Malawi Has Led Before

In 2010, an estimated 16,793 children in Malawi were infected with HIV, the human immunodeficiency virus. Nearly all acquired it from their mothers during pregnancy, birth or breastfeeding.

The following year, Malawi’s Ministry of Health took a step the World Health Organization (WHO), the United Nations’ health agency, did not recommend. Every pregnant or breastfeeding woman found to have HIV would be offered treatment immediately, for life, without further testing.

By 2024, new infections in children had fallen to 2,164 a year, a drop of 87%. Malawi’s National AIDS Commission estimates that the programme has prevented about 147,000 infections since 2011. WHO changed its guidelines in 2013, citing Malawi. Within about a year, 21 of the 22 countries identified as priorities by a United Nations-backed plan had followed.

This is the same country whose Shire Valley irrigation scheme spent $154 million of a $160 million World Bank loan between 2018 and 2024 without watering a single hectare. The same civil service. The same donors. The same election cycle. One programme has run for twenty years and changed world practice. The other has yet to deliver water.

Malawi has shown, more than once, that it can deliver. The question is what was different when it did.

---

The Decision Others Followed

HIV attacks the body’s immune system. Without treatment, it leads to acquired immunodeficiency syndrome (AIDS), the most advanced stage of the disease. Daily medicine called antiretroviral therapy (ART) keeps the virus under control, allows people to live long lives and makes them far less likely to pass it on.

Before 2011, WHO’s guidance divided pregnant women with HIV into two groups, based on an immune-system test or their symptoms. Women judged sick enough received lifelong treatment. The rest received medicine only to protect their babies, stopping soon after birth or when breastfeeding ended.

Malawi could not run that system. According to a 2018 study of how the policy spread, only about 50 of the country’s 417 HIV clinics had a working machine for the immune test. The ministry chose a rule every clinic could follow: lifelong treatment for every pregnant or breastfeeding woman with HIV, without requiring the immune test. The approach became known as Option B+.

The decision came at a cost. The Global Fund to Fight AIDS, Tuberculosis and Malaria, a major international funder of HIV programmes, could support only approaches WHO already recommended. Malawi’s 2011 application for support was “initially unsuccessful”. Funding came instead through revisions to existing grants and new support from the United States and others.

Results came quickly. The United States Centers for Disease Control and Prevention (CDC) reported that the number of pregnant and breastfeeding women starting treatment each quarter rose from 1,257 to 10,663 in little more than a year. By March 2013, Rwanda, Uganda and Haiti had adopted the approach. Three months later, WHO recommended it as an option, particularly where HIV is widespread, noting that Malawi had introduced it in 2011.

Starting treatment, however, is only the beginning of a lifelong commitment. The CDC also checked whether women stayed on it. Among those who began treatment in the policy’s first three months and did not move to another clinic, 77% were still receiving treatment a year later, close to the 80% for adults who had started before Option B+. Some of those recorded as lost to follow-up may have died.

---

Twenty Years, Several Governments

Option B+ reached every health facility in the country within months because Malawi had spent the previous seven years building the system to deliver it.

In January 2004, about 4,000 people were on HIV treatment at nine public health facilities. By September 2005, 30,055 people had started free treatment at 60 facilities. The doctors who built the programme summed up its rule in one sentence: “What is done in one hospital or clinic is done in every other facility in the country.”

By 2024, an estimated 900,000 people, 90% of everyone living with HIV in Malawi, were on treatment. New infections across the population fell by 79% between 2010 and 2024. The Joint United Nations Programme on HIV/AIDS (UNAIDS) names Malawi as one of only five countries in the world to have cut new infections by at least 75% over that period.

The nationwide expansion began in 2004. Twenty years later, the programme was still running on the same rule. Governments changed in 2014, 2020 and 2025; the programme continued.

---

What Was Different

Money alone does not explain the contrast with Shire Valley. Both programmes were funded, mostly from abroad. Development partners paid about 77% of Malawi’s HIV spending between 2019 and 2022. The World Bank put up about three-quarters of the money for Shire Valley’s first phase, the African Development Bank most of the rest, and nearly all of it was spent. Both operated through the same ministries, procurement rules and changes of government.

