Medical laboratory practice in Malawi ­ Current status

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The social and cultural consequences of infertility in rural and periurban

Relatively little is known about infertility experiences among women in rural Malawi and the impact of infertility on women's marital and family relations. This article examines the perspectives of women and health care providers regarding women's concepts of reproductive health and attitudes toward infertility. The paper explores the supports and barriers to managing infertility at the individual, household, and community levels. The data presented was drawn from semi-structured interviews with health care providers and patients within a prevention of mother to child transmission program and focus group discussions with community men and women in four communities in Southern Malawi. Seventy-eight patients, 12 health care providers, and 32 community leaders participated in the study. The findings suggest that gender inequities and kinship relations intersect to produce infertility related stigma which exacerbates the social and cultural consequences of being infertile in these study communities. Social support from other women experiencing infertility is one strategy to help women manage the social and cultural burden of infertility in these study communities. These results shed light on the meaning of motherhood to women living in rural and periurban Sub-Saharan African communities and call for an expansion of infertility services, social services, and mental health services for both women and men who experience infertility. (Afr J Reprod Health 2022; 26[7]: 112-126).

Prevalence and correlates of common mental disorders among children and adolescents in Blantyre-Urban, Malawi

The high global prevalence of mental disorders justifies the need to quantify their burden in the sub-Saharan Africa where there is a dearth of information. These mental disorders are linked to different socio-demographic factors. Objective To determine the prevalence of, and factors associated with mental disorders among children and adolescents in Blantyre City, Malawi. Methods: Children and adolescents aged 6 to 17 years were interviewed to determine their socio-demographic characteristics and assess their mental health status using the Strengths and Difficulties Questionnaire (SDQ) and Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). Associations between mental disorders and socio-demographic characteristics were tested using Chi-square and logistic regression analysis. Results The prevalence of symptoms of psychopathology on the SDQ was 7.3% (95%CI 4.8-10.5%) while for the K-SADS was 5.9% (95% CI 3.7%-8.9%). The prevalence of mental disorders across the age ranges of 6 to 12 years and 13 to 17 years was 5.4% and 7.9 % respectively. Males had a higher prevalence (7.1%) compared to females (4.7%). Conduct disorder was most prevalent (3.4%), followed by either type of ADHD- Attention Deficit Hyperactive Disorders (2.0%). Having a single parent (p<0.001), staying with a nonbiological guardian (p<0.030), engaging in paid work (p<0.039), not attending school (p<0.019) and having teacher difficulties(p<0.028) were positively associated with a mental disorder. Conclusion The socio-demographic factors associated with the risk of developing mental disorders may be important targets for mental health intervention programs

A morphometric study of the mandibular foramen in dry adult human mandibles in a black Malawian population / Un estudio morfométrico del foramen mandibular en mandíbulas humanas adultas secas en una población malauí negra

SUMMARY: The inferior alveolar nerve block (IANB) technique is a common technique performed on patients in dental surgery, placement of mandibular implants and other procedures involving the mandible. Precise identification of the mandibular foramen (MF) is essential for dental surgeons to accurately administer local anesthetics. Inaccurate localization of the mandibular foramen may result in IANB failure and injury to neurovascular tissues. Therefore, this study aimed at investigating the precise location of the MF from various anatomical land marks in dry adult human mandibles of Malawian population. The study was conducted on 29 dry adult human mandibles of unknown sex of Malawian origin from the Anatomy Division collection of human skeletons housed in the Biomedical Sciences Department, College of Medicine, University of Malawi. To determine the position of the mandibular foramen, distances from mandibular foramen to anterior margin, posterior margin, mandibular notch, gonial angle and mandibular base using a Vernier caliper were measured. The mean distance of the MF from posterior margin of mandibular ramus was 11.26±1.22 mm (right side) and 11.47±1.35 mm (left side), from the anterior margin 20.85±3.12 mm (right side) and 20.85±3.22 mm (left side) mandibles. The mean distance between mandibular notch (MN) and MF was 23.87±2.61 mm (right side) and 23.53 ± 2.65 mm (left side). The mean distance between mandibular base (MB) and MF for the right and left were 28.47 ± 2.90 mm and 27.85 ± 2.99 mm respectively. The inferior limit of the mandibular foramen was located at 24.69 ± 3.65 mm (right side) and 24.25 ± 2.77 mm (left side) to the angle (AG) of the mandible. The findings of this study show that the anterior margin mean distance from the MF for both right and left mandibles seem to be bilateral symmetrical suggesting the interpretation that the needle for IANB could be inserted at about 21 mm from the anterior margin to the MF in an adult of Malawian origin during surgery.

