by cutting future demand for fuel wood. 3.11 Another necessary approach to reducing pressure on 'Land will, of course, be the intensification of land use. Yet the margin of manoeuvre here appears to be limited, at least over the next few decades. The productivity of modern managed forestry plantations, such as those envisaged to meet future growth In dewmnd for Malawi, is constrained largely by climate and soil conditions, and cannot easily be increased much above the levels assumed in these illustrative calculations. Land requirements for fuel wood, therefore, are rather inflexible, though there is scope for some reduction in domestic fuel wood consumption through improvements in charcoal-kilm and cooking-stove design. Improvements in agricultural productivity are theoretically much more promising, particularly in the smallholder food crop sector. Average yields at present are far below potential, and Indeed less than a third of those currently being achieved in Malawi on agricultural development projects through the use of improved seed and fertilizer. Since most smallholders still do not use even these inputs, the widespread application of proven and available new technologies alone is capable, given pricing policies that provide adequate incentives to small farmers to increase production, of raising smallholder productivity sufficiently to compensate for the exhaustion of land reserves (see the 1982 BER, Chapter IV, on Agricultural Development). 3.12 The real challenge here, however, is the shortness of the time period for such agricultural development imposed by the rapidity of population growth. The extension to the entire smallholder population in Malawi of agricultural extension services, pluo credit or subsidy arrangements necessary for adoption of new technologies by farmers with low cash incomes, is a lengthy and expensive proress, demanding large amounts of capital and skilled managerial msnpower. It becomes immeasurably more difficult when the deadline for achievement is set by population growth at a couple of decades from now. The National Rural Development Program (NRDP), for example, envisages a period of 15 to 18 years for just such development in each of 45 agricultural areas, with the areas gradually entering the program over a period of 20 years beginning in the late 197Os. The goal of the NRDP is to achieve full countrywide program coverage by the year 2000. Consequently, full countrywide agricultural development would not be completed until 30 - 35 years from now. Yet even so, progress - 20 - in implementation has up to now been slower than envisaged (see the 1982 BER, Chapter IV). It is moreover not yet clear how quickly agricultural productivity and production can be increased even if implementation of the program progresses on schedule. Experience elsewhere suggests that long term sustained annual increases in production of 2.5%, and in yields of 2%, (thus a doubling of production and yields every 25 - 35 years) are unlikely to be surpassed.12/ 3.13 The reduction of fertility, therefore, and consequently of population growth, can make a very important contribution. The slower the speed of population growth over the next few decades, the longer will be the grace period for improving agricultural productivity and production before land reserves are exhausted. For example, if fertility does not fall, more than half of the currently unused land will be required for expansion of tobacco and wood production in 30 years time, under the most optimistic assumptions. Consequently, average agricultural yields will have to be more than doubled by 2015, with an average annual growth of over 21, to support a population three times its current size on only 60% more land than cultivated today. With a rapid fertility decline, on the other hand, only just under 40% of current land reserves would be required for expansion of wood and tobacco production. Thus reserves amounting to around 50% of the land already under cultivation would be available for the extension of agriculture, to support a population less than 90 percent larger than its current size by 2015. Much more time would therefore be available for agricultural development and productivity improvements. 3.14 Rapid population growth will therefore hinder rather than help agricultural and economic growth in Malawi, by intensifying pressure on land resources, and by forcing the pace of agricultural development beyond what can be easily achieved. At the same time, moreover, it will result in huge growth of consumption needs in food, energy and social services such as water, sanitation systems, housing, education and health facilities. Some implications of growth in the demand for food and energy have already been discussed. The effect of population growth on the demand for social services and hence on public expenditures will be illustrated by the cases of education and Maternal and Child Health services; both these are considered high-priority services by both Government and people, are largely financed by the public sector, and are mainly directed to the dependent part of the population. Implications for Provision of Social Services 3.15 Table 11 below shows projected growth in the numbers of primary school pupils in Malawi on two assumptions; the first of a constant enrollment rate at the current level of 62 X and the second of increase in 12/ See WDR, 1982, Part II: Agriculture and Economic Development, Chapter 6; and Pingali and Binswanger: -Population Growth and Technological Change in Agriculture' in 'Population and Food Proceedings of the Fifth Agriculture Sector Symposium": Ed. T. Davis, World Bank, 1985. - 21 - enrollment to 86 % by 1995 and 95 X by 2015: (following the Education Plan's target: for full details see Annex B). It is evident that tremendous growth in the school population must be expected and planned for in Malawi. Even with no improvements in enrollment rates, numbers of primary school pupils will increase by 50 to 70Z over the next 15 years; by 2015 they will at least double under almost any assumption and will TABLE 11 Projected Numbers of Primary School Pupils Primary School Pupils: (in millions) 1985 2000 2015 At Current Enrollment Rate of 62% Constant Fertility .99 1.65 3.06 Standard Decline .99 1.59 2.20 Accelerated Decline .99 1.48 1.27 At Target Enrollment Rates Constant Fertility .99 2.34 4.69 Standard Decline .99 2.26 3.38 Accelerated Decline .99 2.10 1.95 actually triple if fertility does not fall. If the Education Plan's targeted increases in enrollment are achieved, primary school pupils will double in numbers at a minimum by 2000; within 30 years they will at least double and could even, if there is no fertility decline, climb to more than four and a half times their current numbers. 3.16 The implications of such growth in pupil numbers for primary education expenditure are set out in detail in Annex B, and summarized below in Table 12 for Plan targets for both enrollment and pupil teacher ratio improvements. If fertility does not fall, the achievement of Plan targets will entail a near-tripling of annual primary education costs over the next 15 years and a more than six fold increase over the next 30 years. Annual growth of government expenditure, and hence ultimately of the economy, will have to average 6% between now and 2015 in order to - 22 - TABLE 12 Projected Costs of Primary Education Assuming Achieveuint of Targeted Enrollment and Pupil/Teacher Ratio Improvemants Total Costs Average Annual Percent Growth Primary Educa- 1985 2000 2015 in Costs tion Costs (62Z enrollment) (88Z enrollment) (95% enrollment) (million Kwacha) 1985-2000 2000-15 Constant Fertility 24.4 68.2 159.3 6.9 5.7 Standard Decline 24.4 65.8 114.7 6.6 3.7 Accelerated Decline 24.4 61.2 66.1 6.1 .5 support such increases without raising the share of education in the budget. Even a moderate decline in fertility could reduce annual growth in costs to around 5 percent, however, with savings by 2015 of 45 million -wacha, and a rapid fertility decline could cut annual growth to less than 3.5%, with savings of 93 million Kwacha. Even were the economy to grow rapidly enough to support a 6 percent annual increase in costs, such savings could be profitably used for improvements in the quality of education provided, without the need to increase the share of government expenditures devoted to primary education. 3.17 A similar picture for secondary schooling is summarized in Table 13 below, using the Education Plan's target of an increase in secondary school enrollment from the current level of 3.8% to 5% by 1995. (For full details see Annex B.) A decline in fertility could cut annual secondary education expenditure within 30 years by 17% if moderate, and by 43% - 23 - TABLE 13 Projected Costs of Secondary Education, Assuming Achievement of Targeted Enrollment Increases Total Costs Averae Annual Percent Growth Secondary Educa- 1985 2000 2015 in Costs tion Costs at (3.8Zenrollment) (5 enrollment) (52 enrollment) Target Enroll- 1985-2000 2000-15 ment Rates: (million Iwacha) constant Fertility 13.1 24.1 45.0 4.1 4.2 Standard Decline 13.1 24.1 37.3 4.1 2.9 Accelerated Decline 13.1 24.1 25.5 4.1 .4 ; ~~~~1 _ _ if rapid, resulting in annual savings of 8 and 20 million Kwacha respectively. Such savings could very usefully be applied either to improving the quality of secondary education or to raising the very low enrollment target, thus making a valuable contribution to Malawi's development by improving the supply of skilled manpower. 3.18 The effect of population growth on Maternal and Child Health (MCH) service requirements is equally striking. Malawi has recently made considerable progress in this field. Nearly 90 % of young children are now immunized with BCG vaccine and nearly 70X against measles; almost half are covered by MCH services. Two thirds of women receive some prenatal care, and 60Z of all deliveries take place in medical facilities. Yet very rapid population growth may threaten even the maintenance of these health care standards, let alone further improvements. Table 14 below summarizes growth in the numbers of young children and annual births in Malawi: - 24 - TABLE 14 Projected Numbers of Births and Children Under 5 1985 2000 2015 Average Annual Percent Growth Rate 195-215 Number of Children Under 5 (in millions) Constant Fertility 1.41 2.44 4.46 3.8 Standard Decline 1.41 2.07 2.47 1.9 Accelerated Decline 1.41 1.47 1.37 - .1 Annual Births (in thousands) Constant Fertility 394 658 1,152 3.6 Standard Decline 394 534 578 1.3 Accelerated Decline 394 355 325 - .6 3.19 If fertility does not fall, the number of children under 5 years of age will increase by over 70% in 15 years time, and will more than triple within 30 years to 4.5 million. The annual growth in numbers of young children would be 3.8%. A fall in fertility, however, would dramatically cut projected numbers of young children and hence future health costs. With even a moderate decline, the young child population would only increase by 75Z over the next 30 years, while with a fast decline their numbers would actually decline slightly between 1985 and 2015. A similar picture is seen for maternal health. Without a fall in fertility, annual numbers of births, and hence women requiring prenatal and postnatal care, and facilities for supervised deliveries, will increase by 67% over the next 15 years, and almost triple within 30 years. The annual growth in maternity clients would be 3.6%. A decline in fertility, however, would drastically cut annual births, with numbers only 47% higher in 2015 than now if the decline is moderate, and actually 18% lower if the decline is very rapid. 3.20 Even to maintain present standards of MCH care, therefore, MCH expenditure will have to grow by 3.8% per year, if fertility does not fall, in order to match the increase in numbers of MCH clients. Since coverage is still very incomplete, much greater cost increases will be necessary to achieve an adequate standard of MCR care. A decline in fertility, however, could cut MCR costs by at least a half. The implied huge savings could then be devoted to improving coverage and quality in NCR services with no extra burden on government expenditures or the economy. (More detailed estimates of savings and costs can be made upon completion of the National Health Plan.) - 25 - IV. GOVERNMENT POLICIES AND PROGRAMS Government Policies 4.01 Although until recently population growth has not been considered a problem by the Government of Malawi, child spacing has come to be recognized as a valuable component of maternal and child health services on the grounds that unregulated pregnancies endangered the health of both mothers and children. In 1982 the Government decided to include child spacing services as part of the MCH program. The overall goal of the child spacing program is "to reduce maternal morbidity and mortality by allowing the mother to rest between pregnancies and to reduce infant and child morbidity and mortality". The Government further stated that the introduction of child spacing services did not interfere with the right of the family to have as many children as desired, and that the child spacing program was not a tool of population control. These Government statements reflected deeply rooted attitudes in Malawian society favoring large numbers of children. 4.02 The last two years, however, have seen significant changes in attitudes at all levels. There is increasing concern over the consequences of current rates of population growth, and there is awareness that rapid growth may be a constraint to development. At the recent 1984 International Population Conference in Mexico, the Government expressed its support for the concept of educating the public about the benefits of small families. Moreover, the introduction of the child spacing program has revealed a high demand for child spacing services among the public, despite the limited availability of services (at present offered only at three major hospitals). Random record checks at these clinics show that an increasing proportion of clients come from outside the catchment areas. People are willing to travel long distances to obtain contraceptives, and strong demand for services has resulted in the MOH's developing plans for a nationwide child spacing program. 