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Twelve percent of the Malawian population is HIV infected. Eighteen percent of sexual encounters are casual. A condom is used a third of the time. To analyze the Malawian epidemic, a choice-theoretic general equilibrium search model is constructed. In the developed framework, people select between different sexual practices while knowing the inherent risk. The calibrated model is used to study several policy interventions, namely, ART, circumcision, better condoms, and the treatment of other STDs. The efficacy of public policy depends upon the induced behavioral changes and equilibrium effects. The framework complements the insights from epidemiological studies and small-scale field experiments.

Background Chronic diseases such as sickle cell anaemia (SCA) often lead to catastrophic health expenditures, especially in malaria-endemic regions. There is limited evidence on the economic burden faced by households with children suffering from SCA. This study aimed to assess the household economic burden of SCA and the incidence of catastrophic health expenditures in Uganda and Malawi. Methods This prospective cohort study was nested in a clinical trial comparing malaria chemoprevention regimes: weekly dihydroartemisinin-piperaquine versus monthly sulfadoxine-pyrimethamine for children aged 6 months to 15 years in Uganda and Malawi. The economic burden was evaluated using the cost of illness approach by measuring and valuing direct and indirect costs. Quantile regression models were employed to identify factors associated with these costs. Findings The study included 723 children with an SCA (437 in Uganda and 286 in Malawi) with mean ages of 7.3 years (SD 3.9) and 8.0 years (SD 4.1), respectively. The annual median costs per household were $638.8 (IQR: $227–$2,693) in Uganda and $387.3 (IQR: $203–$694) in Malawi. The main contributors to the economic burden were direct costs in Uganda and indirect costs in Malawi. Factors such as malaria episodes, hospitalisation, hydroxyurea use, household wealth, children’s age, and gender significantly influenced direct and indirect costs. The concentration indices (CI) revealed a pro-rich distribution with poorer households incurring higher direct costs in both Malawi, CI=-0.12 (SE = 0.00, P  < 0.00), and Uganda, CI= -0.23 (SE = 0.02, P  < 0.000). Most households in both countries experienced catastrophic health expenditures, with the highest incidence in the poorest quartile. Conclusion Households with children with SCA incur high expenditures, which are catastrophic for a substantial proportion of them. Malaria episodes, hospitalisation and wealth status significantly increase the economic burden on households. Targeted interventions are needed to alleviate this financial strain, reduce disparities and improve outcomes for vulnerable households. Enhancing access to improved treatment strategies, such as effective malaria prevention measures and the consistent availability of hydroxyurea, could help reduce the number of sick episodes and, consequently, the economic burden on households and patients.

As countries pursue sustainable development across sectors as diverse as health, agriculture, and infrastructure, sectoral policies interact, generating synergies that alter their effectiveness. Identifying those synergies ex ante facilitates the harmonization of policies and provides an important lever to achieve the sustainable development goals (SDGs) of the United Nations 2030 Agenda. However, identifying and quantifying these synergetic interactions are infeasible with traditional approaches to policy analysis. In this paper, we present a method for identifying synergies and assessing them quantitatively. We also introduce a typology of 5 classes of synergies that enables an understanding of their causal structures. We operationalize the typology in pilot studies of SDG strategies undertaken in Senegal, Côte d’Ivoire, and Malawi. In the pilots, the integrated SDG (iSDG) model was used to simulate the effects of policies over the SDG time horizon and to assess the contributions of synergies. Synergy contributions to overall SDG performance were 7% for Côte d’Ivoire, 0.7% for Malawi, and 2% for Senegal. We estimate the value of these contributions to be 3% of gross domestic product (GDP) for Côte d’Ivoire, 0.4% for Malawi, and 0.7% for Senegal. We conclude that enhanced understanding of synergies in sustainable development planning can contribute to progress on the SDGs—and free substantial amounts of resources.

We use nationally representative household-level panel survey data in two neighboring countries in Southern Africa—Zambia and Malawi—to characterize the current status of rural land rental market participation by smallholder farmers, and their subsequent welfare impacts. Rural rental market participation is much higher in densely-populated Malawi than in lower-density Zambia, reflecting the role of land scarcity in driving rental market development. Consistent with previous literature, we find evidence that rental markets contribute to efficiency gains within the smallholder sector by facilitating the transfer of land from less-able to more-able producers, on average, in both countries. Furthermore, we find that rental markets serve to re-allocate land from relatively land-rich to landpoor households. We examine the impacts of participation on a number of welfare outcomes and find evidence for generally positive returns to renting in land in both countries, on average. However, our analysis also indicates that the returns to renting in land vary strongly with scale of production: tenants who produce more have larger returns to renting in, and many of the smaller producers who rent in do so at an economic loss. The impacts of renting out (i.e., participating in markets as landlords) are decidedly more mixed, with overall negative returns to landlords in Malawi and negligible returns to landlords in Zambia. The findings in this article highlight the need for researchers and policymakers in sub-Saharan Africa to stay attuned to how land rental market participation and its impacts evolve in the near future.

