Projects In Malawi Research Articles

Technology adoption at scale: the success of USAID’s agriculture diversification project in Malawi

Abstract Dr. Fenton Sands, USAID’s new contract representative, faced some challenges. His office, USAID-Malawi over many years showed great commitment to the country, yet there seemed to be insufficient progress in poverty reduction, agricultural yield improvement, and smallholder farmer incomes. Now in 2017, the mission managed 25 different multimillion-dollar projects that touched on agriculture, the economy, resilience, gender, and nutrition, with little sustainability evident. Dr. Sands’ task was twofold, specifically, how to depart from past practice and actually achieve sustainable impact at scale here in Malawi, as he launched the new $60m Ag Div activity and more generally, if successful, how should USAID scale the success across the region. This case study provides unique insights into how Dr. Sands and his team jettisoned traditional development approaches and builds sustainable economic impact at scale through a novel private sector platform. USAID Malawi’s brave new venture successfully leveraged university research via the Soybean Innovation Lab to assure sound science and evidenced based decision making. Dr. Sand’s novel approach, presented here as a teaching case study, provides an explicit pathway for development officers, university researchers, program implementers, and leaders in the donor community to build sustainable impact in partnership with the private sector.

"Life mapping" exploring the lived experience of COVID-19 on access to HIV treatment and care in Malawi

Background The COVID-19 pandemic in Malawi exacerbated, existing public health challenges including access to HIV treatment and care services. “Life Mapping,” a component of the Citizen Science community-led project in Malawi, documented the lived experiences and perspectives of people living with HIV in the context of COVID-19. Methods Citizen Science Life Maps is a three-year qualitative, longitudinal project utilizing collaborative and participatory research methods through digital storytelling to document peoples’ daily lives. Twenty participants living with HIV were recruited between 2022 and 2023 in two central regional districts of Malawi and two urban areas. The participants were given mobile smart phones to document the impact of COVID-19 on HIV prevention and treatment services, HIV treatment literacy, mental health and the COVID -19 vaccine. Data was analyzed using a thematic analysis approach. Results Access to HIV prevention and treatment slowly recovered yet introducing multi-month anti- retroviral dispensing raised concerns. In the absence of mental health care services, participants were resourceful in seeking alternative ways to deal with mental health. However, state sponsored violence in relation to COVID-19 public health measures impacted negatively not only on mental well-being but also on HIV treatment adherence. Whilst most recognized the importance of the COVID-19 vaccine, especially for people living with HIV, myths, misinformation, and conspiracy theories around the vaccine persisted especially religious themed misinformation. Conclusions The relationship between misinformation and COVID-19 vaccine hesitancy is complex and medical and scientific approaches may not be sufficient to prevent misinformation. Fear and misinformation are likely attributed to global uncertainty during the pandemic and the speed at which vaccines were developed with minimal opportunity to prepare global communities.

Defining community-led monitoring and its role in programme-embedded learning: lessons from the Citizen Science Project in Malawi and South Africa.

Programme Science (PS) and community-led monitoring (CLM) intersect in unexpected and promising ways. This commentary examines a CLM initiative in Malawi and South Africa to highlight the crucial role of CLM in bolstering the PS framework. By leveraging data sources often overlooked by conventional research and evaluation approaches, CLM emerges as a pivotal element in enhancing programme effectiveness. This paper delineates the fundamental principles of CLM, presents programme outcomes derived from CLM methodologies and contextualizes these findings within the broader framework of PS. The Citizen Science Project implements CLM continuously at 33 health facilities: 14 in Malawi (eight in Kasungu District and six in Dedza District), and 19 in South Africa (all in the West Rand District), representing a total catchment area of 989,848 people. Monitoring indicators are developed in an iterative process with community groups. The indicators are unique to each country, but both focus on the uptake of health services (quantitative) and barriers to access (qualitative). Monthly clinic records surveys capture 34 indicators in Malawi and 20 in South Africa and are supplemented by qualitative interviews with care recipients and healthcare workers. Qualitative interviews provide additional granularity and help confirm and explain the more macro trends in service coverage as described in quantitative data. The resulting data analysis reveals key themes that help stakeholders and decision-makers to solve problems collaboratively. Noteworthy outcomes include a substantial increase in multi-month dispensing of antiretroviral therapy (ART) during COVID-19 (from 6% to 31%) with a subsequent recovery surpassing of HIV service benchmarks in Malawi post-pandemic. While quantifying direct impact remains challenging due to the project's design, CLM proves to be a robust methodology that generates credible data and produces impactful outcomes. Its potential extends beyond the health sector, empowering community leadership and fostering interventions aligned with community needs. As CLM continues to evolve, its integration into PS promises to improve relevance, quality and impact across diverse disciplines.

