Although there was some overlap, three major categories (seven subcategories) of perceived governance issues were identified: accountability (enforceability; answerability; stakeholder-led initiatives); health resource management (healthcare financing; drug supply); and influence in decision-making (unequal power; stakeholder engagement).
Stakeholders identified limitations in the accountability of the government to health stakeholders in both the spheres of enforcement (of health decisions made) and answerability (for the impact of these decisions). Challenges focused on the inadequate implementation of health policy and insufficient answerability mechanisms. These included absent implementation plans, poor dissemination of national policy to other levels of healthcare (regional, city, service), limited processes to provide a feedback mechanism between service providers and the government and citizen review in government health policy and governance structures. In response to the perceived inadequacies of government-led healthcare governance, initiatives led by service-providers, NGOs and CSOs have emerged to hold the government to account for their health policy decisions and poor resource management.
An interviewee from a healthcare governance body stated ‘there is always a big difference between the rosy policies or strategies and implementation. Implementation leaves a lot to be desired’ (Participant(P)21). The CSOs shared this view (P6, P9, P11, P13), with one identifying a nationwide need for more affordable, available and accessible health services, but ‘these issues are not very clear in the strategic plan and policy’ (P6). It was considered highly unlikely that improvements would be made without a policy-level commitment to making advances in these areas combined with a clearly defined (monitored and enforced) implementation plan: ‘beyond development of strategies and policies, have they thought about resolving the current recurring problems? (P9)’. This interviewee also referred to the need for greater governance of the drug supply chain and human resources (discussed under ‘health resource management’).
A specific example of poor governance was the Charter on Patients' and Health Service Providers' Rights and Responsibilities which was developed by the MoH together with CSOs but was never implemented (P13). Thus, there is a government commitment to the protection of human rights in the service delivery context, but little public awareness of these rights and they are not protected in practice. Others found the implementation of policy to be ad hoc. For example, there have been sporadic visits by District Health Officers to CHAM facilities to monitor compliance with government standards in accordance with the service level agreements (SLAs) (P5).
The partial implementation of the government policy of decentralisation was viewed as a cause of poor governance in the health sector (P15, P19, P20). The move to devolve power from the government to local level authorities (district and city) had resulted in greater budgetary constraints at these levels with limited dissemination of government policy via implementation guidelines. The city assemblies were not mentioned in the health policies or HSSP II and had not been involved in developing or reviewing them. The representative felt this was short-sighted of the government as implementation of the Essential Health Package (EHP; the package of essential services identified by the government as the starting point for the move towards UHC), ‘cannot be successful without the active input and involvement of the city assemblies’ as the cities are ‘hosting a significant portion of the population’ (P15). Further, the local authorities felt unable to implement the government policy: ‘in reality, each district orders drugs based on the local needs and dynamics. The EHP in the HSSP II provides an ideal scenario, but in practice we have to respond to local realities’ (P19).
Concerns were also raised from within a government governance body, where it was felt that the knowledge, skills and motivation of the members of these bodies/committees could determine the extent to which the government is held to account: ‘the functioning of the committee relies on expertise of the members […] we have to be proactive to facilitate the changes that the country needs’ (P21). When the Chair or membership changes, the body could, therefore, become less effective. The lack of routine and comprehensive communication between the different governance bodies was also mentioned as a weakness:
‘[we have] not previously engaged with the parliamentary committee on health, although they are an important player in the accountability for health. However, they have interacted only at the launch of the NHP II, which cannot be considered as formal or in depth engagement’ (P22).
One instance where the communication procedure has been formalised (and is reported as greatly improved as a result) is between the Office of the Ombudsmen and the hospital ombudsmen (P22).
Efforts to provide answerability mechanisms and their limitations were discussed. These included processes to provide a feedback link between service providers and the government and the extent of citizen review in government health policy and governance structures.
Frustration was expressed about the lack of citizen-level awareness and advocacy for greater government social accountability (P21, P8). A representative of a government-funded governance body stated that the process of parliamentary committee reviews is responsive, whereby issues are brought to their attention, triggering a review. However, they found that ‘Malawians are not proactive in demanding the committee’s legislative intervention’, giving the example of the Mental Health Act, which they said was out of date, yet no one has requested a review or amendment (P21).
