Highlights Community health-workers across Africa use mobile phones ‘informally’ in their work. Informal mhealth is an emergent phenomenon, used to bridge gaps in formal provision. Informal mhealth is happening at scale, far outstripping its formal equivalent. Informal mhealth is inherently responsive to local needs and contingencies. But it carries hidden costs (financial and other) which are inequitably distributed.

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers’ ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

Objective: Few studies have examined the effects of the COVID-19 pandemic on mental health among young people in sub-Saharan Africa and particularly pregnant and parenting adolescents exposed to multiple stressors. Our study addresses this gap by examining self-report of mental health challenges among pregnant and parenting adolescent girls during the pandemic. Methods: We undertook a cross-sectional survey involving 666 girls aged 13-19 in Blantyre district, southern Malawi, between March and May 2021. We recruited eligible respondents from households in 66 randomly selected rural (26) and urban (40) enumeration areas. Mental distress was assessed using nine symptoms including worry, restlessness, fear, anxiety, sadness, loneliness, frustration, fear, stress, and boredom. Girls were asked whether they experienced more of these symptoms after the start of the COVID-19 pandemic. Any girl experiencing one of these symptoms was considered to have experienced mental distress. Bivariate and multivariable regression models were used to examine correlates of mental distress. Findings: Girls’ median age was 18 years with a range of 13-19 years. Most girls (68.3%) reported having experienced somewhat more or much more mental distress, with 17.6% indicating all nine symptoms. In the adjusted model, pregnant and parenting girls aged 19 were more likely to report having experienced more mental distress (OR=1.79; 95% CI 1.15 – 2.77) during the pandemic compared to those aged 13-17 years. Similarly, girls who had ever worked had a higher likelihood of experiencing more mental distress (AOR:1.65; 95% CI 1.12 – 2.41) than before the pandemic. On the contrary, perceived neighborhood safety was protective against mental distress (OR=0.81 95% CI 0.69 – 0.95 p<0.01). Conclusion: Pregnant and parenting adolescent girls' mental health was adversely affected by the COVID-19 pandemic, thereby exacerbating their vulnerabilities and increasing risk of poor mental health. Our findings could inform interventions targeting adolescents’ mental health during pandemics.

Introduction: despite universal efforts, child marriages still occur worldwide. However, not all child marriage unions last, and little is known about how such marriages end. Most critically, there is little information on what happens to young mothers when child marriage unions dissolve. This paper explores the experiences of adolescent mothers who were in child marriages in the cultural context of central Malawi. Methodology: using qualitative methods, data was collected in two districts in central Malawi. One focus group discussion (FGD) was conducted with key community members (n=14) and three FGD, guided by an unstandardized interview guide, were conducted with adolescent mothers aged 15-22 years (n=15). The FGD with adolescent mothers were conducted in three groups, ranging from three to nine participants per group. In addition to this, a key informant interview was conducted with a community leader who is traditionally recognized as paramount chief (n=1). The data was analysed using a content analysis. The study applied the concept of ‘doing gender’ by West and Zimmerman (1987) in the analysis. Results: what emerged from the data is that adolescent mothers embodied fragmented identities that are changing over time given the influence of life events. Amid different combinations of roles, several identities were observed: mother, wife, young, adolescent, girl, married, unmarried, victim of child marriage, survivor of child marriage, unemployed, employed, re-enrolled student, and school dropout. While these identities changed, gender did not, thus the changing identifications provided displays for ‘doing gender’ under a diverse set of subjectivities. Expressions of power at the micro-level were demonstrated by adolescent mothers through ‘resilience vs. perseverance’. Conclusions: the study highlights that cultural sensitivity and responsiveness by traditional leaders, such as the chief, play a role in the empowering revisions of one’s identity by championing liberating life events through the termination of child marriage or access to girls’ education regardless of resistance.

Background Despite efforts from the government and developmental partners to eliminate gender-based violence, intimate partner violence (IPV) remains a pervasive global health and human rights problem, affecting up to 753 million women and girls globally. Few studies on IPV have focused on pregnant and parenting adolescent (PPA) girls in Africa, although the region has the highest rates of adolescent childbearing. This limited attention results in the neglect of pregnant and parenting adolescents in policies and interventions addressing IPV in the region. Our study examined IPV prevalence and its individual, household, and community-level correlates among pregnant and parenting adolescent girls (10–19 years) in Blantyre District, Malawi. Methods We collected data from a cross-section of pregnant and parenting adolescent girls (n = 669) between March and May 2021. The girls responded to questions on socio-demographic and household characteristics, lifetime experience of IPV (i.e., sexual, physical, and emotional violence), and community-level safety nets. We used multilevel mixed-effect logistic regression models to examine the individual, household, and community-level factors associated with IPV. Results The lifetime prevalence of IPV was 39.7% (n = 266), with more girls reporting emotional (28.8%) than physical (22.2%) and sexual (17.4%) violence. At the individual level, girls with secondary education (AOR: 1.72; 95% CI: 1.16–2.54), who engaged in transactional sex (AOR: 2.29; 95% CI: 1.35–3.89), and accepted wife-beating (AOR: 1.97; 95% CI: 1.27–3.08) were significantly more likely to experience IPV compared to those with no education/primary education, who never engaged in transactional sex and rejected wife beating. Girls aged 19 (AOR: 0.49; 95% CI: 0.27–0.87) were less likely to report IPV than those aged 13–16. At the household level, girls with fair and poor partner support had higher odds of experiencing IPV, but the effect size did not reach a significant level in the parsimonious model. A high perception of neighborhood safety was associated with a lower likelihood of experiencing IPV (AOR: 0.81; 95% CI: 0.69–0.95). Conclusion Intimate partner violence is rife among pregnant and parenting adolescent girls in Malawi, underscoring the need for appropriate interventions to curb the scourge. Interventions addressing IPV need to target younger adolescents, those engaging in transactional sex, and those having weaker community-level safety nets. Interventions to change social norms that drive the acceptance of gender-based violence are also warranted.