Abiiro et al.

BMC Health Services Research 2014, 14:234

http://www.biomedcentral.com/1472-6963/14/234

RESEARCH ARTICLE Open Access

Gaps in universal health coverage in Malawi:

A qualitative study in rural communities
Gilbert Abotisem Abiiro1,2*, Grace Bongololo Mbera3 and Manuela De Allegri1

Abstract
Background: In 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.
Methods: We 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.
Results: The 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.
Conclusions: Moving 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.
Keywords: Universal health coverage, Financial protection, Access to health care, Gaps in coverage, Geographical
inequities, Community perspective, Qualitative study, Malawi

* Correspondence: [email protected]
1
Institute of Public Health, Medical Faculty, University of Heidelberg,
Heidelberg, Germany
2
Department of Planning and Management, Faculty of Planning and Land
Management, University for Development Studies, Wa, Ghana
Full list of author information is available at the end of the article

© 2014 Abiiro et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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Background that reforms have often been implemented following a

Many low- and middle-income countries (LMICs) have top-down approach, with little attention being paid to
embarked on health system reforms aimed at achieving documenting and exploring gaps in coverage as experi-
Universal Health Coverage (UHC) [1,2]. Such reforms enced by communities [21].
are designed to introduce or expand public health care This qualitative study aims to fill this knowledge gap
financing systems to pool resources across a wide range by exploring how rural communities in sub-Saharan Africa
of prepaid financing sources, as replacements for out-of- (SSA), specifically in Malawi, experience and define gaps
pocket payments [2-4]. The policy objective of universal in the coverage provided by their health care system. The
health coverage is to ensure that all residents of a nation rationale is to ensure that future interventions, within this
(universal population coverage) enjoy adequate coverage by context, are aligned with people’s actual needs; respecting
prepaid financing systems (universal financial protection) responsiveness as an explicitly acknowledged intrinsic pol-
and have access to needed health services of good quality icy objective of UHC reforms [20].
(universal access) [2,4,5]. Malawi is a low-income sub-Saharan African country
These three main dimensions of universal health with a population of approximately 15 million people
coverage: population coverage, financial protection [22]. The majority (80%) of the population live in rural
and access to services, are inter-linked and interdependent areas and depend on rain-fed agriculture for their liveli-
[4]. Universal population coverage is attained when there hood [23]. The Gross Domestic Product (GDP) per capita
is no systemic exclusion of certain population groups (purchasing power parity (PPP) in 2012) is approximately
(especially the poor and vulnerable) and when all residents 900 United States Dollars (USD) [24]. About 60% of the
enjoy the same entitlements to the benefits of public fund- population live below the international poverty line of 1.25
ing, irrespective of their political affiliations, nationality, USD a day [22].
race, gender, socio-economic status or geographic locations The average total healthcare expenditure of Malawi
[2,3,6-9]. Universal financial protection is attained in stands at about 34 USD per capita, equivalent to 12.3%
the absence of: (substantial) out-of-pocket payments; of GDP [25]. The proportion of government expenditure on
fear of and delay in seeking healthcare due to financial health is 2.1% of GDP and this constitutes about 18.0% of
reasons; borrowing and sales of valuable assets to pay total healthcare expenditure [25]. Health service provision
for healthcare; and critical income losses due to health relies on a public-private mix of providers. Over 60% of all
care payments [2,6]. Universal access includes a num- health services are provided in public hospitals and health
ber of sub-dimensions: availability of health services, centers, 37% by the private not-for-profit Christian Health
personnel and facilities; accessibility of health services Association of Malawi (CHAM) and the rest by individual
based on users’ location relative to health services and private-for-profit health practitioners [23].
transportation possibilities; acceptability in terms of Since 2004, full-cost coverage of an Essential Health
appropriate client-provider relationships and attitudes Package (EHP) has been implemented in Malawi as a
towards each other; accommodation in terms of timeliness, step towards UHC. The EHP includes about 55 interven-
appropriateness and quality of services; and affordability in tions which reflect the main morbidity and mortality
terms of cost of services relative to clients ability-to-pay patterns of the country (see Table 1) [25,26]. The EHP is
[5,8,10-13]. UHC can only be realized if universal access is funded from general tax revenue and donor funds. It is
attained in conjunction with a realization of the other two supposed to be provided free of charge in all public fa-
dimensions of UHC such as universal population coverage cilities, and at the selected CHAM facilities bound by
and financial risk protection. A deficiency in any aspect of Service Level Agreements (SLAs) with the government
these three main dimensions signifies a gap that needs to [25]. Only a few employers and the Medical Aid Society of
be filled for UHC to be achieved. Malawi (MASM) offer private health insurance to formal
Global debates [5,7,14], and to some extent national sector employees [27]. The rest of the population has no
level aggregates and economic modeling [15-18], have access to complementary health insurance [28]. A number