4.03 Contraceptive services are provided by many mission hospitals and health centers. While the Private Hospitals Association of Malawi (PHAM) does not have a formal policy for provision of child spacing services, its protestant members do so within the context of MCH. Private doctors in Blantyre, Lilongwe and Zomba provide child spacing services for fee paying patients. The MOH is supportive of these efforts and has recently issued guidelines for prescription of injectables. Present and Potential Population-related Activities The Health Care Delivery System 4.04 Since child spacing services have to date been delivered through the existing health care system and, even if expanded, will continue to be primarily its responsibility, a review of the system's scope and capabilities is necessary. This section is a summary of the health sector and is based on the Health Sector Review dated November 17, 1981. - 26 - 4.05 Organization. The MOH has the prime responsibility for developing the strategies, programs and plans for health care in Malawi and for the quality of that care. The Principal Secretary of the MOH is responsible for both the administrative and technical branches into which the Ministry is divided. He is accountable to the Minister of Health. A Deputy Secretary heads the administrative branch. This branch deals with financial, personnel and general administrative matters. The Chief Health Planner in charge of the Ministry's Planning Unit reports to the Deputy Secretary. The Chief Medical Officer (CMO) is responsible for the technical branch, assisted by a Deputy Chief Medical Officer (DCMO). District medical officers (DMOs), who report directly to the CMO in the Ministry, are responsible for all health and medical services in their districts. They are also in charge of the district hospital which is the nucleui of district health services. 4.06 Health Facilities. Health facilities are provided by the Government, the Private Hospitals Association of Malawi (PHAM), the Ministry of Local Government (MOLG), and by other groups. Malawi has two central and 44 other hospitp' (22 of which are Government district hospitals, one is a general hosy.tal in Zomba and one a mental hospital) and 20 PHAM hospitals and five leprosaria. The two central hospitals are located in Lilongwe for the Central Region, and in Blantyre for the Southern Region. Each is run by a senior medical superintendent who reports directly to the CMO. The Northern Region has no central hospital. The distribution of hospital facilities is uneven. For every 100,000 people in Malawi, there are 110 general (excluding maternity) beds. The ratio varies by district from 33/100,000 in Salima to 240/100,000 in Rumphi. There are 177 general beds in the Northern Region, 105 in the Central Region and 100 in the Southern Region for every 100,000 people. There is only one bed per 24 km2 in the North, compared to one per 10 km2 in the Central and Southern Region respectively. Hospital services are thus less accessible in the north. Below the hospital level are Primary Health Centers, dispensaries and maternities. In 1979, there were 37 PHCs in Malawi or 1 for about 150,000 people. Of the 37 PHCs, 19 were run by Government and 18 by PHAM. Most of the 94 health units under MOLG are maternities. There were also 456 dispensaries; 80 were run for staff of estates, private firms, and the army and police. At the lowest tier of the health system were health posts, but this concept has been abandoned because of staff shortages. 4.07 A plan to create a health infrastructure providing comprehensive health service below the district hospital level is currently being implemented. Health units would deal with the health needs of up to 50,000 people and theoretically would consist of one PHC and 4 Health Sub-Centers (HSCs). Each HSC would consist of a maternity and a dispensary. There are currently 137 completed HSCs with both a maternity and dispensary, 91 units with only a maternity and 219 units with only a dispensary. In principle, the PHC would be staffed by a Clinical Officer (CO), State Registered Nurse (SRN), Medical Assistant (MA), Health Inspector (HI), 2 Enrolled Nurses (EN), 4 midwives, a laboratory assistant and service staff. The PHC and each HSC would each service the immediate needs of about 10,000 people. HSCs, with a staff of MA, Health Assistants (HA), Enrolled Nurse/Midwife and service staff, would deal with curative and maternity cases and serve - 27 - as a base for health education activities and mobile clinics to service lHPs. This model is theoretically sound, but shortages of finance and staff have resulted in less complete coverage than originally planned. 4.08 Health manpower. There were 4,962 established posts for the government health sector in 1984. Of these 739 (or 15%) were not filled. Nearly 50% of technical posts are currently vacant, and over half the districts do not have medical officers. Other critical shortages were among registered nurses and medical assistants (130 and 166 vacancies respectively). Only 24% health subcenters have one enrolled nurse midwife, and 76Z have no nurse midwives at all. Annex C, Table 1 present the staffing position in June 1984. Nearly 60% of professionals are employed in the hospital sector---36% in the two Central hospitals and the Zomba General llospital alone. The MOH currently employs 70% of the country's health manpower, PHAM employs 18% and other organizations employ 12%. There are currently 18 schools and hospitals that provide training for health workers in the country. There is no medical school in Malawi, and a serious shortage of doctors exists. A detailed manpower analysis is being undertaken as part of the national health plan currently under preparation. The main constraints in developing adequate health manpower are shortages of training facilities and teachers and delays in admissions. 4.09 Besides health personnel formally attached to health facilities, the MOH has traditional birth attendants (TBAs) and health surveillance assistants (HSAs), who together carry out the bulk of outreach health activities in-Malawi. In 1978, the MOH began TBA training on a pilot basis in three districts. Following an evaluation, the program has been expanded, and by the end of 1982, all districts had trained at least 10 TBAs. To date, 367 have been trained. Public health nurses are responsible for conducting training programs which take place at district level. It has been reported that the number of TBA referrals to health centers and hospitals has increased since the training, and that, in some cases, TBAs have reported an increase in the number of deliveries they perform. The MOH has concluded that there is a need to strengthen the links between TBAs and the nearest health center, both in terms of training and supervision. It has also noted that follow-up has been weak, partly due to difficulties in mobilizing female MOH staff to travel to villages and partly because MOB field staff have not been fully involved in the program. TBAs are paid by their clients in cash or in kind. Health Surveillance Assistants (HSAs) are a type of health worker first trained in the early 1970s and successfully used for the specific purpose of combatting cholera. With the decrease in cholera, HSAs were made into village sanitation and hygiene agents. They are currently responsible for environmental health activities. The MOH intends to train TBAs and HSAs as its primary level workers for health and child spacing activities. 4.10 Health education. The Health Education Unit has six main sections publications, radio, mobile vans, graphic art, band/drama and support services. It was started in 1969 primarily to support sanitation programs. With the development of the MCH program, the health education unit became the responsibility of the ACMO (MCH) in 1973. While the unit has made substantial progress in developing health education materials and programs, it is hampered by the lack of competent staff, physical facilities, equipment and supplies. Details of the Health Education Unit are provided in Annex E, pages 1-4. - 28 - Maternal and Child Health 4.11 Prior to 1972 the emphasis in HOH was primarily on curative services. Individual attempts were made to provide antenatal and child care services in hospitals. A tuberculosis control program was begun in 1964 and followed by other communicable disease programs. A MCH program was initiated in 1973 under a five-year mini-plan based in turn on recommendations in the national health plan. 4.12 Early activities included the Expanded Program of Immunization (EPI) and health education. An MCH department was established in the MOH under the Assistant Chief Medical Officer (ACMO) MCH; the department was also responsible for the Ministry's nutrition, health education and primary health care activities. The department head is accountable to the CMO and is assisted by an MCH administrator. At the regional level, an MCH supervisor has been appointed to oversee MCH activities in each of the three regions. At the district level, a member of the existing district health staff, usually a nurse, is appointed as MCH coordinator. 4.13 Child care services include primarily health education, nutritional screening and immunizations. These are provided through under-five clinics by PHC and HSC staff. These are essentially well-baby clinics and provide only very basic treatment of minor ailments to unwell children; sick children are referred to the nearest health unit except in remote rural areas. Children are screened by the most senior staff member available to determine whether or not a child is underweight and which immunizations are required. Up to 1976, BCG vaccines were given as part of the smallpox eradication program; since 1976 they have been given as part of the MCH program together with DPT, poliomyelitis and measles vaccines. The weight of children and record of their immunizations are recorded on 'Road to Health Charts" which are retained by mothers and monitored at the clinics. Many health units also conduct nutrition clinics attended by mothers of children who have been recognized at under-five clinics as underweight and likely to be malnourished or to develop malnutrition. At these clinics, nutrition education and demonstrations are carried out and World Food Program supplementary food is distributed. 4.14 Maternity care is provided at maternity units which conduct antenatal clinics and, if possible, through mobile antenatal clinics on a weekly or monthly basis. In antenatal clinics, physical examinations, including blood pressure, urine and blood examinations, are carried out routinely. Iron, vitamins and chloroquine tablets are provided to patients. Antenatal cards with a record of prior births, pills provided and examination results, are kept at the clinic. 4.15 An overall evaluation has recently been undertaken of MCH activities. The evaluation confirms earlier field observations that the quality of services is consistently high and the people attending appeared to have confidence in the staff providing the services. However, coverage appears to be far from adequate; some 40% of all pregnant women deliver at home, and over 50% of children aged four years and under are not being reached by MCH services. Mothers with young babies under two years do not - 29 - beam to use the services as much as mothers with older children, and this may be significant in attempting to analyze the reasons for Malawi's high IMR. Unregulated fertility, often resulting in short birth intervals and early weaning, is another factor associated with continued high infant and child mortality rates. Child Spacing 4.16 Initial 2-year plan. In light of the continuing problems of infant and child mortality, the MOH organized a workshop on Health and the Family In 1981. Participants examined current MCH activities and recommended the introduction of child spacing services. In 1982, the Government accepted the workshop recom_endations and in 1983 prepared an initial 2-year plan to initiate child spacing, and established a child spacing committee to coordinate the activities. The objectives of the plan were to: (a) Orient health staff on child spacing; (b) include general information on child spacing as part of all pre-service health worker training; (c) provide technical training to providers of child spacing services; (d) develop the capability of the MOH to implement the child spacing program; (e) organize seminars to acquaint community leaders about child spacing; (f) educate mothers and fathers on the importance and necessity of child spacing; (g) provide child spacing services as an integral part of MCH services at various levels of the health care delivery system; (h) provide clinical and applied research activities in sectors related to MCH and child spacing Including fertility and infertility; and (i) develop a simple system for monitoring and evaluation of child spacing activities. 4.17 Child spacing services have been introduced in the two central hospitals at Blantyre and Lilongwe and the Zomba General Hospital. Initially, these services were provided by doctors alone. In 1983, midwives were trained in child spacing, and currently they too provide services. The participation of midwives has resulted in a steady rise in the number of acceptors. As a result, clinics are now held every working day rather than on a weekly basis. The number of reported users of child spacing at the Queen Elizabeth Hospital in Blantyre rose from 223 in October 1983 to 771 in September 1984, an increase of more than 350%. For - 30 - the three hospitals together, 2.648 users were reported for the 6 month period April to September 1984. The most popular method was the Intra-Uterine Device (IUD), representing the choice of 38% of all users; this varied however from 20% at Queen Elizabeth Hospital to 55% at Zomba. It is unclear whether the popularity of the IUD is due to provider or user preference. Training of trainers (senior midwives) in child spacing has been undertaken at courses in a number of countries. A total 15 trainers had been trained by December 1984. The training of midwives which took place in 1983 was a three-week program for 10 midwives at the Queen Elizabeth Hospital. Following an evaluation of the training program and identification of additional needs, a nationwide training program for midwives has been developed, and the first course was held in January 1985. Seminars for community leaders are planned during 1985. 