NGO and CSO representatives remarked on a sense of apathy towards governance among the general population (P2, P8). A Malawian representative of an international NGO stated:
‘the problem with most Malawians is that they view human rights as a charity or a favour, not as an entitlement. When government fails to uphold or protect their rights, they therefore are not to demand rights as an entitlement that they ought to have. That way, issues like poor service delivery continue without any consequences’ (P2).
They criticised the government and courts for not clarifying the ‘state obligations in the protection of the right to health’ and the lack of discussion on the impact of economic, social and cultural rights on health (P2).
Conversely, it was also felt that when NGOs and CSO representatives did try to increase government recognition of specific health needs, the government response was tokenistic - it did not result in sustainable changes to health policy or effective implementation. For example, in response to civil society advocacy efforts, drugs for a vulnerable patient group were purchased by the government via the parliamentary committee for health. However, ‘it was a once off reactive purchase’, the supply was insufficient for the demand, and there was no distribution plan so the drugs could only be accessed via two hospitals in Lilongwe (P3). There was apparently no effective mechanism by which the group could seek an independent review of the situation.
There was, however, some evidence of government efforts to roll out accountability measures reportedly backed by the public. The Office of the Ombudsman had ‘shifted its focus towards service delivery by systematically reviewing institutional processes to recommend corrective measures’ (P22). Interns, being trained as hospital ombudsmen, had been placed in all four central (government-run) hospitals after ‘positive media reporting resulted in public and institutional demands for the idea to be spread to the central hospitals’ (P22). The representative of the governance body who gave this example also remarked that by recruiting and training up interns specifically for the role, they would not be current or previous MoH staff, thus implying a degree of impartiality. However, a structural issue remained as the ombudsmen report back (and are junior to) the District Health Officer, who has decision-making authority in district administration, ‘it is therefore very difficult for the subordinates to play watchdog over their seniors, even more difficult to sanction or report them for any wrongdoing’ (P22).
There was further evidence of collaboration between the government and other health stakeholders in MoH governance processes. For example, an NGO provided technical support to the government by placing local and international technical experts in the MoH as advisors (but the initiative ended in 2016 when the funding expired) (P2). Another NGO sits on the MoH’s Community Health Technical Working Group (TWG) to contribute expertise on how to build an effective community health system (although they approached the MoH to request to be on the group rather than being invited to participate) (P1). The Malawi Health Equity Network (MHEN) is routinely consulted by the MoH, attending regular and ad hoc meetings, and participating in TWGs (P11). However, not all CSOs are members or feel represented by MHEN:
‘the challenge with MoH’s engagement with NGO stakeholders is that they assume that MHEN is the representative of all health NGOs, but not all NGOs doing work in the area of health are members of MHEN. The organisation’s view is that MHEN can’t replace grassroots voices in the engagement with the MoH. MHEN does not have capacity to represent all voices, simply impossible’ (P13).
In the absence of adequate social accountability, examples were given of how service providers, NGOs and CSOs sought to hold the government to account for limitations in the health system. For example, in response to poor government-led governance of healthcare facilities and service inefficiencies, service providers had introduced structures to increase accountability at the service-level and in their interactions with the MoH (P4, P5, P17, P22). Queen Elizabeth Central Hospital sought greater autonomy from the government by establishing their own information management system and is seeking registration as a public trust. To this end, an independent consultant has been engaged to assess the readiness and capacity of the hospital, and they have prepared trust deeds, a constitution, and Terms of Reference for the board (required documents for registration of public trusts with the Registrar General) (P17).
Another approach was to include MoH representatives on the key management boards of the service providers, thus facilitating direct and ongoing communication with the MoH via a designated person. By including a MoH representative on CHAM’s boards, the ongoing issues of funding deficits and drug stockouts (when required drugs are not available at healthcare facilities) would be fed back to the government, and hopefully addressed, more promptly (P5). They successfully lobbied the government to establish a joint SLA Unit whose sole purpose is to communicate with the facilities, monitor the contracts, pay facility staff directly and respond to any issues (P5). Part of the Unit’s role is to visit the healthcare facilities to review the challenges. Further, CHAM now insist on Memorandums of Understanding with the government to ensure that each of their facilities is the only government-registered and recognised facility in that area (P5). This protects them from the government stipulation that funding can be withdrawn if healthcare facilities are within 5 kilometres distance of each other.
