In 2001, I wrote a small article on page 57 of the journal called Development Bulletin, published by the Australian National University. The title of the article I am referring to was: Politics and vestiges of the past preventing the introduction of health care user fees in Malawi. At that time Malawi had completed two years of the second and last term of President Bakili Muluzi. Around 1999 however, as Muluzi was seeking his second term, the government had come up with a suggestion as to how to introduce user fees for our public hospitals. In fact, the main issue then was on hospital autonomy. Hospital autonomy simply meant that the public hospitals that we have would have been removed from the direct control of the Ministry of Health and, instead, independent boards would oversee the functions of those facilities. Anyway, as the campaign heated, the issue of user fees (that is to say that patients should be paying for hospital services) also came up. The government distanced itself from the unpopular proposal and no user fees were introduced.
Now back to my article. In 2001, I argued that Malawi finds it difficult to introduce user fees because of its politics, but also its history. User fees discussions are not new in this country. In 1964, when we got our (political) independence from Britain, the Prime Minister then, Dr Hastings Kamuzu Banda thought of introducing user fees for hospital users. His lieutenants refused vehemently, choosing that the government provides frees services to all. In fact, the wish by Kamuzu to have all patients pay three pence (tik) was one of the reasons we had the infamous 1964 Cabinet Crisis. Today, over 50 years have passed and the issue is yet to be resolved.
Whether there are user fees or the hospital services are charged for, someone must pay for the services. Currently, taxes are the key funds of health services, seconded by donors (or development partners). Then there are those who pay from their pocket either directly or through the few health insurance schemes that exist. The last group is, of course, for those whose medical insurance or medical bills are paid for by their employers. The key point I want to make is that someone must fish out the money to cover the costs. If the user does not pay, then most likely the government must. If the government does not have the cash because it has just funded the Flames, then either we do not have the services or the government must raise taxes to get more cash.
Our government is implementing a results-based financing project in some districts. What it means in part is that women are given items and money to access health care. I am confused somewhat whether these are the same women we will be asking to pay for services. These are one of the few times I am thankful I am not in the policy-making business. It is a messy business as one Damson says: ‘It is messy just like making sausages’. Then there is the essential health package (EHP). User fees could mean the death of the EHP! n