Malawi health delivery system is currently underfunded and has numerous challenges to meet its main goal of “establishing through the joint health SWAp Program of Work, an effective and efficient health care delivery system that is responsive to the health needs and demand of the people of Malawi, especially the vulnerable groups, the poor, women and children.” One mechanism the Malawi Government has done to involve other partners in health sector is through health sector reforms including open policy for private health care provision (which was limited in one-party dispensation) and promotion of public-private partnership (PPP), especially with Christian Health Association of Malawi (CHAM) health facilities.
History of Mixed Health Care System in Malawi
|The exploration of Malawi by the missionaries before British colonialism (1891) is believed to be the source of birth of civilization in the country which later provided a sketchy philosophy for Christianity, education and health. From the British rule until early post-independence, there had been coexistence of health care system between mission health facilities and government health facilities (Elias Ngalande & Henry Simukonda). For instance, in 1965 the stakeholders of Christian owned health facilities recommended the establishment of an association called Private Hospital Association of Malawi (PHAM) which was registered with the Registrar General on 1st December 1966 under the Trustees Incorporation Act (CHAM Secretariat 2008) and later in 1992 the name was changed to Christian Health Association of Malawi (CHAM). However, for a longtime since independence, the Malawi Government did not liberalize the private health sector legislation and registration (Elias Ngalande & Henry Simukonda).The coexistence of public, not-for-profit and for-profit (private) health care system came into full force after the recent changes in the Malawi Health Policy and Legal Framework towards private health care provision since 1987 when the Medical Council of Malawi, a non-profit making statutory body, wholly subvented by the Government, was established by the Medical Practitioners and Dentists Act No. 17 of 1987 and became operational in February, 1988.|
This health policy was a milestone in the history of health care in the country. The Ministry of Health recognized the benefits it could gain from a properly coordinatedprivate health care system. Therefore, it started negotiations for proper coordination with both not-for-profit and for-profit private health care providers in order to establish an effective and efficient health care delivery system that would be responsive to the unlimited health needs and demand of the people of Malawi against very limited health resources, especially amongst the vulnerable groups, the poor, women and children. Eventually, both formal and informal public health sector-private health sector partnership (PPP) started to take its shape in 1990s with the main goal of increasing the accessibility, availability, acceptability, comprehensiveness and continuity of high quality health care in Malawi. The main focal area of partnership had been the delivery of PHC. The country excelled in this thematic area such that all health facilities in the country, regardless of their ownership, were able to offer free immunization to under five and pregnant women as well as tuberculosis treatment. No wonder, the country achieved recommendable core health indicators. (DATA-1990 to 2002).
Later in 2003 the PPP in Malawi took a new twist compelled by the 2000 Summit on MDGs attainment against rising maternal mortality ratio and neonatal deaths. The Ministry of Health in the country recommended to establish a formal PPP with non-for-profit CHAM facilities, especially on maternal and neonatal health (MNH). This partnership arrangement was named Service Level Agreement (SLA) to signify the point of interface and its role for measurement.
Health sector PPP.
The public health sector in this paper refers to national and local government health institutions which are mandated to provide ‘public goods’. The ‘public goods’ in this paper are defined as non-excludable and non-rivalry goods (Uchida, 2009) which denote ‘health care’, however, it is a misnomer because it is not absolutely inexhaustible due to limited resources and also because not all people have absolute equal access to health care.
The private health sector denotes bimodal structures; the for profit private health facilities of any size and the not for profit private health facilities referring to mission health facilities, philanthropic health organizations and other faith-based organizations (FBOs). However, in this study the word private health sector will exclusively be used as CHAM health facilities. The word partnership in this study refers to a one year term but renewable contractual agreements, EHP-oriented but target oriented and deliverables-oriented as a formal relationship between MOH and CHAM through local authorities or assemblies in a decentralization set up.
Health Care Service Level Agreements (SLAs) between MOH and CHAM in Malawi
CHAM is an ecumenical, not for profit NGO umbrella organization with members comprised of religious organizations who provide health care services in Malawi (CHAM Secretariat, 2009).
CHAM has a membership of 171 health facilities spread across the country providing health care services as general hospitals (20), community hospitals (19), mental hospital (1) and health centres (131). The majority of these health facilities (90%) are located in the rural settings of the country, predisposing itself to be the main key health care partner targeting the rural community. Besides these health facilities, CHAM has also 10 Nursing Training Colleges and a college of health sciences from where they produce 77% of the nursing personnel in the country (CHAM Secretariat, 2009). Therefore, CHAM can be described as a key health sector partner who has been instrumental in the health sector reforms.
However, unlike public health facilities which provide health care services free of charge, CHAM health facilities, as not for profit NGOs, charge user fees for cost recovery. Although these user fees are fairly lower than in for profit private health facilities, the majority of rural and semi-urban Malawians cannot afford to pay these charges, such that there is a financial barrier to access the health care although the health structures might be within a stone’s throw distance.