Developing and planning country-specific integrated knowledge translation strategies: experiences from the GELA project in Malawi, Nigeria, and South Africa.

The Global Evidence, Local Adaptation (GELA) project aims to maximise the impact of research on poverty-related diseases by increasing researchers' and decision-makers' capacity to use global research to develop locally relevant guidelines for newborn and child health in Malawi, Nigeria and South Africa. To facilitate ongoing collaboration with stakeholders, we adopted an Integrated Knowledge Translation (IKT) approach within GELA. Given limited research on IKT in African settings, we documented our team's IKT capacity and skills, and process and experiences with developing and implementing IKT in these countries. Six IKT champions and a coordinator formed the GELA IKT Working Group. We gathered data on our baseline IKT competencies and processes within GELA, and opportunities, challenges and lessons learned, from April 2022 to March 2023 (Year 1). Data was collected from five two-hour Working Group meetings (notes, presentation slides and video recordings); [2] process documents (flowcharts and templates); and [3] an open-ended questionnaire. Data was analysed using a thematic analysis approach. Three overarching themes were identified: [1] IKT approach applied within GELA [2], the capacity and motivations of IKT champions, and [3] the experiences with applying the GELA IKT approach in the three countries. IKT champions and country teams adopted an iterative approach to carry out a comprehensive mapping of stakeholders, determine stakeholders' level of interest in and influence on GELA using the Power-Interest Matrix, and identify realistic indicators for monitoring the country-specific strategies. IKT champions displayed varying capacities, strong motivation, and they engaged in skills development activities. Country teams leveraged existing relationships with their National Ministries of Health to drive responses and participation by other stakeholders, and adopted variable communication modes (e.g. email, phone calls, social media) for optimal engagement. Flexibility in managing competing interests and priorities ensured optimal participation by stakeholders, although the time and resources required by IKT champions were frequently underestimated. The intentional, systematic, and contextualized IKT approach carried out in the three African countries within GELA, provides important insights for enhancing the implementation, feasibility and effectiveness of other IKT initiatives in Africa and similar low- and middle-income country (LMIC) settings.

The SCORE project: A COVID-19 remote triage, surveillance, and community engagement project in Malawi

The SCORE project: A COVID-19 remote triage, surveillance, and community engagement project in Malawi

An Information-Theoretic Approach to Reconciling Historical Climate Observations and Impacts on Agriculture

