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Malawi has made remarkable strides in adolescent sexual and reproductive health (ASRHR) over the past two decades. The country has achieved significant reductions in adolescent fertility rates and maternal and neonatal mortality, while also increasing the uptake of voluntary modern contraceptives and improving adolescent sexual and reproductive health and rights. These achievements have earned Malawi recognition as one of six exemplar countries in Adolescent Sexual and Reproductive Health (ASHER) and one of the first three exemplar countries in Family Planning under the Exemplars in Global Health (EHG) Programme. Notably, Malawi has satisfied the family planning demand and outpaced the sub-Saharan regional average plus the percentage of most of the exemplar countries in family planning.  

On August 20, 2024, the African Institute for Development Policy (AFIDEP) in collaboration with the Ministry of Health convened an interministerial workshop to share research findings on Malawi’s achievements in ASRHR and family planning since 2000 and to discuss opportunities for further progress. The workshop brought together government officials, health experts, youth representatives, and international partners. 

From ICPD to FP2020 and FP 2030 

From the International Conference on Population and Development (ICPD) to the FP2020 and FP2030 goals, Malawi emerged as a leading example of success in family planning. The country consistently outpaced the sub-Saharan African (SSA) regional average and most exemplar nations in meeting family planning demands. Its modern contraceptive prevalence rate (mCPR) steadily increased across various methods from 21.5% in 2000 to 45.1% in 2015, demonstrating a commitment to expanding access as compared to fellow exemplar countries. Malawi’s compound annual growth rate (CAGR) in family planning achievements was surpassed only by Senegal and Sierra Leone, reflecting its effective strategies in addressing equity gaps among income groups. 

 The key to Malawi’s success was largely attributed to its strong political commitment and strategic policies that integrated family planning with national development goals. The government promoted gender equality, reduced child marriage rates, increased women’s representation in leadership, combated gender-based violence (GBV) and enhanced economic opportunities. Educational reforms, such as free and compulsory schooling and policies supporting the re-admission of pregnant teens, were also crucial. Additionally, development of cost-effective implementation plans and innovative financing mechanisms, such as results-based financing and health insurance schemes, attracted donor-funding. 

Investments in health systems and community engagement further bolstered Malawi’s family planning efforts. The country expanded access through community health workers, mobile outreach, enhancing user access and agency. Private partnerships helped minimise stockouts, improve supply chain management, and enhance data monitoring, which collectively improved the quality of family planning services. New methods like injectables and implants were introduced, and family planning was integrated with maternal, newborn, and child health (MNCH) and HIV services. Mass media campaigns and community dialogues promoted healthy sexual and reproductive health behaviours and informed decision-making among women and youth.   

Malawi’s Progress in ASRHR  

 The journey in transforming adolescent lives through the promotion and protection of ASRHR was shaped by a combination of policies, legal frameworks, and socioeconomic factors, including cultural and gender norms. These elements played a crucial role in reducing adolescent fertility rates among those aged 15-19 and advancing ASRHR, especially for vulnerable groups such as very young adolescents, adolescents with disabilities, and those in hard-to-reach areas. Furthermore, gaps between the poor and rich, as well as between rural and urban adolescents, in modern contraceptive use and skilled birth attendance narrowed, reflecting progress in addressing disparities. 

Health system strengthening efforts were also central to this progress. Initiatives such as the Population and Family Planning Project, the Youth Friendly Health Services Programme, and the Community-based Family Planning and HIV/AIDS Services Project significantly contributed by increasing the number of healthcare workers trained to provide youth-friendly services, engaging adolescents as community-based distribution agents, and improving the supply chain for family planning commodities. Programmes such as Breakthrough Action and Youth Alert also supported in promoting family planning and HIV services through static and outreach approaches. 

