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 socioeconomic
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 socioeconomic
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 socioeconomic
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 enrolment, general
literacy rates significantly contribute to the reduced burden of diseases. However,
their nature of interaction differs when considering disease caused mortality andprevalence 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 socioeconomic
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.
Keywords: health outcomes, health determinants, poverty, employment, food
security, education, antecedents, Malawi, district, disease burden, mortality.