Background
Many low- and middle-income countries (LMICs) have embarked on health system reforms aimed at achieving Universal Health Coverage (UHC) [
1,
2]. Such reforms are designed to introduce or expand public health care financing systems to pool resources across a wide range of prepaid financing sources, as replacements for out-of-pocket payments [
2‐
4]. The policy objective of universal health coverage is to ensure that all residents of a nation (universal population coverage) enjoy adequate coverage by prepaid financing systems (universal financial protection) and have access to needed health services of good quality (universal access) [
2,
4,
5].
These three main dimensions of universal health coverage: population coverage, financial protection and access to services, are inter-linked and interdependent [
4]. Universal population coverage is attained when there is no systemic exclusion of certain population groups (especially the poor and vulnerable) and when all residents enjoy the same entitlements to the benefits of public funding, irrespective of their political affiliations, nationality, race, gender, socio-economic status or geographic locations [
2,
3,
6‐
9]. Universal financial protection is attained in the absence of: (substantial) out-of-pocket payments; fear of and delay in seeking healthcare due to financial reasons; borrowing and sales of valuable assets to pay for healthcare; and critical income losses due to health care payments [
2,
6]. Universal access includes a number of sub-dimensions: availability of health services, personnel and facilities; accessibility of health services based on users’ location relative to health services and transportation possibilities; acceptability in terms of appropriate client-provider relationships and attitudes towards each other; accommodation in terms of timeliness, appropriateness and quality of services; and affordability in terms of cost of services relative to clients ability-to-pay [
5,
8,
10‐
13]. UHC can only be realized if universal access is attained in conjunction with a realization of the other two dimensions of UHC such as universal population coverage and financial risk protection. A deficiency in any aspect of these three main dimensions signifies a gap that needs to be filled for UHC to be achieved.
Global debates [
5,
7,
14], and to some extent national level aggregates and economic modeling [
15‐
18], have extensively been used to ascertain gaps in universal health coverage in various contexts and to postulate possible solutions. Less attention has been paid to the identification of context specific gaps in universal coverage from the perspective of the community. This paucity of evidence is somewhat disturbing considering that the World Health Organization recognizes responsiveness as an intrinsic objective of any health care system [
19], one that needs to be maintained in the quest towards universal health coverage [
20]. This underscores the fact that reforms have often been implemented following a top-down approach, with little attention being paid to documenting and exploring gaps in coverage as experienced by communities [
21].
This qualitative study aims to fill this knowledge gap by exploring how rural communities in sub-Saharan Africa (SSA), specifically in Malawi, experience and define gaps in the coverage provided by their health care system. The rationale is to ensure that future interventions, within this context, are aligned with people’s actual needs; respecting responsiveness as an explicitly acknowledged intrinsic policy objective of UHC reforms [
20].
Malawi is a low-income sub-Saharan African country with a population of approximately 15 million people [
22]. The majority (80%) of the population live in rural areas and depend on rain-fed agriculture for their livelihood [
23]. The Gross Domestic Product (GDP) per capita (purchasing power parity (PPP) in 2012) is approximately 900 United States Dollars (USD) [
24]. About 60% of the population live below the international poverty line of 1.25 USD a day [
22].
The average total healthcare expenditure of Malawi stands at about 34 USD per capita, equivalent to 12.3% of GDP [
25]. The proportion of government expenditure on health is 2.1% of GDP and this constitutes about 18.0% of total healthcare expenditure [
25]. Health service provision relies on a public-private mix of providers. Over 60% of all health services are provided in public hospitals and health centers, 37% by the private not-for-profit Christian Health Association of Malawi (CHAM) and the rest by individual private-for-profit health practitioners [
23].
Since 2004, full-cost coverage of an Essential Health Package (EHP) has been implemented in Malawi as a step towards UHC. The EHP includes about 55 interventions which reflect the main morbidity and mortality patterns of the country (see Table
1) [
25,
26]. The EHP is funded from general tax revenue and donor funds. It is supposed to be provided free of charge in all public facilities, and at the selected CHAM facilities bound by Service Level Agreements (SLAs) with the government [
25]. Only a few employers and the Medical Aid Society of Malawi (MASM) offer private health insurance to formal sector employees [
27]. The rest of the population has no access to complementary health insurance [
28]. A number of studies have quantified inequities in access and health outcomes, suggesting the existence of important gaps in coverage [
26,
29‐
36]. A recent quantitative analysis identified remarkable weaknesses in actual EHP provision and attributed it to problems of under-funding [
26].