4.18 Despite a promising start, the program has experienced difficulties which have important implications for future child spacing plans. These difficulties have reduced the effectiveness of the health care delivery system and relate to the inadequacy of facilities, supplies and logistics problems, lack of a good reporting system, problems regarding the role of nurses, and inadequacy of the recurrent budget. 4.19 Facilities. Although adequate at the two other hospitals, facilities to provide child spacing services in Lilongwe have been tntally unsatisfactory. Services are provided at a run down facility that is heavily overcrowded. There is one operating theater for all obstetric and gynaecological cases, a single room for outpatient services and an 80 bed ward which on average has 200 inpatients. Prospective clients have had to wait long hours, and a significant number have been turned away. In addition, in the Northern Region, no family planning services are currently being provided despite potentially high demand from the relatively better educated population in the Northern Region. 4.20 Supplies and logistics. The rapid and unforeseen growth in demand has resulted in a severe shortage of contraceptive supplies. These have up to now been ordered randomly and in small quantities from Family Planning International Assistance (FPIA), (Annex C, Table 2). The two most 1,ipular items, the Lippes loop IUD size B and Noriday oral contraceptives, are generally out of stock, and at the time of the mission, the Central r'%dical Stores (CMS) has less than one month's supply of all types of contraceptives, except condoms. In response to emergency requests, two shipments of supplies have been sent by FPIA (Annex C, Table 3). This should alleviate the I ediate shortage, but more permanent solutions must be found. The principal problems to date have been limited knowledge of possible demand and a lack of coordination between MOH headquarters in Lilongwe, which orders commodities, and the Central Medical Stores (CMS), which handles customs clearance, storage, and distribution of contraceptives. Demand has been difficult to project since child spacing services have only recently become available and the MOR has no previous experience. Coordination problems occur since CMS are not informed of what has been ordered, from whom, or expected dates of receipt; furthermore, MHO does not contact CMS to determine current stock levels, usage patterns and issue points before it places orders. Nor are the three hospitals that - 31 - offer child spacing services informed of what supplies are available, and of how and when to order. A possible alternative to the CMS system is the MCH storage and distribution system, which handles UNICEF donated drugs, except for c.ntraceptives. A complete review and analysis of both systems has been undertaken by the Centers for Disease control (CDC), and their recommendations are awaited. In summary, adequate contraceptive supplies need to be ordered with an appropriate mix of methods and brands. Then a stable supply source, a system for ordering, storing and distribution needs to be set up. 4.21 Reporting. The third problem at present is the lack of a good data collection and record system. Forms for information on chili spacing users are still under development and Malawi, at present, follows most other countries in the region, except Zimbabwe, in recording the number of visits by method rather than number of users. This system does not yield the type of data on clients and methods needed for evaluation, monitoring and improvement of service delivery. The program thus urgently needs a simple data collection record system that can be used by both Government and PHAM hospitals. The existing health information system is weak and is unlikely to be able to provide child spacing statistics at present. 4.22 Role of nurses. Long standing regulations of the Nursing Council state that oral contraceptives are prescription drugs and that IUD insertions are medical procedures, and that therefore only doctors can provide either. These regulations have not yet been modified and though these positions are contrary to MOE policy, some hospital pharmacists are reluctant to release contraceptive supplies to nurses. 4.23 Recurrent Budget. The MOH's share of total government expenditure in 1983/84 (net of appropriations in aid) was 7%. This represents a recovery from a decline of 6Z in the late 1970s and early 1980s. However, the recovery is not attributable to an increase in budgetary allocations to MOH, but to an excess of expenditure over the budget. This iP due in part to high utilization levels, few alternatives to MOH services and a limited modern private sector. As another result during the past 8 years, administration/training dnd curative institutions have increased their share of the budget at the expense of prevention and control. The budgetary share of prevention and control has fallen from 9% in 1976/77 to 6% in 1983/84. The shortage of recurrent funds has also gone with a relative abundance of development funds, which implies that demands on the recurrent budget will increase as projects on the development account come into the revenue account. Hence, it is critical that the MOH seek ways to increaRe funds available. There are four main ways to do so: (a) obtaining income from fees; (b) introducing some form of health insurance, (c) increasing tde efficiency of current resource use and thus creating savings; and (d) encouraging donors 'o finance programs that contribute to recurrent rather than capital expenditure. The MOH is already exploring the first 3 options. External support for recurrent expenditures may also be reqlired if child spacing activities are to be introduced throughout the country. - 32 - Child Spacing Plan of Action (1986-1988) 4.24 In view of the continuing high demand for child spacing services, the MOH has prepared a three-year Child Spacing Plan of Action (1986-1988) based on a review of the program to date. The plan establishes training, education, service and research activities. Three phases have been outlined, one for each year. Goals have been established for training outputs and number of clients served. Expanslon to health centers and dispensaries is envisioned. 4.25 Development of this plan is an important first step. As it stands, however, the plan is more a statement of purpose than a guide for specific program activities. It does not contain a detailed analysis of the problems which have hampered initial efforts at child spacing: the lack of facilities, weak supply system for child spacing supplies; and inadequacy of record keeping. It would be a stronger document if it contained an inventory of possible resources which might be applied to effective child spacing efforts, both in regards to personnel and facilities, and also for complementary information, education and communication (IEC) activities. The goals are helpful as far as they go, but do not include provisions for research and evaluation which would allow specific targeting of demographic and educational efforts as well as work output. Work plans which accompany the goals should be more specific, and it is necessary to develop a budget. A clear-cut statement of Government overall goals and objectives regarding child spacing should also be included. Furthermore, it is not clear how this Plan of Action is to be integrated with the National Health Plan currently under preparation. In revising the child spacing plan, the results of the Family Formation Survey will be invaluable for program development. 4.26 In addition to these general issues, the specific plan for training need further thought. The plan calls for the establishment of a training center for each of the 24 districts over the next 5 years, which would provide training in clinical service delivery. The advisability of developing so many training centers should be reviewed. For each training site, adequate space and a large volume of clients are required to enable each student to receive the clinical exposure needed to gain competency in IUD insertion skills. At present none of the three major hospitals have sufficient space to conduct clinical training for classes of more than two or three students. Since there is considerable overcrowding, extra space can only be provided through expansion. The number of training centers that can be usefully developed in Malawi over the next five years requires careful consideration. 4.27 To estimate roughly the scale of program activity required to achieve Ehe projected declines in fertility, the Bongaarts formula for converting total fertility rates to contraceptive prevalence rates (percentage of women using modern contraception) was applied to projected TFRs. These are shown below in Table 15. - 33 - TABLE 15 Number of Users Date TFR CPR(Z) (thousands) Standard Acceler. Standard Acceler. Standard Acceler. decline decline decline decline decline decline 1985 7.75 7.75 .02 .02 24 24 1990 7.65 6.90 .03 .13 47 187 1995 7.20 5.40 .09 .33 153 527 2000 6.55 4.20 .18 .48 343 866 2005 5.80 3.30 .27 .60 616 1175 2010 5.00 2:75 .38 .67 974 1414 2015 4.20 2.60 .48 .69 1400 1560 4.28 Contraceptive prevalence will have to attain about 20X within the next 15 years and about 50% within the next 30 years if the standard decline in fertility is to occur. By 2015 numbers of users would have to increase about sixty times, from about 24,000 at present to 1.4 million. To achieve the accelerated fertility decline, contraceptive prevalence would have to be raised to about 50% by 2000 and about 70X by 2015, with a total of more than 1.5 million users by that year. 4.29 These increases are certainly substantial. The levels and trends implied by the standard decline, however, are by no means unthinkable. Zimbabwe and Botswana have already achieved prevalences of 27Z (39% if traditional methods are included) and 18% respectively, while Kenya is now at a level of 15X. In Kenya and Botswana program development has not been accorded high priority or massive budgets. It is even conceivable that with sufficient government commitment, contraceptive prevalence rates closer to those required for the accelerated fertility decline could be attained. Other Sources of Assistance for Child Spacing Activities 4.30 In addition to seeking ways to improve MOI's capability to deliver child spacing services, it is important to realize that MOH by itself cannot carry the entire burden. MOI would, of course, provide services through the MO4 clinic network, and Information, Education, and Comunication (IEC) messages through its Health Education Unit. Beyond this, however, the capabilities of the MOH are limited. Even the requirements of the Child Spacing Plan as they stand will impose considerable strain on KOH resources. It is, therefore, necessary to plan for the additional utilization of all possible channels beyond these core KHO activities. There are three potential sources of support: other - 34 - ministries, which could provide manpower and assistance for IEC; PHAM, NGOs and private practitioners, which could expand information and services; and the private pharmaceutical sector which might form the basis of a social marketing scheme for contraceptive supplies. 4.31 Other Ministries. Manpower resources, particularly at the local level, could well be augmented by involvement of a number of other outreach and extension programs with potential for child spacing activities. Female Extension Workers, trained by the Ministry of Agriculture, teach and give advice to rural women on nutrition (linked to agriculture) and health, including control and prevention of common diseases in rural areas, sanitation and personal hygiene. They also often collaborate with MCH health workers and teach at Under-Fives Clinics. Male Farm Home Assistants, also trained by the Ministry of Agriculture, give advice Lo rural men on agricultural topics. The Adult Functional Literacy Program, run by the Ministry of Community Services, has 259 Functional Literacy Centers at which reading is taught from a curriculum based on development activities including agriculture, home economics, child care and health. UNFPA and UNESCO have developed a project (not yet approved) to introduce child spacing topics aad reading materials into the program. Male and female Community Development Assistants (CDAs), trained by the Ministry of Community Services, train and supervise the work of female Home Craft Workers (HCWs) who are employed by the Ministry of Local Government to teach rural women about food, nutrition, child care, community health and sanitation, among other topics. HCWs also assist in educational activities at MCH clinics (details of all these programs are given in Annex D). Though there are problems of overlap and duplication with some of these programs, taken together they represent an excellent opportunity for spreading knowledge and appreciation of child spacing benefits and information on available child spacing services among both men and women. The MOH could provide guidance and assistance in designing training programs in child spacing for the ministries. 4.32 The Health Education Unit as discussed earlier, is understaffed and does not function effectively or efficiently (see Annex E for details). Strengthening this unit is an important first step in developing effective IEC programs. Furthermore, IEC units in two other government agencies could cooperate to produce an effective multi-sectoral IEC program delivering an integrated message on the value and accessibility of child spacing activities. These are the Ministry of Agriculture and Natural Resources, Extension Aids Branch (EAB), and the Office of the President and Cabinet (OPC), Information Department (for details of their organization, activities and output, see Annex E). All three produce and/or distribute films, radio programs, newspapers or magazines, and other visual materials such as slides, posters and photographic displays. These units readily cooperate with each other when requested. Both the EAB and the OPC Information Department have produced and distributed materials on health. A thorough review of current IEC activities and capabilities in Malawi should be undertaken, on the basis of which a multi-sectoral IEC program could be drawn up. 4.33 Other health providers. The two other major health care providers in Malawi, namely PRAM and MOLG could also supplement MOB child spacing activities. Their activities should be strengthened and expanded through - 35 - provision of supplies, equipment and staff training. There might also be potential for Introducing child spacing services into estate health programs. A significant portion of working time of female employees li lost through pregnancy and child illness, and companies may therefore be interested (as has happened in Kenya) In program that would improve employee health conditions and consequently reduce time losses. 