Policy In Malawi Research Articles

Policy Analysis on Clean Cooking in Malawi: Case of Improved Cookstoves

Transition from cooking with traditional biomass to clean cooking is a persistent challenge in Malawi. The underlying technologies in clean cooking are improved cookstove. Improved cook stoves are designed to reduce fuel consumption per meal and to curb smoke emissions experienced in traditional three-stone cookstove. However, promotion adoption and utilisation of clean cooking requires coordinated policy and regulatory framework. This study analysed the Malawi policy regulatory framework on clean cooking by benchmarking with relevant literature. The following policy gaps were identified: (i) the lack of clear cookstove rating by Malawi Bureau of Standards; (ii) uncomplimentary policies and regulations in the energy and forestry sectors on clean cooking fuels and technologies; (iii) the lack of empirical data on adoption and utilisation of clean cooking technologies and fuels in Malawi; (iv) predicaments in adopting and using international standards for testing cookstoves; and (v) the value chain of improved cookstoves and other forms of clean cooking fuels and technologies that is not adequately analysed. Coordinated development and harmonious implementation of clean cooking regulations in the key sectors of energy and forestry can promote adoption and utilisation of clean cooking methods and technologies in Malawi.

Missed opportunities to address common mental disorders and risky alcohol use among people living with HIV in Zomba, Malawi: A cross sectional clinic survey.

Common mental disorders (CMDs) and risky alcohol use are highly prevalent among people living with HIV, yet many do not receive treatment for these mental health problems. In Malawi, despite a mental health policy aiming to include mental healthcare into primary health care, many clients with HIV go unscreened and untreated for mental illnesses, indicating missed opportunities to offer mental health care to people living with HIV. The aim of this study was to determine the numbers and types of missed opportunities for screening and treatment of CMDs and risky alcohol use amongst a sample of people living with HIV attending anti-retroviral (ART) clinics in Zomba Malawi. A descriptive cross-sectional clinic survey was used, at three ART clinics in the Zomba district. Random sampling was conducted for all clients attending their ART clinics on specific days. The study surveyed 382 participants living with HIV. Of these participants, the majority were women (N = 247, 64.7%), and 87 (22.8%) screened positive for CMDs and/or alcohol misuse using the self-reporting questionnaire 20 (SRQ-20) and alcohol use disorder identification test (AUDIT). Of these, only 47 (54%) had been screened by health workers for CMDs or risky alcohol use in the past 12 months, and 66 (76%) wanted to receive treatment. Of the total sample of 382 participants, only 92 (24%) and 89 (23%) had been screened for CMDs or risky alcohol use by health workers. Failures by clinical officers and nurses to screen or treat CMDs and risky alcohol use in ART clinics represent missed opportunities to address the mental health of people living with HIV. Providing psychoeducation for staff, guidelines for screening and managing CMDs and alcohol use, increasing human resources, and accelerating implementation of the mental health policy in Malawi may be a few ways of improving mental health service provision at ART clinics in Malawi.

Modeling Spatiotemporal Patterns of Land Use/Land Cover Change in Central Malawi Using a Neural Network Model

We examine Land Use Land Cover Change (LULCC) in the Dedza and Ntcheu districts of Central Malawi and model anthropogenic and environmental drivers. We present an integrative approach to understanding heterogenous landscape interactions and short- to long-term shocks and how they inform future land management and policy in Malawi. Landsat 30-m satellite imagery for 2001, 2009, and 2019 was used to identify and quantify LULCC outcomes based on eight input classes: agriculture, built-up areas, barren, water, wetlands, forest-mixed vegetation, shrub-woodland, and other. A Multilayer Perceptron (MLP) neural network was developed to examine land-cover transitions based on the drivers; elevation, slope, soil texture, population density and distance from roads and rivers. Agriculture is projected to dominate the landscape by 2050. Dedza has a higher probability of future land conversion to agriculture (0.45 to 0.70) than Ntcheu (0.30 to 0.45). These findings suggest that future land management initiatives should focus on spatiotemporal patterns in land cover and develop multidimensional policies that promote land conservation in the local context.

