{"id":1697,"date":"2011-05-03T10:29:18","date_gmt":"2011-05-03T10:29:18","guid":{"rendered":"http:\/\/www.faceofmalawi.com\/?p=1697"},"modified":"2011-05-03T10:29:18","modified_gmt":"2011-05-03T10:29:18","slug":"health-financing-in-malawi","status":"publish","type":"post","link":"https:\/\/new.faceofmalawi.com\/index.php\/2011\/05\/03\/health-financing-in-malawi\/","title":{"rendered":"HEALTH FINANCING IN MALAWI"},"content":{"rendered":"<div id=\"attachment_1698\" style=\"width: 138px\" class=\"wp-caption alignleft\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1698\" class=\"size-full wp-image-1698\" title=\"dr\" src=\"http:\/\/www.faceofmalawi.com\/wp-content\/uploads\/2011\/05\/dr.jpeg\" alt=\"\" width=\"128\" height=\"128\" \/><p id=\"caption-attachment-1698\" class=\"wp-caption-text\">DR RABSON KACHALA<\/p><\/div>\n<p>In literature there are seven forms of health sector funding  mechanisms. They are through tax revenue in government budgets; social  insurance; medical saving account (MSA); private-financing or  out-of-pocket payments; private insurance; external (aid) assistance  through bilateral or multilateral agreements; and philanthropy. However,  in this article, Malawi health sector is financed through tax revenue  in government budgets (approximately covering 60 percent in 2009),  external aid assistance (about 35 percent in 2009), private insurance,  out-of-pocket payments and philanthropy.<\/p>\n<p>Private Insurance, at low scale, only practiced in cities and  out-of-pocket payments, are major sources of financing the private  health sector in Malawi with philanthropy exclusively reported in  mission (private non-for-profit) hospitals through CHAM. Unlike in  private health sector, tax revenue and external aid assistance are main  sources of financing public health sector through joint health SWAp  resource reallocation. The public health sector remains the single most  important source of finance for health care in the country because of  government subsidy through free health services for all Malawians  regardless of level of health care.<\/p>\n<p>Ellias Ngalande Banda and Henry Simukonda in 1994 reported that the  Malawi MOH 1983 Report highlighted public health sector as the most  important source of health-financing then, while CHAM was the major  recipient of the direct out-of pocket payments because for-profit  private health facilities were then insignificant.<\/p>\n<p>Constitutionally, public health in the country is regarded as <strong><em>public goods<\/em><\/strong> as opposed to private goods in health economic concepts.<\/p>\n<p><strong> <\/strong><strong>Health as Public Goods in Malawi<\/strong><\/p>\n<p>In this article, public health in Malawi is conceptualized as <em>public goods<\/em> which are described as non-excludable and non-rivalry such that the  marginal cost of providing the public health to another consumer is zero. The key principles in health care characteristics as economic goods or services in Malawi include;<\/p>\n<ul>\n<li>Health care is considered a right by all Malawians as an analogue to \u201c<em>health for all<\/em>\u201d slogan by WHO.<\/li>\n<li>Malawi Government shoulders both positive and negative <em>externalities<\/em> through internalizing externality costs of public health care probably  through taxatation system or other means deemed possible and justifiable  by the government of the day.<\/li>\n<li>Need for public health care by Malawians is, theoretically, assumed  predictable by the Malawi Government although in economic concepts it is  unpredictable such that she is able to budget it accordingly.<\/li>\n<li>In principle, the Malawi Government provides public health care to  her population under economic guise of small price elasticities of  demand without laissez-faire government.<\/li>\n<\/ul>\n<p><strong>Disadvantages of prescribing Health as <em>public goods<\/em> in Malawi\u2019s Constitution<\/strong><\/p>\n<ol>\n<li>Promotion of dependency by Malawians as regards to their health.<\/li>\n<li>Promotion of irresponsibilities by Malawians as regards to their  indvidual roles, behaviours\u00a0and responsibilities upon their own health  or that of their neighbour etc.<\/li>\n<li>Promotion of favourable conditions by industrial firms and affluent minorities in Malawi to suppress <strong><em>\u201cenvironmental justice\u201d<\/em><\/strong> through locating industrial areas, waste product\u00a0disposal etc to  residential areas of marginalized, poor people\u00a0and\u00a0suburbs like Kanengo  which is close to Area 25, Ndirande industrial \u00a0area and waste disposal  drainage which is close to\u00a0Ndirande Residential Area thereby increasing  environmental health hazard to already disadvantaged, marginalized poor  Malawians.<\/li>\n<li>Promotion of monopoly of national health services by government as  opposed to free health\u00a0market system at the other extreme which  unfortunately results in low healthcare quality, low  healthcare-financing, and promotion of politizing healthcare services  and corruption.<\/li>\n<li>Suppression of private health sector growth.