4.34 Pharmaceutical Company. The company operates three pharmacies and seVen drug stores, and imports and distributes drugs throughout the country. It imports only from large companies, primarily in South Africa, U.K. and U.S., and Informally uses the U.K. guidelines for controlled drugs. Over-the-counter drug prices are controlled, with a percentage of landing costs plus dispensing fee added. On average supplies are received within 4-6 months of ordering. In addition to individual sales, Malawi Pharmacies also distributes to PHAM facilities, estates and commercial farms. They have been buying contraceptives (which are now duty free) for the past eight years, including at present 20 different brands of oral contraceptives, selling for K. 1-3 per packet. They also sell condoms (about 2000 pieces a year), and IUDs, and sold Depo Provera until It was made a prescription drug a few years ago. 4.35 While exact figures are not available, private contraceptive sales have been increasing over the past 2-3 years, particularly to persons of middle and upper income levels. The potential, therefore, exists for the introduction of social marketing schemes through Malawi Pharmacies, if supplies could be distributed through other shops and outlets throughout the country at a reasonable price. These possibilities should be further investigated in light of the child spacing plan. 4.36 National Statistical Office. The NSO is responsible for undertaking the census and for periodic surveys. The Family Formation Survey was undertaken by the NSO with the collaboration of the MOS. Analysis of demographic data is an important functi.on of the NSO. The NSO has made a good start in developing its capability in data analysis. Links have also been established with the newly established demographic unit at the University of Malawi. External Ass'stance 4.37 The Bank has been involved in the health sector in Malawi since 1971 when the first Karonga Rural Development Project included a health component. In all, ten agricultural projects have included health components with a total investment of about US$4.5 million. Inputs have ranged from enlarging and modernizing the Karonga Hospital to bilharzia control programs and the development of sub-centers and health posts. In 1980 the Bank undertook a health sector review, and the first health project began in 1983. In late 1982 the Government decided that, for purposes of facilitating child spacing on health grounds, child spacing services would be available as an integral part of the MCH program. A child spacing component was therefore included in the first health project. Since this very cautious beginning, child spacing services have expanded steadily,and demand has been rising. Despite the changing - 36 - environment, however, family plannlng and population activities remain sensitive subjects in Malawi. 4.38 Concerning external donor assistance in the population sector, levels and scope have been understandably low until recently. Since 1983 USAID has been supplying contraceptives for the child spacing program and has recently increased its involvement in the program. UNFPA has supported the MCH program in the past and has recently begun to support child spacing activities. Other donor agencies have, however, been active in supporting health activities. UNICEF and WHO have ongoing programs which lnclude support for primary health care, water and sanitation and health manpower development. The EDP has financed replacement of 4 old district hospitals. The African Development Bank has also financed the reconstruction of 2 old district hospitals. Bilateral assistance ha been provided by some ten'governments including the Federal Republic of Germany, Japan, the United Kingdom and the United States of America. V. ISSUES AND RECOMMENDATIONS Issues 5.01 The Implications of rapid population growth are detailed in Chapter 1. The rate of growth would slow in primarlly three ways: Unavoidably by a rise in mortality if there is no reduction in fertility, by mass emigration, or by a significant fall In fertility. Obviously, an increase in mortality, already at a very high level, is completely unacceptable. There is indeed a danger, however, that if population growth outstrips the country's land resources, food supplies, and ability to provide adequate health and education services, mortality may, in fact, rise. Large-scale emigration to neighboring countries, all of which are experiencing high rates of population growth and economic problems themselves, is no longer an option. Though redu-ing fertility is the only practical and Important solution, analysis of population problems extends beyond fertility, mortality and migration. Population programs must address issues such as women's development and literacy, and health and education. 5.02 Fertility reduction on the scale required to alleviate the problems of population growth can only be achieved through understanding of these problems by both the Government and the public, followed by the development of appropriate population policies by the Government and their implementation through a multi-sectoral population program. The Government does not support any direct reference to limiting family size, and wishes families to preserve the right to have as many children as they desire. The present policy consists of providing child spacing services to those who want it, and to establish social and educational programs which will develop awareness of the problems of population growth. The mission endorses the objectives of the government, and strongly recommends that they form the basis for the development of a multi-sectoral population program. 5.03 Two principal recommendations flow from these considerations. The first is that the Government should establish a formal capacity for population policy formulation and planning. The second is that the present - 37 - maternal and child henlth program should be further developed and strengthened, both in child spacing service delivery and in the area of information, education and communication. Through a strengthened MCII program child spacing services can be made widely available. Population Policy Formulation and Planning 5.04 Population Planning. It is recommended that a population plInninzg *apacity be established in the Economic Planning Divlsion, Office of the .resident and Cabinet. This unit should have the following functtonn: (a) Integration of population issues within development planning. Economic planning does not at present take into account the implications of population growth. The Government has laid tle preliminary groundwork for inclusion of population concerns, however, by commissioning the preparation of the NPDP (an inventory and projection of national resources over the rest of the century) from the Ministry of Local Government with the assistance of a UNCHS/UNDP team. National plans have not been developed, but when they are, should take population issues ILto account. (b) Reports such as the present one, itself largely based on the work of the NPDP team, can do no more than outline the most important issues. More specific and detailed studies, carried out locally, are required to assess fully the serious implications of current population trends in relation to socio-economic growth; in particular, the prospects for increasing agricultural yields, and the infrastructure, labor and services required to reach given targets, need to be determined in relation to population and labor force growth. Malawi is fortunate in possessing an excellent NSO with a long and creditable record in data collection, demographic expertise among its staff, and close links to the Center for Social Research and the new Demographic Unit at the University. The EPD should collaborate closely w1fh both the NSO and the University, and make full use of their capabilities and their data collection program in population studies. Research and Planning units in other key ministries, such as Agriculture and Town and Country Planning, should alsc be heavily involved. The EPD would identify priority areas for investigation. (c) Design and coordination of a multi-sectoral population program. A multi-sectoral multi-phase population program should be developed. The first phase should consist of strengthening the current MOH child spacing program and introducing IEC activities through other channels, such as IEC units and extension workers of other ministries, the adult literacy program and the school system. Educational activities for specific target groups, such as labor and women's organizations, should also be considered. Ministries such as Cominity Services and Education and the Malawl Young Pioneers need to have their planning capabilities strengthened so that they can develop programs. Activities - 38 - in sectoral ministries ahould not be limited to IEC activities though it is recognized that educational activitios would be vitally important. The MOB should play a leading role in assisting other mdniatrie, to develop population activities. Efforts should be made to ure extension workers from the Ministries of Agriculture, Community Services, local Government, and education and private health institutions and practitioners. 5.05 Leader Education. It is also recommnded that continued efforts be made to Increase public awareness of population issues and support for establishment of population policies. An excellent beginning has been made with the recent NSO seminar, held for a mainly government audience, to disseminate and discuss the results of the 1977 census and their implications. This should now be followed up, however, with a series of seminars involving high-level party and government officials, as well as other prominent citizens. It is recommended that these seminars include chiefs, members of Parliament and their wives, TBAs, district councellors and organizations like farmers' clubs, women's organizations, District Development Committees, Village Action groups and Village Health committees. Church leaders should also be involved, particularly to assist in dealing with the growing problems of adolescent fertility. Similar seminars should follow for a wide cross-section of the public in each district. 5.06 Pending the establishment of a population planning capacity in EPD, it is recommnded that further development and strengthening of the maternal and child health program should be undertaken. The following steps are recom -nded: (a) Strengthening and expansion of the MCR program. MCH services should be expanded to cover the entire country. This involves additional manpower and facilities, particularly in the Northern Region, and other operational details essential to have an effective service system. A strong MCH program is essential for the successful development of the child spacing plan of action. (b) Revision of Child Spacing Plan of Action. The Ministry of Health should revise the current draft Child Spacing Plan of Action to produce a comprehensive five-year Child Spacing Program Plan for incorporation into the five-year National Health Plan currently in preparation. This child spacing plan should include overall goals, specific objectives, activities to carry out the program, targets, an implementation plan, and a budget. In particular, information on the determinants of fertility, and on current knowledge, attitudes and practices of the community in matters of family size, child spacing and fertility is required both as a baseline for evaluation of the impact of the child spacing program, and as a basis for development of effective and targeted IEC activities. When the results of the FFS are available, they should be fully utilized in future revisions of the child spacing plan. Cooperation with the NSO and with the University of Malawi in relevant disciplines should be encouraged. The technical assistance of a child spacing program planner with practical experience in this area will be required to assist MOR in the - 39 - preparation of this plan; this technical assistance should be timed to coordinate with the preparation of the final version of the National Health Plan. (c) Manpower and training. In the course of plan preparation, a detailed review of manpower requirements and training for family planning activities whould be carried out. Specific recommendations in this area are that: (i) The question of nurses' responsibilities in child spacing be discussed between the MOH and the Nurses Council and necessary changes be made in the light of the new program; (ii) all relevant categories of health workers be expected to take an active role in child spacing services and to have their position description updated to reflect their new duties and responsibilities, and that they be trained appropriately; (iii) the MOR ensure that adequate clinical space and volume of clients are available for the necessary clinical practice of child spacing trainees; (iv) a continuing in-service education system for workers in child spacing be established, including preparation of a child spacing procedure, manual covering procedures, complications and referral; (v) provision be made for involving village-level TBAs and HSAs in MCH and child spacing activities; (vi) provision be made for training of staff of other ministries in population planning and child spacing. (d) Logistics. Within the framework of plan preparation, but as a matter of urgency, it should be decided whether the CMS or MCU system is preferable for the storage and distribution of contraceptive supplies to the child spacing program, and a system of full coordination in the ordering and receiving of supplies between MOH and the selected distributor should then be set up. The functioning of the supply system itself should also be improved as a matter of urgency and appropriate training programs be established for the system selected. Specific recommendations in this area are that: Ci) A simple user reporting system be set up w.