NR 553 Week 2 Health System Description Example

Health System Description: Malawi Through Its Collectors, Poolers, Providers and Rule Makers, With the Faith-Based and Informal Sectors Treated as Central and Money Traced as a Route

Student Name

College of Nursing, Chamberlain University

NR 553: Global Health

Instructor Name

Month Day, Year

Health System Description: Malawi Through Its Collectors, Poolers, Providers and Rule Makers, With the Faith-Based and Informal Sectors Treated as Central and Money Traced as a Route

Why Describe Malawi

Malawi is a landlocked country in southern Africa with a population of about 20 million, most living in rural areas. It is one of the poorest countries in the world by income per person, and it has long depended on external donors for a large share of health spending. Its health system has a public backbone that is free at the point of use, a large faith-based network that charges fees, and a wide informal sector that many people use first. This description follows the four functions that any health system must perform, collecting money, pooling it, providing services and setting rules, and names the institutions that perform each in Malawi.

Collectors

Money for health in Malawi comes from three main sources. The government collects general taxes through the national revenue authority and allocates part of the national budget to health through the Ministry of Finance. Households pay out of pocket at faith-based facilities, private clinics, pharmacies and drug shops, and for transport to care. External donors, including bilateral agencies and global funds for HIV, tuberculosis and malaria, provide a large share of total health spending, often more than the government itself. Development assistance for health has grown into one of the main sources of health financing in many low-income countries (Dieleman et al., 2016), and Malawi is a clear example.

Poolers

Pooling is weak. The main pool is the government health budget, which covers everyone in principle, since public services are free. Since the mid-2000s, some donors have put money into a pooled fund under a sector-wide approach, a shared plan agreed between the Ministry of Health and donors, alongside the government's own allocation. Many donors, however, fund their own programs directly, outside the pool, particularly for HIV and malaria. There is no national health insurance covering most of the population. A small share of formally employed people have private medical schemes. For most households, any cost not met by public services is paid out of pocket, with no pooling at all.

Providers

Public facilities. The Ministry of Health runs district hospitals, health centers and central hospitals, organized through district health offices. Services are free. Community health workers known as Health Surveillance Assistants provide immunization, health education and some treatment at village level.

Faith-based facilities. The Christian Health Association of Malawi is the largest non-government provider, running hospitals and health centers, many in rural areas where there is no public facility nearby. Its facilities charge user fees, which can deter poor households. In some districts, the government pays these facilities through service level agreements to provide specific services, such as maternal and newborn care, free to patients. A description that left this network out would miss a large share of rural care.

Private for-profit providers. Clinics and private hospitals serve mainly urban and wealthier patients.

Drug shops and traditional practitioners. Small shops selling medicines, many without a pharmacist, and traditional healers are often the first point of contact, particularly for fever, pain and illness in children. They are paid out of pocket and largely outside government oversight in practice.

Rule Makers

The Ministry of Health sets policy, including the essential health package, the list of services the government commits to provide free. Professional councils license health workers, including the nurses and midwives council and the medical council. A national regulator is responsible for medicines and pharmacies, though its reach into rural drug shops is limited. District councils manage district health services under decentralization. Donors, though not formal rule makers, shape rules in practice through the conditions attached to their funds.

Some rules come from outside the country. Malawi, like other WHO member states, is asked to report on health worker migration under the WHO global code on international recruitment (World Health Organization, 2010), which matters for a country that loses trained nurses abroad, though the code places its main obligations on destination countries.

Money as a Route

Following one kwacha, or one dollar, shows how the parts connect. Tax money flows from the Treasury to the Ministry of Health and districts, which pay public staff and buy supplies through the central medical stores. Pooled donor money follows a similar route under the sector-wide plan. Program donor money often flows around the government: to implementing organizations that hire staff, buy medicines and run clinics for a single disease, sometimes paying higher salaries than the public service. Household money flows directly to faith-based facilities, private clinics and drug shops.

The result is a system with several parallel routes. A woman with fever in a rural district might buy tablets at a drug shop with her own money, be tested for HIV at a government health center with donor-funded kits and deliver her baby at a faith-based hospital under a government service level agreement. Each step uses a different route for money. Record and Mohiddin (2006) observed that staff shortages make it harder for Malawi to deliver its essential health package and to absorb new international funding, which is one way the routes collide: donor money can buy medicines faster than the system can train nurses to use them.

What the Description Leaves Out

This description is organized by function, which makes some things harder to see. It says little about quality: whether a nurse at a rural health center has the medicines, equipment and supervision to give good care, or whether a drug shop sells genuine medicines. It does not measure how far people travel, which in rural Malawi can be many kilometers on foot. And it does not capture how people choose among providers, which depends on trust, cost, distance and past experience as much as on the formal system.

It also treats the four functions as separate when in practice they overlap. Donors act as collectors, poolers and, through the programs they fund, as providers and informal rule makers. A faith-based hospital is a provider that also collects fees and follows both government and church rules. A later analysis could follow a single patient's journey through the system, which would show these overlaps more clearly than a functional description can.

What the Description Shows

Malawi's health system is not a single public system with some private additions. It is a public core, a large faith-based partner, a thin layer of private care and a wide informal sector, financed by taxes, donors and households through routes that often run beside each other rather than together. Any reform, whether to financing, workforce or quality, has to reckon with all four provider groups and all three money routes.

References

Dieleman, J. L., Schneider, M. T., Haakenstad, A., Singh, L., Sadat, N., Birger, M., Reynolds, A., Templin, T., Hamavid, H., Chapin, A., & Murray, C. J. L. (2016). Development assistance for health: Past trends, associations, and the future of international financial flows for health. The Lancet, 387(10037), 2536-2544. https://doi.org/10.1016/S0140-6736(16)30168-4

Record, R., & Mohiddin, A. (2006). An economic perspective on Malawi's medical "brain drain". Globalization and Health, 2, Article 12. https://doi.org/10.1186/1744-8603-2-12

World Health Organization. (2010). WHO global code of practice on the international recruitment of health personnel.