1.0 BACKGROUND AND INTRODUCTION
1.1 Research methodology
The research has been conducted using the Health Rights of Women Assessment Instrument (HeRWAI) to assess progress by the government of Malawi in implementing its commitments to protect and guarantee women's SRHR. The HeRWAI is a strategic tool used to enhance lobbying activities for better implementation of women's health rights. "A HeRWAI analysis links what actually happens with what should happen according to the human rights obligations of a country. It examines local, national and international influences. The HeRWAI analysis consists of six steps, which analyse a policy that influences women's health rights. (1)" A series of questions were answered for each of the six steps; a literature review conducted, key informant interviews and focus group discussions with women groups and male groups, were used to get information on policy related to SRHR; government commitment and capacity to implement; policy impact; state obligations; recommendations and action plans. The assessment has undertaken an extensive analysis of the gender and the reproductive health policies.
1.2 Background on Malawi
Malawi's population is estimated at 13,013,926 (23) with a life expectancy of 41.7 years (4). The country has a large percentage of young people- 46.5% (5) of the population is under 15 years of age. The majority of people are poor- those living below an income poverty line of $1 per day account for 41.7 % (6) of the population. The literacy rate for females is lower than male literacy. There is a relatively low contraceptive prevalence rate of 31% (7) and a high maternal mortality rate of 1,110 per 100,000 live births (8).
The main ethnic groups are: Chewa, Nyanja, Tumbuka, Yao, Lomwe, Sena, Tonga, Ngoni and Ngonde (9). Main languages spoken in the country are Chichewa 57.2% (official), Chinyanja 12.8%, Chiyao 10.1%, Chitumbuka 9.5%, Chisena 2.7%, Chilomwe 2.4%, Chitonga 1.7%, other 3.6% (10). The main religions of Malawi are Christianity 79.9%, Muslims 12.8%, other 3%, with 4.3% (11) not belonging to any denomination.
Adult HIV prevalence rate in 2005 was estimated to be 14.2% (12) while the estimated number of deaths due to AIDS in 2005 was 78,000 (13). The estimated number of orphans aged 0 to 17 years in 2005 was 550,000 (14).
2.0 RESEARCH FINDINGS
Study findings have been presented in accordance to the six steps namely: the policy; government commitment; capacity to implement; impact of the policy; state obligations; and recommendations and action plans. The HeRWAI analysis takes a human-rights approach.
2.1 THE POLICY PROVISIONS
This section describes the gender policy and the rights contained there in.
1.1.1 The policy objectives and how they are operationalised
The overall goal of the National Gender Policy (NGP) is to mainstream gender in the national development process to enhance participation of men and women, boys and girls for sustainable and equitable development for poverty eradication. This goal is in line with the government's national development policy of poverty eradication.
Through the NGP, the government targets children, women and men, girls and boys. Reproductive health is one of the priority areas to improve the health, status of women, men, girls, boys and especially the disadvantaged and vulnerable majority in rural and peri-urban areas. Findings from the study indicate that the gender policy has not been adequately disseminated thus limiting information about the policy to government departments, a few NGOs and donors.
The NGP institutional structure comprises at the top, the main cabinet whose role is to approve and pass policies and legislation. The cabinet also provides direction on Gender Policy and programme implementation. Below the main cabinet is the Cabinet Committee on Gender, Youth and Persons with Disabilities. Its role is to examine and review the Gender Policy, issues and legislation before they are presented to Cabinet and Parliament. This Cabinet Committee is also responsible for lobbying for the adoption of the gender policy, resolutions, and Acts. Two Parliamentary Committees namely the Parliamentary Women's Caucus and Parliamentary Committee on Women and Children Affairs are linked to the Cabinet Committee on Gender. Their major role is to lobby and advocate for gender issues in Parliament.
Under the Cabinet Committee on Gender, is the Gender Advisory Committee (GAC) comprising all Principal Secretaries with the main role of advising Cabinet Committee on Gender, Youth and Persons with Disabilities on what each of the Sectoral Ministries is doing on gender and provides advisory services to the national Gender Machinery. According to the gender policy, below the National Machinery is the Gender Policy Implementation Committee (GPIC) which comprises all gender focal points in all sectoral Ministries, NGOs, parastatals and the private sector. The major roles of GPIC being the identification of priority gender issues, planning for relevant interventions, assessing and reviewing progress in implementation of the policy.
The Ministry of Women and Child Development, (a change from the Ministry of Gender, Youth and Community Services (MOGYCS)), through the Gender Services Department, is charged with the responsibility of spearheading and coordinating gender responsive development and in particular ensuring the improvement of women's status. A gender programme is established within the department for day to day management of the NGP.
The NGP recognizes the influence of the Decentralisation policy and makes use of existing institutions of District, Area and Village Assemblies. In addition, existing or newly established gender networks in NGOs, the Civil Service and the Private Sector are mandated to share information and forge strategies for mainstreaming gender concerns in their respective development programmes.
Besides sectoral ministries, the National Machinery collaborate closely with other key actors, such as NGO's, Community Based Organizations (CBO), the Private Sector and Local Authorities to implement and achieve the goals of the gender policy. Within these agencies, co-ordination of gender issues across sub-sectors are enhanced through establishment of Gender Focal points resourced by senior officers. The gender policy articulates that an Inter-agency Gender Technical Committee be established to oversee the mainstreaming of gender concerns within policies, plans, programmes and activities. The roles of other agencies include, but are not limited to: Co-ordination of gender activities within the sector; Mainstreaming gender in all sectoral policies, plans, projects, programmes and services; Assessing and building sectoral capacities to create awareness and understanding on gender concerns; Identifying and prioritizing gender concerns and issues within the sector and taking appropriate action; Advocating and providing guidance within the sector to develop and implement gender responsive programmes; Mobilizing resources for gender mainstreaming; Establishing a documentation centre within the sector; Instituting an information and management system that is gender sensitive; Linking and collaborating with other sectors and the National Machinery for mainstreaming and information sharing. (15)"
The gender policy's objectives include: to lobby for the provision of equal access and quality education to all school age children; promoting the reduction of dropout rates of girls and boys at all levels of education; to encourage the provision of formal and non-formal education to both girls and boys who are dropouts and illiterate.
The National Economic Council (NEC) as a professional and technical body supporting government and the public on economic and social policy, management and development, has a role of ensuring that gender issues are mainstreamed throughout all aspects of national development planning. These include equal targeting of women and men in all development programmes, building capacity of planners and policy analysts to enhance their gender analysis skills. NEC also ensures the disaggregation by gender of all data collected, analysed and disseminated by the National Statistics Office.
1.1.2 The policy and how it affects different rights
The gender policy affects different rights such as the right to food. The policy focuses on food and nutrition security to improve the nutritional status of the Malawian population particularly that of women and children to ensure good health. Food security is a major concern at household level in both rural and urban areas, as well as at national level.. The policy recognizes discriminatory laws in the Constitution as well as customary laws and legal practices that affect improvement of women's sexual and reproductive health services and calls for their amendment. Given that the Malawi Constitution provides clear and explicit protection from discriminatory practices for women, the gender policy therefore advocates for reform of customary laws and practices in line with the constitutional provisions.
The gender policy addresses the right to education, supporting the right to equal accessibility and availability of education to both girls and boys; expansion of enrolment and enhanced quality of education. The policy also addresses low retention and high dropout rates in schools, and supports non-formal education programmes for out of school youth and illiterate adults.
The Constitution of Malawi enshrines education as a basic human right; furthermore, education as a basic human right is well elaborated in the Global Platform of Action and the Beijing. Free Primary Education and Girls Attainment of Basic Literacy and Education (GABLE) programme influenced the change in policy to allow pregnant girls to go back to school. Other initiatives encourage girls and women to pursue science and technology courses; the role models' initiative highlights the successful careers of Malawian women.
In order to enhance decentralization, implementation of the NGP uses the existing institutions of District, Area and Village Assemblies. Further, information sharing is facilitated among NGO gender networks, Civil Service and Private Sector in order to promote the mainstreaming of gender concerns in their respective development programmes.
The time frame for operationalizing the NGP was 2000 to 2005. However, the NGP was not widely disseminated to stakeholders especially communities. A review of the NGP by the Ministry of Women and Development (MWCD) is underway and is supported by the United Nation's Population Fund (UNFPA) and the Canadian International Development Agency (CIDA).
