Background: Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. Methods: Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. Results: Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p 2 = 0.018; p 3 = 0.001; p 4 = 0.002), and urban residency (p = 0.001). Conclusion: Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.

BackgroundThe HIV and AIDS epidemic in Malawi poses multiple challenges from an equity perspective. It is estimated that 12% of Malawians are living with HIV or AIDS among the 15-49 age group. This paper synthesises available information to bring an equity lens on Counselling and Testing (CT) and Antiretroviral Therapy (ART) policy, practice and provision in Malawi.MethodsA synthesis of a wide range of published and unpublished reports and studies using a variety of methodological approaches was undertaken. The analysis and recommendations were developed, through consultation with key stakeholders in Malawi.FindingsAt the policy level Malawi is unique in having an equity in access to ART policy, and equity considerations are also included in key CT documents. The number of people accessing CT has increased considerably from 149,540 in 2002 to 482,364 in 2005. There is urban bias in provision of CT and more women than men access CT. ART has been provided free since June 2004 and scale up of ART provision is gathering pace. By end December 2006, there were 85,168 patients who had ever started on ART in both the public and private health sector, 39% of the patients were male while 61% were female. The majority of patients were adults, and 7% were children, aged 14 years or below. Despite free ART services, patients, especially poor rural patients face significant barriers in access and adherence to services. There are missed opportunities in strengthening integration between CT and ART and TB, Sexually Transmitted Infections (STI) and maternal health services.ConclusionTo promote equitable access for CT and ART in Malawi there is need to further invest in human resources for health, and seize opportunities to integrate CT and ART services with tuberculosis, sexually transmitted infections and maternal health services. This should not only promote access to services but also ensure that resources available for CT and ART strengthen rather than undermine the provision of the essential health package in Malawi. Ongoing equity analysis of services is important in analyzing which groups are unrepresented in services and developing initiatives to address these. Creative models of decentralization, whilst maintaining quality of services are needed to further enhance access of poor rural women, men, girls and boys.

Malawi is facing a severe HIV and AIDS epidemic with an estimated 12% of its population living with the virus. Health workers are on the front lines of the HIV epidemic and they face the risk of HIV infection in both their personal and professional lives. This mixed method study aimed to explore the enablers and barriers to HIV counselling and testing and antiretroviral therapy by health workers in Malawi. After qualitative data were collected through in-depth interviews with health workers in the Mchinji and Nsanje districts, a survey questionnaire was constructed and administered to 906 health workers in eight districts in Malawi. A majority (76%) of health workers surveyed reported having undergone HIV testing and counselling, of whom 74% reported repeat testing. A striking result of the study is that 22% of health workers reported testing after occupational exposure to HIV. The proportions of respondents reporting that they tested after experiencing symptoms, or self-testing for HIV were 11% each. The in-depth interviews and the survey revealed multiple challenges that health workers face to accessing HIV testing, counselling and treatment, including fear of a positive result, fear of stigma and lack of confidentiality. Additional barriers included health workers’ personal acquaintance with those conducting testing, along with their perception of being “role models” which could exacerbate their fears about confidentiality. Given health workers’ critical role in HIV delivery in Malawi, there is need to develop solutions to help health workers overcome these barriers.

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BackgroundChronic lung diseases contribute to the growing non-communicable disease (NCD) burden and are increasing, particularly in many low and middle-income countries (LMIC) in sub-Saharan African. Early engagement with health systems in chronic lung disease management is critical to maintain quality of life and prevent further damage. Our study sought to understand health seeking behaviour in relation to chronic lung disease and TB in a rural district in Malawi.MethodsQualitative data was collected between March-May 2015, exploring patterns of health seeking for lung disease amongst residents of two districts in rural Malawi. Participants included those with and without lung disease, health workers and village leaders. Participants with a history of TB were included in the sample due to similarities in clinical presentation and in view of potential to cause long-term damage to lung tissue.ResultsOur findings are ordered around a specific model of health seeking devised by adapting previous models. The model and findings span three broad areas that were found to influence health seeking: understandings of health and disease which shaped whether, when and where to seek care; the care seeking decision which was influenced by social and structural factors; and the care seeking experience which impacted future care decisions creating ‘feedback loops’.DiscussionEfforts to improve effective and accessible healthcare provision for chronic lung disease need to address all the determinants of health seeking behaviour identified. This may include: enhancing the structural and financial accessibility of health services, through the strengthening of community linkages; improving communication between formal health providers, patients and communities around symptoms, diagnosis and management of chronic lung diseases; and improving the quality of diagnostic and management services through the strengthening of health systems ‘hardware’ (equipment availability) and ‘software’ (development of trusting and respectful relationships between providers and patients).