Table 1
Broad components of the Malawi Essential Health Package [25,26]
Initial designed Package
|
● Prevention and treatment of vaccine-preventable diseases
|
● Management of acute respiratory infections (ARI) including pneumonia.
|
● Malaria prevention and treatment i.e. using insect treated nets (ITNs) and active case management.
|
● Reproductive health interventions to address adverse maternal/neonatal outcomes (family planning, maternal and neonatal health, PMTCT)
|
● Prevention and control of tuberculosis
|
● Prevention and treatment of acute diarrhoea diseases including cholera
|
● Prevention and treatment of HIV/AIDS and other sexually transmitted infections (STIs)
|
● Prevention and treatment of schistosomiasis
|
● Prevention and treatment of malnutrition and nutritional deficiencies.
|
● Prevention and management of common eye, ear and skin conditions
|
● Treatment of common injuries and emergencies.
|
Later inclusions
|
● Cancer treatment
|
|
● Other non-communicable diseases
|
Discussion
This study reveals the views and experiences of the residents of rural Malawian communities in regards to the existence of gaps on all three UHC dimensions (population coverage, financial protection and access to services). Its uniqueness lies in its explicit focus on reporting the perspective of community members, voicing the concerns of those rural residents who are rarely given the opportunity to actively contribute towards the health policy debate in their country. Community responses constitute an additional source of evidence to inform current UHC discussions and policy reforms in Malawi, advancing knowledge on gaps in UHC beyond what has already been reported in existing quantitative studies [
16,
18], expert opinions, and policy analyses [
5,
7,
14,
17].
We acknowledge that this study was only conducted in two districts in rural Malawi and among a few purposively sampled respondents, whose views may therefore not necessarily represent the opinions of all community residents and all health workers in Malawi. Due to this limitation, typical of qualitative research, findings from this study cannot be generalized to other populations and contexts, since health system gaps are to a large extent context-specific. However, we trust that lessons from the results are transferable to other rural districts in Malawi where over 80% of Malawians reside [
23,
37] and where there exist similar health system characteristics [
26,
30,
32,
35,
39], and at least partially transferable to other rural settings in SSA which experience similar health system characteristics [
38].
Our study confirmed the existence of clear interrelated gaps in the three main dimensions of UHC, as defined by rural communities, indicating a synergy between community perspective on UHC and current global debates [
4,
5,
7,
40]. In terms of population coverage, the unanimous sense of entitlement to coverage of public funds (tax revenue) at public health facilities expressed by the study respondents, implies that the country has made considerable efforts towards UHC [
17]. In practical terms, the existence of geographical inequities in population coverage confirms the assertion that universal health coverage entitlements, as documented on paper and assumed to be offered to the population, often differ substantially in reality [
4]. Also, the operational challenges in effectively implementing the SLAs at the local level, as evidenced in our study, supports findings from previous studies on the Malawian SLA [
26,
36]. This, by implication, suggests a weakness in effectively extending government’s purchasing and regulatory function to the private health sector within a pluralistic health care system like Malawi’s [
41].
Furthermore, our findings clearly indicated that geographical disparities in population coverage have resulted in perceived inequities in financial protection. Being located close to or seeking health care from public facilities were perceived to be associated with opportunities for greater financial protection than being located only close to or having to seek health care from private/CHAM facilities. This implies that the provision of the EHP has mostly been effective when considering the financial dimension (i.e. out-of-pocket payments) at public facilities. The existing literature reveals incidences of illegal or informal charges for medical services that ought to be offered free, in some settings [
9,
42‐
44]. This evidence has been reported within contexts where direct out-of-pocket payments were previously implemented in the public health sector [
9,
42‐
44]. This important financial protection gap was absent in our findings and the findings of earlier published studies within Malawi [
26,
30,
35]. This possibly suggests that informal payments within the public sector are more likely to arise within contexts where free care or exemption systems exist parallel to out-of-pocket payments, rather than in a system like Malawi which has never relied on user fees after independence [
45].
Nevertheless, even in the absence of formal and informal payments at public facilities, our findings indicated that communities perceived themselves to be exposed to some financial risk due to out-of-pocket payments for medical treatment rendered at private/CHAM facilities, transportation costs, and purchases of drugs at private pharmacies. The majority of potential financial protection barriers identified in this qualitative study are not likely to be reflected in quantitative cost/expenditure studies. The reason is that rural residents normally perceive such costs as substantially high, unaffordable and potentially catastrophic, and hence, either completely avoid seeking health care or adopt certain coping mechanisms to avoid incurring the cost. Our findings, therefore, support the widely documented evidence confirming such cost avoiding/coping strategies as very important indicators of gaps in financial protection within poor settings [
2,
35,
46]. The literature also acknowledges long distance to health facilities and transportation difficulties as barriers to accessing services that are supposed to be offered for free [
10,
47,
48]. This implies that UHC reforms, including support for community residents to improve access to transport during health care seeking, can facilitate progress towards universal health coverage in rural Malawi, and within other poor SSA settings.