<\/li>\n<li>Suppression of laissez-faire management at health sector level.<\/li>\n<\/ol>\n<p><strong>My Proffessional Advice to the MOH as regards to Health Sector-Financing Policies<\/strong><\/p>\n<p>I recommend the government and MOH of the country to continue providing <em>primary health care<\/em> (PHC) and essential health package (EHP) as <em>public goods<\/em>.  However, at tertiary level I happen to differ with the current public  health sector financing policy.\u00a0Therefore, this\u00a0article expounds options  in sustaining health care financing at tertiary health care in Malawi,  where specialized health care is currntly regarded as \u201c<em>public goods<\/em>\u201d  as defined above, using available evidences from best performing  low-and middle-income countries (LMICs) like Ghana and Kenya in the  continent.<\/p>\n<p>The theoretical aspect of the\u00a0article is based on two opposing  background forces. On one side there are forces contributed by absolute  poverty of the majority of the population; limited  specialized\/sub-specialized health care infrastructure and health care  services; limited or no authority in critical decision making by the  public central hospital management teams (CHMTs) under the guise of  delegation where the central government returns the right to overturn  critical CHMT management decisions; and political dispensation of  multiparty democracy which is heavily challenged by immense over-flow  effects of neo-patrimonialism and deeply personalized political power.  On the other hand, there are unequal and opposing tangible forces  contributed by escalating costs of specialized\/sub-specialized health  care services due to disproportional high-tech dynamic revolution in  medical technology in diagnosis, pharmaceuticals, surgery and  management. As such, the article\u00a0is an analytical discourse of the  current situation as regards to specialized\/sub-specialized public  health care in Malawi and it goes further to suggesting some imminent  health policy options and their tangible strategies taking into account  of all underlying opposing forces. The center of focus for each  theoretical or practical argument is the health care service\u2019s client  (patient). The\u00a0article is <strong>not<\/strong> articulating the debate of healthcare as <em>public goods<\/em> or <em>private goods<\/em>, <strong>but<\/strong> rather is elucidating the necessary role which can be played by health  care clients or patients as regards to specialized\/sub-specialized  health care in Malawi.<\/p>\n<p>Politically, LMICs\u00a0 including Malawi are expected to subsidize specialized\/sub-specialized health care charges <em>only<\/em> to those clients in absolute poverty through a closed referral health  system which I totally agree as real responsibility of a governmnet.  However, this arrangement is so rigid that it does not allow\u00a0some  potential Malawian citizen to contribute to sustainable health care  financing at government central hospitals as a way of both owning and  improving public central hospital health care system in the country. The  so called paying departments at kamuzu Central Hospital (KCH) and  Queen\u2019s Elizabeth entral Hospital are far from utilizing fully\u00a0the  potential pull of health financing. On the other hand, the new built  health facilities which are\u00a0well equiped with \u201c<em>private wings\u201d <\/em>including Nkhotakota District Hospital are not even utilized due to such rigid policies of<em> \u201cpaying departments<\/em>\u201c.<\/p>\n<p>Since the post independence, cost is not a barrier to access  healthcare at all public health facilities. While it is the  constitutional responsibility of the Malawi Government to provide  affordable and accessible high quality healthcare to all Malawians,  however, I feel it has become highly politicized with the introduction  of multiparty regime in 1994. For instance, Malawi\u00a0politicians take  advantage of the desperation of poor people as a mere bate for their  political advancements at the expense of poor quality healthcare  services. With the technical support from Malawi\u2019s development partners  under the Common Approach to Budgetary Support (CABS) mainstreamed by  European Union (EU), African Development Bank (AfDB), Germany, Norway,  the World Bank and the United Kingdom, it is hopeful that the government  assumes a more hinging role in financing public services including  health sector.<\/p>\n<p><strong><em> The Transformation of CMS into an Independent Medical<\/em><\/strong> <strong><em>Trust.<\/em><\/strong><\/p>\n<p>The first acid test for the Malawi Government as regards to health  delivery system institutional autonomy was in early 2000s when the donor  community was collectively proposing for such a milestone to start with  Kamuzu Central Hospital gradually in a step wise approach. However, the  government stepped her foot down due to two main reasons, political  fear by the then ruling government (UDF) and consideration of\u00a0the near  collapsing situation of the health delivery system in the country at  that time (2002-2003). One Malawian public civil servant bemoaned fate  of hospital autonomy in 2004 in front of the then cabinet minister of  health: \u201cWho would pay for healthcare services at the public hospitals  when the services were very poor if not collapsing, when providers  were\u00a0only paramedicals\u00a0without qualified medical doctors, without  minimum EHP regimen of drugs in such dilapidating infrastructure?