SARS-CoV-2 exposure in Malawian blood donors: an analysis of seroprevalence and variant dynamics between January 2020 and July 2021

BackgroundBy August 2021, the COVID-19 pandemic has been less severe in sub-Saharan Africa than elsewhere. In Malawi, there have been three subsequent epidemic waves. We therefore aimed to describe the dynamics of SARS-CoV-2 exposure in Malawi.MethodsWe measured the seroprevalence of anti-SARS-CoV-2 antibodies amongst randomly selected blood transfusion donor sera in Malawi from January 2020 to July 2021 using a cross-sectional study design. In a subset, we also assessed in vitro neutralisation against the original variant (D614G WT) and the Beta variant.ResultsA total of 5085 samples were selected from the blood donor database, of which 4075 (80.1%) were aged 20–49 years. Of the total, 1401 were seropositive. After adjustment for assay characteristics and applying population weights, seropositivity reached peaks in October 2020 (18.5%) and May 2021 (64.9%) reflecting the first two epidemic waves. Unlike the first wave, both urban and rural areas had high seropositivity in the second wave, Balaka (rural, 66.2%, April 2021), Blantyre (urban, 75.6%, May 2021), Lilongwe (urban, 78.0%, May 2021), and Mzuzu (urban, 74.6%, April 2021). Blantyre and Mzuzu also show indications of the start of a third pandemic wave with seroprevalence picking up again in July 2021 (Blantyre, 81.7%; Mzuzu, 71.0%). More first wave sera showed in vitro neutralisation activity against the original variant (78% [7/9]) than the beta variant (22% [2/9]), while more second wave sera showed neutralisation activity against the beta variant (75% [12/16]) than the original variant (63% [10/16]).ConclusionThe findings confirm extensive SARS-CoV-2 exposure in Malawi over two epidemic waves with likely poor cross-protection to reinfection from the first on the second wave. The dynamics of SARS-CoV-2 exposure will therefore need to be taken into account in the formulation of the COVID-19 vaccination policy in Malawi and across the region. Future studies should use an adequate sample size for the assessment of neutralisation activity across a panel of SARS-CoV-2 variants of concern/interest to estimate community immunity.

Urban planning history of Malawi: case study of the capital Lilongwe

ABSTRACT Like in other cities in the global South, rapid urbanization in Malawi continues to pose challenges for local authorities as manifested in un-ending struggles and contestation for urban space such as squatting and invasions of urban space. The research asks the question: how do the evolving and changing conceptions and perceptions of urban space shape or are shaped by planning and its associated spatial practices and representations of space? Specifically, the article addresses this question in two ways: first, by examining the evolving conceptions and perceptions of space in Malawi; second, by analysing the link between the changing conceptions and perceptions with urban planning and its associated representations and spatial practices. Using archival and secondary data, the article documents the underexplored history of urban planning policy in Malawi in three historical moments namely: the pre-colonial, colonial, and postcolonial eras; before delving into the shifting conceptions of planning from the colonial to post-colonial Malawi using Lilongwe city as a case study.

Nationally Representative Estimates of the Cost of Adequate Diets, Nutrient Level Drivers, and Policy Options for Households in Rural Malawi