Abstract Decision-makers in climate risk management often face problems of how to reconcile diverse and conflicting sources of information about weather and its impact on human activity, such as when they are determining a quantitative threshold for when to act on satellite data. For this class of problems, it is important to quantitatively assess how severe a year was relative to other years, accounting for both the level of uncertainty among weather indicators and those indicators’ relationship to humanitarian consequences. We frame this assessment as the task of constructing a probability distribution for the relative severity of each year, incorporating both observational data—such as satellite measurements—and prior information on human impact—such as farmers’ reports—the latter of which may be incompletely measured or partially ordered. We present a simple, extensible statistical method to fit a probability distribution of relative severity to any ordinal data, using the principle of maximum entropy. We demonstrate the utility of the method through application to a weather index insurance project in Malawi, in which the model allows us to quantify the likelihood that satellites would correctly identify damaging drought events as reported by farmers, while accounting for uncertainty both within a set of commonly used satellite indicators and between those indicators and farmers’ ranking of the worst drought years. This approach has immediate utility in the design of weather-index insurance schemes and forecast-based action programs, such as assessing their degree of basis risk or determining the probable needs for postseason food assistance. Significance Statement We present a novel statistical method for synthesizing many indicators of drought into a probability distribution of how bad an agricultural season was likely to have been. This is important because climate risk analysts face problems of how to reconcile diverse and conflicting sources of information about drought—such as determining a quantitative threshold for when to act on satellite data, having only limited, ordinal information on past droughts to validate it. Our new method allows us to construct a probability distribution for the relative severity of a year, incorporating both kinds of data. This allows us to quantify the likelihood that satellites would have missed major humanitarian droughts due to, for example, mistimed observations or unobserved heterogeneity in impacts.

Chest radiography in children aged 2\u201359\u2009months enrolled in the Innovative Treatments in Pneumonia (ITIP) project in Lilongwe Malawi: a secondary analysis

BackgroundPneumonia is the leading infectious cause of death in children aged under 5 years in low- and middle-income countries (LMICs). World Health Organization (WHO) pneumonia diagnosis guidelines rely on non-specific clinical features. We explore chest radiography (CXR) findings among select children in the Innovative Treatments in Pneumonia (ITIP) project in Malawi in relation to clinical outcomes.MethodsWhen clinically indicated, CXRs were obtained from ITIP-enrolled children aged 2 to 59 months with community-acquired pneumonia hospitalized with treatment failure or relapse. ITIP1 (fast-breathing pneumonia) and ITIP2 (chest-indrawing pneumonia) trials enrolled children with non-severe pneumonia while ITIP3 enrolled children excluded from ITIP1 and ITIP2 with severe pneumonia and/or selected comorbidities. A panel of trained pediatricians classified the CXRs using the standardized WHO CXR research methodology. We analyzed the relationship between CXR classifications, enrollee characteristics, and outcomes.ResultsBetween March 2016 and June 2018, of 114 CXRs obtained, 83 met analysis criteria with 62.7% (52/83) classified as having significant pathology per WHO standardized interpretation. ITIP3 (92.3%; 12/13) children had a higher proportion of CXRs with significant pathology compared to ITIP1 (57.1%, 12/21) and ITIP2 (57.1%, 28/49) (p-value = 0.008). The predominant pathological CXR reading was “other infiltrates only” in ITIP1 (83.3%, 10/12) and ITIP2 (71.4%, 20/28), while in ITIP3 it was “primary endpoint pneumonia”(66.7%, 8/12,; p-value = 0.008). The percent of CXRs with significant pathology among children clinically cured (60.6%, 40/66) vs those not clinically cured (70.6%, 12/17) at Day 14 was not significantly different (p-value = 0.58).ConclusionsIn this secondary analysis we observed that ITIP3 children with severe pneumonia and/or selected comorbidities had a higher frequency of CXRs with significant pathology, although these radiographic findings had limited relationship to Day 14 outcomes. The proportion of CXRs with “primary endpoint pneumonia” was low. These findings add to existing data that additional diagnostics and prognostics are important for improving the care of children with pneumonia in LMICs.Trial registrationITIP1, ITIP2, and ITIP3 were registered with ClinicalTrials.gov (NCT02760420, NCT02678195, and NCT02960919, respectively).

