When Ministry of Health and Sanitation allowed district hospitals to introduce optional paying services, improved service, convenience and mobilisation of domestic resources loomed large but the arrangement has ended up compromising service delivery.
The Nation spot-checks established that in 46 percent of district hospitals, the paying services generate between K2 million and K12 million monthly. Authorities have hailed this as a step in the right direction.
But on the flipside, the facilities are short on infrastructure such that they are using structures meant for free services, thereby creating congestion in non-paying wings. Inadequate staff and skyrocketing costs of drugs and medical supplies further complicate the situation.
In some of the district hospitals, the paying services have been suspended due to queries on use of resources while some patients also allege that the facilities are paying more attention to those in paying wards than the poor seeking free services.
Revenue variations, highs, lows
From our findings, Chikwawa District Hospital generates an average of K12 million per month from paying services while Phalombe makes K7 million, Nkhata Bay is at between K5 million and K12 million while Machinga rakes in K9 million, Mulanje and Rumphi K4 million each, Salima brings K3.5 million, Karonga makes K2 million and Thyolo earns K1.5 million.
Chikwawa district director of health and sanitation services (DHSS) Dr. Grace Momba said in an interview that the district hospital, whose total monthly budget is K68 million, introduced paying services in April 2022.
She said: “Revenue collection systems have been strengthened, including signing of contracts with medical schemes.
“Funds generated have been used for the procurement of drugs and medical supplies, supporting minor infrastructure maintenance and staff. The revenue has helped to improve morale and motivation for health workers.”
In Phalombe, DHSS Dr. Sam Sibakwe said in the context of constrained government funding, the paying wing has become a financial backbone, especially supporting procurement of essential drugs.
Phalombe District Hospital, renamed John Chilembwe Hospital, is a new hospital and was pre-designed with a special paying wing with self-contained rooms, air conditioning systems and refrigerators.
Said Sibakwe: “It [the revenue] also helps cover key operational costs such as fuel, electricity, cleaning materials and other emergency service as required. It also supports locums, pay stipends for additional part time nurses and clinicians.
“At the moment, the council is on a campaign to make sure all members of staff, some traditional leaders and councillors are on Masm [Medical Aid Society of Malawi] scheme so that they pay and we hope will boost revenue generation.”
Kasungu District Hospital. | Nation
The hospital has a monthly budget of K55 million, he said.
Nkhata Bay District Hospital provided the most detailed data with a report from its Accounts Department, sourced through DHSS Dr. Topsy Mdolo showing that the paying services are made up of 21 revenue streams.
Among others, revenue is generated from medical reports, health passports, laboratory tests, X-ray, mortuary, hostel, theatre/surgeries, tent hiring, tuckshop, restaurant, research and Masm payments.
The report shows that the resources help in the procurement of critical drugs and food in times of emergencies as well as buy materials for routine maintenance and fuel for ambulances and other utility vehicles.
Reads the report: “We have been using funds from the paying wing to maintain houses at Ruarwe and once bought a coffin for our staff [on loan] when the family couldn’t afford to buy, let alone borrow.
“Sometimes when a staff member is bereaved, the welfare committee borrows money from the paying section account to meet the costs and then reimburse later when their cashflow improves or when they get their money from staff contributions.”
Challenges
Nkhata Bay District Hospital has its fair share of challenges, with the report showing that delayed funding from the government makes the paying services constrained with emergencies and that some receivables have been outstanding for so long.
“There is need to engage Masm on the price adjustment to update the price list. We need to involve the paying committee and/or health service committee to help in debt recovery as some creditors are prominent people in the society,” it reads.
In Phalombe, the main challenge has been human resource as demand for services sometimes exceeds available staff, prompting the hospital to engage part-time nurses and clinicians to help cover service gaps and maintain quality of care.
Rumphi District Hospital spokesperson Esau Mkamanga also lamented staff shortages, saying the hospital is forced to reallocate available staff to ensure that critical service areas are covered, engaging locum staff where possible and advocating for additional staff deployment.
He said limited space to accommodate more patients also frustrates implementation. He added that the district health office (DHO) is engaging stakeholders to explore infrastructure expansion options.
In a separate interview, Karonga DHSS Dr. David Sibale complemented: “The major challenge is limited space to meet the available demand. We plan to lobby for construction of a standalone structure that will house the paying services, increasing staff and mount sign posts to promote the services.”
Salima DHSS Eugene Kaunda added: “The paying ward is not fully furnished. If we finish that, we would be making K6 million each month. We do not have other separate ways of making funds to renovate the paying ward.”
Another area of concern affecting all hospitals is shortage of drugs and medical supplies, including delays in the procurement processes, with Momba saying they continue engaging relevant authorities to improve supply chain efficiency.
Mulanje DHO spokesperson Peter Nasoni said: “The main challenges include high and unstable prices for drugs and other commodities. Rising prices despite that our price list takes time to be updated by the central government to reflect the changes also erodes our revenue.
“The other challenge is mind-set change. People are used to free services and introduction of optional paying services has not been fully embraced by all.”
Ministry of Health and Sanitation guidelines (2023) provide that the paying services represent a strategic approach aimed at mobilising additional domestic resources through the provision of improved, convenience-based, or premium service options within public health facilities.