A growing literature uses the cost of diets to evaluate how effectively a food system supports access to nutritious foods. We identify baseline levels, nutrient drivers, and potential policy-induced changes in the feasibility and cost of meeting nutrient requirements for whole households based on aggregate needs in rural Malawi from 2013 – 2017. We determine the availability and cost of a nutrient-adequate diet each month using the price and composition of foods available at the nearest market. We run more than 1 million models in total, one for every household in each month under baseline and eight policy simulation scenarios. We find diets containing adequate nutrients for whole families to be available 60% of the time from 2013–2017, and when available, costing an average $2.32/person/day (2011 US$ PPP). Further, we illustrate that as households grow in size and diversity of member types, the cost to acquire 1,000 calories of a sufficiently nutrient dense diet increases. Our policy simulations reveal that selenium is the nutrient hindering the availability of diets adequate and balanced in essential nutrients, but that riboflavin is the costliest nutrient to obtain in the market when a least-cost diet is available. We estimate selenium soil biofortification of maize would result in nearly universally available (94%) adequate diets at half the cost ($1.22/person/day on average). This far exceeds the potential impact of price or availability changes of foods dense in the costliest nutrients including eggs, milk, groundnuts, and dried fish. No other scenario improves availability or exceeds 1% average cost reduction. Of direct relevance to agriculture and nutrition policy in Malawi, this study demonstrates how the availability and cost of whole diets and the shad-ow prices of individual nutrients in retail markets can be used to identify barriers to accessing an adequate diet and estimate the potential impacts of policy options.

Agricultural Resources and Trade Strategies: Response to Falling Land-to-Labor Ratios in Malawi

This study assesses how growing land scarcity relative to family labor is influencing farm household decisions to trade in agricultural land and labor markets to improve their livelihood. Using the farm household model, I analyze decisions to rent-in land or hire out labor among smallholders in Malawi. I use data from two rounds of a nationally representative balanced-household panel and apply a systems approach to jointly estimate land rental and labor market decisions while controlling for simultaneity and unobserved heterogeneity. The results indicate that the falling owned-land-to-labor-endowment ratio can push households to participate in either land rental or seasonal agricultural labor markets. However, the probability of hiring out labor for casual work and short-term gains decreases when potential tenant households rent-in land. Based on asset-wealth-to-labor-endowment ratios, wealthier households are more likely to rent-in land while poorer households, including most smallholder households, are more likely to hire out labor. These results suggest higher friction in the land rental market compared to the agricultural labor markets and liquidity constraints dictating what is necessary to support agricultural operations and household needs. Accordingly, agricultural policy in Malawi should aim to reduce friction in factor markets.

Exploring how and why Care Groups work to improve infant feeding practices in low- and middle-income countries: a realist review protocol

BackgroundWithin our inquiry into the implementation of breastfeeding policy in Malawi, Care Groups have been mentioned as a means to improve maternal and child health and nutrition outcomes. The ‘Care Group model’ is an approach primarily used in international development settings, whereby social and behaviour changes are promoted through supported peer-to-peer (mostly mother-to-mother) knowledge sharing. The aim of most Care Groups is to promote improved infant nutrition, improve hygiene and increase the number of children who are fully vaccinated and exclusively breastfed for the first 6 months. The behavioural changes promoted by Care Groups (such as safe infant feeding, frequent hand washing, consistent mosquito net usage, providing suitable complementary foods from 6 months old) have the potential of averting preventable deaths particularly among children under five.While a variety of approaches are used to promote improved health and nutrition for children under five, the Care Groups model was best known and frequently referenced during our discussions with key stakeholders regarding the delivery at community level of Malawi’s National Multi-Sector Nutrition Policy 2018-2022. A better understanding of how Care Groups achieve their social and behaviour change results and how community-based efforts are sustained can potentially help to ensure more effective planning and budgeting for Care Group interventions and enable greater sustainability and increased coverage of infant feeding support countrywide. This realist review is designed to improve our understanding of how, why, to what extent and under what circumstances Care Groups improve infant feeding practices in low- and middle-income countries (LMICs).Methods and analysisA realist review is a theory-driven approach to evidence synthesis. To undertake this realist review, we will gather evidence by conducting peer-reviewed and grey literature database searches in order to find peer reviewed articles, programme guidelines and evaluation reports, among other texts, associated with the implementation of Care Groups in low- and middle-income countries. Our review process has five key steps: (1) locating existing theories; (2) searching for evidence in literature; (3) selecting articles and other suitable evidence; (4) extracting data, identifying configurations of context-mechanism-outcomes; and (5) synthesising the evidence, drawing conclusions.DiscussionThe results of this realist review will be written up according to RAMESES guidelines and disseminated through a stakeholder workshop in Malawi, through conference presentations and peer-reviewed publications. It is intended to improve the understanding of the potential and limits of working through Care Groups globally and among relevant Malawi Ministry of Health staff and the donor and NGO community, both internationally and within Malawi. This systematic review protocol has been submitted for registration on the PROSPERO database (receipt number: 170261).