RESUMEN: La técnica de bloqueo del nervio alveolar inferior (IANB) es una técnica común que se realiza en pacientes en cirugía dental, colocación de implantes mandibulares y otros procedimientos que involucran la mandíbula. La identificación precisa del foramen mandibular (MF) es esencial para que los cirujanos dentistas administren con precisión anestésicos locales. La localización inexacta del foramen mandibular puede resultar en una falla de la IANB y lesión de los tejidos neurovasculares. Por lo tanto, este estudio tuvo como objetivo investigar la ubicación precisa de la MF de varias marcas anatómicas en las mandíbulas humanas adultas secas de la población de Malawi. El estudio se llevó a cabo en 29 mandíbulas humanas adultas secas de sexo desconocido de origen malauí de la colección de esqueletos humanos de la División de Anatomía del Departamento de Ciencias Biomédicas de la Facultad de Medicina de la Universidad de Malawi. Para determinar la posición del foramen mandibular, se midieron las distancias desde el foramen mandibular hasta el margen anterior, margen posterior, incisura mandibular, ángulo gonial y base mandibular utilizando un calibre Vernier. La distancia media del MF desde el margen posterior de la rama mandibular fue de 11,26 ± 1,22 mm (lado derecho) y 11,47 ± 1,35 mm (lado izquierdo), desde el margen anterior 20,85 ± 3,12 mm (lado derecho) y 20,85 ± 3,22 mm (lado izquierdo) lado) mandíbulas. La distancia media entre la muesca mandibular (MN) y MF fue de 23,87 ± 2,61 mm (lado derecho) y 23,53 ± 2,65 mm (lado izquierdo). La distancia media entre la base mandibular (MB) y MF para la derecha y la izquierda fue de 28,47 ± 2,90 mm y 27,85 ± 2,99 mm, respectiva- mente. El límite inferior del foramen mandibular se ubicó a 24,69 ± 3,65 mm (lado derecho) y 24,25 ± 2,77 mm (lado izquierdo) del ángulo (AG) de la mandíbula. Los resultados de este estudio mues- tran que la distancia media del margen anterior desde el MF para las mandíbulas derecha e izquierda parece ser simétrica bilateral, lo que sugiere la interpretación de que la aguja para IANB podría insertarse a unos 21 mm del margen anterior al MF en una adulto de origen malauí durante la cirugía.

Paediatric surgical conditions in Malawi ­ A cross-sectional nationwide household survey

Background:Untreated surgical conditions may lead to lifelong disability in children. Treating children with surgical conditions may reduce longterm effects of morbidity and disability. Unfortunately, low- and middle-income countries have limited resources for paediatric surgical care. Malawi, for example, has very few paediatric surgeons. There are also significantly inadequate infrastructures and personnel to treat these children. In order to strengthen resources that could provide such services, we need to begin by quantifying the need.Aim: To estimate the approximate prevalence of surgical conditions among children in Malawi, to describe the anatomical locations and diagnoses of the conditions and the presence of injuries. Methods A cross-sectional, nationwide survey of surgical needs was performed in 28 of 29 districts of Malawi. Villages, households and household members were randomly selected. A total of 1487 households were visited and 2960 persons were interviewed. This paper is a sub analysis of the children in the dataset. Information was obtained from 255 living children and inquiry from household respondents for the 255 children who had died in the past year. The interviews were conducted by medical students over a 60-day period, and the validated SOSAS tool was used for data collection. Results:There were 67 out of 255 (26.3%) total children living with a surgical condition at the time of the study, with most of the conditions located in the extremities. Half of the children lived with problems due to injuries. Traffic accidents were the most common cause. Two-thirds of the children living with a surgical condition had some kind of disability, and one-third of them were grossly disabled. There were 255 total deceased children, with 34 who died from a surgical condition. The most prevalent causes of death were congenital anomalies of the abdomen, groin and genital region. Conclusion: An extrapolation of the 26% of children found to be living with a surgical condition indicates that there could be 2 million children living with a condition that needs surgical consultation or treatment in Malawi. Congenital anomalies cause significant numbers of deaths among Malawian children. Children living with surgical conditions had disorders in their extremities, causing severe disability. Many of these disorders could have been corrected by surgical care.