In conclusion, the NGP focuses on mainstreaming gender in the development processes in Malawi. The Ministry of Women and Child Development serves as the country's machinery to ensure gender mainstreaming into programmes for the improvement of services for men and women, boys and girls, including sexual reproductive health rights. The policy is complemented by a number of policies, protocols and strategies. It addresses a number of rights issues including: the right to food, housing, work, education, life, non-discrimination, equality, prohibition of torture, privacy, access to information, and freedoms of association, assembly and movement.
2.1.3 Relevant commitments the government of Malawi has made in relation to the gender policy
This section discusses the national and international treaties, agreements, policies and laws that are relevant to Malawi and the gender policy under analysis.
International and regional treaties Malawi has ratified
Malawi has ratified a number of International Declarations and Conventions including the Convention on the Elimination of All Forms of Discrimination Against Women (1987), the agreements of the: Earth Summit of Rio de Janeiro (1992), The International Conference on Nutrition (1992), the Vienna Human Rights Convention (1993), the International Conference on Population and Development in Cairo (1994), the World Summit for Social Development in Copenhagen (1995), World Food Summit in Rome (1996) and the Fourth World Conference on Women in Beijing (1995). Malawi also ratified the Convention on the Rights of the Child (1991). The National Gender Policy takes cognizance of these UN Conventions and aims at harmonizing them with the national policies and laws. A women in development policy was developed in 1993 followed by the National Platform of Action for Women launched on 8th March 1997 as a follow up to the Beijing Conference. The government has also signed the 'World Fit for Children Declaration and Plan of Action' and has committed to monitoring progress towards the goals and objectives there in contained.
Key among the regional treaties ratified by Malawi is the SADC Gender and Development declaration that commits Malawi to ensure that gender equality and equity is achieved at all levels. The SADC Declaration of 1997 which Malawi signed is committed to ensuring 30% Affirmative Action for women in political and decision making positions by the year 2005.
The consensus documents supported by the government include: the Beijing Platform for Action; the United Nations Millennium Declaration; the ICPD Programme of Action; the Declaration of Alma Ata, adopted on the International Conference on Primary Health Care (1978); the Declaration on the Elimination of Violence against Women (1993); the Declaration of Commitment on HIV/AIDS, 'Global Crisis-Global Action' (2001); the Declaration on the Right to Development (Vienna Declaration and Programme of Action) (1993); Article 41 on women's health, and the Declaration on the Rights of Disabled Persons General Assembly Resolution 3447 (xxx) (1975), Article 5 (e) (iv). Malawi is also a signatory to the Dakar Declaration on Children's Rights to on Education, the OAU Charter, and the UNGASS on HIV/AIDS.
The SADC Protocol on Health (August 2004) This protocol contains three articles (Articles 10, 16 and 17) which are crucial to sexual and reproductive health. The following are extracts from these articles:
Article 10: HIV and AIDS and Sexually Transmitted diseases The article binds State Parties to: harmonize policies aiming at prevention and control; develop approaches for prevention and management; develop regional policies and plans that recognize intersectoral approach to the disease and cooperate in the area of standardization of HIV and AIDS and STIs.
Article 16: Reproductive Health "State Parties shall formulate coherent, comparable, harmonized and standardized policies ... particularly in developing a surveillance system for monitoring maternal mortality; developing strategies to reduce maternal mortality; the reduction of genetic and congenital disorders leading to birth defects and empowering men, women and communities at large to have access to safe, effective, affordable and acceptable methods for the regulation of fertility.
Article 17: Childhood and Adolescent health states that State Parties shall co-operate in improving the health status of children and adolescents; develop and formulate coherent and standardized policies and encourage adolescents to delay engaging in early sexual activities.
The government is also bound to other bilateral and multilateral agreements that influence the gender policy. These include free trade agreements allowing international companies to compete with local industry; World Trade Organization (WTO) agreements; agreements (conditions) attached to loans by the International Financial Institutions (IFIs)-the IMF, World Bank and other funding institutions; and regional agreements such as SADC and COMESA.
2.1.4 National legislation and recognition of women's right to health
Regarding the right to health, the country's Constitution states that policies and laws in Malawi must aim to provide adequate health care "commensurate with the health needs of Malawian society and international standards of health care." (16) The Constitution further recognises that Malawi must achieve "adequate nutrition for all in order to promote good health and self-suffiency." (17) However, the right to health is not explicitly recognized in the Constitution except within the context of the right to development. The Constitution however addresses other rights related to the right to health. For example, the Constitution states that "legislation may be passed addressing inequalities in society and prohibiting discriminatory practices and the propagation of such practices and may render such practices criminally punishable by the courts".
Section 22 of the Constitution states: "All men and women have the right to marry and found a family", "No person shall be forced to enter into marriage", "The State shall actually discourage marriage between persons where either of them is under 15 years of age". Section 23 states that "all children are entitled to equal treatment before the law, children are entitled to be protected from ... any treatment, work or punishment that is, or is likely to--, be harmful to their health, or to their physical, mental, spiritual or social development. Section 24 talks about women's right to full and equal protection by the law and their right not to be discriminated against on the basis of their gender or marital status which includes the right have equal right in the making of decisions that affect [children's] upbringing, legislation shall be passed to eliminate customs and practices that discriminate against women, especially practices such as sexual abuse, harassment and violence. Section 30 of the Constitution provides for the right to development for everyone with women, children and the disabled being given special consideration in the application of this right. In addition, it states that the State shall take all necessary measures for realization and including equality of opportunity for all in their access to health services. The Constitution states that the State shall take measures to introduce reforms aimed at eradicating social injustices and inequalities. Section 44 continues to state that there shall be no derogation, restriction or limitation with regard to (a) the right to Life and (b) the prohibition of torture and cruel, inhuman or degrading treatment or punishment.
The Malawi Constitution guarantees these rights to every citizen and is also specific on women's rights. The Constitution acknowledges that violence against women is a problem that needs to be eradicated from society. Section 24, sub-section 2 (a) states that:
"Any law that discriminates against women on the basis of gender or marital status shall be invalid and legislation shall be passed to eliminate customs and practices that discriminate against women, particularly practices such as sexual abuse, harassment and violence, discrimination in work, business and public affairs and deprivation of property, including property obtained by inheritance."
Gender equity, inheritance provisions and guidelines on family and marriage are enshrined in the Bill of Rights. Other rights that may be relevant to the policy include: sexual rights, reproductive rights, the right to informed decision, rights of people with disabilities, rights of mentally ill people, the right to gender equality, the right to non-discrimination, the right to water, food, housing. Furthermore, the laws of Malawi do not criminalize medical procedures such as those only needed by women.
Local, customary or religious norms and laws influence the health rights of women in relation to the gender policy. There are a lot of gender-based public and domestic violence particularly against women and children despite this constitutional provision. Further more, there is a general lack of access to legal services and education, and lack of support services to the abuser and the abused. In addition, the human rights and legal institutions like the judiciary, the Police, the Prisons, and the Military are generally not fully gender responsive to the needs of women and children.
2.1.5 Government's national health strategy and other relevant policies
Apart from the NGP, other policies, protocols and regulations exist to guide the implementation of sexual and reproductive health services.
Relevant policies include the Reproductive Health Policy (2002) developed by the Ministry of Health under the Reproductive Health Unit. A 2006 review of this policy has been concluded and a new one is in the final stages of development. The policy aims at establishing a framework to guide the implementation of reproductive health programmes in order to address access to information and Sexual and Reproductive Rights.
The Education Policy and Investment Framework articulates policies and strategies to address quality and quantity of education through expanded and improved education provision. Examples are: the recognition by the Education Policy of the right to education among girls and women; Free Primary Education; the Girls Attainment of Basic Literacy and Education (GABLE) programme which influenced the change in policy to allow pregnant girls to go back to school; the initiatives to encourage girls and women to pursue science and technology courses; the revision of education curricula to make it more gender responsive; the inclusion of gender in refresher and training courses for teachers; and the role models initiative which highlights the careers of exemplary Malawian women. The Ministry of Education has a gender policy aimed at promoting gender equity by making the school environment supportive of the needs of both boys and girls in basic education.