Financial Modelling of Feed-In Tariff for Increasing Solar Photovoltaic Energy Portfolio in Malawi

The Feed-In Tariff (FIT) policy has contributed significantly in driving renewable energy investment around the world. Despite the lessons of FIT’s contribution in attracting private investment in renewable energy development around the world, Malawi’s FIT policy of 2012 has not attracted any private investor. This paper examined the financial modelling of feed-in tariff rates, using Kamazu International Airport solar farm in Malawi as a case study. The paper also analysed the major challenges encountered in implementing the FIT policy in Malawi and funding options for the policy. This paper presents policymakers and planners an analysis on why FIT policy in Malawi has not increased renewable electricity generation capacity. The paper outlines a financial modelling of the FIT using RETScreen Expert. The analysis shows that the FIT for solar in Malawi is significantly lower than a minimum rate that would make a solar PV investment financially viable. The Malawi FIT policy stipulate US$0.10 and US$0.20 for non-firm power (without storage) and firm power (with storage) respectively. The results of the financial modelling presented herein show that for a ten years payback period; the minimum FIT required is US$0.34 with an annual escalation rate of 5%. It is also shown that at US$0.22, to achieve a payback period of 10 years; an annual escalation rate of 10% would be required. Given the financial modelling results, the Solar Photovoltaic (PV) FIT in Malawi requires review for enhancement of solar investment in the country.

The Politics of Hunger in an SDG Era: Food Policy in Malawi

This study focuses on the relationship between politics and hunger and the national political discourse on food security in Malawi. Our aim is to better understand the role of local and national actors in pursuing policies that aim to achieve the 2030 Agenda and the Sustainable Development Goals (SDGs). The empirical focus is on the Farm Input Subsidy Program (FISP), introduced by the Malawian government in 2005–2006, which supports smallholder farmers to better access to agricultural inputs. We provide an overview of the food security discourse and highlight the importance of political commitment for policy coherence that is required for achieving the SDGs. Thereafter, we introduce the policymaking scene in Malawi and FISP before critically examining the policy narratives on food security in the country. Our goal is to examine why some issues are effectively dealt with and not others. We argue that food security policies in Malawi are influenced by the political incentives they provide for electoral campaigns and for securing a regular flow of financial resources in agriculture projects that are highly dependent on foreign aid.

"The role of the man is to look for food": Lessons from men's involvement in maternal and child health programmes in rural Central Malawi.

Many studies purport that in low-income countries, women are often responsible for producing, preparing and purchasing food. Consequently, policies related to food and nutrition overemphasise the role of women, underestimating the potential for cooperation and complementarity between men and women. This focus on women does not account for socially constructed expectations of women that undermine their decision-making in resource allocation. Using desk reviews, in-depth interviews and focus group discussions, our case study in Malawi sought to understand the complementary role of men in maternal and child nutrition. International agreements and Malawi’s policies were reviewed to understand how men’s involvement emerged on the nutrition policy agenda. Policymakers, stakeholders and men and women from rural Central Malawi were interviewed, sharing their experiences of men’s role in maternal and child health. The study found that men’s involvement in maternal and child health has been on the development agenda since as early as 1995. Malawi has made efforts to involve men in these areas through several policy actions and programmes. Contrary to literature suggesting that women are the main producers, procurers and preparers of food, this study found that men in rural Central Malawi are increasingly becoming responsible for providing and purchasing food. Men also play a supportive role in food preparation, helping women access diverse diets during and after pregnancy. They also take up a supportive role in household activities, providing women with assistance in housework and looking after children. The positive change in men’s roles presents an opportunity for exploring how men can contribute to food security and nutrition. Opportunities exist for designing inclusive food and agriculture policies that promote cooperation between men and women in food and nutrition. These policies can challenge misinterpretations of women’s role in food security and the underlying systems that reinforce gender inequalities.