A multidrug-resistant Stenotrophomonas maltophilia clinical isolate from Kamuzu Central Hospital, Malawi

Background Stenotrophomonas maltophilia is a significant opportunistic pathogen that is associated with high mortality in immunocompromised individuals. In this study, we describe a multidrug-resistant (MDR) S. maltophilia clinical isolate from Kamuzu Central Hospital (KCH), Lilongwe, Malawi. Methods: A ceftriaxone and meropenem nonsusceptible isolate (Sm-MW08), recovered in December 2017 at KCH, was referred to theNational Microbiology Reference Laboratory for identification. In April 2018, we identified the isolate using MALDI Biotyper mass spectrometry and determined its antimicrobial susceptibility profile using microdilution methods. Sm-MW08 was analysed by S1-PFGE, PCR, and Sanger sequencing, in order to ascertain the genotypes that were responsible for the isolate`s multidrug-resistance (MDR) phenotype. Results Sm-MW08 was identified as S. maltophilia and exhibited resistance to a range of antibiotics, including all ß-lactams, aminoglycosides (except arbekacin), chloramphenicol, minocycline, fosfomycin and fluoroquinolones, but remained susceptible to colistin and trimethoprim-sulfamethoxazole. The isolate did not harbour any plasmid but did carry chromosomally-encoded blaL1 metallo-ßlactamase and blaL2 ß-lactamase genes; this was consistent with the isolate's resistance profile. No other resistance determinants were detected, suggesting that the MDR phenotype exhibited by Sm-MW08 was innate. Conclusion : Herein, we have described an MDR S. maltophilia from KCH in Malawi, that was resistant to almost all locally available antibiotics. We therefore recommend the practice of effective infection prevention measures to curtail spread of this organism

Estimating risk factors of urban malaria in Blantyre, Malawi: A spatial regression analysis

Objective: To estimate risk factors of urban malaria in Blantyre, Malawi, with the goal of understanding the epidemiology and ecology of the disease, and informing malaria elimination policies for African urban cities that have markedly low prevalence of malaria. Methods: We used a case-control study design, with cases being children under the age of five years diagnosed with malaria, and matched controls obtained at hospital and communities. The data were obtained from Ndirande health facility catchment area. We then fitted a multivariate spatial logistic model of malaria risk. Covariate and risk factors in the model included child-specific, household and environmental risk factor (nearness to garden, standing water, river and swamps). The spatial component was assumed to follow a Gaussian process and model fitted using Bayesian inference. Results: Our findings showed that children who visited rural areas were 6 times more likely to have malaria than those who did not [odds ratio (OR) = 6.66, 95% confidence interval (CI): 4.79-9.61]. The risk of malaria increased with age of the child (OR = 1.01, 95% CI: 1.003-1.020), but reduced with high socio-economic status compared to lower status (OR = 0.39, 95% CI: 0.25-0.54 for the highest level and OR = 0.67, 95% CI: 0.47-0.94 for the medium level). Although nearness to a garden, river and standing water showed increased risk, these effects were not significant. Furthermore, significant spatial clusters of risk emerged, which does suggest other factors do explain malaria risk variability apart from those established above. Conclusions: As malaria in urban areas is highly fuelled by rural-urban migration, emphasis should be to optimize information, education and communication prevention strategies, particularly targeting children from lower socio-economic position.

Elderly People and Reproductive Decisions of Couples Living with HIV in Southern Malawi.

Aims: To explore experiences of elderly people on reproductive decisions made by couples living with HIV in rural southern Malawi. Study Design: This was a qualitative exploratory descriptive research. Place and Duration of Study: The informants were recruited from two districts in southern Malawi, patrilineal Chikhwawa - Ngabu area and matrilineal Chiradzulu - Ndunde area between July and December, 2010. Methodology: Four focus group discussions, with thirty elderly men and women, 15 from each district, where division by gender was the criteria employed in attempts to create well-functioning and articulate groups were selected purposively. Data was analyzed concurrently with data collection using content method. The interviews, which, were transcribed verbatim were uploaded into Nvivo qualitative management software enabling a systematization and easier retrieval of data. Results: Emerging themes were generation gap, defeated/ignored, lack of information and blame situation. First there was generation gap which led to the elderly people feel that their role in the community was defeated, which they indicated by being ignored in reproductive decision making. They further indicated that they lack information about current issues related to HIV, AIDS and reproductive decisions in couples living with HIV. All these led to a blame situation where the elderly people blamed either the couples living with HIV or health workers for the current situation. Conclusion: Older people need to be recognized, supported and educated in the fight against HIV and AIDS. The different needs, roles and responsibilities of older men and women need to be acknowledged and included in programs and policies addressing this global epidemic.