Towards a Framework on the Use of Infomediaries in Maternal mHealth in Rural Malawi

Aim/Purpose: The aim of the study is to explore factors that affect how healthcare clients in rural areas use infomediaries in maternal mHealth interventions. The study focuses on maternal healthcare clients who do not own mobile phones but use the mHealth intervention. Background: Maternal mHealth interventions in poor-resource settings are bedevilled by inequalities in mobile phone ownership. Clients who do not own mobile phones risk being excluded from benefiting from the interventions. Some maternal mHealth providers facilitate the access of mobile phones for those who do not own them using “infomediaries”. Infomediaries, in this case, refer to individuals who have custody of mobile phones that other potential beneficiaries may use. However, the use of infomediaries to offer access to the “have nots” may be influenced by a number of factors. Methodology: The study uses a case of a maternal mHealth intervention project in Malawi, as well as a qualitative research method and interpretive paradigm. Data was collected using secondary data from the implementing agency, semi-structured interviews, and focus group discussions. Empirical data was collected from maternal healthcare clients who do not own mobile phones and infomediaries. Data were analysed inductively using thematic analysis. Contribution: The study proposed a theoretical framework for studying infomediaries in ICT4D. The study may inform mHealth designers, implementers, and policymakers on how infomediaries could be implemented in a rural setting. Consequently, understanding the factors that affect the use of infomediaries may inform mHealth intervention implementers on how they could overcome the challenges by implementing mHealth interventions that reduce the challenges on the mHealth infomediaries side, and the maternal healthcare clients’ side. Findings: Characteristics of the maternal healthcare client, characteristics of the mHealth infomediary, perceived value of mHealth intervention, and socio-environmental factors affect maternal healthcare clients’ use of mHealth infomediaries. Recommendations for Practitioners: Implementers of interventions ought to manage the use of infomediaries to avoid volunteer fatigue and infomediaries who may not be compatible with the potential users of the intervention. Implementers could leverage traditional systems of identifying and using infomediaries instead of reinventing the wheel. Recommendation for Researchers: This research adopted a single case study to develop the theoretical framework for mHealth infomediary use. We recommend future studies are conducted in order to test and develop this framework further, not only in ICT4D, but also in other areas of application. Impact on Society: People still lack access. The lack of ownership of technology may still exclude them from participating in an information society. The use of infomediaries may help to provide access to technologies to those who do not have them thereby bridging the digital divide gap. Future Research: We propose herein that traditional systems may offer a good starting point for designing a system that would work for communities. We, therefore, recommend that future research may explore these possibilities.

Implementation and operational feasibility of SAMBA I HIV-1 semi-quantitative viral load testing at the point-of-care in rural settings in Malawi and Uganda.

We monitored a large-scale implementation of the Simple Amplification-Based Assay semi-quantitative viral load test for HIV-1 version I (SAMBA I Viral Load=SAMBA I VL) within Médecins Sans Frontières' HIV programmes in Malawi and Uganda, to assess its performance and operational feasibility. Descriptive analysis of routine programme data between August 2013 and December 2016. The dataset included samples collected for VL monitoring and tested using SAMBA I VL in five HIV clinics in Malawi (four peripheral health centres and one district hospital), and one HIV clinic in a regional referral hospital in Uganda. SAMBA I VL was used for VL testing in patients who had been receiving ART for between 6months and ten years, to determine whether plasma VL was above or below 1000 copies/mL of HIV-1, reflecting ART failure or efficacy. Randomly selected samples were quantified with commercial VL assays. SAMBA I instruments and test performance, site throughput, and delays in communicating results to clinicians and patients were monitored. Between August 2013 and December 2016 a total of 60889 patient samples were analysed with SAMBA I VL. Overall, 0.23% of initial SAMBA I VL results were invalid; this was reduced to 0.04% after repeating the test once. Global test failure, including instrument failure, was 1.34%. Concordance with reference quantitative testing of VL was 2620/2727, 96.0% (1338/1382, 96.8% in Malawi; 1282/1345, 95.3% in Uganda). For Chiradzulu peripheral health centres and Arua Hospital HIV clinic, where testing was performed on-site, same-day results were communicated to clinicians for between 91% and 97% of samples. Same-day clinical review was obtained for 84.7% across the whole set of samples tested. SAMBA I VL testing is feasible for monitoring cohorts of 1000 to 5000 ART-experienced patients. Same-day results can be used to inform rapid clinical decision-making at rural and remote health facilities, potentially reducing time available for development of resistance and conceivably helping to reduce morbidity and mortality.