The National Youth Policy (2006) has an overall goal to provide a framework to guide youth development and implementation of all youth programs. The policy aims to promote the general, SRHR of young people through 10 strategies including: scaling up and accelerating HIV prevention interventions for young people; promoting youth friendly reproductive health services; sustaining SRHR and HIV prevention information in schools; discouraging sexual practices that promote the spread of STIs including HIV/AIDS; promoting programs on gender equity and equality, male involvement, and girls' and young women's empowerment to reduce HIV transmission; provision of information on the effects of tobacco, alcohol and intoxicating drugs to young people to protect them from effects of substance abuse; enforcing regulations and by-laws regarding tobacco, alcohol and intoxicating drugs; and making contraceptives including condoms accessible to sexually active young people. The policy also calls for the review and revision of existing laws and enactment of specific legislation to protect young girls in specific circumstances-including early, forced and arranged marriages, sexual abuse/harassment/incest, harmful cultural practices, child trafficking, prostitution, universal primary and increased access to secondary school, birth registration, juvenile justice, drug, alcohol, and substance abuse; corporal punishment, pregnancy of school girls that involves other males other than school teachers.
Malawi also developed a Policy of Early Childhood Development (ECD) in 2003. The policy seeks to provide guidelines and coordination of ECD activities and to enhance investment in ECD programmes in Malawi. Its purpose is to protect the children's' rights to develop full cognitive, emotional, social and physical potential. Current trends show an increase in rape among especially young children. The ECD policy was developed in recognition of various conventions and other legal human rights instruments to which the Malawi Government is a signatory.
Relevant protocols and guidelines among others include: the Prevention of Mother To Child Transmission of HIV/AIDS (PMTCT), the Antirefroviral (ARV), Voluntary Counseling and Testing (VCT) policy and guidelines; post-abortion care guidelines and guidelines for the management of sexual assault and rape in Malawi (2005).
There is also the Malawi National Plan of Action for Scaling UP SRHR/HIV Prevention Interventions for Young People "Foundations for Safe Guarding Malawi's Future", that covers the 2007-2010 period.
The Malawi HIV and AIDS National Action Framework (NAF 2005-2009) aims to reduce the spread of HIV among the general population and in high-risk subgroups. It outlines objectives for promoting, supporting and scaling up "HIV and AIDS protective interventions specifically designed for young people"; reducing the vulnerability of Malawians to HIV infection, especially girls and women; strengthening socio-cultural values and practices that prevent the spread of HIV; and promoting safer sex practices among the high-risk groups and in high-risk settings.
Malawi adopted the concept of an Essential Health Package (EHP) back in the mid-1990s, and developed a National Health Plan 1999-2004 (NHP) that is applied to date. The EHP is based on a defined range of interventions, a targeted approach, and a strong community health service delivery system. The EHP's objective is to contribute to poverty reduction in response to the Malawi Poverty Reduction Strategy Paper (MPRSP). EHP seeks to increase the efficiency of publicly funded health services, improve equity of access to health services, and has been used as a tool for priority setting as well as the basis for the health Sector Wide Approach (SWAp). The SWAp Implementation Plan for the 2003-6 period, is based on seven key components: institutional capacity; essential health care delivery; human resource development; resource mobilization and allocation; financial management; procurement; and, health management information systems.
The EHP focuses particularly on conditions affecting women during pregnancy and delivery, and on children under five years of age. This is in recognition of the need for a life-cycle approach to health improvement. The EHP prioritizes the diseases or conditions which are responsible for the majority of death and disease within Malawi, particularly among children, women and the poor. The EHP incorporates much of the ongoing work under the Safe motherhood Project and the Reproductive Health Unit to reduce morbidity and mortality in these areas. Interventions relate to pregnancy, delivery, obstetric complications and postnatal care. Much has been drawn from the WHO Mother-Baby Package. In addition, a range of family planning options have been included in order to address pregnancy related problems. Obstetric interventions address post-partum haemorrhage, eclampsia, obstructed labour, severe anaemia, sepsis, and abortion complications. Newborn complications are also addressed. Management of sexually transmitted infection including HIV/ AIDS are incorporated in the health strategy including VCT, PMTCT, provision of, Home Based Care (HBC), ARVs, condom promotion and distribution, management of opportunistic infections.
The Ministry of Health developed guidelines to set standards of care of survivors of sexual assault and rape in 2005 to raise awareness and to ensure that victims of sexual assault and rape receive high quality of care. These guidelines stress that a victim of assault or rape must be attended to immediately upon arrival in the health facility without requiring a police report as was the case in the past.
The National Gender Programme that operationalises the gender policy has indicators to monitor progress; however, the National Gender Programme does not have benchmarks with which to measure its progress. Through the Malawi Demographic Health Survey (MDHS), the government collects and disseminates reproductive health related data which is disaggregated by sex. Malawi has reported on its progress to address gender issues under article 18 of CEDAW.
There is a National Plan of Action (NPA-YP) which will operationalize the National Youth Policy through 10 strategies and specific activities.
The National Standards for Youth Friendly Health Services (August 2006) highlights the national standards for youth friendly services to guide provision of a supportive environment for the delivery of young people's health services; enhancing community and young people's participation in health services; providing services that meet the health needs of youth in an accessible and acceptable manner, while at the same time, availing them with information on their health and rights to health services.
The National Condom Strategy (November 2005) responds to one of the main objectives of the National HIV/AIDS policy (2003) which states: male and female condoms can both prevent unwanted pregnancies and STIs, including HIV. To be effective, condoms must be of good quality, and properly and consistently used, Providing women with support to participate fully in decision to use a condom during every sexual encounter and involving men to promote condom use will enhance more consistent condom use. The strategy also states that government of Malawi should, "ensure that affordable male and female condoms and other barrier methods of good quality are made available to all those who reed them, in particular, to prisoners. Promote the proper use and disposal of both male and female condoms and other barrier methods to prevent HIV and STI transmission."
There is a Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (October, 2005) which is aimed at accelerating the reduction of maternal and neonatal morbidity and mortality towards the achievement of the Millennium Development Goals. The two objectives of the Road Map are: to increase the availability, accessibility, utilization and quality of skilled obstetric care during pregnancy, childbirth and postnatal period at all health care delivery systems; and to strengthen the capacity of individuals, families, and communities, civil society organizations to improve maternal and neonatal health.
The National Plan of Action for Orphans and Vulnerable Children (2005-2009) has an overarching goal of "Building and strengthening family, community and government capacities to scale up response for the survival, growth, protection and development of orphans and other vulnerable children, by the end of 2009."
The Women, Girls and HIV/AIDS: Program and Plan of Action (2005-2010) aims to reduce the vulnerability of women and girls to HIV infection, facilitate their access to health and socioeconomic services and mitigate impacts of HIV and AIDS on women and girls."
Malawi developed a National Strategy to Combat Gender-Based Violence (200-2006). Furthermore, a law has been passed on Prevention of Domestic Violence that guarantees equality between men and women, women's right to property, and invalidates any law that discriminates against women, in particular, practices such as sexual abuse, harassment and violence (18).
2.1.6 Mechanisms far Civil society Participation
The Gender Policy was developed through a consultative process involving organizations and individuals in 177 constituencies. In addition, 15 districts including Village Development Committees, Area Development Committees, Principal Secretaries and Chief Executives were consulted. The composition of participation committees and individuals included men, women, youth, young men and women from different ethnic backgrounds.
Individuals, NGOs and other civil society groups exert influence over policy-making and legislation through participation in village health committees, voting in elections rind referenda (local, regional and national), volunteer organizations, community based organizations, and government-NGO platforms. Consultations also take place in the development and evaluation stages of policy formulation.
There are NGOs such as the Malawi Health Network involved in monitoring government expenditure as a way of ensuring government fulfills its commitments. The Forum For African Women Educationalists of Malawi (FAWEMA) is concerned with eliminating gender disparities in primary and secondary education, advocacy for policy and programs that promote the participation of girl's education.
There are various committees that monitor the implementation of services. The Malawi Economic Justice Network (MEJN) monitors economic issues including government expenditure. At village or community level, there are also a number of committees such as village development committees, village health committees, victim support committees, community action groups and many more.
HIV positive people to some extent, participate during policy development, programme planning as well as implementation of SRH, HIV and related issues. This is through attending national workshops, symposiums, conferences as well as through support groups for people with HIV/AIDS.
