A hundred days into office, the Democratic Progressive Party (DPP’s) health decentralisation pledge faces its first test.
Ahead of the September 16 General Election, the party promised to shift power in the health system away from central government to districts and frontline facilities.
This means decision-making would move closer to patients and congestion, drugstock-outs and slow responses would no longer be managed from Capital Hill.
Thus far, what government has delivered is visible, but whether it amounts to meaningful autonomy at the point of care is less certain.
At the centre of the DPP administration’s early health narrative is renewed activity. Construction sites are active and financing is ongoing. Official statements point to a system stabilising after prolonged strain.
But the key question is whether these interventions represent a transfer of authority, central to the governing party’s decentralisation pledge.
Officials highlight renewed financing for the procurement of medicines as a major stabilisation effort.
Indeed, over K17.1 billion has been committed to the Central Medical Stores Trust at the mid-year budget review, alongside prioritisation of foreign exchange for medical imports.
Initially, the health sector was allocated K741.05 billion in the 2025/26 National Budget (about 9.2 percent of total government expenditure).
After the mid-year review, the allocation rose to roughly K758.15 billion following additional drug financing, split almost evenly between central and district hospitals.
The baseline budget prioritises completion of major infrastructure projects, including the National Cancer Centre, Domasi and Mponela community hospitals, construction of 55 health posts, support to the health sector joint fund and emergency programmes, plus expansion of Direct Facility Financing (DFF) to 13 additional districts.
However, the mid-year review also reveals mounting system pressures. Health contributed to expenditure overruns driven by front-loaded spending and a sharp wage bill overshoot linked to expanded recruitment.
Despite rising nominal allocations, the sector remains well below the 15 percent Abuja target, with spending increasingly focused on crisis management of medicines and personnel costs rather than structural reform.
Secretary for Health Dr Dan Namarika situates the DPP’s pledge within an already decentralised system, insisting that councils exercise substantial control over operations.
“The health system was decentralised by the DPP. We have directors of health services at council level. All human resources for health are recruited, handled and managed by councils. The budget for medicines is now managed by the councils,” he said.
Namarika disclosed that the administration is pursuing a phased expansion of autonomy, with at least half of the country’s roughly 800 health facilities expected to operate with devolved authority under the framework.
He also points to district-led partnerships as proof that decision-making already rests beyond the centre.
“A good example is Mangochi, where the Government of Iceland worked directly with the council to construct various infrastructures,” he said.
Yet local government practitioners caution that fiscal control remains largely centralised.
Malawi Local Government Association executive director Hadrod Mkandawire notes:
“Less than 10 percent of health sector resources are currently held by councils. None of Malawi’s health facilities are operating as cost centres yet. The donor-funded DFF initiative is expected to transition facilities into autonomous budget-holders, but it remains transitional and has not yet shifted facilities into full cost-centre arrangements. No additional domestic resources were added beyond the budget approved at the start of the financial year.”
Professor Adamson Muula of Kamuzu University of Health Sciences (KUHeS) warns that linking central procurement stabilisation to facility autonomy risks conflating two distinct governance functions.
The complexity arises when autonomy is framed as independence over resources such as staffing, equipment and infrastructure.
Muula does not dispute district involvement, but draws a firm line around where authority resides.
Infrastructure investments cited by government similarly attract mixed interpretations. Completion of Khwisa Health Centre in Balaka, Phase One of Domasi Community Hospital and installation of an oxygen plant at Zomba Central Hospital are described as decentralised service strengthening, but critics see them as centrally coordinated expansions.
Dr Lucinda Manda-Taylor, an Associate Professor at KUHeS, situates the debate within ethical and equity considerations, agreeing that decentralisation can be transformative but only under deliberate conditions.
“From an ethical perspective rooted in equity and social justice, decentralisation has real potential because decisions are made closer to the communities who depend on them,” she said.
