Nearly all facility registers were available and complete. But accuracy varied, with antenatal care and HIV testing and counseling performing the best and family planning and acute respiratory infections data less well. Most facilities visibly displayed routine health data and most hospitals and district health offices had staff trained in health management information systems, but training was lacking at the facility level as were routine data quality checks and regular supervision.

BackgroundIn 2010, 7.6 million children under five died globally – largely due to preventable diseases. Majority of these deaths occurred in sub–Saharan Africa. As a strategy to reduce child mortality, the Government of Malawi, in 2008, initiated integrated community case management allowing health surveillance assistants (HSAs) to treat sick children in communities. Malawi however, faces health infrastructure challenges, including weak supply chain systems leading to low product availability. A baseline assessment conducted in 2010 identified data visibility, transport and motivation of HSAs as challenges to continuous product availability. The project designed a mHealth tool as part of two interventions to address these challenges.MethodsA mobile health (mHealth) technology – cStock, for reporting on community stock data – was designed and implemented as an integral component of Enhanced Management (EM) and Efficient Product Transport (EPT) interventions. We developed a feasibility and acceptability framework to evaluate the effectiveness and predict the likelihood of scalability and ownership of the interventions. Mixed methods were used to conduct baseline and follow up assessments in May 2010 and February 2013, respectively. Routine monitoring data on community stock level reports, from cStock, were used to analyze supply chain performance over 18–month period in the intervention groups.ResultsMean stock reporting rate by HSAs was 94% in EM group (n = 393) and 79% in EPT group (n = 253); mean reporting completeness was 85% and 65%, respectively. Lead time for HSA drug resupply over the 18–month period was, on average, 12.8 days in EM and 26.4 days in EPT, and mean stock out rate for 6 tracer products was significantly lower in EM compared to EPT group.ConclusionsResults demonstrate that cStock was feasible and acceptable to test users in Malawi, and that based on comparison with the EPT group, the team component of the EM group was an essential pairing with cStock to achieve the best possible supply chain performance and supply reliability. Establishing multi–level teams serves to connect HSAs with decision makers at higher levels of the health system, align objectives, clarify roles and promote trust and collaboration, thereby promoting country ownership and scalability of a cStock–like system.

BackgroundMalawi has made progress in increasing its overall modern contraceptive prevalence rate since 2000, resulting in a dramatic reduction in its total fertility rate. However, youth, 15–24 years, have not had the same successes. Teenage pregnancies are on the rise and little progress has been made in reducing unmet need for family planning among youth. With two-thirds of the population under the age of 25 and with Malawi’s rapid population growth, reducing unmet need for family planning among youth remains a priority for the government’s reproductive health agenda. To further explore this situation, we conducted a qualitative study to explore the perspectives of youth and adults about the drivers and barriers to youth accessing family planning in Malawi and their ideas to improve services.MethodsWe conducted 34 focus group discussions with youth aged 15–24 and parents or legal guardians of female youth in 3 districts in Malawi. Focus groups were translated and transcribed. Data was input into Dedoose and analyzed using a thematic framework to identify broader patterns and themes.ResultsYouth participants felt motivated to use family planning to protect themselves from sexually transmitted diseases and to prevent unwanted pregnancies. Females focused on the consequences of unplanned pregnancies and believed family planning services were targeted primarily at them, while males thought family planning services targeted males and females equally. Barriers to youth accessing family planning included contraception misconceptions, the costs of family planning services, and negative attitudes. Parents had mixed views on family planning. While many parents acknowledged they could play a role in supporting youth, most said they are reluctant to support youth using family planning. Participants said improving counseling services, integrating family planning services and education within school curricula, and utilizing youth clubs could improve family planning services for youth.ConclusionsPolicy makers and program implementers should consider the diverse preferences among youth and parents and continue seeking their input when designing policies and programs. Youth clubs and school-based services were among the most common suggestions. However, the effectiveness of youth clubs and school-based initiatives to increase contraceptive use among youth in Malawi is not clear.Electronic supplementary materialThe online version of this article (10.1186/s12978-018-0549-9) contains supplementary material, which is available to authorized users.

Background: To effectively deliver on proposed objectives, it is vital that practitioners, policymakers, and other stakeholders are able to clearly understand how strongly their large-scale program is being implemented. This study sought to test the feasibility, cost-effectiveness, and validity of a phone-based method as an innovative and cost-efficient approach to assessing program implementation strength (through an Implementation Strength Assessment-ISA), alternative to the traditional in-person field methods. Methods: We conducted 701 mobile phone and 356 in-person interviews with facility in-Charges and two types of community health workers who provide family planning services in the Dowa and Ntcheu districts in Malawi. Responses received via the phone interview were validated through in-person review of records and inspections. Sensitivity and specificity were calculated to determine validity. Results: Most indicators at the health facility and community health worker levels were above a 70% threshold for sensitivity. However, there were fewer indicators that met this threshold for specificity. The primary reason for lower specificity was due to poor recordkeeping. Collecting data via mobile phone was found to be feasible and twice as cost-efficient as collecting the same data via in-person inspections. Conclusions: The rapid increase in mobile phone ownership and network availability in lower income countries could offer an alternative, cost-effective avenue to collect data for a better understanding of program implementation. Through rigorous assessment, this study found that using mobile phones could be a low-cost alternative to collect data on health system delivery of services, especially in places where routine data quality is poor and traditional, in-person methods are costly.

How strong are Malawi's family planning programs for adolescent and adult women? Results of a national assessment of implementation strength conducted by Malawi's National Evaluation Platform Background To assess the strength of implementation of family planning programs targeting youth (15-24) in Malawi with a specific focus on youth and the Youth-Friendly Health Services program Methods We conducted 9781 mobile phone interviews with facility in-Charge Nurses and health workers (health facility workers, health surveillance assistants [HSAs] and community-based distribution agent [CBDAs]) who provide family planning (FP) services across the 28 districts. Responses were entered in tablet using Open Data Kit. They were summarized and presented using R, Stata (College Station, TX, USA), StatsReport (JHU, Baltimore, MD, USA) and ArcView GIS (ESRI, Redlands, CA, USA). Results Availability of key products was a challenge across all health worker types as only 39% of health facilities, 29% of HSAs and 45% of CBDAs had all the FP methods they are supposed to provide on the day of the interview. About 50% of health workers were supervised within past 90 days preceding the study. Despite most facilities saying that they provide youth friendly health services, youth-specific FP guidelines or protocols were not available in 43% of facilities that provide these services and only 33% of facilities had special rooms and 58% have special days for youth. Conclusions The commodity supply system needs to ensure that all facilities and workers have a consistent supply of all contraceptive methods. Government and program implementers should ensure availability of all FP guidelines and information, education, communication materials at all service delivery points and facilitate creation of special rooms or days for youth.