Efforts were also being made by NGOs and CSOs to increase the social accountability of the government to the public through advocacy and monitoring activities and training (P3, P8, P12). Direct action included pressuring the MoH to respond to health-related incidents, such as aggravated attacks on people with specific health conditions (e.g. albinism) (P3) and for the inclusion of ‘neglected health issues in the national health responses’ (P13). This had resulted in the introduction of a new MoH TWG which includes consideration of these health issues alongside those already receiving a significant focus (e.g. HIV/AIDS) (P13). Other advocacy initiatives were targeted at the national and local government levels and service providers (e.g. hospitals). These included calling on the government to increase the health budget to the level expected under the Abuja Declaration (P9, P11) and educating the public in the need for greater social accountability, thus creating a demand (P8). It was felt that the courts should have (but had not) taken an active role in clarifying the ‘state obligations in the protection of the right to health’ (P2). There were efforts to highlight this and to raise awareness among the public that they can use the court system to demand health services (P8).
Another approach used was to demonstrate to the community the value of specific services with time-limited funding to mobilise them to become accountable for these services and demand the government provide ongoing access (P12). Training initiatives aimed to equip communities and individuals in local government and health service delivery (e.g. health advisory and health centre management committees, faith-based NGO and district health management teams, local government councillors) with skills in budget analysis and monitoring to become advocates for governance and hold to account the service providers that they interact with (P8, P11). For example, manuals have been developed to train service providers on upholding the human rights of vulnerable groups during service delivery (e.g. women, children and sexual minorities) (P8).
Collaboration with other organisations was perceived as strengthening the advocacy efforts of CSOs, such as calling for greater governance to prevent corruption in the health sector. For example, one group found that membership of an international NGO network gave them support with developing a strategic plan to advocate for the creation and adoption of a national response plan in a neglected disease area (P13). Other groups formed a coalition to become the patient voice in government consultation exercises (P8, P11) or lobby international NGOs and donors to advocate for their interests (e.g. drug safety and more health professionals working in their disease area) as they are believed to have more influence with the government and can raise awareness at the international level (P12). These collaborations are also conducting independent monitoring of the national health system and looking at how the government is meeting its legal and policy obligations to publicly hold the government to account for its actions and interventions (or lack of them). For example, monitoring progress towards achieving the UHC target (P8), monitoring the extent to which health interventions specified in the MoH’s policies are being implemented (P11), and assessing whether the health budget approved by Parliament is being implemented (as there is a known deficit in the amount spent versus the amount allocated) (P8, P11, P18). Periodic service delivery satisfaction surveys are also conducted to hold government-funded service providers to account for the quality of the care they deliver (P11).
Health resource management
Most of the challenges to the governance of health resources arose from underfunding (whether due to the insufficient allocation of funds or corruption) and a lack of interconnectivity (communication and resource distribution) between the different levels of the health system. Specific instances of poor governance were identified for drug supply, exacerbated by the fragmented health system.
It was acknowledged by several interviewees that a lack of allocated and available (due to low domestic revenue) funding hindered improvements in the health system in general, and governance specifically (P22). The city assemblies do not receive funding from government as they receive locally generated revenue (city or property rates, licences, and service charges). This produces insufficient funds to meet the health needs that the city assembly are mandated to provide: 1) public cleansing services (e.g. waste management, cemetery services); and 2) preventative community health services (e.g. family planning clinics, health education, pest and infection control, HIV prevention and treatment) (P15, P20). Further, the lack of government funding received by the City Assemblies was flawed as it ‘overlooks the reality of disease or health burdens’. The example provided was cholera outbreaks, which typically spread from rural Lilongwe to more urban areas, ‘yet the City Assembly is expected to bear the cost when the crisis hits the urban population’ (P20). It was felt that the City Assemblies should receive some funds from the Ministry of Local Government as the ‘urban populations also pay for other taxes and must get returns through the national budget’ (P20).