Through voting in elections and referenda at local and national levels, people participate in decision making, There are also a number of associations representing different needs of groups of people which facilitates participation in policymaking and legislation. These associations include women in micro economic enterprises, disabled groups, youth, professional grouping of young women leaders network, a grouping for white ribbon alliance for safe motherhood, international affiliated associations such as the Soroptimist international which is a professional women's group involved in charity, the women lawyers association of Malawi and many other associations. There are quite a number of volunteer organizations at national, district and community levels,
Other forms of participation include oral and written reports presented to international organizations, and participation in national and international conferences. The media also supports civil society participation through radio call in programmes and having people to send in their views on particular issues through the print media. Political and nonpolitical rallies and campaigns are commonly used to push for different agendas.
Strategies and measures are being taken to enhance the role of men in sexual and reproductive health. These include sensitization and awareness campaigns for involvement of males in family planning services and promoting positive behavior change in SRHR issues. Men have been targeted for services such as vasectomy, couple testing for HIV and participation in ante natal care services. However, these strategies to enhance men's participation have not been rolled out at national level.
2.1.7 Mechanisms for redress when reproductive and sexual rights are violated
There are legal provisions for redress of rights violations and denial. The Constitution makes provisions for the protection of human rights. The Judiciary has jurisdiction "over all issues of judicial nature." (19) Any court can decide whether an issue is within its competence. In addition to the Judiciary, the Constitution provides for three offices independent of the Judiciary, the Executive and the Legislature. These are the Office of an Ombudsman, a Human Rights Commission, and a Law Commission (20). The Office of the Ombudsman investigates and grants remedies in cases that meet two stipulated conditions (21). The Human Rights Commission's functions are focused on the protection and investigation of the violations of human rights enshrined in the Constitution; and incorporates public awareness campaigns. The Law Commission has the power to review and make recommendations about the repeal and amendment of laws. Such powers extend to the drafting of laws and civic education. The Constitution prevents the National Assembly or any subordinate legislative authority, and the Executive from making any law or taking any action, which abolishes or infringes the rights enshrined in the Constitution. Such rights include women's rights spelt in section 24. The Constitution is clear that any person "who claims that a fundamental right or freedom guaranteed" by the Constitution has been infringed can seek remedial action. In earlier cases, the High Court took the view that only those, whose human rights had been infringed, could bring an action in a court. However, it is increasingly acknowledged that "any person" including human rights organizations who can show that somebody's human rights have been infringed can seek class and public interest litigation.. The court has powers to make any order to secure enjoyment of the right including a compensatory award.
Another option for legal redress is an appeal to the Ombudsman or the Human Rights Commission for advice or any assistance. However, the majority of Malawians seek redress from traditional or primary justice forums presided by village traditional leaders. The traditional institutions are readily accessible geographically, financially; they encourage participatory discussions, deliver justice quicker, and grant remedies more flexibly. In spite of traditional institutions being most accessible especially among the poor who make up the majority of the population in Malawi, traditional laws, procedures and practices infringe human rights principles, more especially of women.
There are other initiatives being promoted to redress rights of people. Regulatory bodies such as the Medical Council and the Nurses and Midwives Council do apply sanctions on health care professionals guilty of malpractices. Police stations have officers trained in victim support and have established Victim Support Units to provide counseling and support to victims of assault and sexual abuse. These units refer cases to the Criminal Investigations Department (ClD). In the community, Victim support groups are linked to the police and victimized women can use them to report sexual abuse cases.
The Employment Act of 2000 provides for a MK10,000 fine for a breach of the general anti-discriminatory provisions in the Constitution. The Act further provides for an entitlement to maternity leave, the right to return to work subsequent to that leave and forbids termination of employment on the basis of pregnancy or related issues. (22)
The most relevant commitments the government has made in relation to the gender policy include the international treaties it has ratified notably CEDAW, the UDHR and the UNCSCR. Regional treaties ratified include the SADC Gender and Development declaration and the SADC Protocol on Health. Government supports many of the consensus documents such as the Belling Platform for Action, the United Nations Millennium Declaration, the ICPD Programme of Action, the Declaration of Alma Ata, the International Conference on Primary Health Care, Declaration on the Elimination of Violence against Women, Declaration of Commitment on HIV/AIDS, 'Global Crisis-Global Action', the Declaration on the Right to Development (Vienna Declaration and Programme of Action, Article 41 on women's health, and the Declaration on the Rights of Disabled Persons General Assembly Resolution 3447 (xxx), Article 5 (e) (iv). Malawi is also a signatory to the Dakar Declaration on Children's Rights on Education, OAU Charter, and UNGASS on HIV/AIDS.
The are several relevant national legislation/ policies that support the operationalisation of the gender policy and these include the Reproductive Health Policy, the Education and Investment Policy; The National Youth Policy; the Malawi National Plan of Action for Scaling UP SRH/HIV Prevention Interventions for Young People; the Malawi HIV and AIDS National Action Framework; the Essential Health Package; the health Sector Wide Approach (SWAp) Implementation Plan; guidelines on the standards of care of survivors of sexual assault and rape; the National Gender Programme, the National Plan of Action (NPA-YP); the Prevention of Mother To Child. Transmission of HIV/AIDS (PMTCT); the Antiretroviral (ARV), Voluntary Counseling and Testing (VCT) policy and guidelines; the post-abortion care guidelines; guidelines for the management of sexual assault and rape in Ma, the National Standards for Youth Friendly Health Services; the National Condom Strategy; the Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity; the National Plan of Action for Orphans and Vulnerable Children; the Women, Girls and HIV/AIDS: Program and Plan of Action; and the National Strategy to Combat Gender-Based Violence.
This section describes the resources the government has to implement its gender policy and the factors that limit or expand this implementation capacity.
3.0 CAPACITY TO IMPLEMENT POLICY
3.1.1 Financial resources are available for the implementation of the policy
Following the development of the gender policy in 2000, a national gender programme was developed to operationalise the policy for the 2005 to 2009 period. It had an indicative budget of US $11,169,200. However, no adequate financial resources were made available for the implementation of this policy. Despite this challenge, programmes being implemented in the country have addressed the areas stipulated in the national gender programme. Discussions with key informants suggest that there is limited staffing and capacity at MWCD which in turn affects improvement of SRHR of women.
The United Nations Population Fund (UNFPA) is among the funding agencies under the SWAp supporting the reproductive health and gender issues.
Expenditure on health affects progress on implementing governments' commitment to protect and guarantee women's reproductive and sexual rights. In terms of per capita expenditure on health, the World Health Organization estimates that $60 per person per year is needed for reasonable health care. In 2003, Malawi's per capita expenditure was approximately $12, which is inadequate for the delivery of basic Public Health Centre services. In 2002 the Essential Health Package (EHP) was calculated at $17.53 per capita per year. This figure excluded the cost of ART, central level management and supervision of districts and central hospitals. This cost only predicted 67% of the total coverage for EHP. The current per capita expenditure on health is US$48 (23) and is still inadequate. While the budget for the implementation of the gender policy is decreasing, Government's allocations for health expenditure is increasing due to the need to address HIV/AIDS. As opposed to the US$196 million allocated in 1996 by GFATM, SWAp, GFATM, and DFID allocated US$270 million to support the 6 year Human Resources Emergency Relief Fund. Allocations to specific areas of health indicate that the government places its priorities on HIV/AIDS prevention, care and treatment. Currently one doctor serves a population of 100,000 and one nurse serves a population of 200,000. While DFID topped up the salaries of health professionals by 52% for five years, it is not clear what would happen beyond this period.
3.1.2 Human resources are available for the implementation of the policy
Health care is unevenly distributed with 46% having access to a health facility within a 5km radius while 20% access health services within a 25km radius. Distribution of health personnel favors urban areas despite that the majority of people lives in rural areas and are poor (24).
A number of challenges face the public health and healthcare facilities, goods, services and programmes. There is critical shortage of health personnel. Recent assessment (Schouten, E. 2006) shows that there is a shortage of 64% for nurses, 53% for clinical officers and a 85- 100% shortage of specialists in health facilities. Half of 29 districts in Malawi have less than .1.5 nurses per facility while 5 of the 29 districts have Jess than one nurse. In terms of distribution of doctors, 10 districts do not have doctors from the Ministry of Health while four districts have no doctor at all. Availability of human resources is affecting the realization of women's SRHR. In spite of the gender machinery in the Ministry of Women and Child Development, there is limited personnel to effectively coordinate gender programmes in the country. A study by a civil society health network documented drug shortages in all hospitals and clinics (25).