Perceptions of nursing students trained in a new model teaching ward in Malawi / 보건의료교육평가

This study aimed to investigate the perceptions of nursing students trained in a new model teaching ward in Malawi. A total of 90students from five nursing colleges were randomly assigned to one model ward and two ordinary wards in a single teaching hospital. The students were administered a revised version of the Student Evaluation of Clinical Education Environment questionnaire. Significant differences among the three wards were found in all items in the communication/feedback subscale, with the exception of the item "nursing staff provided constructive feedback" (P=0.162). Within the learning opportunities subscale all items showed significant differences among the three wards, whereas 50% of the items in the learning support/assistance subscale had significantly different responses among the three wards. Within the department atmosphere subscale, no significant differences were found in the items assessing whether an adequate number and variety of patients were present in the ward (P=0.978). The strategies that are being implemented to improve the educational environment showed positive results. Students scored the model teaching ward highly. Students who underwent precepting in the model teaching wards reported having more learning opportunities and a positive learning environment.

The Epidemiology of Trachoma in the Lower Shire Valley of Southern Malawi and Implications for the “SAFE” Strategy.

Aims: To determine the prevalence of trachoma and associated risk factors in the Lower Shire Valley of Southern Malawi. Study Design: Population based cross sectional study. Place and Duration of Study: Lower Shire Valley of southern Malawi between July and October 2012. Methodology: Children aged 1-9 years (total 2957) were assessed for clinical signs of active trachoma follicular (TF) and adults aged 15 and above (total 2247) were assessed for signs of trachoma trichiasis (TT), which is potentially blinding trachoma. A questionnaire survey was conducted to explore the potential risk factors. Results: A total of 2957 children aged 1-9 years who were assessed for clinical signs of TF and 2247 adults aged 15 and above were assessed for signs of TT.The prevalence of TF among children aged 1-9 years was found to be 18.5% (95% CI 16.4-20.8) in Nsanje and 7.8% (95% CI 6.6-9.2) in Mwanza districts respectively. The prevalence of TT in adults aged 15 and above was 0.5% (95% CI: 0.1-0.9) in Nsanje district and 0.2% (95% CI: 0.1-0.4) in Mwanza district, respectively. In regards to risk factors, only the presence of a dirty face was associated with trachoma follicular (TF) in Nsanje and Mwanza districts (P< 0.001). Conclusion: In this study, prevalence of active trachoma infections was 18.5% in Nsanje and 7.8% in Mwanza district. Dirty face was associated with trachoma follicular in both districts. According to WHO, Nsanje therefore needs a SAFE (Surgery, Antibiotics, Face Washing and Environmental) control strategy.

Potential Barriers to Healthcare in Malawi for Under-five Children with Cough and Fever: A National Household Survey.

Failure to access healthcare is an important contributor to child mortality in many developing countries. In a national household survey in Malawi, we explored demographic and socioeconomic barriers to healthcare for childhood illnesses and assessed the direct and indirect costs of seeking care. Using a cluster-sample design, we selected 2,697 households and interviewed 1,669 caretakers. The main reason for households not being surveyed was the absence of a primary caretaker in the household. Among 2,077 children aged less than five years, 504 episodes of cough and fever during the previous two weeks were reported. A trained healthcare provider was visited for 48.0% of illness episodes. A multivariate regression model showed that children from the poorest households (p=0.02) and children aged >12 months (p=0.02) were less likely to seek care when ill compared to those living in wealthier households and children of higher age-group respectively. Families from rural households spent more time travelling compared to urban households (68.9 vs 14.1 minutes; p<0.001). In addition, visiting a trained healthcare provider was associated with longer travel time (p<0.001) and higher direct costs (p<0.001) compared to visiting an untrained provider. Thus, several barriers to accessing healthcare in Malawi for childhood illnesses exist. Continued efforts to reduce these barriers are needed to narrow the gap in the health and healthcare equity in Malawi.

Bloodstream Infections and Malaria as Causes of Fever among Adult Medical Patients at a Referral Hospital in Malawi.

