Andrew Likaka

Background: Governments worldwide are increasingly interested in scaling up effective public health innovations, but it is not always easy to institutionalize innovations, arising outside the public health system, as a part of national delivery. Evidence on how country governments can practically achieve this is limited. This article describes the institutionalization of the Chipatala Cha Pa Foni (CCPF, Health Center by Phone) social innovation into the Malawian public health, and identifies positive institutional practices that local actors drew on to achieve this. Methods: A positive-oriented interdisciplinary multi-method qualitative case study design was adopted. Data were collected from key informant interviews, observations, and documents over 18 months. A composite social innovation framework, informed by institutional theory and positive organizational scholarship, guided the thematic content analysis. Results: Four clusters of positive institutional practices aided the institutionalization of the innovation: building high-quality relationships; creating opportunities for experiential interaction; cultivating hope; and logic attunement and awareness. We describe how these four practices operated together as a process of ‘everyday creativity’ to achieve institutionalization. We illustrate the importance of high-quality relationships, marked by respect, mutuality, and appreciation, as the foundation upon which hope can be built and the creativity needed for institutionalization to flourish. National ownership and sustainability of innovations are enhanced when implementation and institutionalization approaches are attuned to the logics inherent in national identity. Conclusion: In this article, we highlight the importance of institutional and interpersonal dynamics in the institutionalization of social innovation in health systems.

Climate change poses a significant threat to women’s health in sub-Saharan Africa, yet the impact of climate change on maternal health is rarely reported in the region. Using an existing Maternal Surveillance Platform (MATSurvey), we estimated the immediate impact of Cyclone Freddy on maternal health care service indicators in Malawi. We analysed facility-level data for pregnant women up to 42 weeks post-partum using the national MATSurvey database. We compared incidences of service utilisation before (1 January to 19 February 2023) and after (20 February to 30 March 2023) the cyclone using a negative binomial regression approach. Between 1 January and 30 March 2023, a total of 37,445 live births, 50,048 antenatal clinic attendances, 23,250 postnatal clinic attendances, 84 maternal deaths, and 1,166 neonatal deaths were recorded by 33 facilities in the MatSurvey database. There was an immediate reduction in service utilisation in the post-cyclone period, including the postnatal attendance per week (pre-cyclone median: 355.0 [IQR 279.0–552.0], post-cyclone median: 261.0 [IQR 154.3–305.5], RR 0.56 [95% CI 0.44–0.71, p .001]) and the antenatal attendance per week (pre-cyclone median: 860.0 [IQR 756.5–1060.0], post-cyclone median: 656.5 [IQR 486.5–803.3], RR 0.66 [95% CI 0.55–0.78, p .001]). Stratified analyses by geographical zones revealed a stronger reduction in postnatal clinic attendance in the Southwest (RR 0.50 [95% CI 0.29–0.85, p = 0.010]) and the North (RR 0.29 [95% CI 0.15–0.56, p .001]). Cyclone Freddy resulted in an immediate decline in utilisation of maternal health services in cyclone-affected regions in Malawi. We observe evidence of catastrophic climate events impacting on the healthcare of women and their babies. Policymakers, researchers, and health systems need to ensure that essential women’s health services are maintained during these events and improve measures to support service resilience in the face of climate change.

Background: Many low- and middle-income countries (LMICs) face the daunting task of digitising, maturing and deciding where to invest in digital health systems. Aim: Describing the facilitators and barriers to conducting digital health maturity assessments and how health leaders can prioritise the assessments. Setting: eHealth leaders from 10 African countries, working or supporting Ministries of Health’s digital health and participating in the eHealth Leaders’ Forum from July 2023 to September 2023. Methods: This qualitative, descriptive study utilised key informant interviews conducted via Zoom with 14 conveniently selected leaders. We used Dedoose Version 9.0 to develop themes based on the health system’s building blocks. Results: Participants identified maturity assessments as a critical first step to digital health strengthening, showing the system’s performance and building a baseline response to systematic data quality challenges. Barriers to conducting digital health maturity assessment include lacking collaborators’ buy-in, fragmented vision, overdependence on donor priorities, non-supportive policies and an inadequately skilled workforce. Facilitators include multi-stakeholder engagement, understanding the country’s digital health ecosystem and appropriately integrating maturity assessment objectives. Recommendations include capacity building in data use and conducting maturity assessments at all health system levels to grow the demand and value of digital health strengthening. Conclusion: Promoting digital health maturity assessments can help leaders to make appropriate decisions to prioritise areas of improvement and steward maturity advancement as a pathway to strengthening the health system. Contribution: We spotlight the perspectives of African eHealth leaders, centering voices on the barriers, facilitators to planning and recommendations for implementing digital health systems maturity assessments.

