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Government of Malawi must end all payments for health

services in public health facilities
If an article published in the Daily Times Newspaper two weeks ago titled User fees in
public hospitals starts July is anything to go by, a lot of poor and vulnerable Malawians risk
dying of curable diseases because many will not afford to pay the numerous charges the
government is introducing in public health facilities.
Recently, the government through the Ministry of Health (MoH) has scaled up parallel
paying wings and introduced bypass fees in all central hospitals and is now attempting
to introduce payments for services in district hospitals - all in an effort to supplement the
dwindling health budget. The extension of paying services to all district hospitals will
happen by July 2016, according to the MoH.
On Tuesday, 10 May 2016, the newspaper quoted MoH Spokesperson and reported that
as part of the ongoing reforms the ministry will introduce [user] fees in district hospitals
for those who want to receive special treatment and can afford to pay.
This is contrary to Malawis commitment to achieve Universal Health Coverage (UHC), a
target within the newly adopted Sustainable Development Goals that the country has
signed up and are being discussed by world leaders, including Malawi, this week at the
World Health Forum in Geneva.
Following the governments recent decision, a coalition of civil society organisations on
UHC is calling on the Government to reverse the decision to introduce out of pocket
expenses for patients in district hospitals and abolish all existing fees in central hospitals
including bypass fees and paying services.
The UHC coalition believes bypass fees is unjust and fails to take into account that
people go directly to central hospitals because health care services at the primary level
is inadequate.
The coalition also questions the ethics behind charging patients at public hospitals for
preferential services when 40% of the fees goes directly into the pockets of health care
workers who are already paid by the government through tax payers money.
The implementation of paying services in hospitals in Malawi has come as a surprise to
many Malawians. Wasnt there supposed to be a legislative approval first before rolling
it out? queries Timothy Mtambo, Centre for Human Rights and rehabilitation Executive
Director. I feel this creates a two-tier system, where the poorest people will be left with
the lowest quality of healthcare and the longest waiting time to access poor quality
Such a system means that money will start to speak louder than real health needs in
Malawi and this may breed corruption within the health service delivery system.
Malawi has a long and proud tradition of providing free public healthcare. In the 1990s,
many countries introduced user fees for health services, often as a result of World Bank/
IMF loan conditions. Malawi resisted this pressure, putting the needs of its citizens first.
As a result, Malawi has outperformed many of its neighbours in achieving the health
MDG on reducing child mortality.

The Ministry of Health move will push a lot of Malawians into poverty as studies elsewhere
have shown - thereby widening the inequality gap and frustrating government efforts
aimed at alleviating poverty and attaining UHC as stipulated in the SDGs.
Universal Health Coverage means all people must be able to access the healthcare they
need, without facing financial hardship. Introducing user fees for health in Malawi will
be tantamount to the violation of the right to health of the citizens, who are currently
struggling to even put food on their tables, says Martha Khonje, ActionAid Country
Studies have shown that direct payments by patients for health services pushes 100
million people worldwide every year into poverty, and countless more go without the
healthcare they desperately need.
While the Government argues that user fees will be introduced on an opt-in basis, the
coalition says this will still have a catastrophic impact on Malawians living in poverty.
Any introduction of user fees will be disastrous for poor Malawians. Richer people who
can afford to pay for healthcare will automatically be prioritised and will receive better
services at the expense of the poor, says Master Mphande, Napham Executive Director.
Evidence on user fees from other countries overwhelmingly points to their failure as a
health financing mechanism says Safari Mbewe, MANET+ Executive Director.
User fees are known to raise negligible amounts of money for the health sector, at an
enormous cost to peoples lives, especially the poorest and most vulnerable, says Mbewe.
Zambia found the expense of administering user fees almost equal to the revenue raised
- forcing the countrys leadership to abolish user fees in primary and secondary health
Oxfam in Malawi Country Director John Makina concurs with Mbewe: Malawi has
historically been a leader in maintaining free, public healthcare. The Government must
abolish all user fees in public health facilities, and instead focus its energies on mobilising
additional public funds for health. It must honour and spend 15% of its annual budgets
to the health sector for a start as committed in the Abuja Declaration.
Nicolette Jackson, Mdecins sans Frontires Deputy Head of Mission in Malawi adds: the
government and civil society organisations must continue to lobby donors to provide
direct funding to the health sector as a way of supplementing government efforts to
deliver quality health care. The international community must do more to address
Malawis health financing gap for the country to achieve UHC.
The international consensus on health financing for UHC is that it is vital to replace private
voluntary financing (user fees and private insurance) with public financing mechanisms
(tax and aid). This is what Malawi did in the 1960s and what the rest of the continent
is now following. It would be a terrible tragedy for Malawi to move in the opposite
direction away from UHC. Recently there has been wide spread calls against User fees
with the World Bank president, Jim Yong Kim describing user fees as both unjust and