The Impact of Structural Adjustment Policies (SAPs) on Manufacturing Growth in Malawi

Malawi has been implementing structural adjustment reforms since 1981 in search of a way to revive its declining economic growth triggered by the oil shocks and general world economic recession of the mid and late 1970’s. These structural reforms were meant to liberalise the economy, broaden and diversify the production base towards non-primary products and allocate resources more productively. Since the theory of Structural Adjustment Programmes (SAPs) has industrial growth, manufacturing in particular, at the centre of its argument for reviving economic growth, this paper primarily aims at establishing whether or not the claim that structural adjustments lead to manufacturing growth has been applicable to Malawi. By comparing the before (1960-1980) and after SAP (1981-1998) manufacturing industry’s growth levels, this study has found out that SAPs have assisted in improving manufacturing growth in Malawi though dismally. This dismal performance is evidenced by manufacturing growth volatilities and low average annual growth rates of 2.8% during the SAP implementation period compared to an average of 1.9% per annum before SAPs. However, despite this dismal growth of the manufacturing sector, there has been a production shift in the economy though not much from agriculture to industry as was the thrust of the structural adjustment. The manufacturing sector’s share of GDP has been rising over the SAP implementation period while that of agriculture especially the agricultural tradable sector has been declining giving hope for a structural move towards industry. This is evidenced by increased share of manufacturing in GDP from 16% before SAPs to 23% in the SAP period while decreasing the share of agriculture from 46% to 41% during similar periods. Despite this economy shift towards the industrial sector, however, GDP growth has been both volatile and declining averaging only 2.5% per annum during the entire SAP implementation period unlike the vibrant 6% per annum before SAPs. This only shows how much little effect the SAPs have had in reversing the declining economic growth trend of the Malawi economy with much of the growth still largely dependent on the agricultural sector. Malawi has continued to produce more and more volumes of agricultural produce for exports and yet due to declining terms of trade, the export values have been very small to assist in bringing the economy back on track. The study further reveals that despite the SAPs having assisted in improving manufacturing growth in Malawi, the sector’s growth has been characterised with incessant volatilities especially in the later part of the 1990’s when Malawi’s traditional donors were withholding economic reform funds due to the government’s failure to meet key economic stabilisation targets of low inflation, low interest rates and prudential spending. Malawi, being an agrarian economy dependent on external factors like climatic changes and international terms of trade, already faces volatilities in the availability of foreign exchange at various times of the year. This has in turn led to volatilities in the exchange rates, inflation levels, interest rates and GDP growth rates making sustainable manufacturing industry growth difficult. The study then, amongst others, recommends that Malawi needs to continue to fully implement economic reforms that are aimed at macroeconomic stability and promotion of industrial sector such as the formulation of an industrial policy separate from the Trade policy which can help to shape the course and pace of industrialisation in Malawi. Further, in order to draw meaningful government interventions and sound implementation of SAPs, it is important to conduct a micro-level study on manufacturing firms so as to find out how SAPs have so far impacted on manufacturing firm’s technical efficiency, capacity utilisation, allocative efficiency, market attaining distributive efficiency, and labour efficiency. Such a study would help in identifying if SAPs have been on the right track in helping to achieve their other main purpose of economic efficiency in the manufacturing sector.Manufacuring, growth, SAPs, economic reforms, malawi

Explaining high transport costs within Malawi - bad roads or lack of trucking competition ?