Subjective Happiness, Health and Quality of Life and Their Sociocultural Correlates among Younger Population in Malawi

Public health research and policy in sub-Saharan Africa are generally disease-oriented, with the focus being largely confined within the biological determinants of health. So far, little attention has been given to developing a more health-oriented approach by emphasising the psychosocial dimensions of health, especially among the younger population. To this regard, we conducted the present study to assess the prevalence and sociocultural correlates of perceived happiness, health, and life satisfaction among the adolescent and young (15–24 years) population in Malawi. We analysed cross-sectional data on 12,610 men and women based on a Malawi multiple indicator cluster survey conducted in 2013–2014. Data were analysed using descriptive and multivariable regression methods. According to the findings, more than 80% of the men and women reported being satisfied about happiness, health, and life. Multivariate analysis showed an inverse relationship between being currently or formerly married and perceived happiness. Ethnic disparities in perceived health and happiness were more pronounced in men, whereas that of life satisfaction was more pronounced in women. Living in households of the highest wealth quintile was positively associated with health and life satisfaction, but not with happiness. These findings highlight the need for prioritising the psychosocial needs of the adolescent and youth populations in designing health and social policy in Malawi. The findings need to be interpreted in light of the factors specific to the sociocultural environment in Malawi.

Constituting Agricultural and Food Security Policy in Malawi: Exploring the Factors that Have Driven Policy Processes in the Farm Inputs Subsidy Programme

Political economy analyses of agricultural and food security policies in Malawi have emphasized the role played by domestic politics and, more specifically, the centralization of power in the executive. This paper builds on this perspective by exploring the view that such policies are in fact negotiated outcomes of interactions at the state–donor interface. Using interview data gathered from expert key informants and a review of publicly available data, the paper explores how certain policy drivers have interacted to shape agricultural and food security policies in Malawi. The results reveal that policy processes in the recent past have been driven and mediated by fiscal considerations, sociopolitical pressures, and pragmatism, which accounts for the unique and complex peculiarities of the Malawi context.

The role of the traditional leader in implementing maternal, newborn and child health policy in Malawi.

Traditional leaders play a prominent role at the community level in Malawi, yet limited research has been undertaken on their role in relation to policy implementation. This article seeks to analyse the role of traditional leaders in implementing national maternal, newborn and child health (MNCH) policy and programmes at the community level. We consider whether the role of the chief embodies a top-down (utilitarian) or bottom-up (empowerment) approach to MNCH policy implementation. Primary data were collected in 2014/15, through 85 in-depth interviews and 20 focus group discussions in two districts in Malawi. We discovered that traditional leaders play a pivotal role in supporting MNCH service utilization, through mobilization for MNCH campaigns, and encouraging women to give birth at the health facility rather than at home or in the community setting. Women and their families responded to bylaws to deliver in the facility out of respect for the traditional leader, which is ingrained in Malawian culture. Fines were imposed on women for delivering at home, in the form of goats, chickens and money. Fear and coercion were often used by traditional leaders to ensure that women delivered at the health facility. Chiefs who failed to enforce these bylaws were also fined. Although the role of the traditional leader was often positive and encouraging in relation to MNCH service utilization, this was sometimes carried out in a coercive manner. Results show evidence of a utilitarian top-down model of policy implementation, where the goal of health service utilization justified the means, through encouragement, fear, punishment or coercion. Although the bottom-up approach would be associated with a more empowerment approach, it is unlikely that this would have been successful in Malawi, given the hierarchical nature of society. Further research on policy implementation in the context of community participation is needed.