-reby numbers of users are estimated from collecting information on numbers of contraceptives by method and brand dispensed to clients; (ii) for forecasting contraceptive supply requirements, a one-year supply plus a one-year safety stock (requirements for the next year) be ordered, in order to ensure adequate supplies and avoid stock-outs, hoarding and inefficient dispensing (this is especially important at the initial stage of a program, when information on users is scanty, and the unmet demand for services - 40 - still unknown; as usage levels become better known, adjustments can be made accordingly); and (ill) alternative methods of financlng contraceptives be studied since in the long torm si%pplies will not be free. (e) Facilities for service delivery. Attention should be given In the plan to ensuring an adequate distribution of facilities for child spacing services throughout the country. An Inventory of existing facilities, equipment and space should be undertaken first, prior to the provislon of a network of child spacing services throughout the country. In particular, it is recommended as a matter of urgency that urban family health services in Lilongwe and in a Northern Regional MCH center at Mzueu, offering a complete range of child spacing services and fully capable of handling complications, be established. Furthermore, the possibility of providing child spacing facilities on estates should be explored. (f) IEC. A multi-media IEC strategy and program should be developed in MHE In the context of plan preparation. Since the Health Education Unit will be the center of IEC activities for the child spacing program, It will require considerable strengthening for this purpose. Specific recommendations in this area are that: (i) The unit develop a written IEC strategy and plan to be reviewed at regular intervals, to identify target groups, set priorities, coordinate and budget all IEC activities within the Ministry; (ii) an IEC Research and Evaluation Section be established in the Unit to review and collect background information (such as knowledge, attitude and practise surveys), to test new strategies, and to evaluate programs in collaboration with other groups such as the EAB, the NSO, the Center for Social Research and the Demographic Unit at the University; (iii) the Unit work more closely with, and seek more assistance from, the EAB and the Information Department, especially in the areas of research, printing and film production and distribution; (iv) numbers of staff in the Unit be expanded and short term technical courses be planned for existing staff. IEC topics should be incorporated in all in-service training programs for MCH/FP workers and included or strengthened in all basic programs for health personnel. It should also be borne in mind, when developing this IEC program in MDR, that It should later become the core of a multi-sectoral IEC program embracing the ca treach, extension and IEC capabilities of other ministries, ana therefore should be structured in such a way as to facilitate these further developments. -41- ANNEX A Page 1 of 6 Table 1: Projected Populat$ o SI=e and Grortb: MIlawi 1985-2C15 Total 1985 1990 1995 2000 2005 2010 2015 freltion (In millions) A:Constant 7.152 8.402 9.976 11.952 14.413 17.474 21.310 Fertility B:Standard 7.152 8.402 9.819 11.437 13.240 15.164 17.087 Fertility Decline C:Acceler- 7.152 8.402 9.521 10.563 11.532 12.395 13.291 ated Fertility Decline I I I I I I I I I I I Average 1985- 1990- 1995- 2000- 2005- 2010- Annual Rate 90 2000 05 10 15 ,of Populs- tion Growth (percent) A:Constant 3.22 3.43 3.61 3.74 3.85 3.97 Fertility B:Standard 3.22 3.12 3.05 2.93 2.71 2.39 Fertility Decline C:Acceler- 3.22 2.50 2.08 1.76 1.49 1.40 ated Fertility Decline - 42 - ANNEX A Page 2 of 6 Table 2: Projected Vital Rate.: IhLInud 1985-2015 1985-90 1990-95 1995-2000 2000-05 2005-10 2010-15 Cruide Birth Rate (per 1000) A: Constant 54.6 54.9 55.2 54.9 54.5 54.2 Fertility B: Standard Fertility 54.6 51.0 48.3 45.1 41.1 36.0 Decline C: Accelerated 54.6 43.5 36.3 31.0 26.4 25.5 Fertility Decline Crude Deatb late (per 1000) A: Constant 22.2 20.5 19.0 17.4 15.9 14.4 Fertility B: Standard Fertility 22.2 19.8 17.7 15.8 14.0 12.1 Decline C: Accelerated 22.2 18.4 15.5 13.4 11.9 11.0 Fertility Decline .ate of Natural Isncrease (percent) A: Constant 3.23 3.44 3.62 3.74 3.85 3.97 Fertility B: Standard Fertility 3.23 3.12 3.05 2.93 2.72 2.39 Decline C: Accelerated 2.23 2.51 2.08 1.76 1.45 1.40 Fertility Decline Crude E!ML Rate (percent) A: Constant .01 .01 .01 0 0 0 Fertility B: Standard Fertility .01 .01 .01 0 0 0 Decline C: Accelerated .01 .01 .01 0 0 0 Fertility Decline Rate of 1'xgU,]titm Crioth (percent) A: Constant 3.22 3.42 3.61 3.74 3.85 3.97 Fertility B: Standard Fertility 3.22 3.12 2.05 2.93 2.71 2.39 Decline C: Accelerated 3.22 2.50 2.0B 1.76 1 44 1.40 Fertility Decline Figures my not add up exactly, due to rounding errors. - 43 - ANNEX A Pap 3 of 6 Tble 3: Projeeted Age Structure of the Populatim: MIhaIi 198S-2015 , I. II -I I I 1985 1990 1995 2000 2005 2010 2015 -emtg Aged Under 15 Yure A: Constant 47.4 47.9 47.7 48.3 49.0 49.6 50.0 Fertility B: Standard Fertility 47.4 47.9 46.9 46.0 44.3 42.9 40.5 Decline C: Accelerated 47.4 47.9 45.2 41.5 36.3 32.3 29.5 Fertility Decline PFr a A: Constant 49.1 49.2 49.2 49.0 48.3 48.0 47.3 Fertility B: Standard Fertility 49.1 49.2 50.0 51.2 52.6 54.3 56.2 Decline C: Accelerated 49.1 49.2 51.4 55.4 60.3 ;4.3 66.2 Fertility Decline A: Constant 3.5 2.9 3.1 2.7 2.7 2.5 2.7 Fertility B: Standard Fertility 3.5 2.9 3.2 2.9 2.9 2.8 3.3 Decline C: Accelerated 3.5 2.9 3.3 3.1 3.4 3.5 4.2 Fertility Decline 1 5 + 651- L--6) A: Constant 103.8 103.3 103.3 104.1 1')7.1 108.6 111.4 Fertility B: Standard Fertility 103.8 103.3 100.1 95.3 90.3 84.1 77.8 Decline C: Accelerated 103.8 103.3 94.0 80.4 65.7 55.5 51.0 Fertility Decline Figures my not add up exactly to 100, due to rounding errors. - 44 - ANNEX A Pape 4 of 6 Table 4: Projected Ptpnlatlom of Working Ape: lm,i 1985-2015 1985 1990 1995 2000 2005 2010 2015 Mae 4SM 15S64 Years (in millions) A: Constant 1.674 1.980 2.374 2.857 3.417 4.134 4.997 Fertility B: Standard Fertility 1.674 1.980 2.374 2.857 3.417 4.063 4.758 Decline C: Acceleri.ed 1.674 1.980 2.374 2.857 3.417 3.928 4.352 Fertility Decline F12a Aged 15-6" Yars (in mIllions) A: Constant 1.836 2.153 2.533 2.999 3.512 4.245 5.086 Fertility 3: Standard Fertility 1.836 2.153 2.533 2.999 3.542 4.175 4.850 Decli{ne C: Accelerated 1.836 2.153 2.533 2.999 3.542 4.042 4.449 Fertility Decline Both Smes Aged 15-64 Years (in millions) A: Constant 3.510 4.133 4.907 5.855 6.959 8.378 10.083 Fertility B: Standard Fertility 3.510 4.133 4.907 5.855 6.959 8.238 9.608 Decline C: Accelerated 3.510 4.133 4.907 5.855 6.959 7.970 8.801 Fertility Decline Figures wy not add exactly to totals, due to rounding errors. - 45 - ANX A Pap 5 of 6 Table 5: Projeted Sc4ool hip 1!pu2at1m: !bli 1985-2015 1985 1990 1995 1 2000 2005 1 2010 l 2015 P rIU Scbool. Ago Petlao(613 YO) (In EiLIMO) A: Constant 1.592 1.914 2.196 2.656 3.262 4.015 4.938 Fertility B: Standard Fertility 1.592 1.914 2.196 2.562 2.873 3.244 3.554 Decline C: Accelerated 1.592 1.914 2.196 2.383 2.197 2.149 2.049 Fertility Decline PlPaU(14-17 Yer) (iLn ulilom) A: Constant .653 .704 .896 1.015 1.241 1.534 1.899 Fertility B: Standard Fertility .653 .704 .896 1.015 1.231 1.370 1.573 Decline C: Accelerated .653 .704 .896 1.015 1.211 1.066 1.076 Fertility Decline - 46 - ANNEX A Pp 6 'of 6 Table 6: Projected MM CiUmt Populatoua: Ma1in 1985-20L5 I I I I I I 1985 1990 1995 2000 2005 2010 2015 Under 5" Years (in milllo-ns) A: Constant 1.409 1.653 2.001 2.442 2.975 3.631 4.461 Fertility B: Standacd Fertllity 1.409 1.653 1.845 2.072 2.289 2.446 2.472 Decline C: Accelerated 1.409 1.653 1.546 1.473 1.409 1.321 1.366 Fertility Decllne tin millions) A: Constant 1.578 1.845 2.213 2.576 3.039 3.635 4.481 Fertility B: Standard Fertility 1.578 1.845 2.213 2.576 3.039 3.566 4.245 Decline C: Accelerated 1.578 1.845 2.213 2.576 3.039 3.433 3.844 Fertility Decllne Total NCR caiant (in millions) A: Ccnstant 2.987 3.498 4.214 5.018 6.014 7.266 8.942 Fertility B: Standard Fertility 2.987 3.498 4.058 4.648 5.328 6.012 6.717 Decline C: Accelerated 2.987 3.498 3.759 4.049 4.448 4.754 5.210 FertiLty Decline Ahml Nhwber of (in thousands) A: Constant 394 459 549 658 788 950 1152 Fertility 3: Gradual 394 444 488 534 577 585 578 Decline C: Accelerated 394 412 380 355 331 319 325 Fertlity Decline _ Figures my not add up exactly to 100, due to rounding errors. - 47 - ANNEX B Fage lof 17 Table I: MODIFIED PROJECTED DEPENDENCY RATIOS 1/: 1985 - 2015 (Numbers in Millions) 1985 2000 2015 Age Group Dependents |Workers Dependents Worker Iepedents Workers Constant Fertility 0 - 4 1.409 0 2.442 0 4.461 0 5 - 14 1.685 .297 2.831 .500 5.265 .922 15 - 64 0 3.510 0 5.856 0 10.080 65+ .125 .125 .164 .164 .282 .282 Dependency Ratio: 82 83 89 Standard Decline 0- 4 1.409 0 2.072 0 2.472 0 5 - 14 1.685 .297 2.705 .477 3.776 .666 15 - 64 0 3.510 0 5.855 0 9.608 65+ .125 .125 .164 .164 .282 .282 Dependency Ratio: 82 76 62 Accelerated Decline 0- 4 1.409 0 1.473 0 1.366 0 5 - 14 1.685 .29, 2.471 .436 2.176 .384 15 - 64 0 3.3io 0 5.855 0 8.801 65+ .125 .125 .164 .164 .282 .282 Dependency Ratio: 82 64 40 1/ Based on values of labor contribution by age group given in the EPD Manpower Budget. Children aged 5-14 are assumed to contribute 15Z of their own upkeep on average, and old people aged 65 years and over are assumed to contribute half their own upkeep. These values have been expressed here in terms of proportion of the age-groups working and dependent. Table nI: e£USG WLU LYD USES AN) WfSIC!1 maDS: 1983 (AHAB Di lIH) 9hilsitence Fazu1xI Rqwo Total Fatates 11 SEr1 NM ?b u 1* Stel S9qpm laid IbIdLp Smtteard Nlrmt. d a hra- Fz A J F11.xu 'dth I Arm Settlint SettlIwt Settlmt Stnetz G F a l (woe) inl ad a (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) -(U) NbrtUum rqtai 26,930 1,249.1 9.25 740.4 877.7 89.45 126.48 4,434 2.056.5S N9.0 11,.9 4,A1.14 Centrml Frxo 35,592 3,522.1 271.63 3,042.1 3,734.9 33D.65 2U4.fi3 4,118 2,272.01 3,179.0 6,aS4.1 8,8iZ rean 31,752 1,538.8 23.40 1,826.9 3,306.7 465.33 194.96 2,661 2,W9..18 2,122.5 5,72.8 10,977.62 1 Jklwi 9%,274 6,310.0 334.28 5,609.4 7,919.3 885.43 566.07 10,913 7,237.77 6,190.S 23,665.8 24,671. 4 (2) : RalM area de not frwh&ie totallaird a of L alawd, lbe, Oduta "d Cdb. (11) 6 (12): M flu w for sutmp alo w dmi do dDt lilude those idthln mst l lrpuk, gm ne aid fieat zmn. S9xm: Table 6.2, HdI awlcl Fhyca DrwCopit P1nw, lad use and ft¶lal CantraULts J. abia m.I E1M3 DISmRJIQl o r m Imm N Am D A L lUlN : 3965 11 ITOW ifautat aM1 Uhofstwm Blt.qa Arms ?azb Pt laue d (S&in, %cw k1mw lad An SUholdnz ffrg mE T_fe1rzu a Fln42a1m, Stw ld Notemf 26,930 1,315 1,722 216 4,134 2,057 12,776 4,709 2/ oatraA 35,592 3,964 7,210 575 4,118 2,V2 9,233 8 Smalhm 31,752 1,632 5,462 660 2,661 2,909 7,847 1O,58D pk1md 94,274 6,912 14,394 1,452 10,913 7,23 29,656 23,50 Perat MstrhLim of l1d Nwthern 1,000 4.9 6.4 .8 15.4 7.6 47.4 17.5 Catl 1,000 11.1 20.3 1.6 11.6 6.4 25.9 Z.l1 S&itan 1,000 5.1 17.2 2.1 8.4 9.2 24.7 33.3 Nolad I,00 7.3 15.3 1.5 11.6 7.7 31,7 24.9 . Noe: F7.2 my 'mt m e.cly to totals, &a to rmxilz ermin. 1/ ptel fri the 1983 fE*m g1yu in lable II by audx, 1mel grwth of 3.U1 i mmste famnlz lad (tb. e1tmI xt of pia1 gusnh tn tim prfid 190-5) betwa 1983 and 1985, ad amml gruwth of 2.2 In etate wd m1llhoLizg lad (m -1 mte of puLd Ina n puhtiaa -1mt In thi Ibd B* R er ILin). 2/ In lIs U, Ko&m ftm nb1e 6.2 In the tNtlaul Rydcal Dl_npt Pim, LId Use ad Ryai Ptgml ubir fo s lw do not m eccly to the mt-I total glt.. fn -u at falt appo r to be th wlm for t lad fwx l;t1 a MWm Lh1d axud ow 1 4,871.44 Umtd of 4,881.44. lwn of 4,871.14 -d fW In the calc,ati*m of this table. s9xm: Table II so TAhl IV: P3WB IADIE NJIUS FM SUISLIDU FOO PEYI:. 1965-20l5 t'al/ 1965 2- 2/ 2M W on Oalt.s.s e T.i Osl,ti te -- V ig " , o 1965 oztiwtic'm Oultiviam LbdUs In bE2 Ntrn Rqgion: Ctant Ferttlity 6,431 I,M 4,7(3 2,877 3,55 5,13 1,30 St lrd I Dbcl 6,431 1,722 4,70 2,754 3,677 4,114 2,317 ArltdI Ifclltc 6,431 1,722 4,7(9 2,543 3,= 3,20 3,231 Catral Regio: Cauwa Fertility 15,431 7,210 6, 20 12,06 3,381 21,63 ( -e) Stard 1heli 15,430 7,210 8,220 11,53 3,90D 17,266 (-1,796) Aa:leratd 1c1m 15,430 7,210 8,220 10,649 4.781 t3,39 2,031 Sithar RWm: Ctmt Fertlity 16,042 5,462 10,580 9,128 6,914 16,274 (- 232) Stadrd D eiz 16,042 5,462 10,380 8,734 7,3C 13,06 2,993 Aelarut.t D clwm 16,042 5,462 10,'80 8,0C7 1,975 10,150 5,892 )blmd: Cbtmat Fertility 37,9Ce 14,394 23,5t8 24,054 13,848 42,188 (-4,966) Stmrd D1wlt 37,9ce 14,394 23,5X 23,018 1 A,884 34,W 3,513 A laatmd Dieln 37,92 14,394 23,5C8 21,23 16,643 26,76 n,lS3 Lwu WU in NE!!uta Harder Rgiona: Otat Fertlity 100 27 73 45 55 80 20 Stanard iLim 100 27 73 43 57 64 36 Aeellu lDc11u 100 27 73 40 60 50 50 Catral Rgioa: tat Fertility 100 47 53 78 22 3 (_ 3) Staihd eUcif 1O0 47 53 75 25 112 (-12) kcelerated WUzM 100 47 53 6 31 87 13 Sauthem RegLo: Coutmt FertilItY 100 34 66 57 43 101 ( 1) StarAsrd Dw1 100 34 66 54 46 81 19 aelerated Wi 100 34 66 50 50 63 37 Malai1: Cttmt Fertility 1O0 3: 62 63 36 113 ( 13) Stmax rdd cIz IOD 38 62 61 3 91 9 kcelsited DwUr 10 3 62 S6 44 n1 29 o Note: Fiwm my t add metly to totals d* to tcuz. - Foortot, am rF pl. - 51 - ANNEX B rage 5 of 17 Footnotes to Table IV: 1/ Excluding land under estate and small holder cultivation in 1985, but including land under subsistence farming and vacant land. 2/ Calculated on the assumption that all vacant land will be used for subsistence food production. Source: Table III Background Note to Table IV: Problems of Agricultural Data for Halawl No attempt has been made to project agricultural production directly in these calculations nor to estimate requirements in food pruduction for an adequate average food intake. The reason for this is the inadequacy of the data base for Malawi. Two recent sets of agricultural production data are available. The first comes from the National Sample Survey of Agriculture (NSSA) in 1980/81, and the second from the sample survey of the Agricultural Development Districts (ADD) in 1982/83. The quality of at least one of these surveys appears to be suspect, for two reason6: 1) The results of the two surveys seem inconsistent. The 1982/83 ADD survey recorded 25% less cropped land than the 1980/81 NSSA, and 25-47% less output of various crops. This trend is implausible, given that 1980-81 was a drought year, followed by a recovery in 1982 and 1983. futput from the agricultural sector is estimated to have grown in value by 5.9% in 1982 and 3.2% in 1983. These inconsistencies more probably arose from sampling differences,1/ or from differentials in completeness of reporting. 