Decentralise health spending

Health sector financing, now centralised in district councils, has led to inefficient and ineffective resource allocation and service delivery where it matters most.

Most public health facilities are not only dilapidated but lack adequate basic drugs, medical supplies, utilities and reliable transport facilities.

For example, the annual budget for Chitipa Directorate of Health and SocialServices is not a consolidation of budgets for Nthalire, Wenya, Chisenga and other health facilities in the district.

Lack of participatory plans and budgets in health facilities leaves rural health staff dependent on sporadic financial support and benevolence of district health authorities.

Rural health workers generally lack motivation as there is no planned financing for essential goods and services for them to adequately serve the citizenry. This forces rural dwellers to flood district hospitals which are better financed.

Unfortunately, overcrowding in district hospitals has caused even more challenges, including staff burnouts, drug stock-outs and scrambles for limited equipment and spaces.

Overcrowding is also fuelling the spread of communicable diseases.

As such, deepening fiscal decentralisation to rural health centres will not only boost sustainable development of health infrastructure, but also motivate workers who will passionately serve patients.

High staff morale creates cordial ties with the community they serve and spur public confidence in the public health service.

Consequently, it minimises staff turnover, one of the greatest challenges. 

Direct financing of health facilities will also enhance good governance, including transparency and accountability, as health management committees will be involved in planning, budgeting and expenditure.

Direct financing could also result in equitable distribution of financial resources to all facilities within the district.

This will require authorities to develop a formula for resource distribution that takes into consideration the population, disease prevalence, rurality and area size.

With direct financing to facilities, maintenance of public health infrastructure, equipment and transport will be done on time.

There will not be a long wait for the benevolence of the messiahs at ‘head office’.

Transportation challenges that delay referrals will be eased because fuels, oils and spare parts will be procured on time.

The district health authorities will achieve managerial efficiencies by delegating the management of health centres’ operations to the facilities health management committees.

This will leave the authorities with the responsibilities of public health policy dissemination, staff recruitment and training, provision of essential drugs and major district health infrastructure investments.

It must be understood that deepening fiscal decentralisation to the facility level has its own challenges, including lack of capacity to handle public finances according to laws and regulations.

The rural facilities also experience a shortage of staff, funding and basic amenities to retain skilled health workers and support staff.

However, the education sector has success stories to share on deepening fiscal decentralisation in Malawi.

District financing is sub-granted at zonal and primary school levels.

Schools now procure furniture, textbooks and fuel for motorcycles and other routine purchases.

The money is also used for minor maintenance services, construction of school structures and allowances for temporary teachers.

The ministries of Finance, Health and Local Government should, therefore, draw a deliberate fiscal devolution plan for direct financing of healthcare facilities to deepen fiscal decentralisation.

Deepening fiscal decentralisation in the health sector will strengthen local governance systems while putting limited resources to optimal use.

The strengthened systems will be a catalyst for the ongoing public health sector reforms while promoting rural development, transparency and accountability through Mphamvu ku Anthu.

Regular financing in health facilities will bring timely maintenance of buildings and equipment and bring improved service delivery, which is  pivotal in achieving the Malawi 2063 long-term vision and Africa’s Agenda 2063.