What are the main determinants of transport costs: network access or competition among transport providers? The focus in the transport sector has often been on improving the coverage of"hard"infrastructure, whereas in reality the cost of transporting goods is quite sensitive to the extent of competition among transport providers and scale economies in the freight transport industry, creating monopolistic behavior and circular causation between lower transport costs and greater trade and traffic. This paper contributes to the discussion on transport costs in Malawi, providing fresh empirical evidence based on a specially commissioned survey of transport providers and spatial analysis of the country’s infrastructure network. The main finding is that both infrastructure quality and market structure of the trucking industry are important contributors to regional differences in transport costs. The quality of the trunk road network is not a major constraint but differences in the quality of feeder roads connecting villages to the main road network have significant bearing on transport costs. And costs due to poor feeder roads are exacerbated by low volumes of trade between rural locations and market centers. With empty backhauls and journeys covering small distances, only a few transport service providers enter the market, charging disproportionately high prices to cover fixed costs and maximize markups.Transport Economics Policy&Planning,Rural Roads&Transport,Roads&Highways,Banks&Banking Reform,Rural Transport

Using prospective methods to identify fieldwork locations favourable to understand divergences in health care accessibility

Central to this article is the issue of choosing sites for where a fieldwork could provide a better understanding of divergences in health care accessibility. Access to health care is critical to good health, but inhabitants may experience barriers to health care limiting their ability to obtain the care they need. Most inhabitants of low-income countries need to walk long distances along meandering paths to get to health care services. Individuals in Malawi responded to a survey with a battery of questions on perceived difficulties in accessing health care services. Using both vertical and horizontal impedance, we modelled walking time between household locations for the individuals in our sample and the health care centres they were using. The digital elevation model and Tobler’s hiking function were used to represent vertical impedance, while OpenStreetMap integrated with land cover map were used to represent horizontal impedance. Combining measures of walking time and perceived accessibility in Malawi, we used spatial statistics and found spatial clusters with substantial discrepancies in health care accessibility, which represented fieldwork locations favourable for providing a better understanding of barriers to health access.publishedVersio

Using locational data in a novel mixed-methods sequence design: Identifying critical health care barriers for people with disabilities in Malawi

The primary aim of this study was to determine which health care barriers were most important for people with disabilities in Malawi. To accomplish this, we devised a sequential mixed-methods research design that integrated locational survey data and qualitative data from field studies. Our secondary aim was to evaluate this research design not only as a design-solution to our particular research objective, but as a tool with more general applicability within social sciences. Malawi has one of the most underserved health service populations in the world with chronic resource shortages and long travel distances where people with disabilities are at a particular disadvantage. Nevertheless, our results show that even in a resource scarce society such as Malawi it is the interpersonal relationships between patients and health service providers that has the largest impact on the perception of access among patients. Our results also suggest that the sequential mixed-methods design is effective in guiding researchers towards models with strong specifications.publishedVersio

Interactions among poverty, gender, and health systems affect women's participation in services to prevent HIV transmission from mother to child: A causal loop analysis

Retention in care remains an important issue for prevention of mother-to-child transmission (PMTCT) programs according to WHO guidelines, formerly called the ªOption B+º approach. The objective of this study was to examine how poverty, gender, and health system factors interact to influence women's participation in PMTCT services. We used qualitative research, literature, and hypothesized variable connections to diagram causes and effects in causal loop models. We found that many factors, including antiretroviral therapy (ART) use, service design and quality, stigma, disclosure, spouse/partner influence, decision- making autonomy, and knowledge about PMTCT, influence psychosocial health, which in turn affects women's participation in PMTCT services. Thus, interventions to improve psychosocial health need to address many factors to be successful. We also found that the design of PMTCT services, a modifiable factor, is important because it affects several other factors. We identified 66 feedback loops that may contribute to policy resistanceÐthat is, a policy's failure to have its intended effect. Our findings point to the need for a multipronged intervention to encourage women's continued participation in PMTCT services and for longitudinal research to quantify and test our causal loop model

Health system assessment for access to care after injury in low- or middle-income countries:A mixed methods study from Northern Malawi

