Malawi Background Information
At 2.7 percent, Malawi has one of the highest rates of population growth in the world, creating substantial demands on the health system. Malawi’s population has grown rapidly from almost 3.6 million in 1960 to around 17 million in 2017 with about 85 percent of the population residing in rural areas1. Almost half (46.4 percent) of this population is below the age of 15 years and owing to an estimated growth rate of 3.2 percent per annum in 2015, Malawi’s total population is expected to reach 26.1 million by 20302. The government of Malawi recognizes rapid population growth as one of its principal development challenges and has prioritized voluntary family planning.
Malawi has made great strides in improving health outcomes over the past decade. While still high, the maternal mortality ratio (MMR) declined from 984 per 100,000 live births in 2004 to 439 per 100,000 live births in 2016, while the infant mortality rate (IMR) decreased from 104 deaths per 1,000 live births in the year 2000 to 42 per 1,000 live births in 2016. The neonatal mortality rate has gone down from 42 deaths per 1,000 live births in the year 2000 to 27 deaths per 1,000 live births in 2016. The child mortality rate has decreased from 95 deaths per 1,000 live births in the year 2000 to 23 deaths per 1,000 live births in 2016, while the under-five mortality rate has gone down from 189 deaths per 1,000 live births in the year 2000 to 64 deaths per 1,000 live births in 2016.
Despite this progress in reducing mortality, weaknesses in the health system could stall or reverse progress. Significant health system bottlenecks limit service coverage and provision of quality health care. These bottlenecks include a critical shortage of key health systems inputs (human resources, medicines and medical supplies, and poor/inadequate infrastructure). An acute shortage of critical health workers is a major constraint to the achievement of all health objectives. Only 52% of established posts are filled (Annual Joint Health sector Report 2017/18).
The epidemiological profile of Malawi is characterized by a high prevalence of communicable diseases like HIV/AIDS, malaria and tuberculosis, high incidence of maternal and child health problems; an increasing burden of non-communicable diseases and resurgence of neglected tropical diseases. Approximately 1.1 million people are living with HIV in Malawi. Sixty-four percent of them are women. Cervical cancer is the most common and leading cause of cancer deaths among women in Malawi. Cervical cancer represents 40% of all cancers among females and Malawi has the highest age standardized incidence rate (ASR) in the world at 75.9 per 100,000 population. It is estimated that 3,684 women develop cervical cancer and 2,314 die from the disease annually3. HPV prevalence is also high at 33.6%4. High-grade pre-cancerous lesions and cervical cancer are also very common among Malawian women5. It is expected that the number of cervical cancer cases and deaths will continue to increase if preventive and treatment efforts are not scaled up to reach more of the infected women. Given that cervical cancer affects women who are still in the economically productive age group, the morbidity and mortality of women with this disease has serious implications on the wellbeing of families and the nation’s development as a whole.
In response to this high burden, the Ministry of Health established a Cervical Cancer Control Program (CECAP), which started the screen and treat program beginning in 2004 with support from USAID partners using voluntary family planning as a point of entry. The vision was to gradually scale- up nationally. However, due to resource constraints the scale-up effort did not progress as envisioned. As a result, screening and treatment services are mainly limited to high volume sites and some MOH partners are providing screening through their outreach services to family planning clients over 30 years of age. Even in sites and outreach services where screening and treatment services should be available, the interventions are not routinely available due to factors including shortage of personnel, space, equipment and supplies. One key constraint has been the unavailability of gas required for cryotherapy. The country is strongly advocating shifting focus to thermocoagulation. Between 2013 and 2015, with support from GAVI and other partners, Malawi successfully implemented an HPV vaccination demonstration program in two districts: Zomba City (urban) and Rumphi (rural). The demonstration project achieved nearly 90% coverage through school-based vaccination sessions for a single-age cohort of 10-year-old girls, both in and out of school. Beginning 2019 MOH and partners will start rolling out the vaccine nationally, but due to inadequate funding, the vaccination effort will be limited to a 9-year-old age cohort only.
The National Cervical Cancer Control Strategy is currently being revised to cover the period 2016-2020, to incorporate new developments and emerging issues such as the availability of the HPV vaccine as a preventive measure and promote the integration of cervical cancer screening into HIV care, in addition to the existing efforts at cervical cancer prevention and control. Recently, PEPFAR Malawi received $5.4 million to support cervical cancer screening and treatment of pre-cancerous lesions among Women Living with HIV/AIDS (WLHIV) at high volume antiretroviral treatment clinics at district hospitals and other high HIV burden facilities. PEPFAR’s cervical cancer activities will be implemented in 39 high burden health facilities spread across 22 districts with an intention to scale-up over time. With this funding, PEPFAR will support revision of guidelines, national level coordination, and technical assistance, and the provision of equipment and supplies, training, hiring of staff. Using Global Fund resources, the Ministry of Health recently procured 300 portable thermocoagulators and other equipment to scale-up cervical cancer screening and treatment. This equipment is already in-country and distribution to sites is in progress.
Challenges for the CECAP include weak national coordination, inadequate funding, inadequate trained providers, inadequate monitoring and evaluation tools, and failure to maintain unbroken supply chain for consumables, poor referral system and inadequate community mobilization. Diagnosis and management of advanced cancer cases also remains a major challenge.
Mozambique Background Information
In Mozambique, cervical cancer comprises 32% of new cancers diagnosed in women—the leading cause of cancer and cancer-related deaths among women. While efforts are underway to strengthen cancer diagnosis and treatment in Mozambique, progress continues to be constrained by a lack of resources, including a limited number of healthcare providers trained and equipped to diagnose and treat pre-invasive cervical disease, and a lack of public education to increase awareness and demand for services.
Women living with HIV are four to five times more likely to develop invasive cervical cancer, are more vulnerable to persistent HPV infections, and can develop pre-cancerous lesions faster. Recognizing this, in 2018, the President's Emergency Plan for AIDS Relief (PEPFAR), the George W. Bush Institute, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) announced the Partnership to End AIDS and Cervical Cancer among HIV-positive women in Africa. As a focus country for this partnership, Mozambique is currently receiving PEPFAR funds to strengthen health system capacity to screen and treat pre-invasive cervical lesions. PEPFAR funding is supporting efforts to prevent progression to cervical cancer and mortality among HIV-positive women by integrating cervical cancer screening for HIV-positive women into routine HIV treatment services. In order to reduce loss to follow-up, those efforts undertake a “screen-and-treat” approach to management of precancerous lesions to maximize opportunities for immediate cryotherapy treatment (for eligible women) without need of diagnostic pathology confirmation.
1https://dhsprogram.com/pubs/pdf/fr247/fr247.pdf; and http://www.nsomalawi.mw/images/stories/data_on_line/demography/mdhs2015_16/MDHS%202015-16%20Final%20Report.pdf
4http://www.hpvcentre.net/statistics/reports/MWI.pdf and Bruni L, Barrionuevo-Rosas L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Malawi. Summary Report 27 July 2017. [Date Accessed]