Towards universal health coverage

Saturday, September 16 2017, was supposed to be a joyous day for Maria Grasiano, but she rues the day,

“I lost my dignity as a woman because I delivered my baby in a vehicle, in the presence of the youth and men, on my way to Balaka District Hospital,” she explains.

Grasiano was feeling labour pains when she left her home for Phimbi Health Centre(DHO). After assessing her condition, nurses at the facility referred her to Balaka, almost 65 kilometres away. But the health centre had no ambulance. Authorities at Balaka District Health Office had withdrawn it five years ago.

“Like any other patient, I jumped on a public transport commuting between Phimbi and Balaka. I paid K5 000. Worse still, nurses at Phimbi do not accompany patients, for doing so would compromise health service delivery at the health centre which has two nurses and clinicians,” she says.

Phimbi Health Advisory Committee chairperson Ephraim Kamtedza says the withdrawal of the ambulance led to preventable deaths, mostly resulting from maternal complications.

“Balaka DHO withdrew our ambulance on the pretext that it needed repairs. But following engagement that communities had with District health management team [DHMT], councillors and our member of Parliament through promoting health governance project being implemented by Development Communications Trust with funding from Oxfam, Balaka DHO brought back the ambulance”, he says.

And medical assistant James Afuwa is “happy and relieved” to have the ambulance back.

“As the in-charge of the facility, I felt bad sending patients to Balaka District Hospital unattended in non-medical vehicles because I have two nurses here.”

There are similar stories across the country. They affect equitable access to health care services and forces the poor to pay huge costs for healthcare services which are supposed to be free.

Last year, the Ministry of Health launched the Health Sector Strategic Plan (2017-2022)—a roadmap towards health financing reforms to make universal health coverage (UHC) a reality.

World Health Organisation (WHO) defines UHC as a situation where all people receive the quality health services they need without suffering financial hardship.

Financial leakage

Government plans to, among others, introduce a National Health Insurance Scheme and creating a Health Fund.

But activist Moses Mkandawire, the executive director of the Church and Society of the CCAP Livingstonia Synod, says there is need to strengthen social accountability structures and mechanisms for Malawi to achieve UHC.

“To achieve universal health coverage, there is a need to tackle corruption which seems institutionalised at all levels,” he says.

He reckons everyone has a role in entrenching efficiency and prudence to stop “financial leakage”.

Mkandawire urges government to increase resources allocated to the health sector in line with the Abuja Declaration. It requires funding for the healthcare services to be no less than 15 percent of the national budget.

He reasons: “We can only attain UHC if we have political will and increased resources allocation in health sector.

“Just imagine 1 doctor per 100 000? Can this ratio contribute to quality healthcare? I think we need to consider human resources for health. We need to train more nurses, doctors and other healthcare workers. But we can only do that if we have enough resources in the health sector.”

Civil society organisations under UHC coalition argue that government’s decision to introduce user fees and other out-of-pocket payments in district hospitals will make the poor suffer financial risks.

One of UHC advocates, Dr. Themba Nyirenda says achieving UHC needs concerted efforts from government, donors, private sector and the civil society.

“In many tertiary facilities and in facilities belonging to Christian Health Association of Malawi [Cham], the user fees and out-of-pocket expenses push the ultra- poor into poverty. Access to health services must be [free] for the poor and protect them from financial risks,” he explains.

User fees often push the poor into an abyss of poverty.  Zambia reversed implementation of user fees to promote universal health coverage.

“Attaining UHC needs serious political will, political leaders must play their role here. We need homegrown solutions. Take note that Malawians spend very low per capita for health services at $30, the lowest in the Sadc region,” says Nyirenda.

He reckons Malawi’s health care is not free as many people think.

“Everyone is paying for it through taxes that we pay. Introducing user fees and other out-of-pocket payments mean bringing inequitable access as the poorest of the poor cannot afford the charges,” argues Oxfam resource governance coordinator Matthias Kafunda.

He says addressing inefficiencies within the health sector would be more beneficial than introduction of user fees.

Estimates indicate that Malawi can increase health per capita expenditure by $10 if it addresses existing inefficiencies in health service delivery.

Think carefully

“For many, UHC is literally a life or death issue. Individuals without access to quality health care are facing the prospect of untreated sickness and premature death for themselves and their children. Government and development partners need to think carefully about health financing in the country that includes financial protection for the poor. It is essential that all three factors of health financing- revenue raising, pooling and purchasing, are properly coordinated to achieve efficiency, equitable utilisation of services and financial risk protection,” he says.

And Grasiano says: “All women regardless of their status must be given necessary essential health care to deliver their babies. No woman must deliver in a vehicle”. n