A number of barriers affect usage of health services including those related to sexual and reproductive health. These include Lack of confidentiality, differential treatment between the poor and the wealthy in terms of waiting time and quality of health service provided (26). Infertility services continue to receive low priority despite the Reproductive Health Policy recognizing this shortfall. The 2002 Reproductive health policy only provided one policy statement regarding infertility- i.e. to make infertility counseling and services available at all levels.
3.1.3 Factors limiting or expanding the government's implementation capacity
Key informant interviews and focus group discussions revealed a number of expectations from women, NGOs and civil society on what government needs to do with respect to women's health rights. The study findings show that although there are programmes promoting SRHR among female sex workers, coverage of these services is small and often project based. Best practices or lessons learnt are not scaled up within the national programmes addressing sexual health rights.
The study also found that although women of post-child bearing age have special sexual and reproductive health needs, primary and even secondary health care facilities rarely provide the related services such as screening, referral and treatment of cervical and breast cancer.
Rural women expressed the need for accessible sexual and reproductive health services. For refugees, there is a maternity health facility that is being constructed at Dzaleka refugee camp which when completed, will provide maternal health services in addition to some of the SRH services being provided at the dispensary.
There is no explicit mention of addressing the sexual reproductive health needs of women with physical or mental disabilities. A key respondent questioned the accessibility of SRHR programmes to people with physical or mental disabilities.
Women living with HIV/AIDS stated the need for laws that encourage positive living among people with HIV for example by passing legislation to criminalize intentional HIV transmission/ infection. There have been reports of men charged with rape, pleading leniency on their sentence on the basis of being HIV positive. Discussions with key informants stated that government needs to accelerate its move towards greater integration of relevant services such as antenatal care, PMTCT, ARV provision, provision of condoms and family planning services. Women accessing ARV treatment commended government for its effort to ensure that ARVs are provided especially for rural areas where attempts are made to link rural health facilities with district hospitals where ARVs are provided. Women also noted that at ARV clinics, a clinician is available to review ARV patients and treat opportunistic infections.
Several cultural, religious, social, environmental factors influence the implementation of gender as well as reproductive health policies. Societal norms that enable men to engage in multiple sexual relationships both before and after marriage and marriage-remarriage cycles remain prevalent (Tsoka 1999 in Coombes 2001). In relation to HIV/AIDS, condom use remains low despite these norms. Hence, young girls and women often find themselves in a culture of high-risk and early onset of sexual activity (CERT 2001). There are a number of gender-based social norms validated through initiation ceremonies which encourage boy assertiveness and girls' submissiveness to men. Incidences of sexual violation of girls by male teachers have been documented (CERT 2001) and girls have cited this as one of the main problems associated with formal education. Sexual activity by the very men who are supposed to be role models for children demonstrates the depth of the belief in male dominance by both schoolgirls and many male teachers and the powerlessness of girls to do anything about it. Links between the customary legal system and the centralized government education system are minimal. To date, action taken on this issue can be described as "weak and inconclusive" (ibid). Puberty rituals are significant to SRHR since during this occasions young women are provided with information on sex, sexuality and maternal health thereby providing a unique opportunity for channeling contemporary SRHR health messages. Some programmes utilize these opportunities to address SRHR and needs. However, harmful and degrading rituals in which a man is hired as a 'fisi' (hyena) whose role is to perform sexual act with female initiates increases exposure to STI/HIV and pregnancy, and undermines the human rights of girls (Coombes 2001).
Powerful 'and pervasive beliefs and practices, based on deep-rooted associations between sex, health, and illness, continue to influence SRHR and health-seeking behavior. Culturally, there are regulations on sexual activity based upon the concepts of 'hot' and 'coolness'. Sexual activity renders a person 'hot'. Coolness arises from sexual abstinence, taking certain herbs, and amongst babies, and women in the menopause (Matinga and Mc Conville). The meeting of 'hot' and 'cool' states is to be avoided if disease and misfortune are to be prevented. Diseases arising from the 'breakage' which occurs should 'hot' and 'cool' mix are believed to account for high mortality through a wasting illness (such as m'dulo) which closely resembles AIDS. Women are believed to be the most vulnerable to such diseases at critical times in their reproductive life cycle (first menstruation, pregnancy), along with newborn babies which is why sexual abstinence is demanded at these times (SMP 1998, Fr Boucher 2002).
Several obstacles limit the right to non discrimination. For example, customary law provides for discriminatory practices such as polygamy, early marriage, wife inheritance, and the payment of bride price or related charges amongst both matrilineal and patrilineal communities. These customary laws are based on gender-stereotyped attitudes and actions that regard women as inferior to men and consider the social determinants of femininity and masculinity.
The government is showing a lot of political will to implement the gender and reproductive health policies. However there are concerns from other players in the social sector that the predominant focus on the national economic growth strategy may undermine strategies aimed at addressing reproductive and sexual health needs of women. International donors and agencies have been very instrumental in assisting Malawi to expand the implementation capacity of the government through support to gender programmes.
The capacity of the government to implement the gender policy is to a large extent, affected by limited financial and human resources. In addition, several cultural, religious, social, environmental factors influence the implementation of the gender and reproductive health policies. Customary laws based on gender-stereotyped attitudes and actions that regard women as inferior to men and consider the social determinants of femininity and masculinity limit the implementation of the gender policy.
4.0 THE IMPACT OF THE POLICY
This section will describe the short and long-term effects of the policy on women's health rights. The four important elements of the right to health which are relevant to the gender policy are: availability, accessibility, acceptability and quality. An analysis of these elements provides more specific insight into the impact of the policy. Thus timely and appropriate health care is analyzed in terms of availability, accessibility and acceptability of health facilities, goods and services.
4.1.1 Availability of health facilities, goods and services Health services are provided by government (60%) and missionaries run facilities (26%). There are private-for-profit health facilities mainly in the urban areas as well as private companies providing health facilities. Other sources of health care especially SRHR include NGOs, grocery stores, pharmacies, community-based distribution agents of Family planning contraceptives and drug revolving funds by volunteers (MOH 2003). The share of total health expenditure in 1998/9 showed that primary health care received the least (4%) funding, tertiary health care received 6% while secondary health care received the majority of the funding (21%). The rest of expenditure was divided among other non government health care providers. Households out of pocket expenditure contribute to 26% of total expenditure on health care while 29% is provided by donors.
All health facilities offer some degree of sexual and reproductive health services although not all facilities have a comprehensive package of SRHR services. In some areas, there are a range of services (medical, psycho-social) for people living with HIV, including some initiatives addressing SRHR needs of young people. However, few programmes specifically address prevention. There is also participation of non-traditional outlets, such as provision of SRHR information by faith based institutions-churches and cultural counselors-who guide young people through their traditional initiation and discuss issues such as HIV prevention.
In relation to HIV prevention, government provides adult antiretroviral therapy at all district government hospitals and a few health centers. The private sector through private clinics and hospitals, and company clinics, provide ARV treatment. The cumulative figures show that by March 2007, the private sector ART sites registered 3,861 patients while public health facilities registered 95,674 patients. The government continues to scale up ARVs including availing paediatric drugs. In some instances, there are strong referral systems, such as between district hospitals providing ARVs and community groups providing support for people living with HIV. In other instances, services are too far apart to be linked.
Male condoms are available through public health facilities, peer educators in the community, community distribution agents, and health surveillance assistants working in the communities and through social marketing outlets. Female condoms are present in the country, but are far less available.
Government supports programmes for specific groups of girls and young women such as orphans, street children, HIV positive women, SRHR programmes for out of school youth, adult literacy programmes that address SRHR, and many other initiatives. However, these targeted approaches are limited and tend to be concentrated in urban areas. Issues about youth-friendly services are included in the training of health workers, and there are a few public health facilities and NGOs supporting the provision of youth-friendly services. However, provision of youth-friendly services have not been scaled up at national level. Young people continue to highlight challenges they face due to poor health worker- attitudes and stigma.
4.1.2 Accessibility of health facilities, goods and services
Acceptability requirements are hereby assessed by considering how health facilities, goods and services are provided with respect to medical ethics, cultural sensitivity and gender responsiveness.
The health indicators in Malawi remain poor. The 2004 MDHS fertility rate of 6.0 is a slight improvement to the 2000 fertility rate of 6.3. however, disparities exist between urban and rural women- urban women have a lower fertility rate of 4.2 compared to that of rural women at 6.4. In addition, there is substantial difference in the percentage of teenagers who live in urban (25%) and rural areas (36%) aged between 15 to 19 who are mothers or are pregnant for the first time (27). The MDHS 2004 documented maternal mortality to be 984 compared to the 2000 figure which at 1,120 was almost double the 1992 data. However the reference periods for the estimates overlap hence suggesting high degree of sampling errors.