When the District and City Assemblies are located in the same city (as in Lilongwe and Blantyre) it was argued that:
‘the District Health Office should be doing more to fill in the gaps [in the City Assemblies’ funding/service provision]. But bearing in mind the financial limitation of the District Assemblies and the District Health Offices, that is a consideration for the City Assembly letting them get away with not covering all the gaps’ (P15).
Accordingly, the health policy cannot be enforced because the City and District Assemblies cannot be made to provide services which they cannot fund. This leads to a mutual acceptance of substandard service delivery at multiple levels. Furthermore, local government representatives expressed frustration at not receiving clearer guidance about resource allocation from the MoH. The government determined the structure for decentralised health resource allocation - health resources are to be decided at the district level by the District Health Allocation Committee - but did not issue any guidance on the composition of the committee or its role in health resource allocation at the regional level (P19). The inference being that it was inefficient for each district to develop their own guidelines and results in inadequate committees.
Issues were also identified between the government and service providers. The government has Service Level Agreements with CHAM, paying them to provide healthcare facilities, hospitals and training of healthcare professionals. However, the government frequently fails to meet their contractual obligations:
‘through CHAM we signed what we call them service level agreements, but are they fully adhered to fully? Not really. But we still have to keep on like providing the services because we are also responsible to the communities that we are in’ (P2).
On some occasions, the MoH has delayed payment to CHAM by four months (accumulated non-payment without warning/agreement) (P5). In some facilities this has resulted in a poorer quality of service delivery as the staff and essential running costs cannot be paid and drugs purchased (P5):
‘the government is currently failing to honour agreements by defaulting on payments to some of the facilities and as a result, citizens whose only option is to go to CHAM facilities to access health services are being turned back because the hospitals won’t offer free services until the government has paid’ (P8).
Conversely, despite the MoH’s funding constraints, it was reported that one government-funded organisation was able to renegotiate additional funding after the budget ceiling for the year had been set. They received an extra one million US dollars by arguing that the allocated budget has a serious shortfall and ‘downscaling would have resulted in public dissatisfaction and diminishing of public support’ (P18). Thus, top-up funding may be possible for organisations who know how to approach and argue their case with the government.
Three interviewees perceived corruption as the greatest ongoing challenge to an effective health system (P2, P8, P9). For example, ‘the problem with our health system may not be about insufficient resources’, inferring that theft and corruption are responsible for the resourcing issues (P9). There was criticism of the government for seeking to introduce user fees to secure additional revenue for the health system, but which would not address the underlying issue of poor resource management:
‘Failure of Malawi’s health system is about corruption because the financial systems are porous. Once we address that problem, then we can talk about whether people can pay user fees. There are many ways to increase availability of resources by avoiding wastage. Malawian people are poor and additional payments won’t address the problem of system failures or drug stockouts. Drug stockouts are a symptom of a dysfunctional system than insufficiency of funding. Even if the idea of user fees was accepted and implemented, there has to be someone to collect the pay and manage the funds. In the current situation, the funds would create more problems than solutions’ (P2).
It was stated that improvements to the national health system will not be possible until governance is strengthened at the national and district government levels to tackle ‘the fact that significant health moneys are lost to theft and corruption on areas such as supply of materials, drug procurement, contracts for construction of health facilities money’ (P8).
The availability of medical drugs and particularly drug stockouts were the issues raised by the greatest number of interviewees (P1, P4, P7, P9, P12, P13, P15, P16, P17, P20). Stockouts were attributed to limited government funding for drugs, a fragmented drug procurement system, inadequate drug supply and distribution, theft, and political disinterest in providing drugs and medical devices to specific vulnerable groups e.g. people with albinism, prisoners and LGBT communities. For example, ‘there is lack of resources to fund disease’ treatment for prisoners. Health of prisoners is not a priority’ (P7) and ‘there are always drug stockouts, yet we continue with the same inefficient supply chain’ (P9). When there are drug shortages, ‘the patients have to find money and buy medicines which they have been prescribed’ (P16).
