Health policy in a time of anger

The Executive Order issued by President Peter Mutharika has sparked intense public debate in recent days. Given the high stakes, it is not surprising that the discussion has been emotionally charged in both social and mainstream media.

While public anger is understandable, the quality of our discourse risks obscuring rather than clarifying the real issues at stake.

For context, it is worth recalling the origins of the order.

Investigations by several media houses exposed a troubling practice in which some health workers in public hospitals were demanding payment from patients for services that are meant to be free.

This conduct is indefensible. The first part of the Executive Order, which warns of dismissal from the civil service and criminal prosecution, directly addresses this malpractice. On that point, there is broad agreement.

The controversy lies in the second part of the order, which imposes a blanket prohibition on public health workers owning, operating or holding shares in private clinics or pharmacies.

Public discourse has largely treated illegal charging of patients and conflicts of interest as inseparable. They are not. One is a matter of criminal misconduct. The other concerns governance, ethics and system design.

Collapsing them into a single moral narrative of corrupt medics may be rhetorically convenient, but it is analytically careless.

This framing has consequences. Legitimate concerns raised by healthcare workers about service continuity, specialist training and retention have been dismissed as self-serving.

Yet these concerns are grounded in the structure of Malawi’s health system. Those who support the Executive Order should recognise that opposing views are not arguing for unchecked conflicts of interest. Rather, they highlight the risk to continuity of care when policy change is abrupt.

Many individuals who own or have stakes in private health facilities are specialists and consultants who anchor tertiary care, train future specialists and sustain institutional memory.

If faced with a choice between divestment and resignation, some may leave public service altogether.

Specialists are not replaced overnight. Training takes years and the loss of experienced consultants would have immediate effects on service delivery and postgraduate training.

A further weakness in the narrative is the assumption that referrals to private facilities are inherently exploitative.

This ignores the reality that many public hospitals are under-equipped and unable to provide certain diagnostic tests, procedures, medications or timely elective surgeries.

When clinicians refer patients to external facilities, whether privately owned or not, it is often because those services do not exist in the public system. In such cases, the ethical failure would be to remain silent.

An uncomfortable truth is rarely acknowledged. Some private facilities offer a lower-cost alternative to seeking care abroad, particularly for elective procedures delayed by long public-sector waiting lists.

For some patients, local private care is not a luxury but the only feasible option. The question is whether it is more ethical to withhold information about available in-country alternatives in the name of moral purity.

The tone of the debate suggests a preference for villains rather than solutions. By isolating medics as uniquely problematic, we avoid confronting deeper structural failures such as chronic underfunding, congestion, shortages, weak oversight and inadequate infrastructure.

There are also unresolved questions about what prompted the conflict-of-interest clause in the Executive Order.

Allegations that supplies are being diverted from public facilities to private ones are serious but largely anecdotal. Policy should be built on evidence, not suspicion.

Overlaying all this are unresolved legal and fairness questions. These include whether an Executive Order is the appropriate instrument for regulating professional ethics and property rights, whether singling out one cadre of public servants is justifiable and whether transitional arrangements should have preceded enforcement.

These are not attempts to defend wrongdoing. They concern how a constitutional democracy governs itself, especially in moments of public anger.

One respected clinician has argued that health personnel should desist from trying to convince non-medical audiences of the potential dangers of the Executive Order.

I understand and largely agree with that instinct. Defensive explanations can entrench positions. But silence leaves a vacuum and vacuums are filled with emotion rather than information.

I am not in favour of conflicted arrangements. However, Malawi needs a more thoughtful approach that allows health professionals to contribute to patient care and training in public institutions while acknowledging that the state cannot currently provide everything.

If ownership by civil servants is to be prohibited, transitional mechanisms are essential because continuity of care and training pipelines matter. Above all, patients matter.

I believe the President means well and the discussion is worth having.

But if discourse continues to be driven by outrage rather than understanding, we risk weakening the very health system we are trying to protect.