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Lack of education and an economic dependence on men are often suggested as important risk factors for HIV infection in women. We assessed the efficacy of a cash transfer programme to reduce the risk of sexually transmitted infections in young women. In this cluster randomised trial, never-married women aged 13–22 years were recruited from 176 enumeration areas in the Zomba district of Malawi and randomly assigned with computer-generated random numbers by enumeration area (1:1) to receive cash payments (intervention group) or nothing (control group). Intervention enumeration areas were further randomly assigned with computer-generated random numbers to conditional (school attendance required to receive payment) and unconditional (no requirements to receive payment) groups. Participants in both intervention groups were randomly assigned by a lottery to receive monthly payments ranging from US$1 to $5, while their parents were independently assigned with computer-generated random numbers to receive $4–10. Behavioural risk assessments were done at baseline and 12 months; serology was tested at 18 months. Participants were not masked to treatment status but counsellors doing the serologic testing were. The primary outcomes were prevalence of HIV and herpes simplex virus 2 (HSV-2) at 18 months and were assessed by intention-to-treat analyses. The trial is registered, number NCT01333826. 88 enumeration areas were assigned to receive the intervention and 88 as controls. For the 1289 individuals enrolled in school at baseline with complete interview and biomarker data, weighted HIV prevalence at 18 month follow-up was 1·2% (seven of 490 participants) in the combined intervention group versus 3·0% (17 of 799 participants) in the control group (adjusted odds ratio [OR] 0·36, 95% CI 0·14–0·91); weighted HSV-2 prevalence was 0·7% (five of 488 participants) versus 3·0% (27 of 796 participants; adjusted OR 0·24, 0·09–0·65). In the intervention group, we noted no difference between conditional versus unconditional intervention groups for weighted HIV prevalence (3/235 [1%] vs 4/255 [2%]) or weighted HSV-2 prevalence (4/233 [1%] vs 1/255 [<1%]). For individuals who had already dropped out of school at baseline, we detected no significant difference between intervention and control groups for weighted HIV prevalence (23/210 [10%] vs 17/207 [8%]) or weighted HSV-2 prevalence (17/211 [8%] vs 17/208 [8%]). Cash transfer programmes can reduce HIV and HSV-2 infections in adolescent schoolgirls in low-income settings. Structural interventions that do not directly target sexual behaviour change can be important components of HIV prevention strategies. Global Development Network, Bill & Melinda Gates Foundation, National Bureau of Economic Research Africa Project, World Bank's Research Support Budget, and several World Bank trust funds (Gender Action Plan, Knowledge for Change Program, and Spanish Impact Evaluation fund).

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.

Since the 1980s, the demographic literature has suggested that maternal schooling plays a key role in determining children's chances of survival in low- and middle-income countries; however, few studies have successfully identified a causal relationship between maternal education and under-5 mortality. To identify such a causal effect, we exploited exogenous variation in maternal education induced by schooling reforms introducing universal primary education in the second half of the 1990s in Malawi and Uganda. Using a two-stage residual inclusion approach and combining individual-level data from Demographic and Health Surveys with district-level data on the intensity of the reform, we tested whether increased maternal schooling reduced children's probability of dying before age 5. In Malawi, for each additional year of maternal education, children have a 10 % lower probability of dying; in Uganda, the odds of dying for children of women with one additional year of education are 16.6 % lower. We also explored which pathways might explain this effect of maternal education. The estimates suggest that financial barriers to medical care, attitudes toward modern health services, and rejection of domestic violence may play a role. Moreover, being more educated seems to confer enhanced proximity to a health facility and knowledge about the transmission of AIDS in Malawi, and wealth and improved personal illness control in Uganda.

This paper evaluates an experiment in which individuals in rural Malawi were randomly assigned monetary incentives to learn their HIV results after being tested. Distance to the HIV results centers was also randomly assigned. Without any incentive, 34 percent of the participants learned their HIV results. However, even the smallest incentive doubled that share. Using the randomly assigned incentives and distance from results centers as instruments for the knowledge of HIV status, sexually active HIV-positive individuals who learned their results are three times more likely to purchase condoms two months later than sexually active HIV-positive individuals who did not learn their results; however, HIV-positive individuals who learned their results purchase only two additional condoms than those who did not. There is no significant effect of learning HIV-negative status on the purchase of condoms.

Introduction HIV self‐testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder‐to‐reach populations. This study provides the first empirical evidence of the costs of door‐to‐door community‐based HIVST distribution in Malawi, Zambia and Zimbabwe. Methods HIVST kits were distributed door‐to‐door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on‐site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start‐up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. Results In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site‐level fixed costs. Site‐level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. Conclusions These early door‐to‐door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale‐up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers’ costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door‐to‐door community‐led distribution to reach end‐users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs.

Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). In this open, three-arm randomised trial, adults (≥18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. clinicaltrials.gov NCT03519425.

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.

