Functionality of technical working groups in enabling evidence-informed decision-making within Malawi's Ministry of Health: a cross-sectional qualitative study

Background: The roles and functionality of technical working groups (TWGs) in the health sectors vary across countries, still they aim to support government and ministries in formulating evidence-informed recommendations for policies and facilitate dialogue and alignment of activities among stakeholders within the health sector. Thus, TWGs have a role in enhancing the functionality and effectiveness of the health system structure. However, in Malawi, the functionality of TWGs and how they utilize research evidence to contribute to decision-making is not monitored. This study sought to understand the TWGs' performance and functionality in enabling evidence-informed decision-making (EIDM) in Malawi's health sector. Methods: A cross-sectional descriptive qualitative study. Data were collected through interviews, documents review and observation of three TWG meetings. Qualitative data were analysed using a thematic approach. The WHO-UNICEF Joint Reporting Form (JRF) was used to guide the assessment of TWG functionality. Results: TWG functionality varied in the Ministry of Health (MoH) in Malawi. The reasons for those perceived to be functioning well included meeting frequently, diverse representation of members, and that their recommendations to MoH were usually considered when decisions were made. For the TWGs that were perceived as not functioning well, the main reasons included lack of funding, periodic meetings and discussions that needed to provide clear decisions on the actions to be taken. In addition, evidence was recognized as important in decision-making, and research was valued by decision-makers within the MoH. However, some of the TWGs lacked reliable mechanisms for generating, accessing and synthesizing research. They also needed more capacity to review and use the research to inform their decisions. Conclusions: TWGs are highly valued and play a critical role in strengthening EIDM within the MoH. Our paper highlights the complexity and barriers of TWG functionality in supporting pathways for health policy-making in Malawi. These results have implications for EIDM in the health sector. This suggests that the MoH should actively develop reliable interventions and evidence tools, strengthen capacity-building and increase funding for EIDM

The health policy response to COVID-19 in Malawi

Malawi declared a state of national disaster due to the COVID-19 pandemic on 20th March 2020 and registered its first confirmed coronavirus case on the 2 April 2020. The aim of this paper was to document policy decisions made in response to the COVID-19 pandemic from January to August 2020. We reviewed policy documents from the Public Health Institute of Malawi, the Malawi Gazette, the Malawi Ministry of Health and Population and the University of Oxford Coronavirus Government Response Tracker. We found that the Malawi response to the COVID-19 pandemic was multisectoral and implemented through 15 focused working groups termed clusters. Each cluster was charged with providing policy direction in their own area of focus. All clusters then fed into one central committee for major decisions and reporting to head of state. Key policies identified during the review include international travel ban, school closures at all levels, cancellation of public events, decongesting workplaces and public transport, and mandatory face coverings and a testing policy covering symptomatic people. Supportive interventions included risk communication and community engagement in multiple languages and over a variety of mediums, efforts to improve access to water, sanitation, nutrition and unconditional social- cash transfers for poor urban and rural households

“Kuteteza”: A community-engaged COVID-19 Prevention and Protection Initiative in Southern Malawi

Background: The COVID-19 epidemic in Malawi involved almost 90,000 recorded cases and 2,638 deaths. Data suggest that the Malawi epidemic developed largely in urban settings, but the extent of rural spread – exposing older adults in particular – is unclear. This concern led us, to develop the ‘Kuteteza’ partnership project: a community-based Public Health intervention involving the shielding of older adults and additional strategies to mitigate COVID-19 impacts in rural Malawi. We now present the results of a realist project evaluation. Methods Clinicians, Public Health professionals, and researchers collaborated with government and district level staff in two Malawi districts. After engagement with local structures, willing older adults (>60 years) and their communities made arrangements for supported 'shielding'. Masks, handwashing stations, and soap were also provided, and government partnerships allowed additional support for vulnerable groups. Finally, context-responsive community engagement reinforced COVID-19 prevention during peak risk periods. Our realist evaluation included collation of anonymised descriptive data and qualitative structured observations and focus groups – involving community members and volunteers – in each setting. Results The project involved 25 villages. Multi-level stakeholder engagement was pivotal in developing and establishing the work, and strong District Health Office support was integral to implementation. Team members contributed to national meetings, aligning the project with national guidance and stakeholder actions. Established partnerships with relevant ministries resulted in the incorporation of shielding in the Malawi COVID-19 response plan. In Kuteteza villages, handwashing stations and soap were used, and there was awareness of COVID-19 prevention measures. Further experiences and evaluation results are presented, including learning points for future outbreak responses. Conclusions Through effective stakeholder engagement and contribution to national response strategy, the Kuteteza project raised awareness and supported populations at a critical time in the pandemic. These approaches can be incorporated in future epidemic and emergency responses

Two decades of malaria control in Malawi: Geostatistical Analysis of the changing malaria prevalence from 2000-2022

