Malawi decides: user fees or gratis is the question


As the road to reforms widens and players start the journey, Ministry of Health is considering re-introduction of user fees in its hospitals ‘to expand paying services to more public facilities’, but not without reaction from all sectors including donors.

This is not a new phenomenon. User fees were in use in 1964 but discontinued for reasons informed by populist policies. User fees re-emerged in the 1980s in sub-Saharan Africa as part of the now infamous structural adjustment programme imposed by World Bank and International Monetary Fund.

At least in Malawi, by the turn of the Century, the health policy debate had moved to ‘hospital autonomy’ encapsulating user fees but again failed to take root because of fear of change.


What is the rationale for user fees?

Simply put health costs are escalating at fiscally unsustainable rates, begging pragmatic policies to maintain services while improving quality.

User fees are a strategy to share the cost of health provision with patients and generate resources that supplement government allocations. Ideally user fees seek to achieve access to high quality services for all without inability to pay becoming a barrier.


For Malawi, a country burdened by debt, a small tax revenue base, an exploding population and widespread corruption, a search for alternative health financing is an imperative. One expert in the debate noted that Queen Elizabeth Hospital would raise K30 million per month supplementing K55 million per month that the hospital needs to run.

As an innovation, user fees would make funds available from outside the predominantly tax-based funding. In effect, the policy would permit government to fund other areas or to maintain an increase in resources for facilities to improve infrastructure and services.

A better image and improved services have the potential to attract people of all economic brackets. They reduce ‘unnecessary use’ of services, cut expensive investigations and curtail over-prescription. User fees have a positive effect on referrals if primary level services are also improved.

With hospital autonomy user fees would fund local procurement which may cut wastage, pilferage of drugs, and abuse of supplies although it can be counter-argued that increased resources available at facility levels could unintendedly fuel corruption particularly where leadership is weak.

The suggestion has been made that Malawi has poor health infrastructure and that services are not adequately productive to make money. While this is broadly the case, most district hospitals have the basic infrastructures and human resources to make a start. What is critical to improving quality of services and growing patronage are staff skills, staff availability at the facility and most vitally a positive attitude to work and people served.

But user fees have opponents too. The reality is that user fees affect the principle of equity because poor people would not be able to pay. The policy regardless of its contribution to quality and efficiency could indeed exclude poor rural populations which already project poor health indicators.

However, patients — including those that are presumed poor — actually spend a lot on transport, food for guardians and travel to see loved ones in hospital. It seems to me that realistically calculated user fees would not make it any more prohibitive if the services were made qualitatively comparable to private hospitals.

In addition, we must admit that generating funds is only one aspect in quality improvement. Facilities must have adequate numbers of trained staff with the capacity to translate the resources generated into quality services. And this is not as straightforward as proponents of user fees suggest.

Improving health services demands commitment to work; accountability for high quality services by all parties at all levels of operations in the facility; and accountability to the people. It requires a vision that aims at high user satisfaction in order to create trust and maintain patronage. Again this ideal relates to quality, attitude and commitment of personnel.

Some countries have applied the user fee policy selectively, that is payment for certain conditions, procedures and or investigations for certain people based on ability to pay. But this can be as tricky as it is vulnerable to abuse. It could well benefit those who can afford additional costs much more than the desperately needy. We see this in access to public loans, in farm inputs and other social security type interventions.

At the same time as opponents of user fees argue, willingness to pay does not translate to ability to pay. Similarly, ability to pay is not the same as willingness to pay. Entrenching a user fee policy would require investing in advocacy and social behaviour change communication to educate, re-assure and mobilise for patronage of services.

The major downside of the user fee policy is the potential to exclude the poor. But there is another side, namely that if people stayed away from paying health services, it means that staff of large hospitals ‘could become under-employed’ while expensive equipment lies idle, drugs expire before use and salaries are still paid.

Less talked about, introducing fees based health systems in poorly resourced countries like Malawi inadvertently promotes the risky behaviour of ‘self-treatment’ relying increasingly on off-the-shelf medications without proper diagnosis.

Similarly, user fees can divert demand for health services from quality public facilities to illicit untrained and unlicensed ‘health providers and pharmacies’ which could increase disease burden and mortality. We see this is Aids treatment!

What should Malawi do then?

It’s a great dilemma. It requires both customised research and authoritative leadership. I am afraid real impetus for innovating will be low because Malawi is considering user fees when many countries in the region are moving away.

As for me, fees are a necessary evil not just to share costs but to generate a spirit of responsibility and accountability among people of this country. I actually don’t believe that all policies must be debated publically before use.

Final word — when a policy makes sense but needs testing, pilot it. Nations shouldn’t stagnate because of ‘opportunistic’ public opinion.

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