A nationally representative sample survey conducted by National Statistical Office known as the 2006 Multiple Indicator Cluster Survey (MICS) aimed at collecting statistically valid estimates at district level on a number of social development indicators related to the Malawi Growth and Development Strategy (MGDS), the Millennium Development Goals (MDGs) and the goals of A World Fit for Children (WFFC). Information on more than 20 of the 48 MDG indicators has been collected in MICS, offering the largest single source of data for MDG monitoring. "The information gathered in MICS would serve as a baseline for the new initiatives and assess the success of the ongoing programmes. MICS also strengthens the M&E component of the new UNDAF 2008-2011 by providing the latest data on a number of key indicators related to GoM-UN programme of cooperation."
Health facilities, goods and services must be accessible to everyone without discrimination, within the jurisdiction of the State party. Accessibility is being assessed by considering how the needs of vulnerable and marginalized groups of women have been addressed, physical accessibility of facilities, affordability of services, accessibility to information such as the right to seek, receive and impart information and ideas concerning health issues.
The 'brain drain' of medical staff to foreign countries or within countries from the public health sector to foreign-funded health programmes, has resulted in a critical human resource shortage. Administrative inadequacies to fill vacant posts are compounded by poor accounting and procurement systems. Poor remuneration and limited resources exacerbate the lack of provision of quality maternal and child health services. In 2005 alone, 300 nurses left the country seeking better conditions and salaries. The capacity to train doctors and nurses is limited, an estimated 30 doctors and approximately 200 nurses can be trained each year.
The core obligations for the right to health that would ensure, at the very least, minimum essential levels of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups, are not being achieved. Health service provision in Malawi is often characterized by a shortage of essential drugs in health facilities. Furthermore, the government is not providing equitable distribution.
Many key sexual and reproductive health services, such as treatment for STIs are provided freely at government facilities. The Malawi National AIDS Policy commits to services being equally open to girls and women, regardless of, their marital or HIV status. In practice, however, there are multiple social, practical and financial barriers to girls and young women accessing services, including judgmental attitudes of service providers, distance to services and cost of transport. Other "hidden' costs are cost of prescription drugs, traditional norms of gender inequality, not abiding to the recommended opening hours for health facilities and long waiting times. A number of studies have also documented lack of privacy and fear of disclosure (particularly in the case of HIV). With regards to HIV Testing and Counselling, government facilities provides free services. However, gender disparities exist. Twice as many men as women access an HIV test. Of the females that get an HIV test, most tend to be aged 20-39.
Malawi has a privatization policy that may affect health service delivery. The privatization policy addresses issues related to inefficient use of resources, but if not addressed properly, could encourage segmentation of the health system, thus undermining the delivery of public health services especially among the poor as service delivery responds more to demand and not need (28). This scenario is possible with a push to involve private sector in health service delivery. A positive development is the increase in the number of service level agreements between government and the Christian Health Association of Malawi (CHAM) to deliver free maternal health services. According to this agreement, government contracts out services to CHAM and provides financial resource to CHAM.
There are limited opportunities for performance monitoring which could improve accountability of government in the provision of ethically, cultural and gender sensitive health goods and services. There is also a weak incentive system for enhancing good clinical practice.
4.1.3 Determinants of health
"Determinants of health are conditions that make it possible to live in health, such as access to safe water, adequate food and housing, safe and healthy working conditions. Resource distribution, gender differences and the access to health-related education and information (including information on sexual and reproductive health) are also health determinants." (29) Determinants of health are not necessarily directly related to health care but analyzing them helps to identify sources of barriers to claiming health rights. Access to safe and potable water and adequate sanitation is very limited and is one of the contributors of poor health and nutrition.
WHO estimates that diarrhea is responsible for 27% of under five mortality. Although government is improving access to water and sanitation, about 0.21 million and 0.36 million people need to be served at a cost of 8.28 million dollars per year (30). Most schools have no water and have poor sanitary conditions. Estimates indicate that 20% of schools have no protected water supply while 150 pupils on average use one latrine against a national average of 40. In addition, 50% of rural health facilities have no proper water supply and sanitation. Hand washing after toilet-use is around 35%. Challenges to provision of safe and potable water, and improved sanitation include frequent breakdowns of water facilities, unavailability of spares parts, lack of trained community committees to repair and maintain water systems, as a result; 38% of water facilities are not functional. Current efforts are to increase access to safe water supply from 60% to 80% and to increase by 12% access to improved sanitation by 2011. An assessment study showed that lack of water supply at health facilities is one of the contributing factors to lack of maternal health services at health facilities (31). Improved water and sanitary conditions will therefore contribute to increasing access to maternal health facilities.
Government has formulated and implemented a nutrition policy. Access to basic food, has greatly improved with the introduction of subsidies on agricultural in puts particularly on the price of fertilizer for subsistence farmers. Access to basic shelter, housing, water and sanitation remain huge challenges for the government. Almost two in ten children under age five in Malawi are moderately underweight (19.4%) and three per cent are classified as severely underweight (Table 4). Forty six per cent of children are stunted or too short for their age and three per cent are wasted or too thin for their height (32).
There is need to raise levels of female literacy by increasing access to education to enhance access to health care information and services. Currently literacy levels remain low. Although access to education at different levels is improving due to affirmative action, it should however be noted that Mathematics and other Science subjects are still a domain of boys. Girls still concentrate in stereotype fields of study such as nursing, teaching, secretarial training and home economics.
For the first time, the 2004 MDHS collected information on domestic violence in recognition of the effects of gender-based violence on human rights and women's health.
4.1.4 The impact of policy on violence against women
Violence against women, or gender-based violence, is violence directed against a woman because she is a woman or violence that affects women disproportionately.
Human rights provisions are outlined in chapter four of the constitution. Section 20 of the constitution provides that "Discrimination of persons in any form is prohibited and all persons are, under any law, guaranteed equal and effective protection against discrimination on grounds of race, colour, sex, language, religion, political or other opinion, nationality, ethnic or social origin, disability, property, birth or other status." The Constitution guarantees the adoption and implementation of gender equality as a goal and non-discrimination as a crosscutting principle. In addition to the non-discrimination clause, the Constitution underlines the importance of gender equality and promotion of "principles of non-discrimination." The Constitution calls for policies that address "social issues such as domestic violence" Legally, every woman can invoke section 24(1) of the Constitution to enforce her right "not to be discriminated against" on the basis of "gender or marital status."
The establishment of the Law Commission facilitates measures to address gender-based discrimination. A number of laws have been made in response to proposals made to Cabinet by government departments, civil society and donors. In 1998, there was an enactment into law, issues relating to dispossession of surviving spouses and children. This assisted in the criminalization of dispossession of surviving spouses and children as well as amending the Wills and Inheritance Act. The Law Commission has been involved in legislative reviews. A Law Commission on Gender and the Law was also established in 2001.
Community Development Assistants of the Ministry of Women and Child Development and human rights NGOs have carried out sensitization campaigns on property dispossession often during the annual 16 days of Activism on Gender Based Violence. The 2006 Malawi report on progress made in relation to CEDAW indicate the problems regarding handling of gender related issues due to lack of mainstreaming of gender issues into law commissions. An example cited is on rape where the Law Commission refused to make rape a gender-neutral crime, arguing that the element of penetration is crucial and that only a man can penetrate a female. However, in 2006 a case involving the rape of a nine year old boy by an adult woman, raised criticism of the bias of the law. Another example is the Law Commission's refusal to recognize marital rape, maintaining that to do otherwise would open up private life in families to public scrutiny (33).
In Malawi, there has been an increase in reporting of violence against women and this has in turn led to provision of services related to GBV such as victim support units, provision of Post Exposure Prophylaxis of HIV.
4.1.5 Participation of Civil Society
Participation refers to the involvement of the population in all health-related decision-making, in the development, implementation and evaluation of policies. Earlier on in the document, participation mechanisms of civil society was explored and here we examine the actual situation and assess whether women are really involved in decision-making, and the groups of women that are involved.
First of all, the Constitution of Malawi states that, "every person shall have the right to freedom of association" which includes the freedom to form an association. No person may be compelled to belong to any association." (34) Unfortunately, participation of women in decision-making is often less than that of men.