At an understaffed and underresourced urban African training hospital, Malawian medical students learn to be doctors while foreign medical students, visiting Malawi as clinical tourists on short-term électives, learn about \"global health.\" Scientific ideas circulate fast there; clinical tourists circulate readily from outside to Malawi but not the reverse; medical technologies circulate slowly, erratically, and sometimes not at all. Medicine's uneven globalization is on full display. I extend scholarship on moral imaginations and medical imaginaries to propose that students map these wards variously as places in which—or from which—they seek a better medicine. Clinical tourists, enacting their own moral maps, also become representatives of medicine \"out there\": points on the maps of others. Ethnographic data show that for Malawians, clinical tourists are colleagues, foils against whom they construct ideas about a superior and distinctly Malawian medicine and visions of possible alternative futures for themselves. In einem unterbesetzten, unterfinanzierten afrikanischen Lehrkrankenhaus werden malawische Medizinstudenten zu Ärzten ausgebildet. Auch ausländische Medizinstudenten studieren dort; sie besuchen Malawi als \"klinische Touristen\" für kurzfristige Aufenthalte, bei denen sie Wahlfächer belegen und etwas über \"globale Gesundheit\" lernen. Wissenschaftliche Ideen zirkulieren dort schnell. Medizinische Technologien verbreiten sich langsam, unregelmäßig, und manchmal überhaupt nicht: die ungleiche Globalisierung der Medizin ist unübersehbar, ich erweitere die Literatur über moralische und medizinische Imaginationen und argumentiere, dass die Studenten sich diese Krankenhausabteilungen auf \"moralischen Karten\" vorstellen, entweder als Orte wo—oder von wo aus—sie eine \"bessere Medizin\" anstreben. Klinische Touristen (die ihren eigenen moralischen Karten folgen) repräsentieren außerdem die Medizin \"da draußen\": Sie werden zu Punkten auf den \"moralischen Karten\" Anderer. Für malawische Medizinstudenten sind diese ausländischen klinischen Touristen Kollegen, ein Hintergrund, vor dem sie Ideen einer überlegenen und spezifisch malawischen Medizin und alternative Zukunftsvisionen für sich selbst konstruieren. Dans un hôpital d'enseignement africain, en sous-effectif et manquant de ressources, les étudiants malawiens apprennent à être médecins alors que les étudiants étrangers, « touristes cliniques » en visite au Malawi, s'informent sur la « santé publique mondiale ». Les idées scientifiques circulent rapidement; les touristes circulent facilement de l'étranger au Malawi mais pas vice-versa; quand les technologies médicales circulent, c'est lentement. La mondialisation inégale de la médecine est exposée. J'accrois la recherche sur les imaginations morales et imaginaires médicaux, argumentant que les étudiants dépeignent cette expérience comme étant un lieu où, et par l'intermédiaire duquel, ils recherchent une médecine meilleure. Les touristes affichent leur scheme moral et représentent également la médecine de « là-bas »: des repères pour les autres. Les données ethnographiques démontrent que pour les Malawiens, les touristes sont des collègues à travers qui ils construisent les concepts d'une médecine malawienne supérieure et d'un avenir différent.

Background Cervical cancer is a prevalent public health concern and is among the leading causes of death among women globally. Malawi has the second highest cervical cancer prevalence and burden in the world. Due to the cervical cancer burden, the Malawi government scaled up national cancer screening services in 2011, which are free for all women. This paper is the first study to examine the socioeconomic inequality in cervical cancer screening uptake using concentration indices, in Malawi. Furthermore, it decomposes the concentration index to examine how each factor contributes to the level of inequality in the uptake of cervical cancer screening. Methods The data used in this paper were obtained from the nationally representative Malawi Population HIV Impact Assessment (MPHIA) household survey, which was conducted in 2015. Concentration curves were constructed to explore whether there was any socioeconomic inequality in cervical cancer screening and, if so, its extent. This was complemented by concentration indices that were computed to quantify the magnitude of socioeconomic inequality. A decomposition analysis was then conducted to examine the factors that explained/were associated with greater socioeconomic inequality in cervical cancer screening. The methodology in this paper followed that of previous studies found in the literature and used the wealth index to measure socioeconomic status. Results The results showed that the concentration curves lay above the line of equality, implying a pro-rich inequality in cervical cancer screening services. Confirming the results from the concentration curves, the overall concentration index was positive and significant (0.142; %95 CI = 0.127, 0.156; p  < 0.01). The magnitude was lower in rural areas (0.075; %95CI = 0.059, 0.090; p  < 0.01) than in urban areas (0.195; %95CI = 0.162, 0.228 p  < 0.001). After undertaking a decomposition of the concentration index, we found that age, education, rural or urban location, and wealth status account for more than 95% of the socioeconomic inequality in cervical cancer uptake. Conclusion Despite the national scale-up of free cancer care at the point of use, cervical cancer screening uptake in Malawi remains pro rich. There is a need to implement parallel demand-side approaches to encourage uptake among poorer groups. These may include self-testing and mobile screening centres, among others.