Abstract Non-communicable diseases like hypertension are increasingly common among individuals living with HIV in low-resource settings. The prevalence of hypertension among people with HIV in Malawi, e.g. has been estimated to be as high as 46%. However, few qualitative studies have explored the patient experience with comorbid chronic disease. Our study aimed to address this gap by using the health belief model (HBM) to examine how comparative perceptions of illness and treatment among participants with both HIV and hypertension may affect medication adherence behaviours. We conducted semi-structured interviews with 75 adults with HIV and hypertension at an urban clinic in Lilongwe, Malawi. Questions addressed participants’ experiences with antiretroviral and antihypertensive medications, as well as their perspectives on HIV and hypertension as illnesses. Interviews were performed in Chichewa, transcribed, translated into English and analysed using ATLAS.ti. Deductive codes were drawn from the HBM and interview guide, with inductive codes added as they emerged from the data. Self-reported medication adherence was much poorer for hypertension than HIV, but participants saw hypertension as a disease at least as concerning as HIV—primarily due to the perceived severity of hypertension’s consequences and participants’ limited ability to anticipate them compared with HIV. Differences in medication adherence were attributed to the high costs of antihypertensive medications relative to the free availability of antiretroviral therapy, with other factors like lifestyle changes and self-efficacy also influencing adherence practices. These findings demonstrate how participants draw on past experiences with HIV to make sense of hypertension in the present, and suggest that although patients are motivated to control their hypertension, they face individual- and system-level obstacles in adhering to treatment. Thus, health policies and systems seeking to provide integrated care for HIV and hypertension should be attentive to the complex illness experiences of individuals living with these diseases.

