The Cost of Accessing Free Health Care in Malawi
MZIMBA, MALAWI – The memory of how she came close to death is still fresh on Jane Chavula’s mind. By the time she arrived Mzimba South District Hospital two years ago to be delivered of her baby, Chavula was close to deathbed. Accessing a medical facility that could address the complications associated with her pregnancy meant traveling about 39 kilometers distance through bad road networks.
“I visited Kamteteka Health Centre awaiting my delivery but then there was a complication, which was beyond the health center’s capacity, so I had to be referred to a secondary facility,” Chavula told Rural Reporters.
But she was told during the referral that there was no ambulance to take her.
“So we had to look for [our own] transportation and lucky enough we had money readily available,” she recounted.
“I was lucky that we managed to reach the hospital in time, and my life was saved, but I keep on wondering what could have happened if we did not have the money,” Chavula said.
The health sector in Malawi is plagued by different challenges including shortage of health workers, lack of drugs, and lack of medical equipment.
Rural Reporters’ visit to Khosolo Health center, which is situated about a hundred kilometers away from Mzimba South District Hospital paints a picture of the situation.
The facility serves an estimated population of 16,000, some of whom travel a distance of around 30 kilometers to access treatment. This is three times more than the recommended distance of 8 kilometers people are required to travel to access health services in Malawi.
Services offered at Khosolo Health center include out-patient services, under five, antenatal, maternity services, HIV testing, provision of Antiretroviral drugs, family planning, treatment of sexually transmitted infections, water, sanitation and hygiene, and community health promotion.
Under-staffing, limited space, as well as limited resources, characterize Khosolo Health Center. Despite having a required number of medical assistants, the facility is short of nurses. As at the time of visit, only two were available.
Malawi Health Equity Network (MHEN) Executive Director, George Jobe, expressed concern over the situation, which he said put lives of patients at risk.
“We know that every health facility is supposed to have two medical assistants and six nurses, but indeed there is huge under-staffing. This means that our health workers are overworked and that can compromise the quality of service because when someone is very tired, it is easy to make mistakes,” Jobe said.
Bed-space is also a challenge at the facility as one room doubles as the labor ward as well as an out-patient room with a curtain dividing the two. Due to issues of privacy and dignity, sometimes out-patient services are offered in an open area outside the building as witnessed during the visit.
Then there are issues of referrals. There is no ambulance for this health center, and they depend on ambulances from the district hospital for referrals. However, the district hospital only has four functional ambulances serving 23 health centers.
Mzimba South District Hospital serves a population of over half a million people. One ambulance is supposed to serve a population size of 50,000. This means that the district needs nothing less than 13 ambulances for smooth operations.
“Most of the time, people are forced to hire private vehicles at an estimated cost of K30 000 (about US$40) for them to make it to a secondary facility as in most cases the ambulance is not available,” Petros Ngwenya, a community member from around Khosolo health facility said.
The challenges at Khosolo health center are common in many health centers across the country as observed by MHEN Executive Director.
“Our observation is that the health sector still has some problems. We do not have enough health workers and as you might know for the past two or three years health workers that have been trained have not been employed by the government because they say they do not have money,” Jobe said.
“We also lack equipment, and some essential drugs are missing in public health facilities,” he said, adding, “We are advocating that government should abide by the Abuja Declaration, which says that government should commit 15 percent of the country’s budget towards health. At the moment we are around 12 percent, but we wish we were on target. Of course, the government has been talking about other priorities, but [we wish they increase the] funding allocation to health,” he said.
Principal Secretary in Ministry of Health, Dr. Dan Namarika, acknowledges the challenges the Malawi health sector is facing. He describes it as being a recipient of what happens in other sectors.
“If you look at health, it is a broad issue; we are at the receiving end of [what is going on in] other sections. If you look at our population, we have a bigger population that is dependent, then social-economically that is a challenge, then there are emerging diseases like HIV, nutritional problems, all those tend to hit the health sector,” Namarika said.
He said, “the other thing that people do not realize is that in Malawi as a country, more than 16 of the 28 districts are bordering districts and all our [neighboring] countries are paying for health services and it is only Malawi offering free services. And if you go to the border districts you will notice that 40 percent of the consumption of our drugs is not from Malawians – it is people across the border, so if you put all those things together you will notice that there is quite a lot that needs to be done.”
But some progress has been made. The government has launched a national registration program to make it easy to track the record of those in need of free medical services.
“Unlike now when everybody takes advantage of the weak system and access care for free,” Namarika said.
In addressing the challenges rocking the health sector, Namarika pointed out that the government was working tirelessly to profer solutions.
“It is true that there is a shortage of health workers. If you go countrywide, its about 50 percent but current efforts are that for the past year we have managed to recruit not less than 1000 health care workers, and this year we have added about 2000 and next year we will do more,” Namarika said.
“In addition to those we have recruited, we have also been offered 300 nurses by Global Fund that will be recruited in the next month or so and then we also have some partners that are bringing in staff into the health care. For example, the Centre for Disease Control (CDC) has recruited 200 in three districts and USAID is recruiting 300,” he said.
Apart from recruiting health workers, Namarika said the government is also working on modalities that will convince health workers to work in rural areas. Currently, some workers shun the idea of working in rural areas due to the absence of amenities like descent houses, electricity and clean water.
Namarika said, “It is quite true that workers especially young graduates are reluctant to work in rural areas and that is not only health workers, but it is the same even in the teaching profession and many other professions especially if they are female members of staff.”
“We are looking at some of the incentives we could [give]. What we are doing is ensuring that health centers have decent houses for staff in all health facilities in rural areas and any other few incentives whenever can come,” he said.
Namarika said that the government would also be working on reducing the distance between health facilities so that people could access health care without needing to travel long distances as is the case currently.
“It’s true that the distance radius is beyond the recommended 8 kilometers and we are working on that. Our target is to even get below the 8-kilometer radius at 5 kilometers at least, and that is where we are heading. If you look at the health sector strategic plan (2017-2022) which has just been launched, we intend to construct new health facilities from community health posts, health centers to even rural hospitals,” he said.