• Odie Halberg posted an update 5 days, 3 hours ago

    It is encouraging to read in the Article by Mercy Kanyuka and colleagues (March, 2016) about Malawi\’s success in reducing child mortality, but I fear the authors might have missed one of the key factors contributing towards this great achievement. Specifically, that Malawi is unique in sub-Saharan Africa in having never charged user fees in public health facilities, apart from a brief experiment in 1964, which the President soon abandoned after protests by the population.The Countdown to 2015 case study reasonably attributes improved child health outcomes to increased coverage of effective preventive and curative interventions. However, in focusing on a scale-up of services (in other words the supply side) it vorapaxar appears to neglect Malawi\’s unique demand-side reform in the 1990s—to provide services for free. Removing this access barrier would have resulted in a higher consumption of effective services by children (especially poor children) in Malawi than in neighbouring countries. Proof of this proposed effect is provided by the numerous examples of countries that have removed user fees since 2000 and witnessed large increases in use of health care. Also, it\’s noticeable that where user fees have become more entrenched in west Africa, due to the Bamako Initiative, child health indicators are now lagging behind the rest of the continent.It\’s true that the authors do mention, in passing, that services have been free at the point of delivery in Malawi, but only to mention that 10% of total health expenditure was still in the form of out-of-pocket payments. This proportion of health expenditure is actually very low for Africa and again shows that Malawi\’s free services policy has also been effective in providing financial protection.We read with interest the study by Mercy Kanyuka and colleagues on Malawi\’s achievements in Millennium Development Goal 4. The authors identified several major health-system barriers to replicating this success throughout all districts in Malawi, the foremost being low numbers of health workers. The authors point out that massive investment in the health workforce will be needed to reach the minimum densities recommended by WHO. Unfortunately, these standards do not take into account the financial burden to the public sector associated with expansion of the health workforce. Previous investment in health-worker training in Malawi supported by development partners led to a glut of graduates across various professions in August, 2015. Yet up to now, most of these graduates have not been employed by the Malawian Government. The Malawi Government is facing fiscal constraints associated with poor economic growth, high inflation, and withdrawal of donor support and is under pressure to constrain its public sector wage bill. Faced with uncertain prospects of employment, it is reported that at least 20 of the 51 medical graduates in last year\’s cohort have emigrated to Lesotho, a nearby country that is actively recruiting doctors. This emigration is despite recent success in retaining newly trained doctors in Malawi in the wake of historically high emigration. Any further investment into expanding Malawi\’s health workforce needs to take into account the associated recurrent costs and long-term budget impact for the public sector.We thank Rob Yates for his letter and agree that Malawi\’s consistent absence of user fees in public facilities will have probably facilitated access to care and financial protection, which might have benefited health outcomes. Indeed, a recent analysis by Manthalu and colleagues found positive effects of user fee removal on access to antenatal and delivery services in private facilities in Malawi. An analysis by Leone and colleagues also found a positive effect of user fee removal on institutional deliveries in Burkina Faso and Ghana. Given the absence of user fees in the vast majority of facilities throughout the period of our study, we were unable to assess the impact of removing user fees on the achievement of Millennium Development Goal 4 (MDG4) in Malawi, but in a forthcoming district-level analysis, we will report on the relationship between out-of-pocket payment levels and mortality of infants younger than 5 years. New studies are needed to explore the effect of removing user fees on the achievement of MDG4, and its speed. Such studies should control for the effect of other financing mechanisms, and consider mediating and moderating factors, when possible.

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