International development and global health efforts have come under increased scrutiny in recent decades, as despite a range of interventions spanning seven-decades, improvements in health and wellbeing lag critically behind aspirations in many places throughout the world. Malawi is an icon for challenges in these arenas, as patients, healthcare personnel and planners continue to struggle with high rates of maternal mortality, deaths of children under the age of five, large burdens of infectious and noncommunicable diseases, one of the worst shortages of healthcare personnel in the world, economic stagnation, and disjointed policies. This complex web of hardships implicates processes that stretch from historic geopolitics to institutional human resource policies, to acute breakdowns in communication within clinical encounters, and frequently produces daunting social and personal challenges for healthcare personnel. Previous research has covered a variety of topics related to development and medicine in Malawi and sub-Saharan Africa, yet studies have left critical voids in understanding the perspectives and practices of Malawian healthcare personnel, themselves-those persons who navigate policies and care for patients on a daily basis. Based upon research from 2011-2017, this dissertation looks closely into healthcare delivery and development efforts in Southern Malawi and delves into Malawi's history, its people, plans and behaviors that make up the quotidian and the extraordinary, the abstract and the intimate, and the successes and the failures of daily experiences. Utilizing 33 in-depth interviews with Malawian clinicians, administrators and medical students, and over 300 hours of participant-observation that involved over 1000 patient visits across each tier of Malawi's referral network, I break these challenges into scalar dimensions so as to render them more tractable (e.g. international and national development efforts, clinician shortages at national and institutional levels, and clinicians' thoughts and practices regarding specific patient populations). I discuss how these pieces fit together, and how and why personnel are seeking greater independence from their national government and international NGOS; how and why Malawi's particular history contributes to discordances between personnel's expectations and realities of practice, and how such contrasts exacerbate shortages of personnel; how clinicians rely on heuristics and preferences to manage a variety of patients within tight time constraints, and how these devices can both facilitate and undermine care. Within this discussion, I highlight the fact that there is no 'universal mechanism' to explain the details of all of these processes, as each follows a series of highly specific interactions that depends upon the actors and conditions involved. This general argument is not new, but its application to this topic provides novel insight into development efforts and clinical behaviors. By taking this approach, I add to the work of other critical medical anthropologists and development scholars who seek to connect the global to the local, and the sociohistorical to the biocultural, while focusing on areas of great need.
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