Four political parties regarded as front-runners in the May 21 2019 Tripartite Elections have made bold promises on how they wish to transform the health sector, but skirt around commitments on financing the sector largely funded by donors.
In their manifestos for the election, the four—governing Democratic Progressive Party (DPP), challengers Malawi Congress Party (MCP), United Democratic Front (UDF) and UTM Party—acknowledge existence of the Health Sector Strategic Plan (2017-2022), but they have not gone far enough to address the funding gap that exists in the plan to ensure achievement of universal health coverage.
The plan indicated that donor contributions to health expenditure averaged 61.6 percent between 2012 and 2015 with the Malawi Government putting in 25.5 percent and households 12.9 percent.
The plan also states that the HIV and Aids subsector is mostly funded by development partners with the contributions going as high as 95 percent of total financing.
Health sector observers say such a health financing model is not sustainable and suggest that alternative mechanisms—including the establishment of a health fund and introduction of a national health insurance scheme for salaried Malawians—should be aggressively pursued.
The K1.3 trillion 2018/19 National Budget expiring on June 30 failed to meet the 15 percent allocation to the health sector as stipulated in the Abuja Declaration to which Malawi committed to allocate as only K86.5 billion went to health. That is just roughly seven percent of total expenditure in the current financial year.
MCP has made bold sweeping promises touching on “adequately funding” primary health care, building more health infrastructure and employing more health workers, but is silent on financing this sector.
In its manifesto, MCP has also not acknowledged the financing challenges facing the health sector or the funding gap that exists as highlighted in the strategic plan.
The party promises to increase funding to Christian Health Association of Malawi (Cham) facilities, but has not indicated how much it plans to pump in.
MCP also plans to establish a Malawi Pharmaceutical Company (MPC) to replace the defunct Malawi Pharmacies Limited, but there are no specifics of how this firm would be capitalised and to what extent it can contribute to the improvement of health service delivery nationwide or indeed what that corporation will mean to the future of the Central Medical Stores Trust, which procures, warehouses and supplies drugs to public hospitals nationwide.
“The goal of the MCP government will be to ensure universal access to decent free public health services to all Malawians,” reads the manifesto.
However, MCP does not explain how setting up a national health insurance to cater for the cost of specialised treatment alone would work in private or public hospitals already lacking equipment and specialists.
National health insurance means that the government would become the sole financier and buyer of health services and compulsory payments will be deducted from the salaries of all people in formal employment.
Like the other parties, MCP has failed to answer the big questions about the insurance initiative such as where the money will come from to pay for universal coverage, given the few taxpayers there are.
On its part, the UTM Party manifesto makes no mention of the ongoing reforms on health financing that include introduction of a national health insurance or ongoing discussion on user fees, but acknowledged that the sector faces inadequate funding.
The UTM manifesto notes that the health sector has a vacancy rate of over 50 percent and the party plans “to recruit more”, but does not state how many it will hire, how much that would cost and where the money would come from.
But the rhetoric is surely high sounding.
“UTM shall improve the availability, retention, performance and motivation of human resources in the health sector for effective, efficient and equitable health service delivery,” reads UTM’s manifesto in part.
DPP, on the other hand, is lauding its successes in the past five years in detailed form, but would not provide similar information on how some of its planned programmes would be implemented.
For example, after claiming to have reduced the doctor-to-patient ratio from 1:55 000 in five years, the DPP manifesto says this will be further reduced from 1:33 000 to 1:5 000 within five years. How this will be done is a detail outsourced to guess work.
In its manifesto, DPP has also been caught owning projects that are fully financed by non-governmental organisations or development partners.
However, in addition to promises of ensuring availability of adequate quality medical and constructing new infrastructure, DPP has committed to rolling out the national health insurance scheme.
DPP claims it will continue to increase funding to the health sector when the health sector budget has increasingly been reduced in recent years. For example, the health sector budget went from K190 billion in 2017/18 to K86.7 billion in this financial year.
“We will continue to increase funding to the health sector to strengthen financial sustainability of the health services. This includes reaching the Abuja Declaration of at least 15 percent allocation of national budget to health,” the manifesto reads, yet at no point in its five years in power has the party ever reached the Abuja Declaration.
In fact, per capita health spending has progressively sunk under the DPP’s watch.
On its part, UDF, whose presidential candidate Atupele Muluzi is the current Minister of Health, seems to understand the impact of a growing population on the health sector, but could only promise a “more detailed discussion on health financing” going forward not how their planned programmes such as construction of regional hospitals to supplement referral hospitals would be funded.
In other words, the party— which led Malawi from 1994 to 2004—has not articulated a plan for breathing life into the country’s ailing healthcare system.
Like the others, the UDF manifesto is too shy to openly suggest means of health sector financing that heavily relies on donor funding, in particular for vaccines, top ups on salaries of selected health workers and reproductive health.
Yet, the party acknowledges that progress on key health indicators such as maternal and child mortality have not come cheap and the cost grows every year with the rapidly growing population.
“We must have a more honest and detailed discussion about health financing that takes a more comprehensive view of the whole sector,” the manifesto reads.
Looking at the manifestos, Malawi Health Equity Network (Mhen) executive director George Jobe said the political parties have clearly understood that most problems in the health sector border on inadequate funding, but he was surprised that they have not made any plans on how to address the financing gap.
He said the political parties are not bold enough to state plainly the challenges facing the country’s health system because they would be unpopular with the masses.
Jobe said the next government should have emphasised on how it would ensure the health sector is funded domestically while not forgetting about universal health coverage.
Among the initiatives that were proposed was introduction of carbon tax on foreign vehicles coming into the country, which would go towards the health sector.
According to the strategic plan, its five-year cost is estimated at $2.6 billion and costs were estimated to increase from $504 million in 2017/18 to $540 million in 2021/22.
Last year, Muluzi confirmed that 62 percent of the total health expenditure is financed by donors while government contributed about 25 percent. n