Poverty, access and immunization in Malawi – a descriptive study

Background: Although a very poor country, Malawi has a good immunisation programme record. But is this programme equitable? If it is, are there lessons to learn for other services that also need to reach the poor? Methods: The performance of the EPI coverage was assessed using DHS and other survey data in relation to socio-economic features and geographical access. Data provided by UNICEF and the Ministry of Health EPI Unit were used to assess coverage. Demographic and Health Surveys of 1992 and 2000 were used to compare immunisation uptake by wealth quintile groups derived from asset scores for each household. Other socio-economic features analysed were the education level of the mother, gender of the child, region of residence, ethnicity, religion and urban or rural residency. Results: The EPI provides an equitable service to rich and poor alike. Coverage is as high in districts with poor access to health facilities as it is in districts with good access. There are no significant differences between ethnic, religious or gender groups. More educated mothers have children with higher immunisation rates. Coverage and inequality have worsened between 1992 and 2000, but not to a significant degree. Conclusions: The EPI in Malawi is both effective and equitable. However, low child survival alongside high immunisation coverage is a reminder that health technology interventions such as EPI may not succeed on their own without improvement in the basic determinants of disease - nutrition, sanitation and mothers\' education. The use of outreach clinics and paid village health workers is an object lesson for other services which need to reach the poor. Malawi Medical Journal Vol. 18 (1) 2006: pp. 19-2