2) Both surveys may underreport food production. When the survey data were used to calculate the nutritional sufficiency of food production in Malawi 2/, total national production in 1980/81, as reported by the NSSA, was idequate to meet only 66% of national calorie needs, while total production in 1982 would meet only 49%. Plausible assumptions about the level of consumption of food items not covered in the survey data (such as oils, meat and beer) would still only raise the proportion of calorie needs 1/ The 1982/83 sample is considered to have been more representative than the 1980/81 sample. (Source: World Bank Staff) 2/ Calculated using assumptions of pre- and post-harvest loss taken from the FAO 1977 food balance sheet for Malawi, and food composition tables. - 52 - ANNEX B Page 6 of 17 met to 75 and 56X respectlvely.3/ While a level of 75% Is conceivable in a drought year, a level of 56Z Tn a normal year is frankly not credible. Data on nutritlonal status in Malawi are admittedly weak, but the country is norolly considered self-sufficient in food, and imports significant quantities of basic foodstuffp only in drought years. A deficit of the scale recorded for 1982/83---even perhaps for 1980/81--- must be due, at least in part, to severe underreporting of food production. However, the possibility that Malawi does not, in fact, produce quite enough food to assure an adequate average calorie intake cannot be excluded, particularly in view of its severe, and still unexplained, childhood mortality. There is some evidonce, for example, that smallholders are being encouraged to produce cash crops at the expense of food crops. Further investigation is needed. Given these data deficitncies, neither the 1980/81 nor the 1982/83 food production figures could be used as a basis for projections of the increase necessary to keep pace with population growth. Lacking such a base, it seemed sensible instead to project directly on the basis of land currently under cultivation. Since data on nutritional levels were so shaky, two assumptions about current calorie production were used for the base. The first assumption was that Malawi, at present, produces enough food on the land currently cultivated to meet the minimum calorie needs of its population. This Is the common assumption, though not based on any solid data. The results are shown in Table IV. The second assumption was that Malawi, at present, produces only 85Z of its calorie needs on currently cultivated land. This is considered as an upper limit of any possible sustained deficit in production for a country that does not import basic foodstuffs in noroal times, though it is, of course, much lower than the reported deficit in both agricultural surveys.4/ The results of these calculations are reported only briefly in the main text of this report, since their basis is so uncertain. 3/ The FAO estimate for 1981 of 94% national calorie sufficiency implies levels of maize production 2.4 times higher than the reported NSSA 1980/81 level and 3.2 times the ADD reported (1982/83) level. No details are available on how the FAO estimate (reproduced in WDR 1984) was derived. 4/ It is, however, similar to the deficit shown in another table from the ADD results which shows mean calorie sufficient levels by size of land holding of the household. When these means were weighted by the proportions of households in each category of land holding size, the overall sufficiency level was 85X (puzzlingly, the overall mean actually shown in the table was 60%, which does not correspond to the result of our calculations from the data in the table). No details of how the data of the table relate to the food production data from ADD were available. - 53 - ANNEX B Page 7 of 17 Table V: PROJECTED DEMAND FOR AND SUPPLY 2F WOOD, 1985 - 2015 (Million Cubic Meters, m4) Type of Use 1985 2000 2015 Urban and Rural Fuelvood (household)1/ Constant Fertility 6.5 10.9 19.4 Standard Decline 6.5 10.4 15.5 Accelerated Decline 6.5 9.6 12.1 Estate Fuelwood (Tobacco)2/ No improvement in efficiency of use 1.1 1.4 1.7 Improved efficiency of use 1.1 .9 1.1 Rural and Urban Industry and Services Fuelwood3/ .6 .9 1.5 Poles3/ .7 1.1 1.7 Wood Processing Industry3/ .1 .2 .2 Total Demand with no Improvement In Estate Use Efficiency Constant Fertllity 9.0 14.5 24.5 Standard Decline 9.0 14.0 20.6 Accelerated Decline 9.0 13.2 17.2 Total Demand with Improved Efficiency in Estate Use Constant fertility 9.0 14.0 23.9 Standard Decline 9.0 13.5 20.0 Accelerated decline 9.0 12.7 16.6 Total Supply from Existing Renewable Resources 4/ 6.1 - - Source: World Bank: 'Malawi Forestry Sub-Sector Study", Report No. 4927-MAI, September 1984. UNDP/World Bank: "Nalavi: Issues and Options in the Energy Sector", Report No. 3903-NAI, Energy Assessment Program, August 1982. - 54 - ANNEX B Page 8 of 17 Footnotes to Table V: 1/ Base value for 1985 taken from 1984 value given in the Forestry Sub-Sector Study, page 5, projected using a population growth rate of 3.2% between 1984 and 1985. Note that no allowance is made in projections out to 2000 and 2015 for the probable increase In urbanization, due to the uncertainties of forecasting urban growth rates. The net effect is probably to understate total growth in fuel wood demand, since urban per capita household consumption is higher than rural (see the Forestry Sub-Sector Study, page 6). 2/ Base value for 1985 taken from the Forestry Sub-Sector Study, page 5. Projected 2000 and 2015 values assuming no changes In use-efficiency calculated using growth rates in demand given In the Energy Assessment Report, Table 2.2 on a similar assumption. Projected values for 2000 and 2015 assuming improvements in use-efficiency calculated on the assumption that demand would decline up to 1994, as given in the Forestry Sub-Sector Study, page 5, and then grow at similar rates to the projection of demand assuming no changes In use-efficiency. The underlying assuimption is thus that all improvements will be instituted over the next decade, and that thereafter demand will increase proportionate to growth in tobacco production. 3/ Base value and projected values based on the Forestry Sub-Sector Study, page 5, which assumes an annual growth rate in demand of 3%. It Is possible that the demand for poles, at least, might vary with population growth like household fuel demand, and the rural industry demand (in part for tobacco processing) might vary like estate demand, but the share of these types of use in total demand is too small to warrant any great refinement In the assumptions. 4/ Taken from the Forestry Sub-Sector Study, page 4. Note that this figure is for potential supply only; actual production is given as only 4.6 m3, because of the inaccessibility of some of the potential forestry resources. Resources include indigenous forests on customary land, mnaged forest reserves and private plantations. The deficit between consumption and production from renewable resources is met currently by diminution of the natural forest cover of Malawi. Table VI: PROJECTED LAND REQUIREMNTS FOR WOOD PLANTATIONS TO COVER PROJECTED SHORTFALL IN WOOD SUPPLY: 2000, 2015 High-Yielding Plantations 1/ Low-Yielding Plantations 1/ 2000 2015 2000 2015 Total Supply_from Existing Renewable Sources (million H') 3.7 3.7 2/ 3.7 3.7 2/ Total Demand (million M3) With improved efficiency: Constant Fertility 14.0 23.9 14.0 23.9 Standard Decline 13.5 20.6 13.5 20.6 Accelerated Decline 12.7 16.6 12.7 16_6-. With no improvement A Constant Fertility 14.5 24.5 14.5 24.5 Standard Decline 14.0 20.0 14.0 20.0 Accelerated Decline 13.2 17.2 13.2 17.2 Shortfall in Supply (million M3) With improved efficiency: Constant Fertility 10.3 20.2 10.3 20.2 Standard Decline 9.8 16.9 9.8 16.9 Accelerated Decline 9.0 12.9 9.0 12.9 With no improvement: Constant Fertility 10.8 20.8 10.8 20.8 Standard Decline 10.3 16.3 10.3 16.3 Accelerated Decline 9.5 13.5 9.5 13.5 F Table VI continued.., HighYielding Plantations 1, Low-Yielding Plantations 1/ 2000 2015 2000 2015 Land Requirements to Cover Shortfall (thousand hectares) With moproved efficiency: Constant Fertility 687 1347 1030 2020 Standard Decline 653 1127 980 1690 Accelerated Decline 600 860 900 1290 With no improvement: Constant Fertility 720 1387 1080 2080 Standard Decline 687 1087 1030 1630 Accelerated Decline 633 900 950 1350 1/ High Yield - 15 M3/ha low yield - 10 M3/ha (Values from NPP Energy Report, Annex 2-5) 2/ Supply assumed to remain constant between 2000 and 2015-probabls an optimistic assumption since the NPP Energy Report projects a continued decline from 8.9 ullion a in 1980 to 3.7 u3 in 2000. Source: Table V II 0 o a Table VII: TOTAL RJECM A[D1TIAONL IAND R01 5M i 200o, 2015 AS PENWLYZ OF I)D VACAHr IN 1985 2000 20t5 no of land Use Constant Standard Acelerated COstant Standard Acclerated Fertiy Deline _el_e F_ty _=11 _ _c3f Additioral L P re Its in km2 Total Vacant Land, 1985 23,508 23,5(8 23,5CB 23,5(B 23,5(8 23,53 Subsistence Production l/ 9,660 8,624 6,865 28,494 19,995 12,355 Ibod and Tobecco 2/ 6,870 6,530 6,000 13,470 11,270 8,600 Total Requirements: 16,530 15,154 12,865 41,964 31,265 20,955 Additional Land RY rezments La as Percrntage of Vacant Land Total Vacant Land, 1985 100 100 100 100 100 100 Subsistence Production I/ 41 37 29 121 85 53 Wbod ad Tobacco 2/ 29 28 26 57 48 37 Total Reqirements 70 65 55 178 133 90 1/ Assuming no change in averag food intake; 2/ Assmmng hige-yield plantations and iprc,emnts in the efficiency of use In the tobac trA try. Give the esztatin stated in the N?tional Physical Develoment Plan Eergy Peport that tobacco estates otd achieve self-Aficiazy in fuel Dod by 1990, vitlxt elxnding lax! arm thereafter, it ma asaled that the additioal laid reqdred for fuel wod with expwm of toibo pctim wiud also suffice for the actual additional tobaco planting. 'fese estlutes are, threfore, wry mi a dnima of the aMdditl lax! that wll be required for grwth In tobacco prdaxtica and wood afply. ' Soure: TAes V aid VI 0 I-a -58 - ANNEX B Page 1Z of 17 Table VIII: PROiECTED NUMBERS OF PRIMARY SCHOOL PUPILS (in millilons) 1985 1995 2000 2015 At Current Enrollment Rate FMZ) 27 Constant Fertility .987 1.362 1.647 3.062 Standard Decline .987 1.362 1.588 2.203 Accelerated Decline .987 1.362 1.477 1.270 At Enrollment of 8t% in 1995 and 95X by 2015 _/ Constant Fertility .987 1.889 2.344 4.691 Standard Decline .987 1.889 2.261 3.376 Accelerated Decline .987 1.889 2.103 1.947 1/ On the assumption that the enrollment rate was the same in 1985 as in 1982 (the base year of the Education Plan, 1984-1994). This seemed a sensible maximum assumption since enrollments actually dropped somewhat from 1981/2 to 1982/3, the latest year available (Education Statistics, 1983). The enrollment rate for 1982 was calculated from the number of enrollments for 1981/82 reported in the Plan, Operational Supplement Table 3.2 (assumed to refer to the beginning of 1982) of 883 thousand, and the projected number of children aged 6-13 at that date in the Bank projections, which was 1.422 million, and came to 62%. This differs from the enrollment rate of 71% reported in the Plan, Operational Supplements, Table 3.2, because their projected number of children aged 6-13 is smaller. 2/ This is intended to correspond to Plan targets of 862 enrollment by the mid 1990s and a long term objective (not dated) of 95%. The enrollment rate in 2000, by linear interpolation, is taken as 88.25Z. Table IX: PROJECTED REQUIRED NUMBERS OF PRIMARY SCHOOL TEACHERS, 1985 - 2015 Numbers of Teachers Required Annual Percentage In-rease 1985 2000 2015 1985-2000 2000-15 At Current Enrollment 1/ and Pupil/Teacher Ratio 2/ Constant Fertility 14,515 24,221 45,029 3.4 4.1 Standard Decline 14,515 23,353 32,397 3.2 2.2 Accelerated Decline 14,515 21,721 18,676 2.7 -1.0 At Target Enrollment I/ and Current P/T Ratio Constant Fertility 14,515 34,471 68,985 5.8 4.6 Standard Decline 14,515 33,250 49,647 5.5 2.7 Accelerated Decline 14,515 30,926 28,632 5.O - .5 At Current Enrollment and Target P/T Ratio 2/ Constant Fertility 14,515 28,643 61,240 4.5 5.1 Stardard Decline 14,515 27,617 44,060 4.3 3.1 Accalerated Decline 14,515 25,687 25,400 3.8 - .1 At Target Enrollment and P/T Ratio Constant Fertility 14,515 40,765 93,820 6.9 5.6 Standard Decline 14,515 39,322 67,520 6.6 3.6 Accelerated Decline 14,515 36,574 38,940 6.2 - .4 1/ Current enrollment (1985) is estimated at 62%. Target enrollment is 86Z by 1995 and 95Z by 2019 (see Table VIII). 2/ The current Pupil/Teacher ratio is taken as 68:1 (following the Education Plan). Ta-gets In the Plan are for the ratio not to rise above 68:1 between 1984 and 1994, and of possible to fall to 60:1; the long term target (not dated) is 50.1. These are interpreted here as a ratio of 60:1 by 1995 and a ratio of 50:1 by 2015. The ratio for 2000, by linear interpolation, is thus 57.5:1. 