Background Mass drug administration (MDA) is one of the key interventions recommended by WHO for prevention and control of neglected tropical diseases (NTD). In Malawi, MDA is widely carried out annually since 2009 for prevention and control of schistosomiasis and soil-transmitted helminths (STH). No study has been carried out to assess effectiveness of the MDA approach and to document perceptions of health providers and beneficiaries regarding use of MDA. This study was done to understand how well MDA is being implemented and to identify opportunities for improvement in MDA delivery in Malawi. Methods Designed as a cross-sectional and multi-methods research, the study was carried out in three southern Malawi districts of Chiradzulu, Mangochi and Zomba. In each district, four health centres and 16 villages were randomly selected to participate. A mixed-methods approach to data collection focusing on quantitative data for coverage and knowledge, attitudes and practices assessments; and qualitative data for assessing perceptions of health providers and beneficiaries regarding MDA was used. Quantitative data were processed and analyzed using IBM SPSS software version 26 while qualitative data were analysed using NVivo 12 for Windows. Results Knowledge levels about schistosomiasis and STH in the districts varied according to disease aspects asked about. Majority are more knowledgeable about what schistosomiasis is (78%) and whether STH are treatable with drugs (97%); with least knowledgeable about the organism that transmits schistosomiasis (18%), types of schistosomiasis (11%) and what causes STH (20%). In 2018 and 2019 the districts registered high coverage rates for praziquantel and albendazole using community-based MDA (73–100%) and using school-based MDA (75–91%). Both the health authorities and community members perceived the MDA approach as good because it brings treatment closer to people. Conclusion With the high MDA coverage obtained in communities and schools, the effectiveness of MDA in the target districts is satisfactory. There are, however, several challenges including disproportionate knowledge levels, which are hampering progress towards attainment of the 2030 global NTD goals. There is a need for promotion of community participation and partnerships as well as implementation of other recommended interventions for sustainable prevention and control of schistosomiasis and STH.

IntroductionChronic cough is a distressing symptom and a common reason for people to seek health care services. It is a symptom that can indicate underlying tuberculosis (TB) and/or chronic airways diseases (CAD) including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis. In developing countries including Malawi, provision of diagnostic services and clinical management of CAD is rudimentary, so it is thought that patients make costly and unyielding repeated care-seeking visits. There is, however, a lack of information on cost of illness, both direct and indirect, to patients with chronic cough symptom. Such data are needed to inform policy-makers in making decisions on allocating resources for designing and developing the relevant health care services to address universal coverage programmes for CAD. This paper therefore explores health seeking costs associated with chronic cough and explores information on usage of the coping mechanisms which indicate financial hardship, such as borrowing and selling household assets.MethodsThis economic study was nested within a community-based, population-proportional cross-sectional survey of 15,795 individuals aged 15 years and above, in Dowa and Ntchisi districts. The study sought to identify individuals with symptoms of chronic airways disease whose health records documented at least one of the following diagnoses within the previous year: TB, Asthma, COPD, Bronchitis and Lower Respiratory Tract Infection (LRTI). We interviewed these chronic coughers to collect information on socioeconomic and socio-demographic characteristics, health care utilization, and associated costs of care in 2015. We also collected information on how they funded their health seeking costs.ResultsWe identified 608 chronic coughers who reported costs in relation to their latest confirmed diagnosis in their hand-held health record. The mean care-seeking cost per patient was US$ 3.9 (95% CI: 3.00–5.03); 2.3 times the average per capita expenditure on health of US$ 1.69. The largest costs were due to transport (US$ 1.4), followed by drugs (US$ 1.3). The costs of non-medical inputs (US$ 2.09) was considerable (52.3%). Nearly a quarter (24.4%) of all the patients reportedly borrowed or/and sold assets/property to finance their healthcare. CCs with COPD and LRTI had 85.6% and 62.0% lower chance of incurring any costs compared with the TB patients and any patients with comorbidity had 2.9 times higher chance to incur any costs than the patients with single disease. COPD, Bronchitis and LRTI patients had 123.9%, 211.4% and 87.9% lower costs than the patients with TB. The patients with comorbidity incurred 53.9% higher costs than those with single disease.ConclusionsThe costs of healthcare per chronic cougher was mainly influenced by the transport and drugs costs. Types of diseases and comorbidity led to significantly different chances of incurring costs as well as difference in magnitude of costs. The costs appeared to be unaffordable for many patients.

Background Mass drug administration (MDA) is one of the key interventions recommended by WHO for prevention and control of neglected tropical diseases. In Malawi, MDA is widely carried out annually since 2012 for prevention and control of schistosomiasis and soil transmitted helminths (STH). No study has been carried out to assess effectiveness of the approach and to document perceptions of health providers and beneficiaries regarding use of MDA. This study aimed to examine perceived strengths and weaknesses, successes and failures, as well as health providers’ and beneficiaries’ perspectives of implementing the strategy in Malawi. Methods As a cross-sectional implementation research, the study was carried out in three southern Malawi districts of Chiradzulu, Mangochi and Zomba. In each district, four health centres and 16 villages were randomly selected to participate. A mixed-methods approach to data collection focusing on quantitative data for coverage and knowledge, attitudes and practices assessments; and qualitative data for assessing perceptions of health providers and beneficiaries regarding MDA was used. Quantitative data were processed and analyzed using IBM SPSS software version 26 while qualitative data were analysed using NVivo 12 for Windows. Results Knowledge levels about schistosomiasis and STH in the districts varied according to disease aspects asked about. Majority are more knowledgeable about what schistosomiasis is (78%) and whether STH are treatable with drugs (97%); with least knowledgeable about the organism that transmits schistosomiasis (18%), types of schistosomiasis (11%) and what causes STH (20%). In 2018 and 2019 the districts registered high coverage rates for praziquantel and albendazole using community-based MDA (73%-100%) and using school-based MDA (75%-91%). Both the health authorities and community members perceived the MDA approach as good because it brings treatment closer to people. Conclusion With the high MDA coverage obtained in schools and communities, the implementation of MDA in the target districts is satisfactory. There are, however, several challenges including disproportionate knowledge levels, which are hampering progress towards attainment of the 2030 global NTD goals. There is a need for promotion of community participation and partnerships as well as implementation of other recommended interventions for sustainable prevention and control of schistosomiasis and STH.