Behind the scenes: International NGOs’ influence on reproductive health policy in Malawi and South Sudan

ABSTRACTGlobal health donors increasingly embrace international non-governmental organisations (INGOs) as partners, often relying on them to conduct political advocacy in recipient countries, especially in controversial policy domains like reproductive health. Although INGOs are the primary recipients of donor funding, they are expected to work through national affiliates or counterparts to enable ‘locally-led’ change. Using prospective policy analysis and ethnographic evidence, this paper examines how donor-funded INGOs have influenced the restrictive policy environments for safe abortion and family planning in South Sudan and Malawi. While external actors themselves emphasise the technical nature of their involvement, the paper analyses them as instrumental political actors who strategically broker alliances and resources to shape policy, often working ‘behind the scenes’ to manage the challenging circumstances they operate under. Consequently, their agency and power are hidden through various practices of effacement or concealment. These practices may be necessary to rationalise the tensions inherent in delivering a global programme with the goal of inducing locally-led change in a highly controversial policy domain, but they also risk inciting suspicion and foreign-national tensions.

An Analysis of the Extent of Social Inclusion and Equity Consideration in Malawi's National HIV and AIDS Policy Review Process.

Background: Equity and social inclusion for vulnerable groups in policy development processes and resulting documents remain a challenge globally. Most often, the marginalization of vulnerable groups is overlooked in both the planning and practice of health service delivery. Such marginalization may occur because authorities deem the targeting of those who already have better access to healthcare a cheaper and easier way to achieve short-term health gains. The Government of Malawi wishes to achieve an equitable and inclusive HIV and AIDS Policy. The aim of this study is to assess the extent to which the Malawi Policy review process addressed regional and international health priorities of equity and social inclusion for vulnerable groups in the policy content and policy revision process. Methods: This research design comprised two phases. First, the content of the Malawi HIV and AIDS Policy was assessed using EquiFrame regarding its coverage of 21 Core Concepts of human rights and inclusion of 12 Vulnerable Groups. Second, the engagement of vulnerable groups in the policy process was assessed using the EquIPP matrix. For the latter, 10 interviews were conducted with a purposive sample of representatives of public sector, civil society organizations and development partners who participated in the policy revision process. Data was also collected from documented information of the policy processes. Results: Our analyses indicated that the Malawi HIV and AIDS Policy had a relatively high coverage of Core Concepts of human rights and Vulnerable Groups; although with some notable omissions. The analyses also found that reasonable steps were taken to engage and promote participation of vulnerable groups in the planning, development, implementation, monitoring and evaluation processes of the HIV and AIDS Policy, although again, with some notable exceptions. This is the first study to use both EquiFrame and EquIPP as complimentary tools to assess the content and process of policy. Conclusion: While the findings indicate inclusive processes, commitment to Core Concepts of human rights and inclusion of Vulnerable Groups in relation to the Malawi HIV and AIDS Policy, the results also point to areas in which social inclusion and equity could be further strengthened.

An Analysis of the Education Decentralization Policy in Malawi

This article makes an assessment on the implementation of the decentralization policy in education in Malawi in relation to the achievement of its objectives. To bring this into perspective, the socioeconomic, legal and political contexts, and the related policies, which have a bearing on education decentralization, have been analyzed. The decentralization of education in Malawi has to a great extent been unable to meet its objectives as a result of reluctance of the central ministry to cede more decision-making power to the local level, and due to insufficient human resources. The article concludes by giving policy recommendations.

Malaria research and its influence on anti-malarial drug policy in Malawi: a case study