Objective To describe the demographic characteristics, clinical manifestations, and clinical outcomes of hospitalised pregnant and recently pregnant women with COVID-19 in Malawi, a low-income country in Sub-Saharan Africa. This study responds to a critical gap in the global COVID-19 data. Methods A national surveillance platform was established in Malawi by the Ministry of Health to record the impact of COVID-19 on pregnant and recently pregnant women and provide real-time data for decision making. We report this facility-based cohort that includes all pregnant and recently pregnant hospitalised women in Malawi suspected of having COVID-19 between 2nd June 2020 and 1st December 2021. Results 398 women were admitted to hospital with suspected COVID-19 based on presenting symptoms and were tested; 246 (62%) were confirmed to have COVID-19. In women with COVID-19, the mean age was 27 ± 7 years. The most common presenting symptoms were cough (74%), breathlessness (45%), Fever (42%), headache (17%), and joint pain (10%). 53% of the women had COVID-19 symptoms severe enough to warrant admission. 31% (76/246) of women admitted with COVID-19 suffered a severe maternal outcome, 47/246 (19%) died, and 29/246 (12%) had a near-miss event. 9/111 (8%) of recorded births were stillbirths, and 12/101 (12%) of the live births resulted in early neonatal death. Conclusion A national electronic platform providing real-time information on the characteristics and outcomes of pregnant and recently pregnant women with COVID-19 admitted to Malawian government hospitals. These women had much higher rates of adverse outcomes than those suggested in the current global data. These findings may reflect the differences in the severity of disease required for women to present and be admitted to Malawian hospitals, limited access to intensive care and the pandemic’s disruption to the health system. What is already known? In pregnant and recently pregnant women, COVID-19 is associated with increased complications such as admission to an intensive care unit, invasive ventilation, and maternal death. In pregnant women with confirmed COVID-19, the current global estimate of all-cause mortality is 0.02%. Most countries in Africa rely on paper-based systems to collect key maternal health indicators such as maternal deaths and severe morbidity, which does not enable timely actions. What are the new findings? Maternal mortality and adverse perinatal outcomes are alarmingly high in a cohort of pregnant and recently pregnant women admitted to Malawian healthcare facilities located in a low-income country in Africa. A national facility-based maternal surveillance platform can be implemented during a pandemic and provide real-time data to aid policymakers in understanding its impacts on this key population. What do the new findings imply? In low-income countries in Sub-Saharan Africa, pregnant and recently pregnant women with COVID-19 admitted to hospital require enhanced care and a renewed focus on their needs to avert these adverse health outcomes. Global and national surveillance systems must specifically record outcomes for pregnant, recently pregnant women and their infants to understand the impact of public health emergencies on these groups, as they may be disproportionately affected and may require special considerations.

UNSTRUCTURED Mathematical modeling of COVID-19 transmission has been instrumental in the global pandemic, particularly to governments in many low- and middle-income countries (LMICs), where empirical data and active surveillance is limited. Simulations can be used to understand disease trajectory and impacts of policy options at little additional cost. We describe an automated, open-source, and web-based dashboard designed to empower Malawi government officials to understand the ramifications of certain policy interventions from a mathematical model of COVID-19 transmission. The dynamic dashboard allows policymakers to simulate scenarios of various COVID responses by allowing them to manipulate model inputs like percentage of population using cloth masks, percentage of population abiding by physical distancing recommendations, and the length of both these interventions in days. The dashboard’s outputs include COVID-19 cases, hospitalizations, intensive care unit (ICU) stays, and deaths based on the user-defined parameters and level of interest for the data (i.e., administrative levels like traditional authority-, district-, or national-level). It also compares the outputs from the user-defined simulation with a baseline scenario that conservatively estimates 15% of the population masking and 8% abiding by physical distancing guidelines. Our dynamic dashboard not only generates pertinent outputs to formulating a pandemic policy response, but it also offers an intuitive, streamlined, and real-time user experience to policymakers who may lack backgrounds in epidemiology and programming. LMICs should continue to invest in their country’s data collection, digital infrastructures, and technical training for key stakeholders to support widespread use of these evidence-based, decision-support tools in the future.

The African Region reported the first COVID-19 case on 14 February 2020 in Egypt and, to date, over 4.5 million cases and 120 000 deaths have been documented in all 57 countries in the continent [ 1]. COVID-19 has exposed huge quality gaps in the health systems in both high and low- and middle-income countries (LMICs). Patient satisfaction with care for normal medical conditions has gone down as a result of long waiting times, limitations in physician to patient contacts, disruption of services or cancellation of services due to newly introduced shift schedules, inadequate personal protective equipment, and indeed, lack of companion in COVID-19 treatment centers [ 2].

Early reports indicate that AKI is common during COVID-19 infection. Different mortality rates of AKI due to SARS-CoV-2 have been reported, based on the degree of organic dysfunction and varying fr...