In the context of education, policies and interventions supported school enrolment, retention, and sexual and reproductive health education, resulting in an increase in adolescents’ mean years of schooling from 5.1 years in 2000 to 6.5 years in 2016. Initiatives such as Keeping Girls in School and the UN Joint Programme for Girls Education were instrumental in providing bursaries, improving school infrastructure, and enforcing school readmission policies to ensure that girls remained in school. Community responses to ASRHR were strengthened through initiatives that tackled gender-based violence, child marriages, and harmful cultural practices, with programmes such as the Spotlight Initiative and Marriage No Child’s Play empowering women and girls, facilitating community-led movements, and supporting the creation of protective bylaws. 

These efforts resulted in a steady decline in adolescent fertility from 172 births per 1,000 adolescents in 2000 to 136 births in 2016. Positive trends in sexual and reproductive health behaviours among adolescents were also observed: the proportion of married adolescents decreased from 32.6% in 2000 to 23.5% in 2016, the age at first sexual activity for women aged 20-24 increased by one year between 2000 and 2020; modern contraceptive use among adolescents rose from 14% in 2000 to 36% in 2016, and the percentage of adolescents attended by skilled health personnel during delivery significantly improved from 58% in 2000 to 93% in 2016.  

Addressing the Ongoing Challenges 

Despite these advancements in family planning and ASRHR, significant gaps remain. In family planning, equity issues still persist, particularly among adolescents and young people. Early sex, marriage, and childbirth are more prevalent in Malawi as compared to other countries like Senegal, where later median ages for these milestones suggest lower adolescent sexual activity. While there has been some advancement in meeting family planning needs for both married and unmarried adolescents, challenges continue to hinder the full realisation of these efforts. In ASRHR, the completion rates of adolescent education still remain low. Factors such as household wealth, place of residence, religious affiliation, and region still influence adolescent pregnancies exacerbated by high rates of child marriage in the Eastern and Southern Africa (ESA) region. School retention rates, especially for girls, remain low due to factors like inadequate sanitation infrastructure, poverty, and pregnancies. Access to quality youth-friendly health services (YFHS) remains limited, with only 60% of services adequately provided, often hampered by irregular support. Additionally, restrictive abortion laws persist, as evidenced by the failure to pass the Termination of Pregnancy Bill in 2021, and the implementation and monitoring of policies and programmes are frequently constrained by insufficient funding. 

 To address the ongoing challenges in Malawi, the following key recommendations were proposed:  

• Scale up the provision of quality youth-friendly health services (YFHS): Ensure all health facilities across the country offer these services and receive regular supportive supervision to maintain adherence to established standards. 

• Strengthen a multisectoral approach to enhance school retention among adolescents, particularly girls: Equip them with the knowledge and skills needed to prevent unintended pregnancies while providing additional support to keep them in school. 

• Tailor interventions to the multifaceted needs of vulnerable adolescents: Focus on those who are out of school or living in rural areas to reduce equity gaps and ensure that all adolescents have the opportunity to thrive. 

From the interministerial workshop, insights highlighted the importance of effective collaboration among stakeholders, emphasising the need for a coordinated approach to tackle ASRHR challenges. Increased investment in education which is crucial for equipping adolescents with the knowledge and skills needed to make informed reproductive health choices. Efficient allocation of resources, to direct funding to areas of greatest need. Developing performance management trackers to help monitor progress and maintain accountability in implementing ASRHR initiatives and expanding access to comprehensive reproductive health services, ensuring that all adolescents, regardless of their location or background, receive the care they need.   

 The EGH Programme convenes experts, funders, and partners to uncover factors driving increased voluntary modern contraceptive use, improved adolescent fertility outcomes, enhanced women’s health and well-being, and reduced maternal and neonatal mortality. The programme provides a strategic framework for scaling public health successes by identifying and analysing countries that excel in various health domains while focusing on understanding current evidence, addressing research gaps, and tailoring recommendations to meet the specific needs of end users. Through this approach, EGH offers valuable insights and adaptable strategies for other countries seeking to replicate and build upon these successes within their own contexts.