Challenges to effective governance in a low income healthcare system: a qualitative study of stakeholder perceptions in Malawi

Abstract

Background: All countries face challenging decisions about healthcare coverage. The scare resources of low income countries prevent improvements in equitable access and quality. Malawi, one of the poorest countries in the world, has committed to achieving Universal Health Coverage (UHC) by 2030. The health sector is highly dependent on donor contributions, but recent poor governance of government-funded healthcare saw donors withdraw funding, limiting services and resources. The 2017 updated National Health Plan II and accompanying Health Strategic Plan II identify the importance of improved governance and strategies to achieve it, including greater harmonisation with health stakeholders. This study explores health sector stakeholders’ perceptions of challenges to improving governance in the national health system. Methods: A qualitative study design was used. Interviews were conducted with 22 representatives of the major international and faith-based non-government organisations, civil society organisations, local government and government-funded organisations, and governance bodies operating in Malawi. Open questions were asked about experiences and perceptions of the functioning of the health system and healthcare decision-making. The transcripts and field notes were analysed using inductive content analysis.Results: Stakeholders view governance challenges as a barrier to achieving a more effective and equitable health system. Three types of challenges were identified: accountability (enforceability; answerability; stakeholder-led initiatives); health resource management (healthcare financing; drug supply); influence in decision-making (unequal power; stakeholder engagement).Conclusions: Health sector stakeholders see a range of serious challenges to improving governance in the national health system in Malawi which will impact on the government’s goal of achieving UHC by 2030. These can be categorised as political, structural, and financial challenges. Stakeholders identify the need for improved oversight, implementation, service delivery and social accountability of government-funded service providers to communities. Eighteen months after the introduction of the NHP II and HSSP II, they see little evidence of improved governance and have little or no confidence in the government’s ability to deliver UHC in the timeframe set out by the Sustainable Development Goals (SDGs). The difficulties stakeholders perceive in relation to building equitable and effective health governance in Malawi have relevance for other resource-limited countries which have also committed to the goal of UHC.

Stakeholder engagement in the health policy process in a low income country: a qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi

“…This study arises from our work on challenges to effective governance of the Malawian healthcare system, where we rst identi ed the potential gap between being consulted and in uencing policy decision-making for these stakeholder groups (14). The interview data used in this study derives from a subset of individuals and questions from wider-ranging interviews on health stakeholder perceptions of their involvement in the health system and healthcare decision-making in Malawi, including effective governance and stakeholder engagement in policy-making.…”

“…The interview data used in this study derives from a subset of individuals and questions from wider-ranging interviews on health stakeholder perceptions of their involvement in the health system and healthcare decision-making in Malawi, including effective governance and stakeholder engagement in policy-making. The methods (and limitations) are described extensively elsewhere (14); therefore, we present only a brief description here and focus instead on the areas where the methods differ.…”

“…If yes, to what extent were you and your organisation involved in the development of the national health policy and health sector strategic plan and or the health budget; and 2) do you think there is an opportunity for you at your level to get involved in health policy-making? Due to the potentially sensitive nature of the wider interview content, and the linkage between this and another study (14), every effort has been made to anonymise the individual participants in the reporting of this research. Attribution is made by type of organisation and participant number only (the numbers differ from those used in the linked publication to further prevent participant identi cation).…”

“…the government) and external (e.g. donors) funders (8,14). It is widely understood that the purpose of these policies is to address the wider public health agenda, going beyond healthcare delivery.…”

“…The effective engagement of local level organisations, including citizens and communities, in policymaking can reinforce democratic ideals and institutions, give the public a sense of ownership of regulation and open up a channel of two way communication between the public and health decisionmakers in the government (37). There have been efforts to engage communities and citizens in local policy-making to ensure the policies meet their needs, although they have been hampered by the retention of power over local decision-making by the centralised government, due to the incomplete implementation of the policy decentralising powers to the District level (14,(37)(38)(39). As observed in our study, the result may be an obscuring of local government voices in deference to centralised government decision-makers in MoH policy-making.…”