The government’s drug policy is that they have ‘a final say on what to do with the drugs, where to distribute them and how to distribute’ (P16). Some drugs are included in the EHP, but additional drugs may need to be procured for conditions not covered (P4, P19). The government was perceived as not understanding the differences in the needs of different communities: ‘in reality, each district orders drugs based on the local needs and dynamics. The EHP in the HSSP II provides an ideal scenario, but in practice we have to respond to local realities’ (P19). The government was considered impervious to variation in population needs - even when evidence of a need for drugs/medical devices can be provided using information management systems, the government had failed to respond:
‘there is insufficient availability of lubricants and dental dams. There should be coordination to estimate the needs and purchase the sufficient amounts. [We have] statistics on the need of lubes and the state should use the supply-returns [the system for accounting for lubricants distributed] and the state can purchase based on the trends from it’ (P14).
The government requires that all national health system drug-procurement is via the Central Medical Stores (CMS) or their approval is sought before using other sources or distributing donations (P5). When this procedure is followed the supply can be poor, sometimes drugs are available in the CMS but not received by the hospitals (P13). There were calls from the interviewees for an improved system to coordinate between the CMS and the hospital pharmacies, and better auditing of drugs at healthcare facilities (P4, P13). In reality, drugs are accessed from a variety of sources i.e. the CMS, District Health Officers, donors and disease-specific programs (P5) and CHAM all use their preferred suppliers as an alternative to the CMS (P5, P15). For example, ‘since the city assembly is autonomous, they have at times decided to purchase from preferred local suppliers’ and ‘we have prequalified suppliers each and every year then we negotiate the prices and we buy our own drugs’ (P15). Further, when the service providers receive donations of drugs (including prenatal multivitamin tablets for pregnant mothers) from ‘international well-wishers’ they are supposed to consult the government about distribution but instead, they distribute them as they see fit, according to the needs of the community (P15). Other providers refuse them as ‘the drugs received are based on donor preferences. The MoH has given District Health Officers powers to refuse drugs which are not needed because it costs more to receive drugs that will not be used’ (P19).
This fragmented system of different facilities procuring drugs from different suppliers requires effective information management. One NGO was developing an information management system to harmonise the supply chain across their facilities by getting an ‘overall picture of supply of medicines (P1). They described the scale of the project:
‘to support harmonisation of the system including all drugs that run through the system, and donor-run supply chains e.g. USAID’s global Health Supply Chain. The government system ideally should take account of drugs that are procured by development partners [donors]. Ideally, a country should have one drug procurement agent but the current system in the country is chaotic’ (P1).
Influence in decision-making
The health stakeholders interviewed consistently felt that they did not have any power to influence healthcare decision-making, particularly in the development of health policy (the NHP II and HSSP II); whilst donors were perceived as exerting a, largely positive, governing influence over the government.
Examples of unequal power and its impact in different health system contexts (governance bodies, services, donor-government relations) were identified.
A human rights organisation with a health-focus spoke of a lack of political will for greater governance as the reason why corruption and financial irregularities in construction contracts for healthcare facilities (which are centralised and led by the MoH) occurred, ‘government has enough authority over public services, but political will is crucial for things to work’ (P8). The deficit in health sector governance is exacerbated by a lack of top-down leadership:
‘the systems for effectiveness are simply not there in the public health sector and in the end there are chaos. The lack of functioning across the system is worsened by the fact that we do not have the leadership that understands the importance of functional systems and how much it would save on time and resources’ (P21).
They added that the governance mechanism of the parliamentary committee on health is underfunded, ‘meetings of the committee only takes place when parliament is able to fund the committee’. Governance is not considered a priority by the MoH and the Government of Malawi more broadly, ‘having a well-funded and functional committee is not a priority at the moment. Nothing will change in terms of legislative oversight without additional funding’ (P21).
Arguably, unequal power over the health sector is also maintained by the MoH’s insistence on oversight of top-level appointments to the boards/committees of organisations and facilities which receive (partial) government funding, such as the National AIDS Commission and Queen Elizabeth Central Hospital (P18, P17). For example, in the 2018 HIV and AIDs Act, the MoH retained the powers to approve high-level appointments (made by the board) in the National AIDS Commission, despite this public-private institution being established in law as independent of the government (P18). This degree of government oversight raises questions about transparency and the risk of corruption. There were also concerns about disproportionate influence in the relationship of the government to health facilities. For instance, when the Queen Elizabeth Central Hospital sought a change in status from government to private or public-private funding, the government appeared obstructive. The preferred option, to become a statutory corporation (a private-public concern with the government as the majority stakeholder), would have required a new law. It had the support of the public but not the politicians and no law was enacted, ‘the idea died because there was no political will to prepare the law and submit to parliament’ (P17). The issues of delayed payment to CHAM facilities were also considered political: ‘somehow when it is issues to do with the MoH the political part of it you can’t avoid’ (P4).
