Malawi emerges as a leader in family planning

Over the last two decades, through a mix of demand-side and supply-side interventions and data-driven strategies, Malawi has emerged as a leader in improving women’s access to contraception.

Women in Malawi have roughly double the rate of modern contraceptive use (58%) when compared with women across the rest of sub-Saharan Africa (29%). This access to and use of contraception has helped Malawi improve women’s health and socioeconomic wellbeing.

Malawi has faced significant hurdles in its journey to improve access to family planning. In 1983, the country had only two family planning clinics, and the nation is overwhelmingly rural, complicating distribution.

Nevertheless, Malawi has succeeded in making a range of contraceptive choices – including self-injectables and long-acting reversible contraceptives (implants and intrauterine devices) available across the nation – including the 85% of the population living in rural areas. The country has even been able to reach adolescents, a traditionally difficult population to serve, with contraception services.

In advance of this week’s International Conference on Family Planning in Thailand, Exemplars News spoke with Dr. Fannie Kachale, Malawi’s Director of Reproductive Health at the Ministry of Health and Long-Term Care, about what other health leaders can learn from her country's success.

What were the key drivers of Malawi’s progress?

Dr. Kachale: We have identified a few key drivers of success.

First, the Malawi government committed to increasing access to modern family planning. They set the goal of reaching 60% mCPR for all women.

This was ambitious. In the 1990s the modern contraception prevalence rate was just 7%. By 2010, they were able to increase the rate to 46% and by 2015-2016 it had increased to 58.6%.

To achieve that progress, the Malawi government made several commitments at the London Family Planning Summit of July 2012. Some of the commitments were to elevate the Reproductive Health Unit to become a Reproductive Health Directorate, create a family planning budget line item, and finalize the Population Policy by the end of 2012. In 2013, the government created a budget line item specifically for family planning and committed to increasing it gradually. The funding started small at Malawian Kwacha 26 million and reached MK 200 million (nearly US$200,000) for the financial year 2020-2021. For the 2022-2023 financial year, the government’s committed funding for family planning is 475 million Malawian Kwacha (about US$463,000).

Second, we engaged in task shifting to ensure that contraceptives were available through a larger number and greater variety of health providers.

For example, Malawi has long had community health workers, called Health Surveillance Assistants (HSAs), who serve their communities in a specified catchment population. This cohort debuted in the 1950s as child vaccinators. In 2007, the government added modern contraception (specifically the injectable DMPA) to the basket of services they provide, in addition to motivating and educating women about family planning. We also have community-based distributor agents who go door-to-door motivating women on family planning, offering oral contraceptives and male and female condoms, if it is the method of choice chosen.

Third, the government recognized the key role that supply chains play in family planning. Women want protection all year, not just for three months at a time. So, the government established a steering committee, with representatives from all partners involved in supply, to cooperatively manage product procurement and discuss product pipeline and manage stock status. We work hard to make sure commodities are available when women need them.

This isn’t just an effort to manage the supplies from warehouse to clinic. We participate in the Global Family Planning Visibility Analytical Network, that allows us to see what products our partners are buying on our behalf, and monitor the flow of contraceptive commodities from the manufacturer to our country, and then we can plan distribution and minimize stockouts and product expiration.

Fourth, we rolled out access to self-injection nationally.

And fifth, we developed youth friendly health services.

Can you expand on that last point, how does the government connect adolescents with contraception?

Dr. Kachale: A 2014 evaluation of contraceptive services for youth found that some providers were hostile to youth trying to access contraception. A provider might judge a teen and say, ‘You are so young. Why are you doing this?’ Adolescents also reported that sometimes they would see a neighbor in the waiting room of the clinic and then feel embarrassed and leave. That feedback led us to a new strategy for the provision of contraceptive services to adolescents. The youth don’t want to be visible. So, we must provide services to them separately from the rest of the population. In health centers, there is a youth corner apart from the other areas. We also have mobile vans that travel to deliver contraception to adolescents specifically within communities. We might know of a community event where teens will be present and make sure our staff attend the event. And we have accredited partners, such as the Family Planning Association of Malawi [an affiliate of Planned Parenthood International] and Banja La Mtsogolo [supported by Marie Stopes International], who do so following the guidelines we established.

Tell us about the promise of self-injectables and how Malawi rolled this out?

Dr. Kachale: Self-injectables offer tremendous benefits for women who are interested. It is very popular with women in Malawi.

When considering adding this option for women to the services we already offer, we started with a pilot program. During the pilot in one district, we saw this type of contraception was extremely popular. The pilot demonstrated that self-injectables were safe and effective even for women with limited education. We then expanded availability to another six districts and then finally rolled out availability across the entire country.

To achieve this, we trained 8,897 public health providers, across all 29 districts, on providing counseling and training women to self-inject. And we continue to offer post-training supportive supervision for both providers and women.

Today, about 21% of women using modern contraception in Malawi have chosen to self-inject.

The benefits of self-administration for women include saving time and money, by no longer needing to travel to health clinics as often, which is a significant benefit for women living in remote and rural areas. Self-injection also offers women increased privacy and confidentiality, because they simply go to the clinic once a year to receive their annual supply.

During COVID, this was a huge benefit. Those women could stay home and didn’t have to visit the already overwhelmed clinics.

What prompted the government’s investment in improving access to family planning?

Dr. Kachale: Previously, we had poor health indicators. Our maternal mortality ratio has since declined by more than half, from 942 per 100,000 births in 2000 to 439 in 2016. And our neonatal mortality rate has declined from 39 deaths per 1,000 live births in 2000 to 27 in 2020. We had high rates of teenage marriage. And those girls couldn’t complete their schooling. We knew that we couldn’t develop the country like that. There was also a recognition that the government would struggle to support the basic needs of a rapidly growing population.

Our efforts are having the desired effect. We see a lot of young women and families now prefer to have two to three children and are able to act on those preferences. Our fertility rate has dropped from an average of 6.7 children in 2004 to 4.2 children in 2020 - much closer to the mean ideal number of children women in Malawi expressed in surveys, which was 4.1, even in 2004.

What impact is this having on women and women’s rights?

Dr. Kachale: Now women can plan their pregnancies and decide to have a family when they are ready and at a size that they can manage.