Background: Injuries represent a vast and relatively neglected burden of disease affecting low- and middle-income countries (LMICs). While many health systems underperform in treating injured patients, most assessments have not considered the whole system. We integrated findings from 9 methods using a 3 delays approach (delays in seeking, reaching, or receiving care) to prioritise important trauma care health system barriers in Karonga, Northern Malawi, and exemplify a holistic health system assessment approach applicable in comparable settings.Methods and findings: To provide multiple perspectives on each conceptual delay and include data from community-based and facility-based sources, we used 9 methods to examine the injury care health system. The methods were (1) household survey; (2) verbal autopsy analysis; (3) community focus group discussions (FGDs); (4) community photovoice; (5) facility care-pathway process mapping and elucidation of barriers following injury; (6) facility healthcare worker survey; (7) facility assessment survey; (8) clinical vignettes for care process quality assessment of facility-based healthcare workers; and (9) geographic information system (GIS) analysis. Empirical data collection took place in Karonga, Northern Malawi, between July 2019 and February 2020. We used a convergent parallel study design concurrently conducting all data collection before subsequently integrating results for interpretation. For each delay, a matrix was created to juxtapose method-specific data relevant to each barrier identified as driving delays to injury care. Using a consensus approach, we graded the evidence from each method as to whether an identified barrier was important within the health system.We identified 26 barriers to access timely quality injury care evidenced by at least 3 of the 9 study methods. There were 10 barriers at delay 1, 6 at delay 2, and 10 at delay 3. We found that the barriers “cost,” “transport,” and “physical resources” had the most methods providing strong evidence they were important health system barriers within delays 1 (seeking care), 2 (reaching care), and 3 (receiving care), respectively. Facility process mapping provided evidence for the greatest number of barriers—25 of 26 within the integrated analysis. There were some barriers with notable divergent findings between the community- and facility-based methods, as well as among different community- and facility-based methods, which are discussed. The main limitation of our study is that the framework for grading evidence strength for important health system barriers across the 9 studies was done by author-derived consensus; other researchers might have created a different framework.Conclusions: By integrating 9 different methods, including qualitative, quantitative, community-, patient-, and healthcare worker-derived data sources, we gained a rich insight into the functioning of this health system’s ability to provide injury care. This approach allowed more holistic appraisal of this health system’s issues by establishing convergence of evidence across the diverse methods used that the barriers of cost, transport, and physical resources were the most important health system barriers driving delays to seeking, reaching, and receiving injury care, respectively. This offers direction and confidence, over and above that derived from single methodology studies, for prioritising barriers to address through health service development and policy

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Development and validation of quantitative PCR assays for HIV-associated cryptococcal meningitis in sub-Saharan Africa: a diagnostic accuracy study

Background: HIV-associated cryptococcal meningitis is the second leading cause of AIDS-related deaths, with a 10-week mortality rate of 25–30%. Fungal load assessed by colony-forming unit (CFU) counts is used as a prognostic marker and to monitor response to treatment in research studies. PCR-based assessment of fungal load could be quicker and less labour-intensive. We sought to design, optimise, and validate quantitative PCR (qPCR) assays for the detection, identification, and quantification of Cryptococcus infections in patients with cryptococcal meningitis in sub-Saharan Africa. Methods: We developed and validated species-specific qPCR assays based on DNA amplification of QSP1 (QSP1A specific to Cryptococcus neoformans, QSP1B/C specific to Cryptococcus deneoformans, and QSP1D specific to Cryptococcus gattii species) and a pan-Cryptococcus assay based on a multicopy 28S rRNA gene. This was a longitudinal study that validated the designed assays on cerebrospinal fluid (CSF) of 209 patients with cryptococcal meningitis at baseline (day 0) and during anti-fungal therapy (day 7 and day 14), from the AMBITION-cm trial in Botswana and Malawi (2018–21). Eligible patients were aged 18 years or older and presenting with a first case of cryptococcal meningitis. Findings: When compared with quantitative cryptococcal culture as the reference, the sensitivity of the 28S rRNA was 98·2% (95% CI 95·1–99·5) and of the QSP1 assay was 90·4% (85·2–94·0) in CSF at day 0. Quantification of the fungal load with QSP1 and 28S rRNA qPCR correlated with quantitative cryptococcal culture (R2=0·73 and R2=0·78, respectively). Both Botswana and Malawi had a predominant C neoformans prevalence of 67% (95% CI 55–75) and 68% (57–73), respectively, and lower C gattii rates of 21% (14–31) and 8% (4–14), respectively. We identified ten patients that, after 14 days of treatment, harboured viable but non-culturable yeasts based on QSP1 RNA detection (without any positive CFU in CSF culture). Interpretation: QSP1 and 28S rRNA assays are useful in identifying Cryptococcus species. qPCR results correlate well with baseline quantitative cryptococcal culture and show a similar decline in fungal load during induction therapy. These assays could be a faster alternative to quantitative cryptococcal culture to determine fungal load clearance. The clinical implications of the possible detection of viable but non-culturable cells in CSF during induction therapy remain unclear. Funding: European and Developing Countries Clinical Trials Partnership; Swedish International Development Cooperation Agency; Wellcome Trust/UK Medical Research Council/UKAID Joint Global Health Trials; and UK National Institute for Health Research

