Category Archives: Healthcare

Rules of the Road

As I was doing my research backwards and forwards before heading off to Malawi, I learned that the majority of traffic fatalities in the developing world are pedestrians. This was a statistic I read and acknowledged, but didn’t really understand until I’d spent a bit of time walking around cities in Malawi. The roads are narrow, filled with potholes and other hazards, the cars are old and poorly maintained, and people don’t pay attention as they should. Sidewalks? Streetlights? I can count their numbers on my fingers and toes.

The result is that being a pedestrian in Blantyre is a hazardous affair. An African in their late teens or twenties statistically has more to fear from walking down the road or using public transportation than they do from TB, malaria, or even HIV/AIDS. In recent years, about one-fifth of the world’s road deaths have occurred in sub-Saharan Africa, even though the region is home to only two percent of the world’s cars.

I had planned to spend this Friday evening at the world premiere of the Malawian version of An Indecent Proposal. I’m really not sure of the specifics, except to say that somehow a number of characters in the Blanytre community wound up starring in the film, so the premiere at a hotel downtown was a big event in a city not exactly known for its nightlife. However, on my way to the movie I was flagged down by two frantic young men in the middle of the dark street near my house, yelling at me to stop the car. When I noticed a figure knocked out near the side of the road, I pulled over. The two young men helped an elderly Malawian into the car, explained that he had been hit by the bus that just passed, and asked me to drive him to the hospital.

I took this man, Joseph, to Queen Elizabeth Central Hospital. It’s the largest referral hospital in the country, and it’s government run, which means that if you are a citizen, you are treated for free. When we arrived, I fell into conversation with another driver there looking to commiserate. “You hit someone too?” At first I tried to explain that no, of course I had not hit the man, but failed to make myself clear with the language barrier and the like, so I gave up. Whereas at home I might worry about prosecution for taking someone out on the street, it is so common here that I saw several such cases filter into the emergency room as I waited. Most did not look as lucky as Joseph, who was conscious, able to walk, and communicate with his family when they arrived a few hours later.

Even though my perch in the waiting room was right near the ambulance lane, those vehicles were the one thing I didn’t see in my few hours at the hospital. I asked my newfound companion about this, who explained that ambulances are not meant to pick people up who have been hurt, but just to transfer the very ill to the city from the rural clinics. The two young guys who flagged me down to drive Joseph in weren’t doing “the right thing,” they were just doing what is normal in a country where government does not have the capacity to provide services like bringing the sick to the hospital. “Community” feels different living here in Malawi. There is no safety net beyond family, friends, and the American lady who happened to driving down the street.

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Maternal Healthcare in Malawi

Today’s Guardian has a piece on maternal health in Malawi. Since I began closely following news in Malawi in March, I have been grateful for the Guardian‘s attention to Malawi, which is by all accounts a small country with little geopolitical or economic importance to Europe at this point. I notice the Guardian covers Malawi more so than any other British or certainly American paper, or at least has during the few months I’ve been paying attention.

I found two facets of today’s article particularly interesting. First, inherent in any discussion of maternity issues in a developing country like Malawi is the question of population. On this score, the news is not good. Despite the mind-bending rates of maternal and child mortality, Malawi continues to have one of the world’s fastest growing populations:

The country’s population has swelled from 4 million in 1966 to 14.8 million in 2012, with an average of 5.7 births per woman. At the London Summit on Family Planning, in July, NGO Marie Stopes International (MSI) pledged to double the number of women using contraception provided by them globally to 20 million by 2020. But the Population Reference Bureau (PRB) estimates that, even if the fertility rate declined to 4.6 births per woman by 2020, the population of Malawi will hit 26 million in 2030.

Malawi is now in a position where even the good news tricks of education and health, which improve the lot of the individual, are slow to improve society writ-large, because the economy does not generate enough jobs to employ the country’s educated graduates. Last week a local paper was headlined by news about just how dismal the situation is for new graduates in the country. I wonder at how much worse this situation will be in 18 years, when the population is nearly double. Further north, some social scientists have argued that the Arab Spring was in part due to the population bulge that occurred in part due to lifesaving technologies for mothers and babies, concurrent with a failure to adequately invest in generating new jobs to give the additional North Africans they types of lives they deserve.

A second aspect of the article that I found interesting was the discussion of health services delivery. The author writes:

The private sector provides 40% of healthcare in Malawi, mostly via faith-based organisations, such as churches or religious NGOs.

I wonder at the author’s classification of faith-based organizations as “private sector,” but that aside, the point I find noteworthy is that government services can only cover about 60% of Malawi’s population. The government is fortunate to be able to provide free healthcare, largely through donor support, to 60% of its population, the majority of which lives on less than $1 a day (or even less as the Kwacha continues to devalue).  This statistic emphasizes the need for public-oriented non-profit organizations.

There is a trend in development right now towards the private sector. The argument is that the publicly-funded development community has not achieved its objectives over the past 60 years, and that a new approach with a triple bottom line in mind can work miracles that the public sector simply can’t. While I agree with this sentiment, and in fact back it up by spending the year at a private company that works on private sector development, the gap between what the government can provide and what resource-poor Malawians need underscores the continued place for non-profits in development. Non-profits fill the gap between where government capacity stops and private sector profit motive begins. The fact that 40% of Malawians fall in that gap doesn’t mean they should not receive care. It means that we should be grateful that this latest development fad has not yet entirely squeezed out the role of the non-profit.

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