In Malawi, policymakers have used data and statistics on reproductive health practices to make gradual changes to the primary health care system through policy development. Over two-thirds of Malawi’s population is under 25, and many young people begin having sex before age 18.33 In 2015, just about half of sexually active young men ages 15-24 reported using condoms, while one in three unmarried sexually active girls ages 15-19 reported using contraception.34 Low educational attainment is an ongoing challenge with only 37% of 15-19-year-olds reporting completion of primary education, and a high proportion of adolescent women marry and have children before age 18.35 Almost 30% of all pregnancies in 2016 were unintended 36, and three in 10 teenage girls in Malawi reported dropping out of school due to teen pregnancy. 34 Comprehensive knowledge about HIV/AIDS was low among young people, and data from 2008 showed that just under half of maternal deaths in Malawi were among girls and young women ages 14-23.
Evidence-based policy development to promote reproductive health and family planning
In Malawi, the government focused on improving access to the underserved youth population, finding that often services were not available, convenient, or acceptable. Young people needed basic information about their bodies and about prevention of pregnancy and sexually transmitted infections, but they also needed services that would address gender inequality and empowerment, their rights and responsibilities, and sexual and reproductive decision making.37 In 2013, Malawi’s government passed the Gender Equality Act, giving young people the right to high-quality, accessible, and acceptable sexual and reproductive health services.34 Public health facilities were mandated to provide free care for youth aged 24 and under.34 New policies on youth and population linked adolescent family planning services to policies around adolescent development, and Malawi became a signatory to all major international agreements and treaties focused on supporting adolescent access to family planning.33
Focus on equity and broad stakeholder engagement
The government worked with stakeholders across the Ministry of Health and other ministries, regulatory bodies, development partners, implementing partners and NGOs, and networks and associations including youth councils 36 to develop policies tailored to the family planning needs of adolescents and sexually active, unmarried young people.33 These included policies to promote male involvement in family planning behaviors, such as the National Sexual and Reproductive Health and Rights Policy (2015-2020) whose guiding principles included community participation, evidence-based decision making, and equity-based approach, partnership and multisectoral collaboration, and accountability.37 Male involvement is being viewed by Malawi’s government as “a new health or social and behavioural change activity,” having found that “male unfriendly infrastructure at the health facilities, illiteracy, ignorance, poverty, increasing rural urban migration, and cultural beliefs contribute to lack of male involvement” in sexual and reproductive health issues.37
Progress tailoring PHC policies, but still more to be done
Between 2010 and 2015, Malawi’s total fertility rate was reduced from 5.7 to 4.4, but age-specific reductions showed still more needs to be done to decrease rates among young women between ages 15-19 and 20-24.38 Many of the evidence-based policy changes are still too recent to show profound changes. However, a 2018 focus group study of youth and their parents or guardians found that while awareness of the different types of contraceptive options were high, misconceptions of their mechanisms were common – and that youth who had dropped out of school had lower knowledge about family planning than those who were still in school.38 Primary health care facilities are an important route to improving knowledge and equitable access, but support and time are needed to turn national policy commitments into programs implemented in a standardized way across communities and health care facilities nationwide.39