The Malawi Health Network conducts budget monitoring and findings reveal that although drugs are purchased for district health facilities, they are not available in all local districts. Another discovery was the theft of drugs by one business man amounting to 528,000 Euros--worth a full years supply for one health facility. Monitoring of health budgets also reveals that although government spending increased, there is no commensurate increase in most services as the budget increase supported human resource management.
HIV positive people to some extent, participate during policy development, programme planning as well as implementation of SRH, HIV and related issues. However at a recent national youth symposium organized by the International Family Planning Parenthood Federation in conjunction with UNFPA and Family Planning Association of Malawi, young girls and women who were HIV positive reported that they often do not participate in support groups because these groups tend to be patronized by adults. Young people feel out of place in such groups and their specific needs are not catered for.
There are some mechanisms in place for channeling user views to elected community representatives through village development committees and village health committees. However, there are few citizen advocacy groups who can effectively link health service users with policy-makers and hold them accountable to equitably address health rights. very often, people's voices are channeled to policy makers as part of a patron-client relationship where responsiveness is seen as a 'favor' and not part of the policy makers' obligation to address health rights.
There is also limited use of information on sexual and reproductive health as a basis for lobbying pro-poor policymakers to investigate citizen complaints and concerns about health service provision. An example is lobbying the parliamentary committees on gender and also the committee on health. In spite of networks monitoring health expenditure, expenditure on SRHR has not been specifically monitored to assess the extent of government prioritization of SRHR services in terms of financial allocations. These weaknesses have been taken into account in the development of the current National Youth Policy, the Sexual and, Reproductive Health Policy as well as the National Plan of Action for Young People (NPA-YP). In order to ensure that the NPA-YP is based on the current SRHR and HIV status of Malawian youth and status of programming aimed for them, the Government, through the Ministry of Youth Culture and Sports (MoYSC) commissioned a Rapid Assessment, Analysis and Action Planning on SRH/HIV Prevention for Young People aged 10 to 24 in Malawi (RAAAP). The findings of the RAAAP have been used to guide the development of the NPA-YP for HIV prevention interventions among young people. Additionally, the RAAAP findings form the key benchmark against which the progress registered by scaling up SRH/HIV prevention programs for young people.
5.0 STATE OBLIGATIONS
This section establishes the state obligations that are relevant in relation to the impact (direct and indirect) of the gender and reproductive health policies.
The Ministry of Health monitors provision of health services in both public and private owned clinics. The Medical Council of Malawi is responsible for the regulation of clinical practice while the Pharmacy Medicines and Poisons Board is concerned with issues relating to certifying drugs, dispensing drugs and certification of clinics. Codes of conduct for nurses, clinicians, doctors, teachers, lawyers and a number of professions do exist to guide different professional practices. Government monitors implementation of health services through a number of mechanisms such as: the joint Malawi Health Equity Network (MHEN) and Ministry Of Health patient's rights and responsibilities charter which is displayed in most of the health facilities. This is an attempt towards increasing awareness of patients' rights.
5.1.1 The government's compliance to core obligations
The government is complying with the ICESCR treaty by providing minimum essential levels of core obligations such as access to health facilities, goods and services on a nondiscriminatory basis, especially for vulnerable or marginalized groups, access to basic food, access to basic shelter, housing, water and sanitation, and having a national public health strategy and plan of action.
Malawi has almost double the recommended minimum number of Comprehensive Emergency Obstetric Care (EmOC) facilities with only 2% of the recommended number of basic EmOC facilities (35). Following a national EmOC assessment by the reproductive health unit of the Ministry of Health, the government in 2006 developed a road map for accelerating the reduction of maternal and neonatal mortality and morbidity in Malawi. This study identified capacity building of the health care delivery system to reduce MMR and neonatal mortality as being important. The Road Map is hence the action oriented plan stipulating various strategies to guide policy makers, development partners, training institutions and service providers in supporting government efforts towards the attainment of MDGs related to maternal and neonatal health.
The government has achieved a lot of progress in immunization against major infectious diseases. Malawi's Expanded Programme on Immunization (EPI) follows WHO guidelines for vaccinating children. Full vaccination includes one dose of BCG vaccine, three doses each of DPT and polio vaccine, and one dose of measles vaccine. The 2004 MDHS shows that 91% Of children aged 12 to 23 had been vaccinated against TB. A good number of children (82%) received DPT3, 78% received polio vaccine while 79% received measles vaccine. Overall, 64% of children aged 12 to 23 months received all the recommended vaccines while 4% of children received no vaccine. For immunization against tetanus, 85% of women had at least one tetanus toxoid injection given during pregnancy while only 66% of women had two or more tetanus toxoid injections. A recent survey on Monitoring the Situation of Children and Women Malawi Multiple Indicator Cluster Survey conducted in 2006 by the National Statistical Office Zomba, in collaboration with UNICEF has latest figures on immunization (the report is still in draft form). From this study, approximately 96% of children aged 12-23 months received a BCG vaccination and a similar per centage were given the first dose of DPT. The percentage declines for subsequent doses of DPT were: 93 per cent for the second dose, and 86 per cent for the third dose. Similarly, 96% of children received Polio 1, declining to 81 per cent by the third dose. The coverage for measles vaccine is 85%. Overall, 71% of children age 12-23 months received all the recommended vaccines and 2.5% received none. The percentage of children who had all eight recommended vaccinations by their first birthday has increased to 62% in the last two years compared to 51 per cent in MDHS 2004. (36)
Government has instituted measures to prevent, treat and control epidemic and endemic diseases. In addition, government has a health education unit within MOH that is concerned with providing education and improving access to health information. One of the strategies for improving maternal and neonatal health stipulated in the road map for accelerating the reduction of maternal and neonatal mortality and morbidity is strengthening human resources to provide quality skilled care.
The obligation of progressive realization applies since the government can still achieve more progress towards women's health rights by putting more resources--human and financial--into the implementing structures and programmes. Government needs to do more to provide essential drugs in all health facilities and to equitably distribute health facilities, goods and services. Government also needs to accelerate improvements in maternal (prenatal as well as postnatal) and child health care, as well as training for health personnel. There are a number of NGOs involved in providing education on health and human rights. There is concentration in promoting political rights, participation of women in politics and decision-making, gender based violence and less on SRHR. There is need to put emphasis on SRHR in order to improve education and access to information concerning SRHR.
5.1.2 Government attempt to obtain international technical and financial assistance
DFID provided technical support to strengthen institutional and operational capacity of the MWCD, drafting revised National Gender Programme. Donor harmonization has also been facilitated through the Development Assistance Group on Gender (DAGG). Attempts to mainstream gender have also been through support to civil society and division of responsibility within DAGG.
The reluctance of donors to support public sector recurrent and salary costs led to placement of consultants and expatriates in key posts within MOH. Although this assisted government to achieve some of its obligations, the effect was inequalities in salaries and allowances between externally supported and government employees thereby undermining good working relationships (37). Recent development has led to budgetary support from DFID to the health sector to support the Human Resources Emergency Relief Plan. The Health SWAp has assisted in reducing the number of donors' vertical projects, set often within their own health priorities, financial systems, and information systems with little regard for the national health system.
The escalation of HIV infection and the availability of the Global Fund, enabled MOH to address HIV and AIDS, including provision of ARV and scaling up of PMTCT of HIV/AIDS activities. On the other hand, the increased funding and attention given to HIV/AIDS is influencing to some extent, de-prioritising of other health policies and services (38). The allocation to health care is increasing. For example, there was an increased allocation (16%) in 2006. Allocations stood at 7.5% in 2005.
According to the Malawi Health Network Coordinator, donor assistance comes with its ties. "There are other challenges for example, the World Bank places restrictions on the amount of money the Ministry of Health can spend."
A major obstacle to implementation of SRHR programmes highlighted by government is the lack of financial and human resources. However, government continues to put its efforts to obtain international technical and financial assistance for sexual and reproductive health. There are technical experts attached to the Ministry of Health and the reproductive health unit that assist government in issues relating to improving the sexual and reproductive health of women. Malawi has a high structural dependency on foreign aid to an extent that about 70% of the annual state budget is funded by international donors, whose development programs tend to shift in focus depending on changes in their respective governments. This affects governments' sustainability of programmes including SRHR.