Incidence and predictors of hospital readmission in children presenting with severe anaemia in Uganda and Malawi: a secondary analysis of TRACT trial data

Background: Severe anaemia (haemoglobin < 6 g/dL) is a leading cause of recurrent hospitalisation in African children. We investigated predictors of readmission in children hospitalised with severe anaemia in the TRACT trial (ISRCTN84086586) in order to identify potential future interventions. Methods: Secondary analyses of the trial examined 3894 children from Uganda and Malawi surviving a hospital episode of severe anaemia. Predictors of all-cause readmission within 180 days of discharge were identified using multivariable regression with death as a competing risk. Groups of children with similar characteristics were identified using hierarchical clustering. Results: Of the 3894 survivors 682 (18%) were readmitted; 403 (10%) had ≥2 re-admissions over 180 days. Three main causes of readmission were identified: severe anaemia (n = 456), malaria (n = 252) and haemoglobinuria/dark urine syndrome (n = 165). Overall, factors increasing risk of readmission included HIV-infection (hazard ratio 2.48 (95% CI 1.63–3.78), p < 0.001); ≥2 hospital admissions in the preceding 12 months (1.44(1.19–1.74), p < 0.001); history of transfusion (1.48(1.13–1.93), p = 0.005); and missing ≥1 trial medication dose (proxy for care quality) (1.43 (1.21–1.69), p < 0.001). Children with uncomplicated severe anaemia (Hb 4-6 g/dL and no severity features), who never received a transfusion (per trial protocol) during the initial admission had a substantially lower risk of readmission (0.67(0.47–0.96), p = 0.04). Malaria (among children with no prior history of transfusion) (0.60(0.47–0.76), p < 0.001); younger-age (1.07 (1.03–1.10) per 1 year younger, p < 0.001) and known sickle cell disease (0.62(0.46–0.82), p = 0.001) also decreased risk of readmission. For anaemia re-admissions, gross splenomegaly and enlarged spleen increased risk by 1.73(1.23–2.44) and 1.46(1.18–1.82) respectively compared to no splenomegaly. Clustering identified four groups of children with readmission rates from 14 to 20%. The cluster with the highest readmission rate was characterised by very low haemoglobin (mean 3.6 g/dL). Sickle Cell Disease (SCD) predominated in two clusters associated with chronic repeated admissions or severe, acute presentations in largely undiagnosed SCD. The final cluster had high rates of malaria (78%), severity signs and very low platelet count, consistent with acute severe malaria. Conclusions: Younger age, HIV infection and history of previous hospital admissions predicted increased risk of readmission. However, no obvious clinical factors for intervention were identified. As missing medication doses was highly predictive, attention to care related factors may be important. Trial registration: ISRCTN ISRCTN84086586. Keywords: Severe anaemia, Readmissio