Retention-in-care in the PMTCT cascade: definitions matter! Analyses from the INSPIRE projects in Malawi, Nigeria and Zimbabwe.

IntroductionDefinitions of retention‐in‐care in Prevention of Mother‐to‐Child Transmission of HIV (PMTCT) vary substantially between studies and programmes. Some definitions are based on visits missed/made, others on a minimum total number of visits, or attendance at a final clinic visit at a specific time. An agreed definition could contribute to developing evidence‐based interventions for improving retention‐in‐care. In this paper, we estimated retention‐in‐care rates according to different definitions, and we quantified and visualized the degree of agreement between definitions.MethodsWe calculated retention in care rates using nine definitions in the six INSPIRE PMTCT intervention studies, conducted in three sub‐Saharan African countries between 2013 and 2017. With data from one of the studies (E4E), we estimated the agreement between definitions using Gwet’s agreement coefficient (AC1) and concordance. We calculated positive predictive values (PPV) and negative predictive values (NPV) for all definitions considering successively each definition as the reference standard. Finally, we used a Multiple Correspondence Analysis (MCA) to examine clustering of the way different definitions handle retention‐in‐care.ResultsRetention‐in‐care rates among 5107 women ranged from 30% to 76% in the complete dataset with Gwet’s AC1 being 0.56 [0.53; 0.59] indicating a moderate agreement between all definitions together. Two pairs of definitions with high inner concordance and agreement had either very high PPV or very high NPV, and appeared distinct from the other five definitions on the MCA figures. These pairs of definitions were also the ones resulting in the lowest and highest estimates of retention‐in‐care. The simplest definition, that only required a final clinic visit to classify women as retained in care, and classified 55% of women as retained in care, had a PPV ranging from 0.7 to 1 and a NPV ranging from 0.69 to 0.98 when excluding the two pairs afore‐mentioned; it resulted in a moderate to substantial agreement and a 70% to 90% concordance with all other definitions.ConclusionsOur study highlights the variability of definitions in estimating retention‐in‐care. Some definitions are very stringent which may be required in some instances. A simple indicator such as attendance at a single time point may be sufficient for programme planning and evaluation.

Effectiveness of the lead farmer approach in agricultural extension service provision: Nationally representative panel data analysis in Malawi

The lead farmer (LF) approach has been implemented and heavily promoted nationwide in Malawi since 2009 to support government extension workers and accelerate technology dissemination. Earlier reports have shown that donor-funded projects in Malawi widely adopted the LF approach, indicating positive roles and contributions of LFs. However, national data show persistently low rates of adoption of management practices being promoted by the LFs, prompting this study to look closely at the nationwide implementation and effectiveness of the LF approach. Specifically, we model the effects of farmers’ interaction with and exposure to LFs, and farmers’ access to LFs’ advice, on farmers’ awareness and adoption of several promoted technologies and management practices. We use data from 531 randomly selected LFs linked to panel data from 2,880 farming households and, using correlated random effects, model the effectiveness of the LF approach on technology awareness and adoption. This modeling is complemented by 52 focus group discussions and in-depth interviews with agricultural extension development officers (AEDOs) and service providers.Our results point to two major conclusions. First, LFs support and assist AEDOs in their work, especially in organizing community meetings and farm demonstrations, and are also an important bridge between farmers and AEDOs. But LFs complement AEDOs’ work rather than substitute for it. In communities without strong AEDOs and community leaders to work with and monitor them, LFs were not active or performed at a substandard level. Second, results show limited coverage and weak implementation and effectiveness of the LF approach at the national level. Only 13 percent of farmers reported receiving agricultural advice from an LF in the last two years, and only 20 percent reported having interacted with an LF. Our econometric models also consistently show neither the farmers’ exposure or interaction with LFs nor farmers’ access to LFs’ advice had an effect on awareness and adoption of the major agricultural management practices being promoted. When heterogeneity and types of LFs are unpacked, results show that quality of LFs, adoption behavior of LFs, and regular training of LFs have strong and consistent effect on the awareness and adoption of most agricultural practices promoted.

