Malawi has a three tier healthcare system in which each level is connected by a patient referral system. Patients enter into the system at the first tier and flow to higher tier facilities as needed. Medical supplies and human resources, however, flow in the opposite direction. The already limited resources are first allocated to the top tier facilities, leaving the second and third tier facilities with little to no resources.
Malawi’s Ministry of Health is responsible for healthcare in Malawi. And 62% of health services are provided by the government, 37% are provided by the Christian Health Association of Malawi (CHAM), and a small fraction of the population receive health services through the private sector.
Private doctors and non-governmental organizations (NGOs) offer services and medicines for a nominal fee. The public health system has three separate tiers (primary, secondary, and tertiary care). A system of referrals links these three tiers.
Primary care, “where the bulk of health care actually happens in Malawi,” consists of community-based outreach, manned and unmanned health posts, dispensaries, urban health centers and primary health centers (including rural/community hospitals).
At the primary level (third tier), hospitals have holding beds, post-natal beds, holding wards and are able to provide out-patient, maternity, and ante-natal services.
If the patient’s condition is considered to be too critical for primary care facilities to handle, they will be referred to the next level of the healthcare system. Secondary level care is provided by district hospitals that are located in each of Malawi’s 28 districts.
These hospitals are equipped to provide the same basic services as the primary care facilities (mentioned above) in addition to a few more, such as: x-ray, ambulance, operating theatre and a laboratory. The top tier of care is provided by the central hospitals located in the major urban areas. These hospitals differ from the second tier hospitals in the existence of various specialized services.
According to the World Health Organization's statistics on Malawi, there has been a sharp increase in health expenditures in the past decade. From 2002 to 2011, the per capital total expenditure on health (PPP int.) increased from $27.2 to $77.0 and per capita government expenditure on health (PPP int.) increased from $16.4 to $56.5.
These statistics indicate that the healthcare in Malawi is receiving greater attention and resource allocation. They also reflect the increased health focus of the government of Malawi. From 2002 to 2011, the percentage of total government expenditures allocated to health increased from 13% to 18.5%.
Malawi's increased government expenditure on healthcare has coincided with a decrease in the country's dependence on external healthcare resources, such as international and non-governmental aid. In 2009 external resources were responsible for 97.4% of total health expenditures, in 2011 they were responsible for 52.4%.
In Malawi’s health profile, last updated in May 2013, the World Health Organization reported that there were only .2 physicians per 10,000 population and 3.4 nurses and midwives per 10,000 population.
Malawi’s shortage of healthcare personnel is the most severe in the region. Additionally, the minimal body of health workers are not evenly distributed in the healthcare system. Challenges that lead to this shortage are low outputs of medical training institutions, health worker retention, and disease.
In the 1990s Malawi stopped training auxiliary nurses and medical assistants. In 2001, this training was resumed in an effort to increase human resources for health care. In 2005, Malawi began to implement its emergency human resource program which concentrates on increasing output of trained medical personnel, improving health worker compensation and retention.
Limited access to health services in Malawi affect a large number of Malawians. Only 46% of citizens live within a 5 km radius of any kind of health facility. Despite most public health services being free for the patients, there are often costs associated with transportation to and from a facility.
These costs deter many individuals that may be in dire need of care but cannot afford to assume the costs of transportation. Additional transportation needs complicate matters when an individual is referred from either a rural hospital to a district hospital or a district hospital to a central hospital.
The Ministry of Health explicitly states the goals of healthcare improvement efforts in Malawi.
-Range and quality of health services for mothers children under the age of 5 years expanded
-Better quality health care provided in all facilities
-Health services to general population strengthened expanded and integrated
-Efficiency and equity in resource allocation increased
-Access to health care facilities and basic services increased
-Quality of trained human resources increased, improved equitably/efficiently distributed
-Collaboration and partnership in health sector strengthened
-Overall resources in health sector increased
These objectives have been addressed in a variety of ways. In 2002, Malawi published the Poverty Reduction Strategy which included the Essential Health Package (EHP). The EHP was derived from estimates of the most significant burdens of disease in Malawi provided in 2002 by the World Health Organization. Its central focus is to combat 11 health issues that most greatly affect the poor.
In 2004, the government of Malawi, in collaboration with partners, developed a six-year program of work (POW) that revolved around the EHP and guided the implementation of a health sector-wide approach (SWAp).
In 2007, POW transitioned to become the Health Sector Strategic Plan, effective from 2007 to 2011. Measuring the outcomes of interventions, such as those facilitated by the SWAp, is very difficult due to the absence of a vital registration system and surveys to track changes in mortality.
The shortage of health workers in Malawi is an obstacle to utilizing Global Health Initiatives (GHI) funds effectively. Increasing health services such as HIV/AIDs treatment commonly prompt an increase in the number of minimally trained health care workers and a modest increase in clinical staff members.
According to an extensive study published in 2010, when Malawi received a large amount of GHI funding from the Global Fund to fight AIDS, Tuberculosis, and malaria, there was an increase in faculty and staff across all levels of the health system. This increase in paid health workers was supported by task-shifting to less trained staff.