By Suzgo Chitete

Though it remains a politically emotive issue, the newly adopted Malawi Growth and Development Strategy (MGDS) III has brought to life the debate to introduce user fees in public hospitals.

The user fees are looked at as solution to the struggling health system which runs on a shoe-string budget.

The proposal has received an endorsement from health experts within government ranks.

But a health activist and the Ministry of Health remain wary of the proposal, saying it contradicts the Universal Health Coverage Policy, which recommends that countries should reduce the burden on households when accessing healthcare.

The new government development blue-print [MGDS III] describes Malawi as the only country in the Southern Africa Development Communtiy (Sadc) region that offers free public healthcare yet also has the lowest per capita investment in health, which stands at $39 (about K28 000) against the Sadc regional average of US$229 (about K170 000).

The document, among other financing mechanisms, proposes expanding user fees to ensure sustainability of health service provision.

“Develop and implement a health financing policy. Institutionalise National Health Accounts to provide evidence about sources, uses, and expenditure. Introduce an affordable national health insurance scheme. Reform hospital operations with the aim of increasing their autonomy—making them public trust hospitals,” reads part of the recommendations in the document.

Random interviews Nation on Sunday conducted, targeting 10 district health officers (DHOs), showed that most health experts are in favour of expansion or introduction of user fees in public health facilities to improve service delivery.

Eight of the 10 DHOs we spoke to, argued that user fees would lead to improved service delivery if well implemented while two fear that such an attempt would disadvantage the poor.

“I think it would also mean we will have some responsibility towards resources, but also make health workers accountable to their attitudes towards our patients…I suggest something like K500 that would go a long way. How that is rolled out or expanded, I am not sure. I am always of the view that everybody should have some sort of responsibility towards their health,” said one DHO from the Central Region who, like others, refused to be named.

Said another DHO based in the North: “We have exaggerated our poverty. To me it is an issue of mentality. If you go to some areas in this country where public health facilities are nowhere near, people survive on [Christian Health Association of Malawi] hospitals where they pay something. And in these facilities, there is always value for money. The fees should be commensurate with our poverty levels. That way we will improve service delivery.”

In some cases, plans to introduce user fees are at an advanced stage.

According to Ntcheu district health office, they plan to begin with the district hospital, which is more of a referral, before they extend to health centres.

Ntcheu district health officer Mike Chisema, said in an interview, the plan is part of public reform programme for the hospital and currently awaits approval of the district council.

Those who oppose the arrangement cite poverty levels as a reason the country should not introduce a fee for accessing healthcare.

The Malawi Health Equity Network (Mhen) calls proposals to introduce or expand user fees as an ‘elitist view’ to punish the poor.

Mhen executive director George Jobe does not also support plans of paying wings in central hospitals, whose costs are to be borne by patients.

“We do not also support the arrangement where central hospitals have special paying wards which are not congested while general wards are highly congested with some patients sharing beds and sleeping on the floor.

“We have always said that public hospitals can have an initiative to be paid by medical scheme firms that refer their patients there, especially at central hospitals, but there should never be out-of-pocket payments made by patients as some are already struggling to make such payments at Cham facilities whenever service level agreements (SLAs) are not serviced,” Jobe said.

He said government should instead work towards addressing the inefficiencies in the system, which include corruption and wastage of resources.

Jobe fears that if these vices are not attended to, introduction of user fees “will just increase what is being stolen”.

College of Medicine (CoM) public health expert Professor Adamson Muula argues that introduction of user-fees alone is not a panacea to challenges facing the health sector.

He attributed limited resource allocation to public health to factors such as limited national resource base, rapid population growth and theft of public resources.

“The introduction of user fees in the Malawi public health care system needs to be given a chance. It must also be accompanied by other changes in the system. I am told there is an on-going rationalisation exercise within the Ministry of Health.

“This is important and its effects, both good and bad, need to be assessed continuously and mitigating measures employed. The quality of health services cannot be reduced just to user-fees or not,” said Muula.

Asked what he makes of the policy clash user fees would have on Universal Health Coverage Policy, Muula said: “The issue of user fees emanates from economic and pragmatic principles, recognising that resources within the health sector are limited.

“More resources are needed and yet the national purse is constrained. Universal health coverage on the other hand is an equity and human-rights oriented approach. Sometimes equity considerations throw out the realistic economic principles and yet both can be pursued in search of a middle ground.

“Programmes that support user-fees must also have well-thought through exemptions scenarios. For Malawi, such exemption will include most of the population. If we said that all children should receive free health services, then close to 40 percent of the population is already exempted.

“Further, since we have a high maternal mortality ratio, then all pregnant women must be exempted, then we are going to have another five percent exempted. Many people would suggest that people living with HIV must also have some consideration. This is another eight percent; although some would also be in the child and pregnant categories. It is a difficult balancing act”.

In 2015, the Ministry of Health announced plans to introduce user fees in some public hospitals targeting central and district hospitals as part of public reforms, but the decision was reversed a year later after public criticism.

With the MGDS III making it a point, the Ministry of Health remains elusive in terms of policy direction as regard the proposed expansion of user fees, emphasising more on alternative funding mechanisms.
In an e-mail response, Ministry of Health spokesperson Joshua Malango said the ministry is looking at various options.

“Out of pocket payments are clearly a hindrance to access to health care. However the ministry is still looking at issues around health financing, creation of health fund, and issues around National Health Insurance. These issues are multi-sectoral and therefore the final decision is not a MoH only decision but also others, including MoF [Ministry of Finance]”.

“As stated above, ‘Out of pocket’ payments for health care discourage access to health care. National Health insurance and health fund should still be explored,” he said.

Health financing in Malawi has remained an issue as the country has usually failed to meet the Abuja Declaration which demands 15 percent of the National budgets to health. The issue of user fees has remained sticky in the country.

Available literature show that this emotive issue was partly the cause of the 1964 Cabinet crisis, when some ministers stood opposed to Kamuzu Banda’s suggestion to introduce public hospitals user fees.