The HIV programme had four things the irrigation scheme did not:

• A clear task. Every clinic, however small, could understand the instruction: offer every pregnant or breastfeeding woman with HIV treatment for life.
• One method. Every clinic followed the same approach.
• A count every quarter. Every clinic reported the same outcomes every three months, so a problem in one district showed up within months, rather than at the end of a loan.
• Continuity. Each new government kept the rule it inherited.

An irrigation canal needs engineers, contractors and foreign currency that no clinic guideline can supply. But these four features concern how work is organised. Malawi made those choices in 2004 and has benefited from them for twenty years.

---

It Was Not Only HIV

The same pattern—a clear task carried out consistently—appears elsewhere.

The first malaria vaccine. Children under five account for about three in four malaria deaths in WHO’s African region. When WHO and its partners tested the first malaria vaccine in ordinary health services, three countries took part: Malawi, Ghana and Kenya. Malawi went first, on 23 April 2019.

Malawian scientists at Kamuzu University of Health Sciences, including Don Mathanga and Victor Mwapasa, were among the authors of the main evaluation, published in The Lancet in 2024. Four years of results show that about one in eight child deaths were prevented among children eligible for the vaccine. By January 2026, 25 African countries had introduced it. In Malawi itself, the vaccine was still given in only 11 of 28 districts that month.

A Malawian trial that changed WHO’s advice. Children who survive severe malarial anaemia, when the blood has too few red cells to carry oxygen, face a high risk of dying or returning to hospital in the months after they go home. A trial in southern Malawi, with Malawian scientist Kamija Phiri as first author, tested giving these children monthly courses of malaria medicine for two months after discharge. In 2022, WHO recommended the approach for areas where malaria transmission is moderate or high, based on three trials.

Nine million people registered in 180 days. Before 2017, only an estimated 40,000 to 50,000 Malawians held a national identity card. Between May and November 2017, the government registered more than 9.1 million citizens, according to a 2019 World Bank account. The government led the design and management, with the United Nations Development Programme (UNDP) as partner and other donors providing funding. The exercise cost US$52 million and employed 4,200 registration officers, mostly university students.

The card is now the only identification accepted for registering to vote and is required for banking and SIM cards. Keeping up has proved harder. In April 2024, the government promised to clear a backlog of unprinted cards, with its existing printer managing about 800 a day.

A clear job, one method and a count at the end. Each time, the job got done.

---

The Limits

These successes were not Malawi’s alone, and they are not secure.

When funding from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) was halted in January 2025, a study of 16 clinics found that clinical staff numbers fell and had not returned to earlier levels by December 2025. Viral suppression, the share of patients whose virus is kept at very low levels, had recovered but remained below earlier levels. The programme also has its own gap: in 2024, only about 58% of children living with HIV were on treatment, compared with 92% of adults.

Nor does being copied establish that a policy works. In 2005/06, Malawi launched the Farm Input Subsidy Programme (FISP), a large subsidy on fertiliser and seed for small farmers. It reached 1.3 million households in its first year. Economists Thomas Jayne and Shahidur Rashid found that Malawi’s example encouraged at least nine other African governments to start or revive similar programmes by 2010. They also reported that later analyses found the early claims of success “highly debatable in some respects and factually incorrect in others”. A 2008 evaluation credited good rains as well as fertiliser.

Between 2016/17 and 2021/22, the subsidy took over two-thirds of the government’s budgeted spending on farming and food. The World Bank’s 2025 review estimates that each kwacha, Malawi’s currency, returns a kwacha or less in extra crops. In 2019/20, only 17% of Malawian households grew more maize than they needed. In the 2025/26 season, two weeks after the programme opened, fewer than 10% of target households had collected their fertiliser.

The subsidy has survived every change of government since 2005. Continuity alone is not enough. The HIV programme combined it with a clear task, a consistent method and regular measurement.

---

In 2010, nearly 17,000 Malawian children acquired HIV, almost all from their mothers. In 2024, the number was about 2,200. No outside agency handed Malawi the rule behind that change. Malawi’s Ministry of Health wrote it, ahead of WHO, with about fifty working machines for more than four hundred clinics. The world followed.

Malawi has proved it can set a clear task, carry it out the same way in every district, count the results every quarter and keep going through every change of government since. Those are skills in organising and sustaining public work. The country’s unbuilt canals, dry taps and dark villages are waiting for them.