P8 Successful Reintroduction of Landrace Orange Maize in Rural Malawi is not Dependent on Understanding Nutritional Advantages

<h3>Background</h3> Orange maize, rich in carotenoids, is a possible sustainable solution for combating Vitamin A deficiency and reducing dependence on fortification. The ProFarmer project in Malawi has successfully re-introduced landrace orange maize (MW5021) to replace or complement white hybrid varieties in over 2000 farms. <h3>Objectives</h3> This study was designed to determine the acceptability of foods made with orange maize in children and to assess the knowledge, attitudes and behaviors (KAB) of women in farming families that currently grow orange maize. <h3>Study Design, Setting, Participants</h3> Organoleptic evaluation of white and orange maize food products was carried out in school age children (n=160) of ProFarmer families living in the Dedza and Thyolo Districts. Additionally, a cross sectional study was completed in female household members (n=336) living on farms that produce orange maize. Participants were interviewed regarding reintroduction of orange maize and diet quality was assessed. <h3>Measurable Outcome/Analysis</h3> Acceptability of orange maize food products was determined using a 7-point hedonic scale. Women's responses to questionnaires were used to determine nutritional knowledge regarding orange maize. A Minimum Dietary Diversity questionnaire (MDD-W) evaluated diet adequacy. Independent t tests and Chi square tests were performed where appropriate. <h3>Results</h3> Organoleptic testing of orange maize porridges by children indicated high levels of acceptance. Survey results showed positive attitudes towards the orange maize with 75-85% of households consuming the product. However, only 32% of the women understood its nutritional benefits. Dietary Diversity scores, a proxy for nutrient adequacy, were low with only 34% of women consuming a sufficiently diverse diet. <h3>Conclusions</h3> Despite low levels of nutritional knowledge, landrace orange maize is well accepted by both children and adults in rural Malawi and is an option for increasing dietary sources of provitamin A. Nutrition education emphasizing the advantages of eating carotenoid-rich foods and expanding diet diversity are recommended.

From complexity to simplicity – how chasing success stories affects gendered NGO practices

ABSTRACT This article argues that the “production” of success has become crucial for NGOs to manage their individual brand and secure funding within the contemporary global health and development landscape. Based on an empirical study of a Save the Children project in Malawi aimed at reducing teenage pregnancies by retaining girls in school, it illustrates how gender has become de-politicised within global health. Furthermore, it also shows how their changing role and growing pressure on NGOs to achieve impact and success stories affect NGOs’ ability to represent and understand the lives of women and girls.

Sustainable value for money – a glimpse of the holy grail?

ABSTRACT This practical note presents striking findings from a research project in Malawi, comparing the cost effectiveness of a traditional project approach with a church and community mobilisation approach (CCM). The research found that CCM had the same level of positive impact on quality of life but at 4% of the cost. It also found that CCM communities were almost four times more confident in solving problems themselves, indicating a much greater likelihood of sustainability. To realise the potential advantages of faith in development means funders and faith-based organisations have to mobilise local faith communities. CCM is a challenging but cost-effective alternative to the NGO-project approach.

Enhancing Pharmacovigilance in Sub-Saharan Africa Through Training and Mentoring: A GSK Pilot Initiative in Malawi.

