The Right Choices: Achieving universal health coverage in Malawi

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Malawi has a proud history of delivering free healthcare for its citizens, but this is now seriously under threat. Bypass fees for hospitals are already causing major hardship by excluding poor people from accessing the healthcare they need. The Government of Malawi must reject the fees system completely and instead use tax financing and development aid. Development partners must support the health sector with adequate financing to fulfil world leaders’ commitment to ensuring that no one is left behind. Malawi cannot be the first country in a generation to introduce these dangerous fees while the world watches. 
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  JOINT AGENCY BRIEFING NOTE 7 JUNE 2016 Patients at a hospital in Ngabu, Malawi, some lying on beds with no mattresses. Photo: Joseph Mawale/Oxfam THE RIGHT CHOICES  Achieving universal health coverage in Malawi Malawi has a proud history of delivering free healthcare for its citizens, but this is now seriously under threat. Bypass fees for hospitals are already causing major hardship by excluding poor people from accessing the healthcare they need. The Government of Malawi must reject the fees system completely and instead use tax financing and development aid. Development partners must support the health sector with adequate financing to fulfil world leaders’ commitment to ensuring that no one is left behind. Malawi cannot be the first country in a generation to introduce these dangerous fees while the world watches.  2 1 INTRODUCTION Malawi has a long tradition of free healthcare. In the 1990s, when African countries from Angola to Zambia introduced user fees for health services, often as a result of World Bank and IMF loan conditions, 1  Malawi resisted, putting the interests of its citizens first. The past two decades have seen significant progress in health outcomes, 2  while the country has maintained a public health service that is free at the point of use. Following the global adoption of the new Sustainable Development Goals (SDGs) in 2015, Vice-President Saulos Chilima outlined Malawi’s vision of achieving the target of universal health coverage (UHC), 3  where all people can access the healthcare they need without facing financial hardship. However, Malawi is currently facing a health sector funding crisis. A series of corruption scandals, including 2013’s infamous ‘Cashgate’ affair, has seen mass donor withdrawal of direct budget support for health. 4  As aid accounted for as much as 70 percent of Malawi’s health spending, 5  its withdrawal has had a dire impact. Compounded by the country’s overall economic woes, health services are battling widespread staff shortages and medicine stock-outs, and hospitals and clinics are overwhelmed by demand. Even ambulance services and meals for patients have been suspended in recent months. 6  Malawi’s health workers face an impossible situation in trying to maintain a functioning health system, while the Ministry of Health (MoH) is unable to address the current crisis without additional revenue. Faced with this emergency, in 2015 the Government of Malawi convened a series of committees to investigate potential healthcare reforms, including one exploring the expansion of paid-for services in hospitals.  An outcry from civil society groups saw the committee rule out any introduction of universal user fees for healthcare, 7  and ministry officials have since publicly highlighted the regressive nature of direct payments. 8  Yet despite this, Malawi’s central hospitals have increasingly been charging user fees, allowing those who can afford it to pay for higher-quality, hospital-based care, while leaving the poorest people behind. For many people these fees have been unavoidable, necessitating the selling of assets critical to their livelihoods, or their going without much-needed care altogether. Recent reports indicate that fees will be expanded to district-level facilities in July 2016, and a policy governing user fees will be submitted for Cabinet approval in the coming months. 9  This paper presents the results of interviews commissioned by Oxfam, Save the Children International, Médecins Sans Frontières, National  Association of People Living with HIV and AIDS in Malawi (NAPHAM) and Global Hope Mobilization. 10  The interviews illustrate how Malawi’s current experiment with hospital user fees is a highly regressive step that simply pushes the burden of financing the health sector onto the country’s poorest people. If the Government of Malawi is to achieve   3 UHC, it must urgently abolish user fees in all health facilities, and instead prioritize mechanisms to raise more public finances for all levels of the health system. Free and high-quality public healthcare could mitigate the growing gap between rich and poor seen in Malawi today and afford every Malawian the chance to live a healthy, productive life. As such, this should be a presidential, government and donor priority.  4 2 HEALTHCARE USER FEES, THE FLAWS The wrong solution: bypass fees and fee-paying wards Bypass fees – fees charged when treatment is sought directly at hospital level, circumventing primary healthcare – are being charged in four tertiary hospitals in Malawi. A charge of Malawian Kwacha (MK) 1,500 at Kamuzu (in the capital Lilongwe), Mzuzu and Zomba Central Hospitals was drastically scaled up in the first half of 2015 as part of the government’s health reform agenda, with fees since implemented also at Queen Elizabeth Central Hospital (QECH) in Blantyre. 11  The bypass fee now stands at MK 2,500 in at least two of these facilities, while there are reports of an increasingly arbitrary charging system in others. 12   At the same time, fee-paying wings have been expanded in Kamuzu, Queen Elizabeth and Zomba Central Hospitals, where people seeking care and who are able to pay can choose to receive treatment in a separate ward. User fees will also reportedly be charged at district-level facilities from July 2016. 13  According to statements from the MoH, these will be levied on an opt-in basis, and will secure higher-quality services and preferential treatment for those who can afford them. 14   Box 1: Healthcare fees and ongoing debt ‘I am Mrs Mwale 15   and I live in Mzuzu. I am a mother of five and a vegetable vendor. My third-born child died of malaria when she was six years old. In May this year [2015] my last-born child had malaria. I went to our Central Hospital (Mzuzu) for medical attention. I was told I should pay MK 1,500 or go to Mzuzu Health Centre. I only had MK 500 on me. Knowing that there are very long queues at the health centre, I called my friends and borrowed the money so that I could have my child attended. I didn’t want to go and queue and end up losing her. I lost one before and I didn’t want to go through the pain again. I was helped out by my friends,  paid the MK 1,500 bypass fee, and the child was attended. My business was, however, not going well. I failed to raise money to repay the friends who helped me. I ended up selling my bicycle that we were using for the vegetable vending business to pay off my debt. I am struggling to make ends meet but I am happy I have my child with me. With God’s grace, I will make some more money and buy another bicycle.’ Life-or-death decisions Even the smallest fee for healthcare can have a catastrophic impact on people living in poverty. For some, like Mrs Mwale, fees necessitate the selling of household assets to pay for vital care, jeopardizing their livelihoods. Each year 100 million people worldwide are pushed into
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