The emergence and incremental development of priority for noncommunicable diseases in Malawi between 1999 and 2024

Chronic noncommunicable diseases (NCDs, such as cancers and diabetes) account for ∼75% of global deaths. Approximately 80% of premature NCD-related deaths (before age 70) occur in lower-income countries. Agenda setting for NCDs in lower-income countries is crucial and under-analyzed. This study aimed to reveal ways in which priority for NCDs may transpire in lower-income countries in the absence of common drivers, such as focusing events and international aid. We conducted a comparative case study of agenda setting for NCDs in Malawi over 25 years, asking how and why priority emerged, changed and varied at the disease level. The exploratory study is informed by health policy analysis and process scholarship, extensive document analysis and 26 key informant interviews with experts representing a range of perspectives (bureaucratic, political, civil society, media, international agency and NGO). Priority for NCDs in Malawi remained low compared to high profile issues like HIV/AIDS, tuberculosis and malaria. Priority levels varied among NCDs, with priority for cervical cancer emerging early and becoming well-established; priority for other cancers, diabetes and hypertension emerging later and growing incrementally; and priority for other NCDs largely latent. We traced differences to interactions between varying problem and solution frames; international aid flows; the strength of lead agencies, networks and institutional infrastructure; and resonance with domestic political and economic interests. The trajectory of NCDs—a proxy for health systems strengthening—appears unlikely to change in Malawi without stronger resonance with the interests of authorities who control budgetary commitments domestically.