Background and Aims: In Sub-Saharan Africa management of adult patients with febrile illness consists very often of empirical antibacterial and ant malarial treatment. This study examines the frequency, species identification and antibiotic susceptibility of bacterial isolates from blood and determines the frequency of malaria and the proportion of verified malaria cases among presumptively treated patients at a Malawian hospital. Study Design: This is a cross-sectional survey. Place and Duration of Study: Patients were enrolled at the Medical Department of Kamuzu Central Hospital, a referral hospital in Lilongwe, Malawi, between October 2010 and March 2011. Methodology: Patients ≥18 years with an axillary temperature ≥37.5°C were included. Blood cultures, malaria rapid diagnostic tests (RDTs), thick blood smears and HIV testing were performed. Results: 180 patients (58.3% female, median age: 31 years) were enrolled. Out of 157 patients, 89 (56.7%) tested HIV positive. Bacteremia was found in 19 (10.6%) patients including 6 (31.6%) Streptococcus pneumoniae, 6 (31.6%) Escherichia coli and 5 (26.3%) Salmonella enterica (4 Salmonella enterica serotype Typhimurium and 1 Salmonella enterica serotype Typhi). S. typhimurium and E. coli isolates showed frequent resistance to chloramphenicol, ampicillin and cotrimoxazole. Ceftriaxone was given to 110 (61.1%) patients. Malaria was confirmed by positive smear and/or positive RDT(s) in 57 (31.7%) cases. Presumptive antimalarial treatment was administered to 120 (66.7%) patients, however only 54 (45%) of these tested malaria positive. Conclusion: Empirical treatment of bloodstream infections should be based on antibiotic susceptibility of common local pathogens. Clinically suspected malaria should be confirmed by using malaria diagnostic testing before treatment. The use of malaria RDTs has to be carefully supervised and adherence to test results is advisable.

Assessment of the accuracy of dried blood spot (DBS) sample in HIV-1 viral load as compared to plasma sample using Abbot assay.

Background: HIV has claimed millions of lives with the Sub-Saharan Africa being the most affected. There is a significant increase in access to antiretroviral drugs which also demands frequent monitoring to determine the drug effectiveness and efficacy. Thus there is a great need to evaluate simplified methods to monitor treatment with such antiretroviral drugs. Use of dried blood spots (DBS) can be ideal if evaluated in resource limited countries such as Malawi since they are easy to collect, store and convenient. The main objective of this study was to evaluate the accuracy of a dry blood spot sample in the quantification of viral particles in HIV reactive patients using the Abbott m2000rt assay. Methods: 87 participants were recruited from the ART clinic at Queen Elizabeth Central Hospital using convenience sampling method. 29 were on antiretroviral therapy and 58 had not started the therapy. HIV-1 RNA extraction and quantification was performed from DBS and plasma using Abbott m2000sp and m2000rt systems respectively. The results were statistically analyzed by Bland-Altman method using medcalc software version 12.6.1. Results: 66 paired samples with detectable viral loads were analysed. These gave a correlation of 0.98. The mean difference was 0.05 log10 copies/ml with a standard deviation of 0.17 at 95% confidence interval.The Bland-Altman plots showed limits of agreement which ranged from -0.38 to 0.28 log10 copies/ml at 95% confidence interval. Conclusion: Results showed strong agreement between the plasma and DBS samples. A slight and clinically insignificant difference was observed between the two methods. A larger sample size can give support to the study findings. Since samples were less than a week old, it is not known if the results would be different if they were to be stored for a longer period.

Perceptions of Malawian Nurses about Nursing Interventions for Malnourished Children and Their Parents.

In developing countries, malnutrition among children is a major public-health issue. The aim of the study was to describe perceptions of Malawian nurses about nursing interventions for malnourished children and their parents. A qualitative method was used. Data were collected and analyzed according to the phenomenographic research approach. Twelve interviews were performed with 12 nurses at a rural hospital in northern Malawi, Southeast Africa. Through the analysis, two major concepts, comprising four categories of description, emerged: managing malnutrition today and promotion of a favourable nutritional status. The categories of description involved identification and treatment of malnutrition, education during treatment, education during prevention, and assurance of food security. The participating nurses perceived education to be the most important intervention, incorporated in all areas of prevention and treatment of malnutrition. Identification and treatment of malnutrition, education during treatment, education to prevent malnutrition, and assurance of food security were regarded as the most important areas of intervention.

