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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.

In the past few decades, climate-smart agriculture (CSA) has been promoted to improve food security and raise incomes as a strategy for sustainable agricultural development. The adoption rates among smallholder farmers, particularly in Africa, remain low and have varied in different contexts. We investigated the market participation spill over effects from the adoption of CSA practices in central Malawi. We tested the hypothesis that the extent of the use of CSA practices in the past 10 years can lead to production surpluses that enable smallholder farmers to participate in markets and thereby increase agricultural incomes. The findings suggest, among others, the need to intensify efforts to promote CSA adoption specifically over a longer period for benefits of the technologies to materialise. The adoption of CSA practices over time enhances crop market participation – an important aspect required for production sustainability as well as for transforming agriculture towards greater market orientation among smallholder farmers.

Many years of significant investment into the production and adoption of productivity-enhancing technologies and practices in agriculture have not yielded the desired results. Most smallholder farmers in Africa remain trapped in poverty. Having realised that addressing production challenges alone is not enough to impact the lives of poor smallholder farmers, resources and attention have now shifted to the marketing side of agriculture. Organising farmers into farmer producer organisations (FPOs), like clubs, associations and cooperatives, has been one of the strategies aimed at commercialising smallholder agriculture. In Malawi, smallholder farmers have been organised into FPOs of various types and sizes. This qualitative study interrogated the effectiveness of FPOs in Malawi in meeting their objectives, including the objective of enhancing commercialisation of smallholder farmers through increased access to farm inputs, markets, and agricultural extension and advisory services.

Many sub-Saharan African countries implementing agricultural input subsidies programmes (AISP) concentrate on fertilizers and staple food crops which may have little or no effect on consumption of diverse nutrient dense non-staple foods. The programme in Malawi – the Farm Input Subsidy Programme (FISP) – includes legume seeds, but little research has been undertaken to evaluate the effects of this strategy on household dietary diversity. In this study, we used two waves of integrated household panel survey data of 2013 and 2016 to examine the dietary diversity gains from inclusion of legume seed coupons in the programme. The control function approach for dealing with selection bias into a programme is used in Poisson regression of panel data. The results show that access as well as redemption of legume coupons is positively associated with diversified diets. This is especially through location fixed effects in the southern region of Malawi, higher production diversity, greater land holding sizes and the sale of maize. Further, households that had less need to satisfy hunger through the growing of maize were those likely to redeem legume coupons. The results suggest a more nuanced pathway of impact from coupon access, redemption or type of crop produced to dietary diversity than the pathway that might be expected, and have implications for how best to understand and conceptualise the tensions and synergies between addressing different aspects of malnutrition in all its forms – and suggest the importance of addressing food insecurity constraints that potentially limit the growing of nutrient-rich legume crops as well as wider increases to dietary diversity. The results also point to the importance of the income pathway and food markets in facilitating greater dietary diversity. Further consideration of these issues by policymakers and the wider agri-nutrition community will be important to advance the discussion and research of how best to design AISP and other public policy to address malnutrition in all its forms.