Malawi’s civil society organizations (CSOs) have endorsed the introduction of modest user fees in public hospitals as a strategic step to improve healthcare delivery, stressing the need for clear protection measures to shield the poorest and most vulnerable citizens.
The endorsement came during a National Dialogue on Health Financing and Access to Essential Medicines, held at the Bingu International Convention Centre (BICC) in Lilongwe, co-hosted by the Kenya Ethical and Legal Issues Network (KELIN) and Community Health Rights Advocacy (CHRA).
The discussion comes amid a backdrop of chronic underfunding of Malawi’s health system, with rising demand for services and dwindling donor contributions placing mounting pressure on public facilities.
According to the African Institute for Development Policy (AFIDEP), while Malawi’s health budget rose from 8.8 percent in 2023/24 to 12 percent in 2024/25, it remains below the Abuja Declaration target of 15 percent.
The country still relies heavily on external support, with donors contributing 54.5 percent of the total health expenditure, while government financing accounts for only 24.1 percent.
George Jobe, Executive Director of the Malawi Health Equity Network (MHEN), emphasized that user fees—when structured with care—could support service delivery without excluding the poor.
“We should be reminded that one of the reforms in the health sector was the National Health Insurance. This was a way to make clients contribute to healthcare in advance,” Jobe said. “Looking at the National Health Financing Strategy, we really need to identify how to correctly determine who is poor, so that those individuals can continue to access free services in public hospitals.”
He added that “Paying Wings” have long operated in central hospitals and are now being introduced in district hospitals to raise internal revenue, an approach MHEN supports so long as safeguards for the poor are in place.
The Ministry of Health has echoed similar sentiments. Dr. Rabson Kachala, Deputy Director of HIV and Viral Hepatitis, argued that a small user fee could contribute to better equity and service quality.
“The idea to pay for health services will help the government to provide equitable healthcare for its people,” he stated. “There are people that may require privacy in public hospitals, and we must respond to those needs. But the government remains committed to ensuring that everyone—rich or poor—can access the same standard of care.”
Harry Madukani, Programs Manager at the Coalition of Women Living with HIV and AIDS, added a critical voice representing marginalized groups, noting that the realities of health service delivery demand a shift in how services are financed.
“Malawi’s health system is strained. With donors reducing support and the government budget still falling short of the 15% Abuja target, we need bold measures,” said Madukani.
“User fees must not be viewed as punishment but as part of a broader solution—provided mechanisms are in place to protect those who cannot afford to pay.” She also emphasized the need for targeted subsidies and exemptions, particularly for women and people living with chronic illnesses, including HIV and cervical cancer.
However, not all voices were in full agreement. Kondwani Mjanthu, representing the Pharmaceutical Association of Malawi (PHASOM), warned of potential consequences if the system is not carefully designed.
“Government must tread carefully on this matter as it may risk denying access to healthcare to some Malawians,” he said. “There are numerous people in the country who depend entirely on government for survival. How sure are we that people will be able to pay?”
The dialogue highlighted that over 72 percent of Malawians live on less than $2.15 per day, making affordability a legitimate concern.
Still, participants agreed that inaction is not an option. Recommendations included: introducing user fees with an exemption framework for the poor; developing a national health identification system to determine eligibility for free care; expanding community health posts and mobile clinics; and exploring taxation on alcohol to raise domestic health financing.
As Malawi navigates these reforms, the message from civil society is clear: health financing must be equitable, transparent, and sustainable so that no Malawian should be left behind in the pursuit of better health.