IntroductionPharmacovigilance (PV) systems to monitor drug and vaccine safety are often inadequate in sub-Saharan Africa. In Malawi, a PV enhancement initiative was introduced to address major barriers to PV.ObjectiveThe objective of this initiative was to improve reporting of adverse events (AEs) by strengthening passive safety surveillance via PV training and mentoring of local PV stakeholders and healthcare providers (HCPs) at their own healthcare facilities (HCFs).MethodsAn 18-month PV training and mentoring programme was implemented in collaboration with national stakeholders, and in partnership with the Ministry of Health, GSK and PATH. Two-day training was provided to Expanded Programme on Immunisation coordinators, identified as responsible for AE reporting, and four National Regulatory Authority representatives. Abridged PV training and mentoring were provided regularly to HCPs. Support was given in upgrading the national PV system. Key performance indicators included the number of AEs reported, transmission of AE forms, completeness of reports, serious AEs reported and timeliness of recording into VigiFlow.ResultsIn 18 months, 443 HCPs at 61 HCFs were trained. The number of reported AEs increased from 22 (January 2000 to October 2016) to 228 (November 2016 to May 2018), enabling Malawi to become a member of the World Health Organization Programme for International Drug Monitoring. Most (98%) AE report forms contained mandatory information on reporter, event, patient and product, but under 1% were transmitted to the national PV office within 48 h.ConclusionRegular PV training and mentoring of HCPs were effective in enhancing passive safety surveillance in Malawi, but the transmission of reports to the national PV centre requires further improvement.

Sustainability evaluation of community-based, solar photovoltaic projects in Malawi

BackgroundA novel project sustainability framework is used to evaluate 65 off-grid solar photovoltaic (PV) energy system projects in Malawi. This study addresses PV projects serving rural public facilities, a solution known to have had historical issues with poor sustainability. A recent countrywide program targeting such facilities was evaluated against existing projects to determine whether this latest iteration offered better results.MethodSustainability is defined at the project-level with metrics justified under the main themes of technical, economic, social, and organizational. Data captured for each project is based on a custom survey and interview of key stakeholders. Projects are grouped according to age, project implementer, income level, and PV system size to compare relative results.ResultsThe sustainability outlook for each project is evaluated. We find sustainability for most projects to be low. Social sustainability was weak with many projects due to low local community stakeholder engagement in terms of numbers of stakeholders, meeting frequency, and community contributions. Organizational challenges included a lack of key management positions in place and extremely limited training provisions. Furthermore, the evaluation highlights the economic health of the system to be key to sustainability, with the “healthiest” projects affording only 37% of expected operations and maintenance costs. Relative to expected demand, systems were found to be undersized for both panels (53% of required) and batteries (57%). Users reported achieving only 60% of their desired consumption. Poor sizing standards related to the lack of load profiles for first-time electricity users as well as poor quality components reduced the overall technical sustainability.ConclusionRural public facilities with solar PV in Malawi are not well served by isolated community management. Improved sustainability requires the establishment of a robust financial framework prior to project development that includes formal local government support. This paper discusses ideal management frameworks and their ultimate implications for project developers, policy makers, and the research community.

Assessing the role of stakeholder platforms as drivers of resilient communities: the case of Malawi

ABSTRACT Purpose: Climate-related shocks increasingly stress food systems, making resilience-building among rural communities crucial to food security. The Strengthening Agricultural and Nutrition Extension (SANE) project in Malawi strengthens stakeholder platforms to improve farmers’ capacities towards climate change, food security, and community resilience. This paper provides empirical evidence for SANE’s Theory of Change. Design/methodology/approach: A mixed-methods approach was used to evaluate how strengthening stakeholder platforms affects farmers’ voice and community resilience. Quantitative and qualitative data, captured via structured interviews of stakeholder platform members in SANE and non-SANE districts, was used to track changes over time and analyze how differences in platforms’ functionality relate to farmers’ voice, responsiveness to farmers’ needs, and more resilient communities. Findings: Results show tangible improvements in platform functionality in SANE districts over time as well as substantial differences when comparing the performance of these stakeholder platforms in SANE and non-SANE districts. The qualitative evidence also illustrates how stronger platforms help farmers’ advocacy and ability to deal with climate-related shocks. Practical implications: Stronger platforms not only facilitate better extension service delivery, but also reduce the need for external support as communities work to address their own problems, itself a form of resilience. Theoretical implications: The adoption of bottom-up and participatory extension approaches where farmers become active drivers of extension curricula can be instrumental in improving food security and resilience to shocks. Originality/value: This study shows that efforts directed at the extension system are part of the solution, and system-focused research can provide unique insights.

