24 April 2017

Paying wards may soon be established in district hospitals across the country – if a feasibility assessment that has been undertaken in the last month gets the go ahead.

Health advocates are expressing their strong reservations about this latest attempt by the Ministry of Health to generate more money for the health sector – arguing it will only further escalate health inequities in Malawi.

Country Director for Oxfam Malawi, John Makina says, “Any system where paying fees gives access to higher-quality services, leaving lower quality for those who cannot afford to pay, is fundamentally inequitable. Oxfam and other members of Malawi’s Universal Health Coverage (UHC) Coalition argue there is a strong risk that patients who pay, will get prioritised over those who cannot afford to pay. In short-staffed hospitals, doctors and nurses may end up spending more time in paying wards, and when there are shortages of drugs, the available drugs may be given to those patients who can pay,” explains Makina.

MSF, Doctors Without Borders, Malawi
"There is a strong risk that patients who pay, will get prioritised over those who cannot afford to pay" - John Makina, Country Director for Oxfam Malawi. 
Photo: Aurelie Baumel

The Government of Malawi has been conducting a dangerous experiment with out of pocket payments in recent years, introducing bypass fees charged when accessing central hospitals without a referral, and expanding fee-paying wards in the same facilities. Despite government claims that fees will remain optional, situations where they are in effect compulsory are widespread. For example in Lilongwe City, which only has a few primary healthcare centres, people are often forced to seek health services directly at the central hospitals and then have to pay the bypass fee.

We understand that three weeks ago Directors of Central Hospitals and District Health Officers met to discuss the feasibility of expanding optional paying wings to the districts and a team from the Ministry of Health has been travelling around the country visiting various facilities to assess the logistics of setting up paying wings. The UHC Coalition was alarmed to see that the idea has also been mentioned in the government’s recent funding request to the Global Fund - in response to a question regarding Malawi’s plans for increasing domestic resources for health. 

The members of the UHC coalition are sending an urgent message to government and development partners that introducing regressive health financing mechanisms, and especially out of pocket payments is not  an equitable way for the country to mobilise domestic resources.

The health sector has been suffering from a severe lack of financing in recent years, accelerated by corruption scandals within the sector and a subsequent withdrawal of donor budget support. While the Coalition supports the need for the Government to mobilise additional revenue for health to fill this financing gap, it is deeply worried by any proposals to introduce or expand out of pocket payments, which will only punish the poorest people. If some of the few bed spaces in district hospitals are subjected to paying, there will definitely be increased congestion in the non-paying wards. In addition, revenues raised from such payments are often minimal, rarely contributing more than 5 per cent of running costs for health systems.

MSF, Doctors Without Borders, Malawi
If some of the few bed spaces in district hospitals are subjected to paying, there will definitely be increased congestion in the non-paying wards. Photo: 
Aurelie Baumel

The UHC coalition calls upon the Government to:

  1. Desist from expanding or introducing out-of-pocket payments, through paying wings in the district hospitals, because such plans are not a progressive way for the country to meet donor expectations around scaling up domestic resources for health.
  2. Ensure that the country is currently getting value for money from limited health funds, by reducing inefficiencies and ensuring cost-effectiveness.

The UHC calls upon development partners to:

  1. Support the Government of Malawi to remove existing out of pocket payments in the public health care system and expand public financing for the health sector.
  2. Support mechanisms for transitional funding for the health sector (rather than adopting piecemeal project based activities) with a view to restoring direct budget support to the health sector in the medium term.

Finally, the UHC coalition would like to remind the Malawi Government that it has the responsibility to ensure that all policies that are developed and implemented are pro-poor and protect the poor from further impoverishment.  The government should also ensure that current and new policies in the health sector aim at attaining universal health coverage for Malawians.

MSF, Doctors Without Borders, Malawi
Open call from Malawi’s Universal Health Coverage (UHC) coalition to the Government

Read more about MSF's activities in Malawi.