Developmental and operationalisation influences of Malawi's Health Sector Strategic Plan III 2023-2030: A qualitative study of the context, processes, content and actors

IntroductionMalawis Ministry of Health (MOH) launched the Health Sector Strategic Plan III (HSSP III) 2023-2030, which features catalytic efficiency and accountability reforms under the "One Plan, One Budget, One Report" framework. This policy analysis examined the context, historical influences, processes, and stakeholders shaping the development and early implementation of the HSSP III. MethodsBetween June and December 2023, we conducted a document review guideline (n=21) and in-depth semi-structured interviews with health stakeholders (n=12). We initially analysed the data using inductive content analysis, employing the HSSP III development process, followed by a deductive approach that utilised the Walt and Gilson policy triangle, complemented by other conceptual frameworks, with triangulation and consensus validation. ResultsHistorically, economic and decision-making inequities in Malawis health sector have led to centralised processes, vertical funding, and low staff motivation. In response, HSSP III was aligned with current movements for universal health coverage and donor aid coordination. The plans development promoted capacity building, country ownership, and accountability through an inclusive and participatory approach, as well as a performance management-oriented framework. However, incomplete operational plans and misaligned decision-making systems have impeded early implementation. Discussion/ConclusionThe Malawi HSSP III responded to the fragmented health sector through a government-led, sector-aligned approach. Its development leveraged long-term leadership and a consultative learning environment to foster capacity and stakeholder ownership. However, the transformative development process alone was not sufficient. Operationalisation and long-term reform require increased government accountability. These findings provide valuable insights for policy development, implementation, and long-term transformational change in Malawi and similar settings.