Sustainability of 'mHealth' interventions in sub- Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi.

The global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa. Between January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers. Overall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management. Future developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.

Access to local books: the effects of Read Malawi from a children's rights perspective

AbstractChildren in low‐income, postcolonial countries such as Malawi have few opportunities with quality reading materials that promote independence as readers. In this study, we argue that access to locally produced text relevant to linguistic and cultural contexts is a fundamental human right for children throughout the world. Situating this study within the intersection of research on children's rights and complementary reading materials, we analyse data from a project in Malawi. We consider the ways in which a respect for children's educational rights – specifically, their rights to access information via children's books – can help them develop their biliteracy. Additionally, we examine how the Read Malawi program contributes to Malawian children's literacy development in both national and official languages. Our findings suggest not only a humanistic need for quality complementary books, but also the empirical justification for books in the hands of children; in particular, an interconnected relationship between borrowing books from school and engagement with Read Malawi was found, especially when we explore children's English proficiency. Through Read Malawi, this study exemplifies what a quality literacy intervention can do in supporting children's Chichewa and English proficiency and improving their rights to quality education.

HIV self-testing: breaking the barriers to uptake of testing amongmen and adolescents in sub-Saharan Africa, experiences from STAR demonstration projects in Malawi, Zambia and Zimbabwe.

IntroductionSocial, structural and systems barriers inhibit uptake of HIV testing. HIV self‐testing (HIVST) has shown promising uptake by otherwise underserved priority groups including men, young people and first‐time testers. Here, we use characteristics of HIVST kit recipients to investigate delivery to these priority groups during HIVST scale‐up in three African countries.MethodsKit distributors collected individual‐level age, sex and testing history from all clients. These data were aggregated and analysed by country (Malawi, Zambia and Zimbabwe) for five distribution models: local community‐based distributor (CBD: door‐to‐door, street and local venues), workplace distribution (WD), integration into HIV testing services (IHTS), or public health facilities (IPHF) and during demand creation for voluntary male medical circumcision (VMMC). Used kits were collected and re‐read from CBD and IHTS recipients.ResultsBetween May 2015 and July 2017, 628,705 HIVST kits were distributed in Malawi (172,830), Zambia (190,787) and Zimbabwe (265,091). Community‐based models, the first to be established, accounted for 519,658 (82.7%) of kits distributed, with 275,419 (53.0%) used kits returned. Subsequent model diversification delivered 54,453 (8.7%) test‐kits through IHTS, 23,561 (3.7%) through VMMC, 21,183 (3.4%) through IPHF and 9850 (1.7%) through WD. Men took 294,508 (48.2%) kits, and 263,073 (43.1%) went to young people (16 to 24 years). A higher proportion of male self‐testers (65,577; 22.3%) were first‐time testers than women (54,096; 17.1%) with this apparent in Zimbabwe (16.2% vs. 11.4%), Zambia (25.4% vs. 17.7%) and Malawi (27.9% vs. 25.9%). The highest proportions of first‐time testers were in young (16 to 24 years) and older (>50 years) men (country‐ranges: 18.7% to 35.9% and 13.8% to 26.8% respectively). Most IHTS clients opted for HIVST in preference to standard HTS in each of 12 delivery sites, with those selecting HIVST having lower HIV prevalence, potentially due to self‐selection.Conclusions HIVST delivered at scale using several different models reached a high proportion of men, young people and first‐time testers in Malawi, Zambia and Zimbabwe, some of whom may not have tested otherwise. As men and young people have limited uptake under standard facility‐and community‐based HIV testing, innovative male‐ and youth‐sensitive approaches like HIVST may be essential to reaching UNAIDS fast‐track targets for 2020.