BackgroundIn 1993, Malawi changed its first-line anti-malarial treatment for uncomplicated malaria from chloroquine to sulfadoxine-pyrimethamine (SP), and in 2007, it changed from SP to lumefantrine-artemether. The change in 1993 raised concerns about whether it had occurred timely and whether it had potentially led to early development of Plasmodium falciparum resistance to SP. This case study examined evidence from Malawi in order to assess if the policy changes were justifiable and supported by evidence.MethodsA systematic review of documents and published evidence between 1984 and 1993, when chloroquine was the first-line drug, and 1994 and 2007, when SP was the first-line drug, was conducted herein. The review was accompanied with key informant interviews.ResultsA total of 1287 publications related to malaria drug policy changes in sub-Saharan Africa were identified. Using the inclusion criteria, four articles from 1984 to 1993 and eight articles from 1994 to 2007 were reviewed. Between 1984 and 1993, three studies reported on chloroquine poor efficacy prompting policy change according to WHO’s recommendation. From 1994 to 2007, four studies conducted in the early years of policy change reported a high SP efficacy of above 80%, retaining it as a first-line drug. Unpublished sentinel site studies between 2005 and 2007 showed a reduced efficacy of SP, influencing policy change to lumefantrine-artemether. The views of key informants indicate that the switch from chloroquine to SP was justified based on local evidence despite unavailability of WHO’s policy recommendations, while the switch to lumefantrine-artemether was uncomplicated as the country was following the recommendations from WHO.ConclusionAmple evidence from Malawi influenced and justified the policy changes. Therefore, locally generated evidence is vital for decision making during policy change.

The Sensitivity and Specificity of Loop-Mediated Isothermal Amplification (LAMP) Assay for Tuberculosis Diagnosis in Adults with Chronic Cough in Malawi.

BackgroundCurrent tuberculosis diagnostics lack sensitivity, and are expensive. Highly accurate, rapid and cheaper diagnostic tests are required for point of care use in low resource settings with high HIV prevalence.ObjectiveTo investigate the sensitivity and specificity, and cost of loop-mediated isothermal amplification (LAMP) assay for tuberculosis diagnosis in adults with chronic cough compared to Xpert® MTB/RIF, fluorescence smear microscopy.MethodsBetween October 2013 and March 2014, consecutive adults at a primary care clinic were screened for cough, offered HIV testing and assessed for tuberculosis using LAMP, Xpert® MTB/RIF and fluorescence smear microscopy. Sensitivity and specificity (with culture as reference standard), and costs were estimated.ResultsOf 273 adults recruited, 44.3% (121/273) were HIV-positive and 19.4% (53/273) had bacteriogically confirmed tuberculosis. The sensitivity of LAMP compared to culture was 65.0% (95% CI: 48.3% to 79.4%) with 100% (95% CI: 98.0% to 100%) specificity. The sensitivity of Xpert® MTB/RIF (77.5%, 95% CI: 61.5% to 89.2%) was similar to that of LAMP, p = 0.132. The sensitivity of concentrated fluorescence smear microscopy with routine double reading (87.5%, 95% CI: 73.2% to 95.8%) was higher than that of LAMP, p = 0.020. All three tests had high specificity. The lowest cost per test of LAMP was at batch size of 14 samples (US$ 9.98); this was lower than Xpert® MTB/RIF (US$ 13.38) but higher than fluorescence smear microscopy (US$ 0.65).ConclusionThe sensitivity of LAMP was similar to Xpert® MTB/RIF but lower than fluorescence smear microscopy; all three tests had high specificity. These findings support the Malawi policy that recommends a combination of fluorescence smear microscopy and Xpert® MTB/RIF prioritised for people living with HIV, already found to be smear-negative, or being considered for retreatment of tuberculosis.

The new language of instruction policy in Malawi: A house standing on a shaky foundation

This research note is a critique of Malawi’s new language of instruction (LOI) policy. The new policy stipulates English as the medium of instruction from the first year (Standard 1) of primary school in a country where English is not the dominant language of household communication. The children are now expected to learn (and that includes learning to read and write) in English, a language they have not had any contact with before their first day at school. Moreover, some of the teachers themselves struggle to use English as a medium of instruction. The results of this policy are devastating, and the fact that the school system is poorly resourced in terms of infrastructure, materials and teachers is further thwarting positive learning outcomes. On the strength of ample empirical evidence which supports the mother tongue as the best medium of instruction in the initial phases of primary education, the author of this research note argues that the new language policy stands on a shaky foundation, and that it cannot serve as a strategy for eradicating low English proficiency among Malawian learners.