0ii 0 - 60 - ANNEX B Page 14 of 17 Table X: PROJECTED EXPENDITURE ON lRIMARY EDUCATION WITH GOVERNMENT ENROLLMENT AND PUPIL/TEACHER RATIO TARGETS: 1985-2015 (In Constant Kwacha ailllons) Percent Average Annual Increase 1985 2000 2015 1985-2000 2000-15 Capital Costs I/ Constant Fertility 9.87 23.44 46.91 5.8 4.6 Standard Decline 9.87 22.61 33.76 5.5 2.7 Accelerated Decline 9.87 21.03 19.47 5.0 - .5 Recurrent Costs 2/ Constant Fertility 14.52 44.80 112.40 7.5 6.1 Standard Decline 14.52 43.21 80.89 7.3 4.2 Accelerated Decline 14.52 40.19 46.65 6.8 1.0 Total Costs Constant Fertility 24.39 68.24 159.31 6.9 5.7 Standard Decline 24.39 65.82 114.65 6.6 3.7 Accelerated Decline 24 39 61.22 66.12 6.1 .5 1/ Capital costs per pupil are estimated from the projected costs of development projects given in the 1984-94 Education Plan Operational Supplements, Table 3.12 over that ten-year period and projected number of pupils as given in Table VIII. The average annual cost is given as Kw 14.35 million. Since the average annual number of projected pupils for this period is roughly 1.44 million (using figures for 1985 and 1995 given in Table VIII), the average annual capital cost per pupil is estimated at roughly Kw 10. This figure is assumed to remain constant up to 2015. No details of the development projects are given in the Plan, so it Is not known whether they contain any elements more strictly classifiable as recurrent expenditure. 2/ Recurrent costs are estimated from unit costs per teacher (following the methodology of the Plan, Operational Supplements, p. 3.20), plus projected numbers of teachers as given in Table IX. Unit costs per teacher of Kw. 1000 for 1985 and Kw. 1066 for 1995 are taken, on the assumption that the costs given in the Plan for 1983/84 and the mid-1990s will apply also to these dates. Unit costs in 2000 and 2015 are estimated assuming that the 1985-95 annual increase (Kw. 6.6) will remain constant up to 2015, and come to Kw. 1099 and Kw. 1198, respectively. - ~~~~~~ 61 - ANNEX B Page 15 of 17 Table XI: PROJECTED NUM1IRS OF FULL-TINM SECONDARY SCHOOL PUPILS: 1985-2015 -(in i-i - 1l4ons ) 1985 1995 2000 2015 At Current Enrollment of 3.8Z I/ Constant Fertility 24,814 34,048 38,570 72,162 Standard Decline 24,814 34,048 38,570 59,774 Accelerated Decline 24,814 34,048 38,570 40,888 At Target Enrollment of 5% by 1995 2/ Constant Fertlllty 24,814 44,800 50,750 94,950 Standard Decline 24,814 44,800 50,750 78,650 Accelerated Decline 24,814 44,800 50,750 53,800 1/ Estimted from the numbere reported enrolled in secondary school in 1982/83 (Education Statistics, 1983) of 19,832, and the number of children aged 14-17 years at the beginning of 1983 according to the Bank's population projections (527,000). It was assumed that this enroll nt rate remained the same up to 1985. 2/ On the assumption that the enrollmnt rate rises to 5% in 1995 (the target given In the 1984-94 Educatlon Plan for 1994) and stays at that level thereafter. No long-term enrollment target Is mentioned In the Plan. - 62 - ANNEX B Page 16 of 17 Table XI: PROJECTED REQUIRED NUMBERS OF SECONDARY SCHOOL TEACHERS, 1985-2015 I Annual Numbers of Teachers Required Percentage Increase 1985 2000 2015 1985-2000 2000-15 At Current rntollment I/ and Target '/ Pupil Teacher Ratios Constant Fertlllty 1253 1543 2886 1.4 4.2 Standard Decline 1253 1543 2391 1.4 2.9 Accelerated Decline 1253 1543 1636 1.4 .4 At Target Enrollumnt and P/T Ratios '/ Constant Fertility 1253 2030 3798 3.2 4.2 Standard Decline 1253 2030 3146 3.2 2.9 Accelerated Decline 1253 2030 2152 3.2 .4 1/ Current enrollment (1985) is estimated at 38Z. Target enrollment is 5% by 1995 and remaining at that level thereafter (see Table XI). 2/ The current pupil/teacher ratio is estimated at 19.8, using numbers of teachers in 1982/83 given in the 1984-94 Education Plan, Table 4.5 (1,000) and numbers of pupils enrolled in 1982/83 from Education Statistics, 1983 (19,832), and assuming no change between 1982/3 and 1985. The Plan sets a target increase in the pupil/teacher ratio to 25:1 during the plan period. Hence target P/T ratios are taken as 19.8 In 1985, 25:1 In 1995, and remaining constant at 25:1 thereafter. No long term target is given in the Plan. 63 ANNEX B Pane 17 of 17 Table XIII: PROJECTED EXPENDITURE ON FULL-TIME SECONDARY EDUCATION WITH GOVERNMENT ENROLLMENT AND PUPIL/TEACHER RATIO TARGETS: 1985-2015, (In Constant Kwacha Millions) Average Annual Growth Percent 1985 2000 2015 1985-2000 2000-1S Capital Costs I/ Constant Fertility 6.80 13.91 26.02 4.8 4.2 Standard Decline 6.80 13.91 21.55 4.8 2.9 Accelerated Decline 6.80 13.91 14.74 4.8 .4 Recurrent Costs 2/ Constant Fertility 6.27 10.15 18.99 3.2 4.2 Standard Decline 6.27 10.15 15.73 3.2 2.9 Accelerated Decline 6.27 10.15 10.76 3.2 .4 Total Costs Constant Fertility 13.07 24.06 45.01 4.1 4.2 Standard Decline 13.07 24.06 37.28 4.1 2.9 Accelerated Decline 13.07 24.06 25.50 4.1 .4 :/ Capital costs per full-time secondary school pupil are cstlmated from the projected costs of development projects as given in the 1985-94 Education Plan, Table 4.15, but omitting projects G, H and J which apply only to other forn of secondary education, and the projected number of full-time secondary school pupils as given in Table XI. Average annual total capital costs for the period 1985-95 (assumed to equal those In the Plan for the 1983/4 - mid-1990s period) come to Kw. 9.54 million; average annual numbers of pupils come to roughly 34.8 thousand. Hence average annual capital cost per pupil is estimated at Kw. 274. This value is assumed to remain constant up to 2015. 2/ Recurrent costs are estimated from unit costs per teacher, following the methodology of the Plan, Operational Supplements, p. 4.24. According to the Plan, the unit cost per teacher will remain constant at Kw. 5,000 throughout the Plan period. It Is assumed that it will further remain constant up to 2015. -64 - ANNEX C Page 1 of 5 Table 1- MOH STAFFING SITUTATION - June 1984 Category Establishment Staff-In In-Post as Z Post Establishment Medical Officer 136 84 62 Dental Officer 11 8 73 Clinical Officer 184 178 97 Medical Assistant 517 351 68 Registered Nurse 497 367 74 Enrolled Nurse/M 907 919 101 Pharmacist 13 9 69 Pharmacy Technician 6 1 17 Pharmacy Assistant 26 32 123 Laboratory Technician 29 25 86 Laboratory Assistant 84 55 65 Radiographer 17 9 53 X-Ray Assistant 8 89 Dental Technician 11 7 64 Dental Assistant 12 9 75 Physio/OT 12 6 50 Health Inspectors 101 70 69 Health Assistant 231 169 73 Other Established 2159 1916 89 Total: 4962 4223 85 Table 2 CONTRACEPTIVi SUPPLIES ORDERED TIROUG8 FMA 1981 - 1984 (THRCL Y*AR PERIOD) Date Recipient Oral Contraceptives IUDe Coadoms Fom_/Jelly Otber Noriday Worminest Total (all alzes) Oct. 81 Central Medical (500 1) Storts 2,000 (1,000 C) (500 D) June 82 Central Medical Store. 5,400 cycles 10,200 cycles 15,600 March 83 Centrai Medical (500 3) Stores 19,600 cycles 23,600 cycle. 43,200 1,500 (500 C) (500 D) April 83 Central Medical Stores 14,000 cycles 15,600 cycle. 29,600 may 83 Central Medical Stores 30,000 cycles 15,600 cycles 45,600 12,000 June 83 Adventist Health Service Center 16,800 cycles 8,400 cycle. 25,200 125,000 1152/22"6 1.000 pair glowes Blantyre Sept. 83 Queen Elizabeth Poepital 12,000 cycles 12,000 2,000 e July 84 Central Medical r Stores 1,200 (600 C) ' (600 D) Total: 97,800 cycles 73,400 cycles 171,200 4,700 (1,000 3) 139,000 3.420 1.000 (2,100 C) (1,600 D) - 66 - ANNEX C Page 3 of 5 Table 3: CONTRACEPTIVE SHIPMENTS SENT TO MALAWI BY FPIA Method Oct. 12, 1984 Oct. 15, 1984 Total Shipped Noriday 90t,000 30,000 120,000 Norminest 30,000 30,000 60,000 CU-T 600 600 Lippes Loop Size B 500 5,000 5,500 Size C 300 5,000 5,300 Size D 1,300 10,000 11,300 Condom (colored 52 mm) 36,000 6,000 42,000 Foam with applicators 10,000 10,000 Jelly with applicators 2,268 2,268 Diaphragms Size 65 48 48 Size 70 96 96 Size 75 144 144 Size 80 144 144 Size 85 96 96 Medical Kit No. 6 (IUD insertion) 25 25 Medical Kit No. 3 (IUD back-up) 25 25 Gloves (several dozen) 1. - 67 - ANNEX C Page 4 of 5 Table 4. *CALCULATION OF 1985 CONTRACEPTIVE REQUIREMENTS FOR MALAWI Method Amount Required 10% Increase One Year Total Amount at 1985 level Buffer Stock Required Orals 72,644 cycles 7,264 cycles 72,644 cycles 152,552 cycles IUDs 2,100 units 210 units 2,100 units 4,410 units Condoms 7,656 pieces 765'pieces 7,656 pieces 16,077 pieces *Based on previous year supply distribution pattern, a 10 increase in usage plus a one year buffer stock. 68 - ANNEX C Page S of 5 Table 5: MALAWI - CONTRACEPTIVE AND EQUIPMENT REQUIREMENTS 1985 Femenal 20,000 cycles Lo-Femenal 132,552 cycles *Lippes Loops Size B 2,200 Size C 2,200 Size D 4,400 *Condoms colored 52 mm 33,000 pieces Foaming Tablets 5,000 Diaphragms Size 65 48 Size 70 96 Size 75 144 Size 80 144 Size 85 96 Medical Kit No. 6 (IUD insertion) 27 Medical Kit No. 3 (IUD back-up) 27 Medical Kit No. 1 (Mini-lap) 6 *Due to anticipated increase in use of these methods in 1985, amount required has been doubled. - 69 - ANNEX D Page l of 3 Outreach Programs of Ministries other than MOH in Malawi Feawle Extension Workers-Ministry of Agrlculture and Natural Resources The Ministry of Agriculture and Natural Resources trains Female Extension Workers (FEWs) at the Natural Resources College. They take the saw course as Agriculture Field Assistants, but with additional components on family economics and management, housing and technology, human nutrltion, food managemtnt and child care and development. FEWs also recelve two week refresher courses at the Agricultural Development Divisions (ADD) annually. Once trained, FEW's primary responsibility includes giving short two week courses to rural women at agriculture training centers throughout the country. For the most part, FEWs are based at Agriculture Training Centers and as of December 1983, there were three farm institutes, 21 residential training centers and 138 Day Training Centers. The farm institutes and residential training centers offer more extensive training and usually have plots, livestock and a kitchen. FEWs also provide extension advice to women through home visits and are recently being encouraged to extend agriculture advice through establishing group demonstration gardens. In line with the new curriculum, FEW training courses stress growing foods and the link between nutrition and agriculture. Some of the health topics FEWs include in their courses are control and prevention of common diseases in rural areas, sanitation, nutrition and personal hygiene. They also frequently collaborate with MCH health workers and teach at Under-Fives Clinics. Ministry of Community Development Adult Functional Literacy Program Available data show that a high percentage of the adult population In Malawi are illiterate. According to the final report of the 1977 Population Census, 77.9Z of the total population aged 15 and over are illiterate in Chichewa. (Illiteracy is defined as not completing four years of school.) There has been a government tendency to favor formal education of school age children over non-formal education programs. Nevertheless, with assistance from UNESCO/UNDP, the government started a pilot functional literacy project In 1979. The aim of the project is to provide an opportunity for learning and assistance to small holder farmers and rural populations. The government realizes that rural women and men should be participants in the country's development process. Literacy of rural populations is therefore seen as an important condition to the improvement of life in rural areas. The first phase of the project was focused on establishing policies, developing and pretesting instructional materials, and staff training. Literacy courses were then introduced in three pilot ADDs. To date, 259 Functional Literacy Centers have been developed and 12,840 trainees have participated in the project. There is a need for better training and understanding of leaders and teachers on what functional literacy is and how to reach others. One - 70 - ANNEX D iage Z of 3 challenge of the program has been to link literacy training to development activities and develop a curriculum that includes these elements. The content of the instructional materials flows from national development goals. Messages relate to Agriculture, Home Economics, Community Participation, Child Care, Health, Religion and personal needs of Individuals working in rural settings. The development and modification of the currlculum is still underway. A system is currently being developed for assessing learner performance. Last year, UNFPA and UNESCO developed a proposed project (not yet approved) to introduce child spacing topics and reading materials through the pilot areas of the functional literacy project. The project proposes to produce booklets on Child Spacing as reading materials for new literates. 15,000 would be printed and distributed to 750 literacy centers. The aadantages of introducing child spacing through the Functional Literacy Prpgram includes the ability to reach men (although at present limited numbers attend) and working through an established infrastructure that has produced print material as part of its program. Female Community Development Assistants The Ministry trains Community Development Assistants (CDA) in a one year training program at Magomero Training College. CDA's primary responsibility is to supervise the work of Ministry of Local Government Home Craft Workers (HCWs) and to give training to women in rural areas. They teach courses in food, nutrition, child care, village health, sanitation, textile and clothing and development of family resources. One emphasis of their training is on how to teach these topics to people in rural areas. CDAs are employed by the Ministry of Community Development and work in rural areas at the District and Area level. Approximately 210 Community Development Assistants have been trained, with 128 being male and 82 female. Home Craft Workers - Ministry of Local Government Home Craft Workers (HCWs) are female workers trained for six months at the Magomero Training Center. The curriculum is a shortened version of the CDA training program, and once they are trained, CDA supervise their work. Each trainee is sponsored by local District Councils, Missiors or private associations and after training (HCWs) return to their sponsoring organization. Over 1,000 HCWs have been trained since the program began in 1959; however, only a little over half, or 529 are currently working. HCWs are trainers and conduct weekly courses for rural women reaching about 50,000 women annually. They also assist with educational activities at MCH clinics. In 1981, a comprehensive evaluation was done of both HCWs and CDAs. The evaluation looked at recruitment, financing, basic and in-service training, teaching effectiveness, working conditions in the field, supervision and staff support and overall program effectiveness. - 71 - ANNEX D Page 3 of 3 One finding showed a high dropout rate for both HCW and CDAe. For example, 51.6Z of trained HCWs and 33.3% trained