Lost investment returns from the migration of medical doctors from Malawi

Migration of medical doctors from African countries to developed nations compromises the delivery of health care on the continent. The full cost of producing a medical doctor was estimated in Malawi by adding the costs of education from primary school through undergraduate medical education. The cost in fees for one medical doctor produced was US$ 56;946.79. The amount of lost investment returns for a doctor who migrated out and served for 30 years in the receiving country ranged from about US$ 433;493 to US$46 million at interest rates 7and 25; respectively. Quantitative assessments of the estimated loss in investment allows for informed policy discussions and decisions

Prevalence and determinants of cigarette smoking among adolescents in Blantyre City; Malawi

Tobacco smoking is a major risk factor for non-communicable diseases such as ischaemic heart disease; stroke; chronic obstructive airways disease and several cancers. There is little data about the prevalence and determinants of smoking among adolescents in southern Africa. This study aimed to determine the prevalence and determinants of cigarette smoking among adolescents in Blantyre City; Malawi. Cross-sectional data were obtained from school-going adolescents in Blantyre in 2001 using the Global Youth Tobacco Survey data collection instrument. Data were analysed to determine prevalence of current and ever cigarette smoking; and predictors of smoking. The prevalence of urrent smoking and ever smoking were 3.0and 15.6; respectively. Predictors of current tobacco smoking included male gender; having friends or parents who smoked; having been exposed to advertisements about tobacco brands on television and having seen a lot of advertisements in newspapers and magazines. School programmes that included being taught about smoking in class and a class discussion on the dangers of tobacco were not associated with reduced current smoking. Intervention programmesaiming to curb tobacco smoking among adolescents should focus on dealing also with parental smoking; peer influence and pay special attention toward male gender. School-based programmes to prevent smoking should be evaluated as some may have little impact in influencing current smoking status

JOCV pharmacists' activities and Malawi medical situation / 国際保健医療

[Background] Japan Overseas Volunteer Cooperation (JOCV) pharmacists have been sent to Malawi. There were two big reasons. One was there were no colleges to train pharmacist. When people want to be pharmacists, they have to go to abroad to have education. However many of them never come back to Malawi after finishing the course. Thus a lack of pharmacists was severe. And almost pharmacy staffs were untrained. Another was medicines had been stolen by insiders. At that time hospital in charge wanted to be managed by credible outsiders. I was also one of pharmacists in Malawi. However I often heard Japanese pharmacists were dull to be faced the rigid situation of Malawi health sector and the difficulties of mutual understanding even they had been full of hope. [Aim] The aims of this study were to explore the activities of Japanese pharmacist's volunteers in Malawi and to investigate our problems and solutions. [Method] Project cycle management (PCM) method was adopted. Participants were 10 members of the Malawi JOCV pharmacists committee. The JOCV volunteer coordinator and the JICA expert took part in this discussion as observers. Those statements were categorized into each category. [Results] Japanese pharmacists have had the clams and complaints against their missions. Their clams and complaints were separated to three. One was the problems of Malawi side, which were un-cleared Japanese pharmacists' position and insufficient infrastructure. Other was JOCV side, which was lack of communication with Malawian. And the other was both sides, which was an absence of mutual understanding. When we ignored these problems, the opportunities of international aids by pharmacists would be decrease. [Conclusion] According to the results, Malawi JOCV pharmacists committee recommended to JICA Malawi office reconsidering about sending pharmacist volunteers and made efforts to appeal their actions.

Experience of Health Sector Development Study in Malawi / 国際保健医療

 Between June 1998 and January 2000, "The Master Plan Study on Strengthening Primary Health Care Services (JICA PHC Study)" was executed in the Republic of Malawi. The purpose of the study was to formulate a central region master plan and a national master plan to improve the primary health care (PHC) system, and to transfer essential research, analytical skills, and methodologies to Malawian counterparts. The health investigations covered the referral system, human resources, health finance, policy and management, the health management information system, community participation, logistics systems and health facilities and supplies. As a result of the study, childhood malnutrition, maternal health, and the inappropriate role of informal drug-sellers, in the PHC system were found to be key health issues, and on the basis of these problems the national master plan was formulated with six prioritized proposed projects. In this report, the following challenges to the execution of effective and efficient study were discussed and recommended through the review of health development studies conducted in five developing countries including Malawi; 1) the study purpose and the concept of a master plan should be clarified, 2) the study outcome should be evaluated and utilized effectively, 3) terms of reference for the study should be reviewed and improved, 4) a better relationship with counterparts and donors should be developed, and 5) a capacity of participants in the study such as consultants should be built up.