Therefore, it is against this background that MOH had to formalize the partnership with CHAM health facilities in order to increase the accessibility, availability, adequacy, acceptability, completeness, comprehensiveness and continuity of health care to all Malawians if the vision of the health sector is to become a reality. This arrangement has been supported by all stakeholders including the developmental partners not only because it is cost-effective if implemented efficiently since duplication of managerial, administrative and infrastructure costs are avoided but also because various studies have shown increased quality of health care if contracted out through private partners (Gill Z, Carlough M). The previous decade witnessed various forms of memoranda of understandings (MOUs) between this partnership from planning, implementation, monitoring, supervision, evaluation, reporting and resource mobilization. For instance, CHAM is a signatory to major health reforms including the Joint Health Sector SWAP. On the other hand, pharmaceuticals and medical supplies covering EHP conditions, the basic salary package for technical staff and paramedics as well as some capital investiments in CHAM health and training facilities are injected by the MOH.
Unfortunately, there are scanty evaluation surveys or researches done to explore and analyze the conceptual frame work (terms of references), policy implications, governance and accountability issues as well as implementation capacity or intermediate impact of this intimate marriage.
Ideally, most CHAM health facilities are already located in rural areas where now the health reform compels the MOH to provide the full EHP. Therefore, instead of building new public health facilities within the same catchment areas of the CHAM health facilities, the MOH opted for maintaining, rehabilitating and extending the same infrastructures in a mutual bound agreement. Therefore, the concept of SLA between MOH and CHAM is EHP-centred and target oriented (for instance, pregnant women and neonates). The objective of introducing the SLAs is to replace the user fees charged by CHAM with government subsidies and thus removing the financial barrier that prevents poor patients from accessing health care services. This is in line with the Malawi Government’s pro-poor health care principle in order to achieve not only national health goals set in the Malawi Poverty Reduction Strategy (MPRS) and Malawi Growth & Development Strategy (MGDS) but also regional and global goals set as Millenium Development Goals (MDGs). Gill Z and Carlough M observed that it will be unlikely that some low-income countries will achieve health related Millennium Development Goals (MDGs) unless governments find new approaches. One innovative possibility is through government partnerships with mission hospitals and other faith-based organizations.
In Malawi, the SLAs are being phased in with the initial round covering only Maternal and Neonatal Health (MNH) services. The understanding between the MOH and CHAM has been that the costs of providing services covered under the SLAs will be shared between them. The SLAs will cover direct costs – primarily pharmaceuticals and medical supplies and, where necessary, bed/food and emergency transport costs. Some necessary building expansion, renovation and new equipment can also be funded by the MOH. The MOH will continue to cover basic staffing costs through salary of technical staff. Indirect costs (maintenance etc) are paid by CHAM members but there is, reportedly, a willingness on behalf of the MOH to consider covering or sharing additional indirect costs related to patients covered under SLAs (USAID 2007). In some cases the MOH would, reportedly, prefer to provide drugs and medical supplies but the supply from CMS was not always reliable and on the other hand to procure from prequalified medical suppliers demanded procurement bureaucracy leading to procurement delays and shortage of drugs (USAID). So there was a wide range of choices for the DHOs to maneuver against the SLAs’ terms of references (TORs). Was this open policy on contractual agreement flexibility by the DHOs and their counterparts (CHAM health facilities), a sign of failure to come up with consensus on both sides of the coin, CHAM secretariat and MOH?
Major Challenges of PPP in Malawi.
- Ghost Workers in CHAM. Its not a secret any more that CHAM has had been milking tax payers money through MOH as basic salaries for health technical staff amounting to K14,711, 886 [about $96 788] per month or annually K176 542 636 [about $1.2 million]. For details, the link is: http://www.mwnation.com/index.php?option=com_content&view=article&id=16419:ghost-workers-drain-k2bnyear&catid=1:national-news&Itemid=3 . But who is to blame? The MOH is sorely to blame because its the one who finally compile a renumeration for health workers to draw salary from treasury. There are a lot of staff turn over even at CHAM but monitoring by HR Department of MOH has been scanty or not at all. This is just an iceberg on probable abuse of tax payers money in this PPP. I am sure, there are likely to be more than this. therefore, the way forward is to engage all parties in vigorous monitoring at all levels. Those who can be traced to have had masterminded the scam, they have to face the wrath of ACB!
- Poor Monitoring and Evaluation of SLAs. SLAs is likely to be another facet where milking of tax payers by unscrupulous CHAM hospital officials could be substantiated. My personal experience in Nkhotakota District Hospital revealed that if proper robust monitoring is not insituted, believe me or not, tax payers money could be siphoned out unscrupulously. My suggestions as way forward include institutionalizing a robust monitoring system (for instance, independent government clerk in CHAM facilities to document every patient seen as what I initiated with St. Annies Mission Hospital) and formalization of common charging system. Currently each CHAM facility conducting SLA has the liberty to charge uniform fees for instance, ceasarian section operation or not; ie not standardized nationally. This is a potential ground for abuse as other CHAM facilities intend to charge in US Dollars (US$) instead of Malawi Kwacha as what St. Annies Mission Hospital initially wanted.
- Poor or lenience of Medical Council of Malawi (MCM) upon CHAM health facilities. As a physician, it worries me to see that many health centres and dispensaries run by CHAM in the country are still managed by sub-standard health personnel. This is more pronounced in pharmacy or drug store departments where there are mere ground labours promoted to manage those offices without proper training. This is not only a violation of Medical Practitioners and Dentists Act No. 17 of 1987 but also endangering lives of innocent people. Its high time MCM has to close such pharmacies etc. My suggestion is appealing to MCM to uphold health care standards and regulations as regards to health delivery in the country.