Background Malaria remains a public health problem in Malawi and has a serious socio-economic impact on the population. In the past two decades, available malaria control measures have been substantially scaled up, such as insecticide-treated bed nets, artemisinin-based combination therapies, and, more recently, the introduction of the malaria vaccine, the RTS,S/AS01. In this paper, we describe the epidemiology of malaria for the last two decades to understand the past transmission and set the scene for the elimination agenda. Methods A collation of parasite prevalence surveys conducted between the years 2000 and 2022 was done. A spatio-temporal geostatistical model was fitted to predict the yearly malaria risk for children aged 2–10 years (PfPR 2–10) at 1×1 km spatial resolutions. Parameter estimation was done using the Monte Carlo maximum likelihood methods. District level prevalence estimates adjusted for population are calculated for the years 2000 to 2022. Results A total of 2,595 sampled unique locations from 2000 to 2022 were identified through the data collation exercise. This represents 70,565 individuals that were sampled in the period. In general, the PfPR2_10 declined over the 22 years. The mean modeled national PfPR2_10 in 2000 was 43.93 % (95% CI:17.9 to 73.8%) and declined to 19.2% (95%CI 7.49 to 37.0%) in 2022. The smoothened estimates of PfPR2_10 indicate that malaria prevalence is very heterogeneous with hotspot areas concentrated on the southern shores of Lake Malawi and the country's central region. Conclusions The last two decades are associated with a decline in malaria prevalence, highly likely associated with the scale up of control interventions. The country should move towards targeted malaria control approaches informed by surveillance data

Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Global survey on COVID-19 self-testing using SARS-CoV-2 Ag-RDTs

This data is from the Global survey on COVID-19 self-testing using SARS-CoV-2 Ag-RDTs. It was part of the work on developing guidelines for using SARS-CoV-2 antigen-detection rapid diagnostic tests for COVID-19 self-testing. </p

Malaria Burden Stratification in Malawi- A report of a consultative workshop to inform the 2023-2030 Malawi Malaria Strategic Plan

Background: Malawi's National Malaria Control Programme (NMCP) is developing a new strategic plan for 2023-2030 to combat malaria and recognizes that a blanket approach to malaria interventions is no longer feasible. To inform this new strategy, the NMCP set up a task force comprising 18 members from various sectors, which convened a meeting to stratify the malaria burden in Malawi and recommend interventions for each stratum. Methods: The burden stratification workshop took place from November 29 to December 2, 2022, in Blantyre, Malawi, and collated essential data on malaria burden indicators, such as incidence, prevalence, and mortality. Workshop participants reviewed the malaria burden and intervention coverage data to describe the current status and identified the districts as a appropriate administrative level for stratification and action. Two scenarios were developed for the stratification, based on composites of three variables. Scenario 1 included incidence, prevalence, and under-five all-cause mortality, while Scenario 2 included total malaria cases, prevalence, and under-five all-cause mortality counts. The task force developed four burden strata (highest, high, moderate, and low) for each scenario, resulting in a final list of districts assigned to each stratum. Results: The task force concluded with 10 districts in the highest-burden stratum (Nkhotakota, Salima, Mchinji, Dowa, Ntchisi, Mwanza, Likoma, Lilongwe, Kasungu and Mangochi) 11 districts in the high burden stratum (Chitipa, Rumphi, Nkhata Bay, Dedza, Ntcheu, Neno, Thyolo, Nsanje, Zomba, Mzimba and Mulanje) and seven districts in the moderate burden stratum (Karonga, Chikwawa, Balaka, Machinga, Phalombe, Blantyre, and Chiradzulu). There were no districts in the low-burden stratum. Conclusion: The next steps for the NMCP are to review context-specific issues driving malaria transmission and recommend interventions for each stratum. Overall, this burden stratification workshop provides a critical foundation for developing a successful malaria strategic plan for Malawi

Two decades of malaria control in Malawi: Geostatistical Analysis of the changing malaria prevalence from 2000-2022 [version 2; peer review: 1 approved, 3 approved with reservations]

Background Malaria remains a public health problem in Malawi and has a serious socio-economic impact on the population. In the past two decades, available malaria control measures have been substantially scaled up, such as insecticide-treated bed nets, artemisinin-based combination therapies, and, more recently, the introduction of the malaria vaccine, the RTS,S/AS01. In this paper, we describe the epidemiology of malaria for the last two decades to understand the past transmission and set the scene for the elimination agenda. Methods A collation of parasite prevalence surveys conducted between the years 2000 and 2022 was done. A spatio-temporal geostatistical model was fitted to predict the yearly malaria risk for children aged 2–10 years (PfPR 2–10) at 1×1 km spatial resolutions. Parameter estimation was done using the Monte Carlo maximum likelihood method. District-level prevalence estimates adjusted for population are calculated for the years 2000 to 2022. Results A total of 2,595 sampled unique locations from 2000 to 2022 were identified through the data collation exercise. This represents 70,565 individuals that were sampled in the period. In general, the PfPR2_10 declined over the 22 years. The mean modelled national PfPR2_10 in 2000 was 43.93 % (95% CI:17.9 to 73.8%) and declined to 19.2% (95%CI 7.49 to 37.0%) in 2022. The smoothened estimates of PfPR2_10 indicate that malaria prevalence is very heterogeneous with hotspot areas concentrated on the southern shores of Lake Malawi and the country's central region. Conclusions The last two decades are associated with a decline in malaria prevalence, highly likely associated with the scale-up of control interventions. The country should move towards targeted malaria control approaches informed by surveillance data