The government is working towards providing minimum essential levels of core obligations such as access to health facilities, goods and services on a non-discriminatory basis, access to basic food, access to basic shelter, housing, water and sanitation, and having a national public health strategy and plan of action. However, it needs to do more to ensure that the strategies and activities are well funded and supported with the required infrastructure, skills and personnel.
Many policies, strategies, protocols developed require coordination for effective implementation. In addition, benchmarks need to be set and used to monitor progress on implementation.
The government should be held accountable for the high numbers of deaths of women due to maternal mortality and morbidity and more resources need to be earmarked to improve the delivery of EmOC.
6.0 RECOMMENDATIONS AND ACTION PLAN
The policies developed need to be widely disseminated for their wider application. The current review of the gender policy being carried by the Ministry of Women and Development requires wider dissemination to government departments, NGOs and the community so that people can participate in contributing to the recommendations and action plans. Any subsequent gender policy requires bench marks and time frames for strategies as well as a monitoring mechanism to check level and quality of implementation.
There is need for a capacity needs assessment for the MWCD in order to determine what support is needed for effective coordination and monitoring of gender related programmes.
There is need to address sexual and reproductive health not only from a health perspective, but also from a gender perspective such as dealing with the implications of pregnancy in a family, community and at the work place.
There is need to develop recommendations and strategies that will enhance the enjoyment of women's health rights. Changing societal attitudes towards the value of females and promoting their empowerment, improving the quality and relevance of education, increasing financial resources for education and SRHR are needed.
Malawi should rigorously work towards Universal Primary Education so that all school going children have access to education. Although access to education at different levels is improving due to affirmative action, it should however be noted that Mathematics and other Science subjects are still a domain of boys. Girls still concentrate in stereotype fields of study such as nursing, teaching, secretarial training and home economics and this needs to change.
Participation of civil society especially at grass root level in promoting women's SRHR is very minimal. The community action groups initiative instituted by MWCD is a positive development, however, monitoring of its activities is very minimal. Such community based initiatives need to be promoted and supported.
The majority of people need to be educated that it is their right to be provided with reproductive and sexual health services and should hold government accountable to its commitments.
There is need for the NGOs involved in lobbying government to monitor expenditure on sexual and reproductive health in order to see to it that SRHR services are being promoted and exercised.
Enforce across the country all SRHR legislation, including in relation to early marriage. In particular, maximize the positive aspects of the Prevention of Domestic Violence Law, including its broad definition of the crime and broaden it out to ensure that, among other measures, legislation adequately covers unmarried women and workplace situations.
Strengthen the links between HIV prevention and legal services--so that if, for example, a woman taking an HIV test reports being raped, she can be referred to a group that can provide appropriate and sensitive legal support.
Ensure that abortion services respond to the realities of girls' and young women's lives. Ensure safe legal abortion on request and develop comprehensive high quality services to the fullest extent permitted by law.
Introduce legislation, complemented by community programmes, to address harmful cultural practices that exacerbate HIV transmission. For example, develop measures to ensure that girls are not put under pressure for early marriage and that traditional counsellors do not encourage young people to have sex as part of their initiation.
Ensure that a 'core package' of youth-friendly HIV-related services (including access to treatment for STIs, VCT and ARVs) is available in at least all major district health outlets and start scaling up to health centre level. Ensure universal access to ARV therapy, while also promoting prevention. Ensure that girls and young women living with HIV, including those who are poor and in rural areas can receive treatment in an environment that not only addresses their HIV status, but recognizes their needs relating to their gender and age.
Address some of the barriers to the use of such services, for example by more systematically incorporating youth-friendly and confidential approaches into the training of government health staff, provision of adequate drugs and equipment.
Gender relations contribute greatly to negotiation and full enjoyment of women's SRHR. Hence, whatever their context or audience, all sexual and reproductive health and HIV and AIDS programmes need to address gender relations, facilitate the participation of and dialogue between both girls/young women and boys/young men. There is also need for concerted efforts to promote and sustain activities that economically empower girls and young women.
Government needs to continue facilitating the participation of girls and young women in national planning and programming relating to SRHR as well as promote capacity building initiatives in areas such as decision-making and public speaking.
There have been a lot of best practices and lessons learnt in SRHR; however these remain project -based. There is need for national programmes to incorporate and scale up best practices in sexual and reproductive health into national programmes.
(2) CIA(2006) The WorldFactbook Malawi--(13 June, 2006) http://www.odci.gov/cia/publications/factbook/geos/mi.html (Date accessed 21/06/06).
(3) CIA (2006) The World Factbook-Malawi--(13 June, 2006)
(4) 2006 est. CIA (2006) The World Factbook -, Malawi http://www.odci.gov/cia/publications/factbook/geos/mz.html. (Date accessed 21/06/06).
(5) CIA (2006) The World Factbook Malawi, http://www.odci.gov/cia/publications/factbook/geos/mz.html, (Date accessed 21/06/06).
(6) 1990-2003. UNDP (2005) Human Development Reports 2005: Malawi, http://hdr.undp.org/ statistics/data/indicators.cfm?x=23&v=l &z=l (Date accessed 21/06/06).
(7) 1995-2003. UNDP (2005) Human Development Reports 2005: Malawi, http://hdr.undp.org/ statistics/data/indicators.cfm?x=56&v=l&z=l (Date accessed 21/06/06).
(8) 1985-2003. UNDP(2005)Human Development Reports 2005: Malawi, http://hdr.undp.org/ statistics/data/countries.cfm?c=MWI (Date accessed 21/06/06).
(9) CIA (2006) The World Factbook--Malawi, http://www.odci.gov/cia/Dublications/factbook/geos/mi.html, (Date accessed 21/06/06).
(10) 1998 census. CIA (2006) The World Factbook--Malawi, http://www.odci.gov/cia/publications/factbook/geos/mi.html (Date accessed 21/06/06).
(11) 1998 census. CIA (2006) The World Factbook--Malawi, http;//www.odci.gov/cia/publications/ factbook/geos/mi.html (Date accessed 21/06/06).
(12) Estimate 2003. UNAIDS (2006) Report on the GIobal AIDS Epidemic, http://data.unaids.org/pub/ GlobalReport/2006/2006 GR ANN2 en.pdf(Date accessed 21/06/06).
(13) UNAIDS (2006) Report on the Global AIDS Epidemic. http://data.unaids.org/pub/GlobalReport/2006/2006_GR ANN2_en.pdf(Date accessed 21/06/06).
(14) UNAIDS (2006) Report on the Global AIDS Epidemic. http://data.unaids.org/pub/GlobalReport/2006/2006_GR ANN2 en.pdf (Date accessed 21/06/06).
The National Gender Policy, 2000.
(16) Malawi Constitution, section 13 (c)
(17) Malawi Constitution, section 13 (b)
(18) MDHS 2004.
(19) Malawi Constitution, section 103
(20) Malawi Constitution, section 120
(21) Malawi Constitution, section 123 and the Ombudsman Act
(22) Employment Act, No 6 of 2000, sections 47, 48 and 49.
(23) 2002. 2004 Report on the Global AIDS Epidemic: Malawi,
(24) MOH 2003
(25) Malawi Health Equity Network, 2003.
(26) Kapulula et al, 2001; Chilowa et al, 2001; Ashwood-Smith, Bokosi, Matinga 1999.
(27) Malawi Demographic Health Survey. 2004.
(28) McCoy et al 2005 Going from bad to worse: Malawi's maternal mortality. An analysis of the clinical, health systems and underlying reasons, with recommendations for national and international stakeholders, Commissioned by Task Force 4 of the UN Millennium Project.
(29) ICESCR General Comment 14, paragraph 4 and 11.
(31) Matinga 2007. Assessment of European Union Micro Projects on Health.
(32) The Draft Monitoring the Situation of Children and Women Malawi Multiple Indicator Cluster Survey 2006 report. National Statistical Office Zomba, Malawi United Nations Children's Fund Lilongwe, Malawi.
(33) Law Commission, 'Report of the Commission on Criminal Justice' (Lilongwe; Malawi Law Commission, 2000).
(34) Malawi Constitution, section 32
(35) Emergency obstetric care services in Malawi. Report on a nationwide assessment, July, 2005
(36) Monitoring the Situation of Children and Women Malawi Multiple Indicator Cluster Survey 2006. National Statistical Office Zomba, Malawi United Nations Children's Fund Lilongwe, Malawi
(37) Aitken 20003.
(38) Kemp et al, 2003.