Paying for Happiness: Experimental Results from a Large Cash Transfer Program in Malawi.

This study analyzes the short-term impact of an exogenous, positive income shock on caregivers' subjective well-being (SWB) in Malawi using panel data from 3,365 households targeted to receive Malawi's Social Cash Transfer Program that provides unconditional cash to ultra-poor, labor-constrained households. The study consists of a cluster-randomized, longitudinal design. After the baseline survey, half of these village clusters were randomly selected to receive the transfer and a follow-up was conducted 17 months later. We find that the short-term impact of household income increases from the cash transfer leads to substantial SWB gains among caregivers. After a year's worth of transfers, caregivers in beneficiary households have higher life satisfaction and are more likely to believe in a better future. We examine whether program impacts on consumption, food security, resilience, and hopefulness could explain the increase in SWB but do not find that any of these mechanisms individually mediate our results.

Short-term Impacts of an Unconditional Cash Transfer Program on Child Schooling: Experimental Evidence from Malawi.

This study analyzes the impact of a positive income shock on child schooling outcomes using experimental data from an unconditional cash transfer program in Malawi. Since households receive the cash and parents are responsible for making spending decisions, we also examine the intervening pathways between cash transfers and child schooling. Data comes from a cluster-randomized study of Malawi's Social Cash Transfer Program (SCTP). After a baseline survey, households in village clusters were randomly assigned to treatment and control arms with treatment villages receiving transfers immediately and control villages assigned a later entry. We test for treatment impacts on a panel of school-aged children (6-17) using a differences-in-differences model. After a years' worth of transfers, we find the Malawi SCTP both improves enrollment rates and decreases dropouts. The main intervening pathway between the program and schooling is education expenditures, suggesting that the cash improves the demand for education by reducing financial constraints.

Political economy analysis of subnational health management in Kenya, Malawi and Uganda.

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.

Using Photo-Elicitation Methods to Understand Resilience Among Ultra-Poor Youth and Their Caregivers in Malawi.

Unconditional cash transfer programs are a form of structural intervention to address poverty, a "fundamental cause" of disease. Such programs increasingly aim to build resilience to sustain improved outcomes and provide a solid foundation for longer term transformations. As such, there is a need to understand what resilience means in specific contexts. The goal of this formative study was to explore local experiences of resilience and vulnerability among 11 youth-caregiver dyads ( n = 22) who were beneficiaries of the Malawi Social Cash Transfer Program in Balaka district. We used a photo-elicitation approach informed by the participatory, visual methodology photovoice to guide the study and conducted an iterative content analysis using thematic coding of transcripts and photos. Participants took pictures of their daily struggles and shocks and participated in audio-recorded discussions to reflect on the photos using an adapted version of the SHOWeD method. We found that participants characterized resilience as a tireless process of using all available individual, family, and community resources at all times in pursuit of survival and well-being. In the context of daily struggles, resilience was an essential part of survival. Shocks, mostly health-related, were depicted through staged images candidly highlighting individual and environmental vulnerabilities. Community support was an essential component of resilience for both daily struggles and shocks. Using photo-elicitation methods facilitated an intergenerational, community-driven reflection on the meaning of resilience and the multilevel determinants of health in a context of extreme poverty. Findings can inform the design of resilience-focused cash transfer programs to improve health equity.

Social networks, social participation, and health among youth living in extreme poverty in rural Malawi.

Extensive research documents that social network characteristics affect health, but knowledge of peer networks of youth in Malawi and sub-Saharan Africa is limited. We examine the networks and social participation of youth living in extreme poverty in rural Malawi, using in-depth interviews with 32 youth and caregivers. We describe youth's peer networks and assess how gender and the context of extreme poverty influence their networks and participation, and how their networks influence health. In-school youth had larger, more interactive, and more supportive networks than out-of-school youth, and girls described less social participation and more isolation than boys. Youth exchanged social support and influence within their networks that helped cope with poverty-induced stress and sadness, and encouraged protective sexual health practices. However, poverty hampered their involvement in school, religious schools, and community organizations, directly by denying them required material means, and indirectly by reducing time and emotional resources and creating shame and stigma. Poverty alleviation policy holds promise for improving youth's social wellbeing and mental and physical health by increasing their opportunities to form networks, receive social support, and experience positive influence.

Benefits of Meeting the Contraceptive Needs of Malawian Women.

(1) In 2013, an estimated 54% of pregnancies in Malawi were unintended. (2) More than four in 10 women have an unmet need for modern contraception­that is, they want to avoid pregnancy, but either are not practicing contraception or are using a relatively ineffective traditional method. (3) Meeting just half of this unmet need would prevent 213,000 unintended pregnancies annually, which would result in 34,000 fewer unsafe abortions and 800 fewer maternal deaths each year. (4) If all unmet need for modern contraception were met, maternal mortality would decline by more than two-fifths, and unintended births and unsafe abortions would drop by 87%. (5) Investing in contraceptive commodities and services to fulfill all unmet need for modern contraception would result in a net annual savings of US$11 million (4.1 billion Malawi kwachas) over what would otherwise be spent on medical costs associated with unintended pregnancies and their consequences. (6) Expanding contraceptive services confers substantial benefits to women, their families and society. All stakeholders­including the Malawi government and the private sector­should increase their investment in modern contraceptive services.

Measuring vulnerability among orphans and vulnerable children in rural Malawi: validation study of the Child Status Index tool.

OBJECTIVES: To validate the Child Status Index (CSI) as an instrument that can meaningfully measure the vulnerabilities of orphaned and vulnerable children, including those infected and affected by HIV/AIDS. METHODS: Two age-specific instruments, comprised of previously validated tools and indicators commonly considered best practice, were administered to 102 children aged 5-10 years and 100 children aged 11-17 years in Mchinji, Malawi. Respondents were randomly sampled from a roster of children recently scored with the CSI. For each of the CSI's 12 subdomains, we assessed construct validity using Spearman Rank correlation coefficients. We also calculated cross tabulations to explain the resulting correlation coefficients. Analyses were conducted separately for the 2 age groups. RESULTS: No relationships exceeded the standard for high construct validity (≥0.7). Only 2 were moderate (0.3-0.7), both for the younger age group: food security (0.4) and wellness (0.36). All other relationships were weak or negative. In most subcategories, a substantial proportion of surveyed children indicated distress that was not evident from CSI scores. In the abuse and exploitation subdomain, all children were rated as "good" or "fair" by the CSI, but among surveyed children aged 11-17, 20% or more reported being beaten, kicked, locked out of the house, threatened with abandonment, cursed, and made to feel ashamed. CONCLUSIONS: In this rural Malawi population, we were not able to validate the CSI as a tool for assessing the vulnerabilities of orphaned and vulnerable children. We recommend caution in interpreting CSI scores and revisions to the tool before global scale-up in its use.