An investigation of socio-economic antecedents of health outcomes in Malawi
Kuyeli, Sanderson Sabie
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The study investigated the socio-economic antecedents of the health outcomes in Malawi from a district level perspective. There is a gap emerging from the analysis of the key social economic factors determining health outcomes. This is mainly towards systematic linkages between the socio-economic factors and health outcomes. Therefore, there is a need to analyse practically the specific socio-economic factors on their level and nature of interaction with the ultimate health outcomes like the maternal mortality rate (MMR), infant mortality rates (IMR), under-five mortality rates and disease burden. Considering that the country is divided into 28 districts, which have unique socio-economic features, the study considered the health outcomes trend at the district level. The underlining basis is that these health outcomes are being determined and shaped by the district socio-economic factor levels. General correlations, descriptive statistics and regression analyses were conducted and used in order to establish the nature of the relationship and effects on how the socio-economic factors at district level are shaping health outcomes, specifically in the context of maternal and childhood mortality as well as disease burden outcomes. In investigating the socio-economic factors of education, population, poverty, employment and food security on health outcomes, the study had a number of specific objectives, both theoretical and empirical. The theoretical objectives of the study were to review the literature on health from both its determinants and their models’ premises. The study has established from the literature review that socio-economic factors continue to impact the health outcomes across the globe. The role of social determinants of health (SDH) in improving the health outcomes cannot be overemphasised. In analysing the trends on health outcomes across the globe, both developed and developing countries, with special attention to the sub-Saharan region in which Malawi belongs, countries with low income, high population growth rate, high poverty levels and low literacy rates have continued to experience high burden of diseases and mortality rates. This is despite declining trends in the past decade where most of these countries have achieved slow or minimum progress. The study considered the SDH, both in literature and implications on health systems by isolating the linkages between the critical SDH and health outcomes. In considering the limitations of the SDH, especially the differences that arise from location, level of analysis and the ever-changing environments, the study specifically focused on the district level analysis by employing a district random effect model (DREM) to establish the nature and level of impact, pathways and the socio-economic intermediaries (referred to in the study as socio-economic antecedents), on the relationship between the SDH at the district level. The study used data from the routine studies that are conducted by the national statistical office in Malawi. These are primarily the welfare monitoring surveys from 2005 to 2011 and IHS2 and IHS3, which mainly provided the socio-economic variables. The main socio-economic variables used in the study included employment levels, education, literacy, maize output, population growth and poverty levels. Health management information system of the Ministry of Health and the demographic and health surveys informed the study on the health outcomes. The main health outcomes analysed included maternal mortality rate, infant mortality rate, malaria mortality rates disaggregated for the under-five and all ages groups, the disease burden mainly malaria and tuberculosis prevalence rates. All these outcomes measured at district level. The results of the study have demonstrated that the distribution of social-economic factors of education, population, income levels have a random effect on the health outcomes across the country based on the district level analysis. The use of the DREM was chosen on the basis that district level data provide a more comprehensive base in terms of level and distribution of both health outcomes and socio-economic factors. The results have shown that some health outcomes, for example maternal and infant mortality rates, as well as malaria mortality in the districts can improve significantly by investing in education. This is mainly through reduction of primary school dropout rates. These health outcomes can also be improved significantly by improving general literacy levels, increased employment in the agriculture sector, as well as reduced household dependency ratio. The results have also shown that improved female literacy, primary school enrollment, general literacy rates significantly contribute to the reduced burden of diseases. However, their nature of interaction differs when considering disease caused mortality and prevalence rates. For example, higher education attainment level contributes significantly to the reduction of malaria caused mortality and not on the malaria prevalence rate. The results have demonstrated that the district level model in improving health outcomes would bring more meaningful results considering that the country is implementing a decentralisation programme. This further implies that despite the investigated socio-economic factors being outside the realm of the health sector, these factors have had and will continue to shape both individual and population health. A number of policy interventions have been suggested from the results of the study, in a bid to improve the health outcomes of the country. These include: enhancement of the district level leadership, strengthening the role of organisation and private companies, strengthening the role of the district health committees in the running of health services, deliberate broadening of economic activities within districts, and strengthening malaria monitoring in light of improving food security for example expansion of irrigation activities. The special contribution of the study is the significance of adopting and adapting the approach in implementing interventions. This implies that some districts’ health outcomes can significantly be improved by having the initiatives toward or within the district adapted based on the key socio-economic factors in the districts. The study has therefore provided insights towards a scientific framework in improving the health outcomes amidst limited resources developing countries may face. It further calls for more district-adapted initiatives (micro-based) towards improving health outcomes as opposed to national wide (macro) mode of interventions.