BackgroundIn sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities’ perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage.MethodsWe conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers.ResultsThe results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers’ attitudes, distance and transportation difficulties, and perceived poor quality of health services.ConclusionsMoving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.

BackgroundDiscrete choice experiments (DCEs) are attribute-driven experimental techniques used to elicit stakeholders’ preferences to support the design and implementation of policy interventions. The validity of a DCE, therefore, depends on the appropriate specification of the attributes and their levels. There have been recent calls for greater rigor in implementing and reporting on the processes of developing attributes and attribute-levels for discrete choice experiments (DCEs). This paper responds to such calls by carefully reporting a systematic process of developing micro health insurance attributes and attribute-levels for the design of a DCE in rural Malawi.MethodsConceptual attributes and attribute-levels were initially derived from a literature review which informed the design of qualitative data collection tools to identify context specific attributes and attribute-levels. Qualitative data was collected in August-September 2012 from 12 focus group discussions with community residents and 8 in-depth interviews with health workers. All participants were selected according to stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three researchers to identify context-specific attributes and attribute-levels. Expert opinion was used to scale down the attributes and levels. A pilot study confirmed the appropriateness of the selected attributes and levels for a DCE.ResultsFirst, a consensus, emerging from an individual level analysis of the qualitative transcripts, identified 10 candidate attributes. Levels were assigned to all attributes based on data from transcripts and knowledge of the Malawian context, derived from literature. Second, through further discussions with experts, four attributes were discarded based on multiple criteria. The 6 remaining attributes were: premium level, unit of enrollment, management structure, health service benefit package, transportation coverage and copayment levels. A final step of revision and piloting confirmed that the retained attributes satisfied the credibility criteria of DCE attributes.ConclusionThis detailed description makes our attribute development process transparent, and provides the reader with a basis to assess the rigor of this stage of constructing the DCE. This paper contributes empirical evidence to the limited methodological literature on attributes and levels development for DCE, thereby providing further empirical guidance on the matter, specifically within rural communities of low- and middle-income countries.

BackgroundPrimary Health Care (PHC) is a strategy endorsed for attaining equitable access to basic health care including treatment and prevention of endemic diseases. Thirty four years later, its implementation remains sub-optimal in most Sub-Saharan African countries that access to health interventions is still a major challenge for a large proportion of the rural population. Community-directed treatment with ivermectin (CDTi) and community-directed interventions (CDI) are participatory approaches to strengthen health care at community level. Both approaches are based on values and principles associated with PHC. The CDI approach has successfully been used to improve the delivery of interventions in areas that have previously used CDTi. However, little is known about the added value of community participation in areas without prior experience with CDTi. This study aimed at assessing PHC in two rural Malawian districts without CDTi experience with a view to explore the relevance of the CDI approach. We examined health service providers’ and beneficiaries’ perceptions on existing PHC practices, and their perspectives on official priorities and strategies to strengthen PHC.MethodsWe conducted 27 key informant interviews with health officials and partners at national, district and health centre levels; 32 focus group discussions with community members and in-depth interviews with 32 community members and 32 community leaders. Additionally, official PHC related documents were reviewed.ResultsThe findings show that there is a functional PHC system in place in the two study districts, though its implementation is faced with various challenges related to accessibility of services and shortage of resources. Health service providers and consumers shared perceptions on the importance of intensifying community participation to strengthen PHC, particularly within the areas of provision of insecticide treated bed nets, home case management for malaria, management of diarrhoeal diseases, treatment of schistosomiasis and provision of food supplements against malnutrition.ConclusionOur study indicates that intensified community participation based on the CDI approach can be considered as a realistic means to increase accessibility of certain vital interventions at community level.

BackgroundNo community prevalence studies have been done on chronic respiratory symptoms of cough, wheezing and shortness of breath in adult rural populations in Malawi. Case detection rates of tuberculosis (TB) and chronic airways disease are low in resource-poor primary health care facilities.ObjectiveTo understand the prevalence of chronic respiratory symptoms and recorded diagnoses of TB in rural Malawian adults in order to improve case detection and management of these diseases.MethodsA population proportional, cross-sectional study was conducted to determine the proportion of the population with chronic respiratory symptoms that had a diagnosis of tuberculosis or chronic airways disease in two rural communities in Malawi. Households were randomly selected using Google Earth Pro software. Smart phones loaded with Open Data Kit Essential software were used for data collection. Interviews were conducted with 15795 people aged 15 years and above to enquire about symptoms of chronic cough, wheeze and shortness of breath.ResultsOverall 3554 (22.5%) participants reported at least one of these respiratory symptoms. Cough was reported by 2933, of whom 1623 (55.3%) reported cough only and 1310 (44.7%) combined with wheeze and/or shortness of breath. Only 4.6% (164/3554) of participants with chronic respiratory symptoms had one or more of the following diagnoses in their health passports (patient held medical records): TB, asthma, bronchitis and chronic obstructive pulmonary disease)ConclusionsThe high prevalence of chronic respiratory symptoms coupled with limited recorded diagnoses in patient-held medical records in these rural communities suggests a high chronic respiratory disease burden and unmet health need.

Background: People with disabilities experience significant health inequalities. In Malawi, where most individuals live in low-income rural settings, many of these inequalities are exacerbated by restricted access to health care services. This qualitative study explores the barriers to health care access experienced by individuals with a mobility or sensory impairment, or both, living in rural villages in Dowa district, central Malawi. In addition, the impact of a chronic lung condition, alongside a mobility or sensory impairment, on health care accessibility is explored. Methods: Using data from survey responses obtained through the Research for Equity And Community Health (REACH) Trust's randomised control trial in Malawi, 12 adult participants, with scores of either 3 or 4 in the Washington Group Short Set (WGSS) questions, were recruited. The WGSS questions concern a person's ability in core functional domains (including seeing, hearing and moving), and a score of 3 indicates 'a lot of difficulty' whilst 4 means 'cannot do at all'. People with cognitive impairments were not included in this study. All who were selected for the study participated in an individual in-depth interview and full recordings of these were then transcribed and translated. Results: Through thematic analysis of the transcripts, three main barriers to timely and adequate health care were identified: 1) Cost of transport, drugs and services, 2) Insufficient health care resources, and 3) Dependence on others. Attitudinal factors were explored and, whilst unfavourable health seeking behaviour was found to act as an access barrier for some participants, community and health care workers' attitudes towards disability were not reported to influence health care accessibility in this study. Conclusions: This study finds that health care access for people with disabilities in rural Malawi is hindered by closely interconnected financial, practical and social barriers. There is a clear requirement for policy makers to consider the challenges identified here, and in similar studies, and to address them through improved social security systems and health system infrastructure, including outreach services, in a drive for equitable health care access and provision.