Interestingly, most of the reported gaps in financial protection and population coverage are often triggered by access-related gaps in the public health sector. Affordability of medical costs at private/CHAM facilities and transport costs remain the main access barriers to seeking health care in rural Malawi. In line with earlier studies in Malawi, supply side deficiencies, ranging from drug shortages to perceived poor quality of care, were reported as the main barriers to accessing health care in public facilities [
26,
30,
34‐
36,
39,
49]. These perceived access-related gaps, especially supply side deficiencies in availability of medical products, equipment and facilities, are also frequently reported by studies within other SSA settings [
50,
51]. However, some studies from Burkina Faso, for instance, revealed that, unlike what has been reported in our study, respondents had relatively good perceptions about the attitude of their health care providers [
50,
51]. This is probably due to contextual differences between the two health systems or to underlying differences in expectations about what constitutes good quality of care. In rural Malawi, these access-related gaps have led to low satisfaction with services provided by public facilities, and hence, a high preference for private/CHAM facilities, as already reported in previous studies [
32,
35]. This further widens gaps in financial protection, since the private/CHAM facilities collect out-of-pocket payments. It should be noted that although the community perceived better quality of care at private facilities, in line with what was reported in other studies within SSA settings [
52,
53], the reality of such facilities actually providing high standard quality of care may differ substantially. In rural Malawi, for instance, probably only the CHAM facilities have a better capacity in terms of infrastructure, medical equipment and personnel than most public facilities. The private-for-profit facilities that exist in the study area are mainly individual business organizations, with few staff, who lack the capacity to handle certain serious cases, such as maternal cases. It is not surprising, therefore, that these private-for-profit providers do not qualify for SLAs with the government. The perception of a relatively low quality of care at public facilities, therefore, mainly comes from the increased utilization rates in these facilities, which has been induced by community desire to access health care free of charge. This has led to frequent shortages of medicines and increased providers’ workload, and hence probably less attention spent on clients. Again, this difference in quality of care between public and private health facilities borders on health systems governance, specifically the role and capacity of government to regulate the private health sector.
Several implications for people-centered universal health coverage policy reforms in Malawi, and similar SSA contexts, can be drawn from our study. The clear illustration of an interrelationship of gaps in universal health coverage implies the need for an integrated and inclusive approach to fill existing gaps [
12]. To move towards UHC in Malawi, the possibility of an effective public-private partnership needs to be explored, in order to harness the potentials of the private sector to complement the UHC efforts in the public sector [
41,
54,
55]. The contracting arrangement under the SLA in Malawi, therefore, offers great prospects for universal financial protection, if its implementation can be strengthened through governmental commitment to regular payments of bills and expansion to cover all services under the EHP. Other recommendations on how to strengthen the EHP outlined by Chirwa et al. [
36] should also be considered. Given that, in Malawi, private/CHAM facilities provide approximately 40% of health services, are perceived to provide the best quality of care, and (especially CHAM facilities) are located mostly in rural areas [
23,
36], a strategy that completely integrates both the public and private/CHAM sectors will be essential for filling gaps in universal health coverage. UHC can be achieved to the extent that community residents perceive less difference in cost and quality when seeking health care from any type of facility. This could also imply reforms in the purchasing function of the health system, by introducing a third party purchaser, tasked to purchase EHP equitably from both public and private/CHAM facilities [
17,
56]. This has the potential of reducing geographical inequities in population coverage of public funds, financial protection and access to quality health care [
2].
The above recommendation however, needs to be supported by improvement in the quality of services and an expansion of the service provision capacity of the public health sector. However, directly overcoming the access-related gaps in the public health sector is a complex issue, since such gaps are also generally rooted in the low economic development of the districts and of the country [
57]. Insufficient funds to supply enough drugs, train more health professionals and adequately motivate them, provide sufficient health facilities, accommodation for health workers and enough ambulances, is one root cause of the supply side gaps [
26]. Given the obstacles to raising additional domestic revenue from the traditional UHC revenue sources (taxes and insurance contributions) within poor settings, overcoming these access-related gaps in rural Malawi may require economic empowerment, increased external intervention and alternative innovative mechanisms of raising additional revenue for the health sector [
2].
Competing interests
We declare that we have no competing interests.
Authors’ contributions
GAA and MDA conceptualized and designed the study and its data collection tools. GBM supported the design of the data collection tools. GAA administered and transcribed the interviews with health care workers, and supervised the data collection. GBM supervised the transcription of the FGDS. All authors participated in the data analysis. GAA wrote the first draft of the manuscript. GBM and MDA revised the draft. All authors read and approved the final manuscript.