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. Malawi has committed to achieving Universal Health Coverage (UHC) by 2030, the timeframe set out by the Sustainable Development Goals (SDGs). As in other low income countries, scarce resources stand in the way of more equitable health access and quality in Malawi. Its health sector is highly dependent on donor contributions, and recent poor governance of government-funded healthcare saw donors withdraw funding, limiting services and resources. The 2017 National Health Plan II and accompanying Health Strategic Plan II identify the importance of improved governance and strategies to achieve more effective cooperation with stakeholders. This study explores health sector stakeholders’ perceptions of the challenges to improving governance in Malawi’s national health system within the post-2017 context of government attempts to articulate a way forward. Methods A qualitative study design was used. Interviews were conducted with 22 representatives of 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. Content relating to healthcare governance was identified in the transcripts and field notes and analysed using inductive content analysis. Results Stakeholders view governance challenges as a significant barrier to achieving a more effective and equitable health system. Three categories 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 serious political, structural, and financial challenges to improving governance in the national health system in Malawi which will impact the government’s goal of achieving UHC by 2030. 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 policy documents, they see little evidence of improved governance and have little or no confidence in the government’s ability to deliver UHC. The difficulties stakeholders perceive in relation to building equitable and effective healthcare 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

“…the government) and external (e.g. donors) funders [ 7 , 17 ]. It is widely understood that the purpose of these policies is to address the wider public health agenda, going beyond healthcare delivery.…”

“…This study arises from our work on challenges to effective governance of the Malawian healthcare system, where we first identified a potential gap between being consulted and influencing policy decision-making for these stakeholder groups [ 17 ]. The interview data used in this study derives from a subset of individuals ( n = 19/22) and questions from wider-ranging semi-structured 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.…”

“…Interviews with three local-government representatives were excluded from this study as not containing content relating to stakeholder engagement. The study methods (and limitations) are described extensively elsewhere [ 17 ]; therefore, we present only a brief description here, with a focus on the areas where the methods differ.…”

“…This exercise was performed by AM and Thanzi la Onse project partners in the College of Medicine at the University of Malawi and the Oversees Development Institute who have local and specialist knowledge from conducting health research in Malawi. Full details of the mapping exercise and sampling strategy are described in our related publication [ 17 ]. Verbatim transcripts from face-to-face interviews with 19 individuals identified via the mapping exercise form the empirical basis of this paper They are representatives from: NGOs ( n = 5); CSOs ( n = 9); local government ( n = 3) and government-funded but otherwise independent institutions (e.g.…”

“…Due to the potentially sensitive nature of the wider interview content, and the linkage between this and another study [ 17 ], 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 identification).…”