\u201d  However, with the current drastic improvements in all facets (human  resources\/providers, pharmaceuticals, infrastructure development,  medical equipment and quality standards) the situation analysis of  tertiary hospital autonomy in Malawi if revisited now, I strongly  feel\u00a0may provide otherwise results.<\/p>\n<p>On the other hand, in a fresh wave,\u00a0the Malawi Government succumbed  to pressure from health pundits, civil society and donor community as  regards to the second acid test for transformation of the Central  Medical Stores (CMS) into a <strong><em>medical trust<\/em><\/strong> following a public outcry over its inefficiencies, in servicing the  country\u2019s public hospitals\u2019 needs. The MOH Report of 2010 stressed that  there was a tremendous progress in the process of turning the CMS  institution into an independent medical trust and would be registered by  the Ministry of Health through the Registrar of Companies, under the  Companies and Corporate Act soon after appointment of the board of  trustees who would run the operations of the Medical Trust.<\/p>\n<p>However, the progress of the CMS Trust remains retrogressive if <em>public health cost centres<\/em> (hospitals)\u00a0still receive unrealistic vote of funds for pharmaceuticals due erratic drug budget estimates.. <a href=\"http:\/\/www.nyasatimes.com\/health\/malawi-hit-by-medication-shortage.html\">http:\/\/www.nyasatimes.com\/health\/malawi-hit-by-medication-shortage.html<\/a><\/p>\n<p><a href=\"http:\/\/www.mwnation.com\/index.php?option=com_content&amp;view=article&amp;id=15561:shortage-of-drugs-hits-malawi-hospitals&amp;catid=119:national-news&amp;Itemid=125\">http:\/\/www.mwnation.com\/index.php?option=com_content&amp;view=article&amp;id=15561:shortage-of-drugs-hits-malawi-hospitals&amp;catid=119:national-news&amp;Itemid=125<\/a><\/p>\n<p>Therefore, politically, Malawi rejected hospital autonomy in the  disguise of putting rural and poor or vulnerable people at heart for  personal political advancement. \u00a0The potential fear of posing a barrier  to access the comprehensive healthcare by the poor people through  central hospital autonomy in Malawi is rather theoretical than  practical. With the current improved referral health system, central  hospital autonomy will provide a better checkpoint of government subsidy  for the poor at tertiary hospitals. No poor Malawi citizen could be  denied of free tertiary healthcare in the public central hospitals but  rather would be to be referred from satellite health facilities thereby  being easily accountable in goverbance for the government to re-imburse  the autonomous public hospital etc. Unlike what happens now, the central  hospital autonomy would promote the importance of entering the  healthcare delivery system through either primary or secondary level.  Congestion at central hospitals is currently due to unnecessary petty  ailments which could be successfully managed at the secondary healthcare  level. Technically, district hospitals are now operating at a higher  quality of healthcare than some central hospitals (SWAp Annual Report,  2010) in specific area of interest. If anything, it is imperative to  encourage the MOH to continue instilling high quality of healthcare at  district hospitals under local government leadership. I think most  Malawians are now willing to pay for their health services for those who  can manage.<\/p>\n<p><strong>Why Hospital Autonomy at Central Level is now important or imminent\u00a0 in Malawi?<\/strong><\/p>\n<ol>\n<li>Healthcare services is fast becoming extremely expensive globally demanding<br \/>\nsustainable health-financing! For how long is Malawi Government still  going to shoulder both re-imbursements and positive or negative <em>externalities<\/em> through internalizing externality costs of public health care even to  those who are able to pay as it is now? Next is the obvious breakdown  which was about to be witnessed in 2002-2003\u2026\u2026..!!!!!<\/li>\n<li>Civilization demands patients or clients\u00a0in developing countries to be given a new role<br \/>\nof responsibilities for their own both individual and community health maintenance.