Tobacco control norms have gained momentum over the past decade. To date 43 of 47 Sub-Saharan African countries are party to the Framework Convention on Tobacco Control (FCTC). The near universal adoption of the FCTC illustrates the increasing strength of these norms, although the level of commitment to implement the provisions varies widely. However, tobacco control is enmeshed in a web of international norms that has bearing on how governments implement and strengthen tobacco control measures. Given that economic arguments in favor of tobacco production remain a prominent barrier to tobacco control efforts, there is a continued need to examine how economic sectors frame and mobilize their policy commitments to tobacco production. This study explores the proposition that divergence of international norms fosters policy divergence within governments. This study was conducted in three African countries: Kenya, Malawi, and Zambia. These countries represent a continuum of tobacco control policy, whereby Kenya is one of the most advanced countries in Africa in this respect, whereas Malawi is one of the few countries that is not a party to the FCTC and has implemented few measures. We conducted 55 key informant interviews (Zambia = 23; Kenya = 17; Malawi = 15). Data analysis involved deductive coding of interview transcripts and notes to identify reference to international norms (i.e. commitments, agreements, institutions), coupled with an inductive analysis that sought to interpret the meaning participants ascribe to these norms. Our analysis suggests that commitments to tobacco control have yet to penetrate non-health sectors, who perceive tobacco control as largely in conflict with international economic norms. The reasons for this perceived conflict seems to include: (1) an entrenched and narrow conceptualization of economic development norms, (2) the power of economic interests to shape policy discourses, and (3) a structural divide between sectors in the form of bureaucratic silos. Les normes de contrôle du tabagisme ont pris de l’ampleur au cours de la dernière décennie. À ce jour, 43 des 47 pays de l’Afrique subsaharienne sont parties à la Conventioncadre pour la lutte antitabac (CCLAT). L’adoption quasi universelle de la CCLAT illustre la force croissante de cette réglementation, bien que le degré d’engagement en faveur de la mise en œuvre de ces dispositions varie considérablement. Cependant, la lutte antitabac est liée à un réseau de règles internationales qui influent sur la manière dont les gouvernements mettent en œuvre et renforcent les mesures de lutte antitabac. Étant donné que les arguments économiques en faveur de la production du tabac demeurent un obstacle majeur aux efforts de lutte antitabac, il est nécessaire de continuer à examiner l’apport des secteurs économiques dans l’encadrement et la mobilisation des engagements politiques en faveur de la production du tabac. La présente étude explore la proposition selon laquelle la divergence des règles internationales favorise la divergence des stratégies politiques au sein des gouvernements. L’étude a été réalisée dans trois pays africains: le Kenya, le Malawi et la Zambie. Ces pays représentent un continuum de la politique de lutte antitabac; en effet, le Kenya est l’un des pays africains les plus avancés à cet égard, alors que le Malawi est l’un des rares pays à ne pas avoir adhéré à la CCLAT et à n’avoir mis que peu de mesures en place. Nous avons mené 55 entretiens avec des informateurs clés (Zambie = 23, Kenya = 17, Malawi = 15). L’analyse des données impliquait un codage déductif de la transcription des entretiens et des notes afin d’identifier la référence aux normes internationales (engagements, accords, institutions), associé à une analyse inductive visant à interpréter le sens que les participants attribuaient à ces normes. Notre analyse suggère que les engagements en matière de lutte contre le tabagisme n’ont pas encore investi les secteurs non sanitaires, qui considèrent que la lutte antitabac est dans une large mesure en conflit avec les normes économiques internationales. Les raisons de ce conflit apparent semblent inclure: 1) une conceptualisation étroite bien ancrée des normes de développement économique, 2) la faculté des intérêts économiques à façonner les discours politiques, et 3) une division structurelle entre les secteurs sous la forme de cloisonnements bureaucratiques. 烟草控制规范在过去十年加速发展。目前47个撒哈拉以南非 洲国家中, 有43个签署了hh烟草控制框架公约ii （FCTC） 。 几 乎所有国家都加入了FCTC, 显示了烟草控制规范日益增强的 势头, 尽管履行规定的程度不一。然而, 烟草控制处在国家规 范网络之中, 这一网络会影响政府的控烟措施。有鉴于支持烟 草生产的经济论据仍然是烟草控制的主要障碍, 需要持续研究 经济部门如何建构和削弱对烟草控制的政治承诺。本研究探 讨的问题是, 国际规范的分歧产生政府内的政策分歧。研究涉 及3个非洲国家：肯尼亚、马拉维和赞比亚。这些国家代表了 3种不同强度的控烟政策：肯尼亚是非洲烟草控制力度最强的 国家之一, 而马拉维是少数未加入FCTC的国家之一, 几乎未实 施控烟措施。我们进行了55次关键知情人访谈（赞比亚23, 肯 尼亚17, 马拉维15）。数据分析包括对访谈记录和笔记采用演 绎法编码, 发现提及国际规范的内容（即承诺、协议和制 度）, 同时采用归纳法分析受访者赋予这些规范的意义。我们 的分析显示, 对烟草控制的承诺还未渗透至卫生以外部门, 这 些部门认为烟草控制与国际经济规范相冲突。这种观点的原 因包括： （1） 对经济发展规范的理解狭隘, 根深蒂固； （2） 经济利益对政策话语有强烈影响力； （3） 结构划分导致部门 相互隔绝。 Las normas de control del tabaco han ganado impulso en la última década. Hasta la fecha, 43 de los 47 países del África Sub-Sahariana son parte del Convenio Marco para el Control del Tabaco (CMCT). La adopción casi universal del CMCT ilustra la fuerza creciente de estas normas, aunque el nivel de compromiso de implementación varía ampliamente. Sin embargo, el control del tabaco está enlazado en una red de normas internacionales que se relacionan con la forma cómo los gobiernos implementan y fortalecen las medidas de control del tabaco. Dado que los argumentos económicos en favor de la producción de tabaco continúan siendo una barrera importante para los esfuerzos de control del tabaco, existe una necesidad continua de examinar cómo los sectores económicos enmarcan y movilizan sus compromisos de política con la producción de tabaco. Este estudio explora la idea que la divergencia de las normas internacionales fomenta la divergencia de políticas dentro de los gobiernos. Este estudio se realizó en tres países africanos: Kenia, Malawi y Zambia. Estos países representan un continuo de políticas de control del tabaco. Kenia es uno de los países más avanzados de África en este aspecto, mientras que Malawi es uno de los pocos países que no es parte del CMCT y ha implementado pocas medidas. Llevamos a cabo 55 entrevistas con informantes claves (Zambia=23, Kenia=17 y Malawi=15). El análisis de datos implicó la codificación deductiva de transcripciones de entrevistas y anotaciones para identificar referencias a normas internacionales (es decir, compromisos, acuerdos, instituciones), junto con un análisis inductivo que buscaba interpretar el significado que los participantes atribuyen a estas normas. Nuestro análisis sugiere que los compromisos con el control del tabaco aún no han penetrado los sectores no relacionados con la salud, los cuales perciben que el control del tabaco está en gran parte en conflicto con las normas económicas internacionales. Las razones de este conflicto percibido parecen incluir: (1) una conceptualización arraigada y estrecha de las normas de desarrollo económico, (2) el poder de los intereses económicos para dar forma a los discursos políticos y (3) una división estructural entre sectores en forma de silos burocráticos.

Abstract Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems—i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.

Substantial inequalities exist in cancer survival rates across countries. In addition to prevention of new cancers by reduction of risk factors, strategies are needed to close the gap between developed and developing countries in cancer survival and the effects of the disease on human suffering. We challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deployment of primary and secondary caregivers, use of off-patent drugs, and application of regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage with a focus on people living in poverty. These strategies can reduce costs, increase access to health services, and strengthen health systems to meet the challenge of cancer and other diseases. In 2009, we formed the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, which is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation, and evaluation of strategies to advance this agenda.