LILONGWE, Malawi – I’ve always believed the best way to learn about US foreign policy isn’t in Washington. It’s in the countries where policy plays out.
And so two years into the Obama administration’s ambitious Global Health Initiative (GHI), what is happening in the field?
A team of reporters from GlobalPost will be looking at that question in five countries this summer, starting with Malawi. All five are among the US administration’s eight focus countries, the so-called GHI plus nations.
Malawi’s GHI program is interesting because there was no shortage of possible areas of focus: The country has some of the world’s worst health measurements – high rates of HIV, TB, malaria, child deaths and women dying in child birth, to name a few. And yet in the last several years, the country has made significant progress in some fields: the numbers of people on AIDS treatment, for instance, rose from just a few thousand in 2004 to roughly 270,000 today.
One of my first stops was the US Agency for International Development office, where a team of senior health officials walked me through the GHI country program. Malawi’s GHI team includes officials from the State Department, USAID, Centers for Disease Control and Prevention, and the Peace Corps. One of its central tenets was to find ways of improving the health of women, and one of the key GHI strategies, they said, was to improve reproductive health.
In particular, they were aiming at making childbirth safer and giving women greater access to family planning.
Lilly Banda, USAID’s deputy team leader in the Health Office in Lilongwe, said while maternal deaths have gone down, the number was still very high. “The quality of care is not as good as we want,” she said.
Malawi’s 2010 Demographic and Health Survey – a comprehensive door-to-door undertaking on a range of health questions – found that 42 percent of women in their reproductive years used modern contraceptives, up from 28 percent in 2004.
What will GHI do in Malawi? A range of things, Banda said, including: expanding the numbers of scholarships of nurses and other health workers (in return for an agreement to work in the country for a number of years); training health workers in communities to educate couples about family planning and to make a wide variety of contraceptives available; and helping expand the country’s program to prevent HIV from spreading from mother to child.
The issue of family planning, they acknowledged, carried great sensitivities – in the politics of the United States as well as the traditions of Malawi.
I went to see Malawi’s Permanent Secretary for Health, Willie Samute, to ask him about the cultural issues around family planning. He said that the country must do a much better job at reducing the fertility rate, which stood at an average of 5.7 children per women in 2010, down only slightly from 6.3 children per women in 2004.
Samute said one problem was that villages still wanted to use traditional birth attendants to deliver babies. That contributed to Malawi’s high death rate during child birth because some performed poorly, especially in complicated deliveries. But he cited another problem with them, too: The birth attendants were telling young women to have more babies.
I decided to go to a village and talk to women about the changing dynamic in Malawi. What was an accepted number of babies for a family these days, and who should be delivering the babies?
This would be undeniably a long-term process – and GHI, back in Washington not Malawi, would soon be feeling pressure to show results, especially in the tight-fisted budget climate in Congress.
And was Congress in a mood to increase funds for family planning in Malawi and elsewhere?
Maybe some of that depended on what rural Malawi women thought about it.
Next: A visit to Chakwindima village.