<\/li>\n<li>The current referral structure provides a feasible autonomy at central level<br \/>\nas only \u201c<em>bonafide public patients or clients<\/em>\u201d referred by District Hospitals or Urban Health Centres (eg Kawale, Ndirande, Chilomoni\u00a0or Area 18) will be allowed \u201c<em>free<\/em>\u201d  re-imbursements by Malawi Government to the autonomized central  hospital thereby still continuing with free tertiary healthcare services  to poor or rural people as is done now. On the other extreme hand, only  those Malawians with potential to pay\u00a0(<em>well to do)<\/em> people will  go direct to central\u00a0hospital for primary and secondary care\u00a0BUT FULLY  CHARGEABLE as controlled by Ministry of Health and Finance through a  revised Public Health Act etc! In that way there will be full equittable  access both horizontally and vertically\u00a0to all Malawians regardless of  status or economic muscle etc. Again this will addmittedly improve  quality of healthcare\u00a0services at Central Level through self sustenance  as reported in Kenya, Uganda and Ghana Hospital Autonomy Practices.<\/li>\n<li>In order to accomodate more than 100 Medical Specialists and  Sub-Specialists currently studying within Malawi and abroad  successfully, various positions\u00a0will be created at Central Level  Hospitals in all departments to avoid frustrating those newly  accreditated medical specialists working within Malawian borders.<\/li>\n<li>Central Hospitals will be able to buy befitting medical equipment to  improve quality and sustain them thereby satisfying medical and  surgical\u00a0specialists.<\/li>\n<li>Hospital Autonomy in Malawi will improve accreditation of central hospitals<br \/>\nin the country to meet international standards.<\/li>\n<li>Hospital Autonomy in Malawi will necessitate an empire of donor confidence<br \/>\nfor sustainability just like Ghana and Kenya at African Level as it will  be a momentous step in challenging private health sector in Malawi  competitively.<\/li>\n<li>Hospital Autonomy in Malawi will instil a healthcare quality competition\u00a0of<br \/>\nhospitals with private hospitals through local and international accreditation board etc.<\/li>\n<li>Hospital Autonomy in Malawi will reduce significantly the forex the Government spent on refering abroad the current <em>deserved<\/em> patients.<\/li>\n<li>If Central Medical Stores (CMS) has finally taken its foot in public  institutional autonomy in\u00a0health sector, am sure this milestone will  remain unmature unless\u00a0\u00a0autonomy\u00a0 culture is deliberately encouraged at  all levels starting with central level hospitals.<\/li>\n<li>Hospital Autonomy in Malawi will definitely decongest unnecessary  petty patients at Central Hospitals thereby easing public central  hospitals of unnecessary bills on feeding and accomodating them etc.<\/li>\n<li>Hospital Autonomy at central level\u00a0in Malawi will improve the  teaching arena by training institution among others KCN, Health  Sciences\u00a0Colleges, Nursing Colleges and COM as reported in Ghana and  Kenya\u2019s Teaching Hospitals.<\/li>\n<\/ol>\n<p>With these pertinent facts compelling health officials\/planners\/stakeholders\/financiers for a<br \/>\nsecond thought about Hospital Autonomy in Malawi I think within next  five years a policy to introduce hospital autonomy at KCH\u00a0may be  feasible in all facets. However, if it could be started in 2015 for  instance, Malawi needs to start planning the ground work\u00a0today (2011)\u00a0by  conducting:<\/p>\n<ul>\n<li>Feasibility Assessment through doing research on how ready are people willing to pay<br \/>\nfor their services at tertiary level etc (many donors would come in, I guess).<\/li>\n<li>Benchmarking with other successful African Countries like Ghana and  Kenya etc to learn better practices and challenges in hospital autonomy.<\/li>\n<li>Drawing Terms of References including board of trustees\/board members compilation\/responsibilities\/who to be hired\u00a0etc.<\/li>\n<li>Conduction of wide consultations through general population, public\u00a0and specific health pundits etc.<\/li>\n<\/ul>\n<p>In conclusion, Malawi has a bright vision in health sector which  needs to be supported\u00a0through all other sectors and stakeholders in the  country, in the region and world at large. Reasearch<br \/>\nand Planning is the way to start laying the foundation for the implimenatation.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>In literature there are seven forms of health sector funding mechanisms. They are through tax revenue in government budgets; social [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":1698,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[76],"tags":[409,410,411,412],"class_list":["post-1697","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-health-well-being","tag-health-policy","tag-health-sector-reform","tag-health-financing","tag-hospital-autonomy"],"_links":{"self":[{"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/posts\/1697","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/comments?post=1697"}],"version-history":[{"count":0,"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/posts\/1697\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/"}],"wp:attachment":[{"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/media?parent=1697"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/categories?post=1697"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/new.faceofmalawi.com\/index.php\/wp-json\/wp\/v2\/tags?post=1697"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}