Donors were perceived as the only health stakeholder to exert any influence over the government and health system governance, possibly even requiring the development of a strategic framework for the NHP II as a condition of aid (i.e. the HSSP II) (P2). There was the widespread perception of greater governance when donors were involved (P8, P15, P18, P21), ‘the challenge in Malawi is that things only work when there is a donor funded project which has a higher standard of accountability in terms of milestones and reporting’ (P21). Since the collapse of the Sector wide Approach (SWAp; a donor-government partnership to map international funding to the activities of external development partners in Malawi), during which donors had close collaboration with the government, there has been less supervision of health funding (P15). Donors continue to fund the essential resources of the government’s healthcare facilities (e.g. electricity and water), but these are no longer paid into a basket fund shared with the government via the Ministry of Finance. There are much tighter controls on their use, with budget lines for specific organisations/programmes e.g. HIV-specific resources for the National AIDS Commission (P18). Due to a distrust of the government, some donors continue to operate in Malawi but independent of the government:
‘since cashgate, donors do not trust the government system and cannot transact their resources through the government system. So far USAID is not open to cooperating or collaborating with the government systems, but DFID is more open to collaboration or harmonisation’ (P1).
The internal governance mechanisms used by donors, international NGOs and multi-level organisations were regarded as indirectly affecting healthcare governance. For example, Oxfam conducts citizen satisfaction surveys to assess the impact of their programmes. These baseline and monitoring assessments are used to guide the programme’s strategy and assess its success but are also used to determine the focus and provide evidence for their advocacy agenda (P8). Ultimately, it was felt that the donors had and could have great influence over governance in the health sector, ‘donors have leverage because their funds are the lifeline of the health sector. So, everyone has to listen to their views’ (P8).
Stakeholders viewed the government as always putting their agenda ahead of the interests of the service providers and public (P4, P8, P17). Eleven interviewees (50%) had some involvement in either the development or validation of the NHP II and/or the HSSP II. Five (22.7%) felt this involvement was inadequate as not enough time was allowed for civil society or local government consultation, or that their involvement was a government afterthought (P6, P8, P17, P19, P20). As such, they felt that their priorities (the affordability, availability and accessibility of health services) were either not reflected in these documents or in insufficient detail (P6, P18). For example, the ‘NAC [National AIDS Commission] is mentioned in the NHP II and HSSP II, but only in passing and without much detail as to how the strategy or plan will manage HIV and AIDS and coordination around it’ (P18).
Efforts were made by the government to consult civil society and local government health stakeholders, with the significant involvement of MHEN (comprised of CSOs) (P2, P13). Despite this, CSOs that were not consulted reported that ‘the documents do not reflect the voices of patients’ (P13) and the local government representatives felt that they had minimal involvement (P19, P20):
‘involvement during the processes for developing the NHP II and HSSP II mostly happened at the MoH headquarters level. There were times when the District Health Office would be involved. Teams from the ministry headquarters would go to the districts with a questionnaire to ask questions related to policy and strategy. Consultations to finalise the two documents mostly happened at the Ministry headquarters’ (P19).
The NHP II and HSSP II were perceived as ‘this is a MoH thing. It’s also very political’ (P4), ‘[they] are only political tools which are mentioned in political speeches to show progress in the health system’ (P21). They were perceived as developed to appeal to the donors as it was donor-driven and funded (P1, P18, P21) but there was little confidence in the implementation of the policy and strategic plan (P4, P21), especially its ability to deliver the EHP (the starting point for the move towards UHC):
‘it is all about politics, but little to do with bringing change to better lives of the poor Malawian. Whatever the case, what Malawi is promising in the policy and strategy in terms of the essential health package, it cannot sustain due to domestic funding constraints’ (P21).