The role of the traditional leader in implementing maternal, newborn and child health policy in Malawi Aisling Walsh 1, *, Anne Matthews 2 , Lucinda Manda-Taylor 3 , Ruairi Brugha 1 , Daniel Mwale 3 , Tamara Phiri 4 and Elaine Byrne 5 1 Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin, Ireland, 2 School of Nursing and Human Sciences, Dublin City University, Dublin, Ireland, 3 College of Medicine, University of Malawi, Malawi, 4 Department of Nursing and Midwifery, Mzuzu University, Malawi and 5 Institute of Leadership, Royal College of Surgeons in Ireland, Dublin, Ireland *Corresponding author. Aisling Walsh, Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland. E-mail: aislingwalsh@rcsi.ie Accepted on 8 June 2018 Abstract Traditional leaders play a prominent role at the community level in Malawi, yet limited research has been undertaken on their role in relation to policy implementation. This article seeks to analyse the role of traditional leaders in implementing national maternal, newborn and child health (MNCH) policy and programmes at the community level. We consider whether the role of the chief embodies a top-down (utilitarian) or bottom-up (empowerment) approach to MNCH policy imple- mentation. Primary data were collected in 2014/15, through 85 in-depth interviews and 20 focus group discussions in two districts in Malawi. We discovered that traditional leaders play a pivotal role in supporting MNCH service utilization, through mobilization for MNCH campaigns, and encouraging women to give birth at the health facility rather than at home or in the community set- ting. Women and their families responded to bylaws to deliver in the facility out of respect for the traditional leader, which is ingrained in Malawian culture. Fines were imposed on women for deliv- ering at home, in the form of goats, chickens and money. Fear and coercion were often used by traditional leaders to ensure that women delivered at the health facility. Chiefs who failed to en- force these bylaws were also fined. Although the role of the traditional leader was often positive and encouraging in relation to MNCH service utilization, this was sometimes carried out in a coer- cive manner. Results show evidence of a utilitarian top-down model of policy implementation, where the goal of health service utilization justified the means, through encouragement, fear, punishment or coercion. Although the bottom-up approach would be associated with a more empowerment approach, it is unlikely that this would have been successful in Malawi, given the hierarchical nature of society. Further research on policy implementation in the context of commu- nity participation is needed. Keywords: Malawi, traditional leader, maternal, newborn and child health, community health, top-down policy, utilitarian, em- powerment, community participation Introduction Despite decades of global recognition (WHO 1978) and empirical studies recognizing the importance of the community in improving their own health and accessing health services (McCoy et al. 2012; Molyneux et al. 2012; Walsh et al. 2012; Rifkin 2014; George et al. 2015) and in particular in accessing maternal and child health serv- ices (Coutinho et al. 2005; Rosato et al. 2008; Kumar et al. 2012; Marston et al. 2013; Prost et al. 2013; Kumar and Agrawal 2016), V C The Author(s) 2018. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 879 Health Policy and Planning, 33, 2018, 879–887 doi: 10.1093/heapol/czy059 Advance Access Publication Date: 31 July 2018 Original Article Downloaded from https://academic.oup.com/heapol/article/33/8/879/5062267 by guest on 04 May 2021