CDAs are tot working. Unfortunately, little is known as to the reason for this. Concerning the training programs, the evaluation recommended that the curriculum of both HCWs and CDAs should be revised. It was thought that too much emphasis was placed on sewing and handicrafts and not enough time was spent on food production, storage and preparation in addition to family health and sanitation. As a follow up to this recommendation, in 1982/83 an extensive review of the HCW curriculum was made. As a result, major curriculum revisions were made to include more topics on basic needs such as preventive health. The HCW training was increased from 3-6 months. In light of these new charges in the HCW training program, it has also been recommended that the CDA training be reviewed, modified and extended in length. Potential of Existing Extension Services Currently, four Ministries train women workers in community development related activities. The Ministry of Health, Local Government, Community Development and Agriculture and Natural Resources all train women in Home Economics, some aspects of health and broader issues of economic and social development. Evend though the Ministry of Community Development has the primary responsibility for home economics, otier ministries include it in their programs and there is the potential for overlap and duplication. While the three major categories of workers (aside from Health) that are trained,and deployed all include training in many of the same topics, FEWs emphasize agriculture topics (agriculture production and food utilization), whereas CDAs and HCWs emphasize home economics topics. All three categories conduct training courses, however only FEWs train in established training centers. CDAs place more emphasize on teaching methods and group learning and organize people informally for courses in rural settings. However, there are many similarities in the trainirg courses offered by FEWs and CDAs/HCWs even though they all have different levels of education and training. The curricula of both FEWs and HCWs have recently been revised to strengthen aspects of preventive health care. Both work at MCH clinics primarily Under-Fives clinics, in collaboration with health workers. It is clear that they enjoy this highly structured and organized work although there is little indication,that they do any follow-up beyond the clinic. The basic curricula of each of those workers could be modified to include child spacing topics. FEWs and HCWs could continue to work with Health workers at MCH clinics and be encouraged to do follow-up or home visiting, when indicated. Male Farm Home Assistants and CDAs could also be taught child spacing topics with special emphasis on appropriate information to reach men. - 72 - ANNEX E Page 1 of 5 Information, Education and Communication Activities The Health Education Unit - Ministry of Health The overall goal of the Health Education program in the Ministry of Haalth is to lnitiate and support activities and programs which motivate individuals and communities to underatand their health needs and utilize existing services. Priority areas in Hlealth Education Programming include: a) Designing s National Health Education Program Plan; b) Training qualified Health Education and; c) Organizing a National Health Educatlon Unit within the Ministry capable of planning and coordinating all Health Education activities in the country. The Health Education Unit was originally developed to produce MCH materials. However its responsibilities were later changed to include coordination of the entire Health Education Program with emphasis on Primary Health Care. The Unit consists of six sections which include: a) Graphic Art; b) Radio; c) Mobile Cinema; d) Publications; e) Health Education Band/Drama; and, f) Support Services. Graphic Arts Section This section produces posters, flipcharts, and a calendar. Material is designed and screen-printed within the section. A darkroom is available for simple black and white photograp'y along with a screen-printing room which is adequate for small runs of simple posters. The materials produced are frequently of poor quality due to lack of detail, poor reproduction due to deficient equipment, confusing scale of items and/or complicated or wrong messages. This is primarily due to a shortage and lack of staff competency in these areas. Radio Section Radio Programs are designed by staff in the section and four programs are aired each week free of charge by the Malawi Broadcasting Corporation (NBC). Topics for programs are selected one year in advance based on seasonal needs and prevalence or outbreak of diseases. It is not known whether health messages reach target audiences, as there has been no evaluation of these programs. Letters from listeners are sent to staff, but are from a self-selected audience who can read and write. Two problems are the need to change air time from early morning hours and the need to include field interviews as part of radio program development. It is planned to include selected Child Spacing topics in the 1985 program as -part of the new program emphasis. Mobile Cinema Section The activities of this section include mobile units that travel to village where staff give health education talks and show films. The - 73 - ANNEX E Page 2 of 5 section has a van for each of the three regions and each one travels about 3-4 times a month. Film are borrowed from the British Council and the American Cultural Center as the section has few of its own. The film are frequently inappropriate to the needs of rural populations, although three films have been made for the unit, one on Bilharzia, one on Rural Piped Water, and one on Malnutrltlon. The section needs relevant films and slides, and there Is a need to train staff in equipment and vehicle maintenance. Publicatiun Section The main activity of Lhis section Is production of a bimonthly publication, Moyo Magazine. It is written by unit staff and is printed elsewhere. Circulation is approximately 2,000 copies and the content, is geared primarily toward clinicians. Therefore, the magazine reaches only a specialized audience. There has been no feedback or evaluation done. to determine its usefulness or impact. The magazine should expand Its audience to Include rural health workers and focus more on the general needs of these workers, including primary health care topics. Health Education Band/Drama Section Perhaps the most innovative health education activity of the program is the Health Education Band. Local musicians and singers compose and sing songs on health topics and perform throughout the country. Demonstrations are also part of the program. ror example, the Band sings a song on Round Worms during which they demonstrate a large specimen in a bottle as part of the performance. The musicians perform at conventions, fairs and sing on the radio. The Band needs assistance with transport, should work full time (at present it only works part time) and should relocate from Zomba to the Health Education Unit headquarters in Lilongwe. One major problem of the Health Education Unit is need for appropriately trained staff. Also, though the Unit has five semi-professional and eight support staff, the positions that staff are currently holding have not actually been established, Heads of sections are filled by Health Assistants and Health Inspectors who are only given interdepartmental transfers to work in these positions without additional salary. The head of the unit has an office across town at the central MOB headquarters. This makes communications among staff difficult. Health Education Officers in the country are primarily men, which makes it difficult to implement effective health education activities that focus on women, especially Child Spacing. A recent UNICEF evaluation of the Unit recommended additional staff and staff development in all major areas. A restructurlng of programs was also recommended and described along with specific suggestions on how to upgrade the physical facilities, equipment and supplies. - 74 - ANNEX K jg- -rof 5 The Extension Aids Branch - Ministry of Agriculture and Natural Rasource. The Extension Aids Branch (EAB) is the largest government communications program; it organizes and coordinates extensive education programs for the Ministry and is responsible to educate rural farmers In crop production, growing cash crops and food, health and nutrition. UAB provides mass coverage through radio, development, prlnting and distribution of materials, production and provision of visual materials, a research and evaluation service and an extenslve mobile cinema program. Publications Section The section produces and prints a wide variety of materials which includes flipcharts, books, textbooks and posters. The section handles over 200 different jobs annually and produces 1.5 million copies in an average year. The section also produces a bimonthly farmrs magazine in Chichewa and prints approximately 32,000 copies. Upon request, the Publications Section develops materials for other Ministries and Is currently developing a book on Schistosomiasis for the MOH. Technical Section This section operates a Mobile Unit of Land Rovers which travel to every district in the country to show films and give puppet shows. The purpose of the Mobile Unit Section is to present effective and entertaining messages on agricultural and rural development to people from all parts of the country. The section also provides maintenance service for audio visual equipment. Photographic Section This section produces black and white still photography for use in development of print materials or displays. Color slides are produced and a library maintained which lends slides to training centers and other departments and Ministries. Radio Section This section develops and produces six radio programs or a total of five hours and 12 minutes of broadcast time per week. In developing these broadcasts, EAB staff travel to rural areas and interview farmers on various agricultural topics. The programs are produced and edited by EAB staff and broadcast by Malawi Broadcasting Corporation. All programs are in Chichewa. Cinema Section Agricultural films are produced by the staff in this section. EAB film crews have made approximately 40 films, which are shot locally and printed outside the country. A catalogue of available films is produced and films borrowing is encouraged. The EAB film section has assisted other - 75 - ANNEX E Page 4 of 5 Ministries, and is currently assisting the MOH In producing a film on Bilharzia. Such MOH requests come through technical units rather than the Health Education Unit at the Ministry. Editorial Section The staff In the Editorial Section have the responsibility for writing and editing all HBA materials and publlcations. The section also develops the scrlpts and produces a puppet show that Is part of the cinem program. It ensurem that whatever material is produced and printed by HAB Le clear, simple and understandable. Evaluation and Action Research Sectlon This section was established to assist all staff to ensure that materials and program content are relevant, and are the best media response to deliver messages. The section field tests materials, develops background information studies on topical areas and carries out evaluations to assess how well messages are belng understood by the target audience. The HAB was established in 1958 and has gained a lot of experience and expertise in communications program development and implementation. It is EAB policy to assist other departments within the Ministry of Agriculture, as well as other Ministries, In communication and educatlon activities. The Information Department of OPC The overall goal of the Information Department in OPC is to provide information and education to rural communities which will support the government's development policies and programmes. The department works fairly independently in general, though it does cooperate with other government, NGO, and international agencies in the preparation and distribution of materials. Productions include films, publications, radio programmes and photographic displays, the latter a relatively unimportant element. In each district there is a District Information Officer with functions such as counting of film audiences, occasional passing on of requests for specific films, monthly reports of popularity of films shown, etc. Publications The chief publication is a monthly newspaper in Chichewa, Boma Lathu, with a circulation of 40,000 and an estimated 8 to 10 readers per copy. The newspaper is distributed free through party officials down to area level; it is sent automatically to all headmasters and headmistresses and to all village headmen who request it. The department spends Kw. 7,000 on the production of Boma Lathu. It covers general development topics and political news and messages. - 76 - ANNEX E Page 5 of 5 The Information Department produces its own films and has three mobile f.1m units (one per region), each with a van, for showing tlhem. Their films are also shown through the EAh's systom which Is more extensive, with a van in each district. The subjects of the films are very varied, including one on housing (correct construction techniques, etc.), which was co-produced by the Information Department and Habitat, anotler on water supply systems (extremely popular) and various films with a political content, suchI as state visits, political messages, etc. In the PHN field, the only film so far produced has beon on child nutrition for mothers ("Look after Children well"), sponsored by the JCs at the initiative of the Information Department as a contribution to the International Year of the Child. It has been quite popular. Some of the relevant films are borrowed by the Health Education Unit. Radio The radio section operates semi-independently and only occasionally is used to b-oadcast special messages from the government. It compiles its own programmes on development topics. In the health field, the section has been broadcasting regular health spots, in collaboration with the Red Cross and the Health Education Unit. am *\+ ' Z. \< f h 'i *_. I, i' ' ~ ~ ,s * .->\ .; )t. \'\ r ~~~: M,,. . 9 - . * '! ...-.*'- , '| RELIE ). W. ,~~~~~~ 4*-.-*K ~~~~-~~~-* ~ Il r!f.r 1s n - ,, . . ,~~~ ~ --'J. /