extensively been used to ascertain gaps in universal of studies have quantified inequities in access and health
health coverage in various contexts and to postulate outcomes, suggesting the existence of important gaps in
possible solutions. Less attention has been paid to the coverage [26,29-36]. A recent quantitative analysis iden-
identification of context specific gaps in universal coverage tified remarkable weaknesses in actual EHP provision
from the perspective of the community. This paucity of and attributed it to problems of under-funding [26].
evidence is somewhat disturbing considering that the
World Health Organization recognizes responsiveness as Methods
an intrinsic objective of any health care system [19], one Study setting, design, sampling and data collection
that needs to be maintained in the quest towards uni- We conducted our study in Thyolo and Chiradzulu,
versal health coverage [20]. This underscores the fact two rural districts in Southern Malawi, with a combined
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Table 1 Broad components of the Malawi Essential Health selected from purposefully sampled healthcare facilities to
Package [25,26] reflect variations in healthcare provision in the study area.
Package Broad categories of services The sampled facilities were comprised of: two public dis-
Initial designed ● Prevention and treatment of vaccine-preventable diseases trict hospitals (Thyolo and Chiradzulu district hospitals);
Package two public health centers (Chivu in Thyolo and Ndunde in
● Management of acute respiratory infections
(ARI) including pneumonia. Chiradzulu); two private-not for-profit (CHAM) hospitals
● Malaria prevention and treatment i.e. using insect (Adventist –Malamolo in Thyolo and St. Joseph -Nguludi
treated nets (ITNs) and active case management. in Chiradzulu); and two private-for–profit clinics (Hiwa in
● Reproductive health interventions to address adverse Thyolo and Akasale in Chiradzulu). The health workers
maternal/neonatal outcomes (family planning, that were interviewed from these facilities were comprised
maternal and neonatal health, PMTCT)
of: two medical doctors, two nurses/midwives, two med-
● Prevention and control of tuberculosis ical assistants, one clinical officer and a paramedic. All
● Prevention and treatment of acute diarrhoea study participants were identified, contacted, and re-
diseases including cholera cruited with the help of community leaders and trained
● Prevention and treatment of HIV/AIDS and research assistants.
other sexually transmitted infections (STIs)
All FGDs and key informant interviews were conducted
● Prevention and treatment of schistosomiasis in secure enclosed places at the community and facility
● Prevention and treatment of malnutrition and levels, respectively. Due to the less sensitive nature of the
nutritional deficiencies. study topic, FGDs made it relatively easier to explore con-
● Prevention and management of common eye, sensus and differences in opinions on UHC gaps among
ear and skin conditions
community residents. To respect local socio-cultural
● Treatment of common injuries and emergencies. concerns, FGDs were gender-specific and included either
Later inclusions ● Cancer treatment only men or only women. All FGDs were conducted in
● Other non-communicable diseases the local language (Chichewa) by a trained facilitator,
accompanied by a note-taker. The first author conducted
all interviews with health workers in English. Two different,
population of 878,401, equivalent to 6.7% of the country’s but mirrored, interview guides containing open-ended
population [37]. The districts have about 54 health facil- questions and probes were used to facilitate both the FGDs
ities, comprised of 37 public, 13 CHAM and 4 private- and the key informant interviews. The relevant sections of
for-profit facilities. the guides covered the following topics: cost and payments
The data was collected from August to September 2012, associated with seeking health care, access to health
within the framework of an exploratory qualitative study providers, facilities and medical products, transportation
aimed at informing a subsequent discrete choice experi- and distance to facilities, perceived quality of health care
ment [28]. Within the context of this study, we purposely (waiting times, perceived quality of drugs) and attitude of
collected information on perceived and experienced gaps health workers, among others (see Additional file 1). Prior
in universal health coverage from the target population. to field work, both guides were pre-tested and modified to
We collected information from both adult community reflect the pretest experience. All FGDs and key informant
residents and health workers from selected health facilities. interviews were tape-recorded and transcribed verbatim,
Sampling and recruitment procedures have been described with the FGDs being translated into English for analysis.
in detail elsewhere [28]. In brief, based on an anticipated
saturation point, stratified purposive sampling was used to Ethical considerations
select participants for 12 focus group discussions (FGDs) Ethical approval for the study was obtained from the
(size = 8-12 participants each) among community resi- Ethical Committee of the Faculty of Medicine of the
dents and 8 key informant interviews with health University of Heidelberg and from the National Health
workers. A total of 127 community residents, distributed Science Research Committee (NHSRC) in Malawi. Written
in 6 rural communities, participated in the 12 FGDs informed consent was obtained from all participants prior
(6 with men and 6 with women). An equal number of to the beginning of the FGD/interview process. All sampled
FGDs and key informant interviews were completed respondents consented to and participated in the study.
in the two districts. Because of their experiences with To ensure confidentiality, respondents in the FGDs were
the challenges that community residents face when discouraged from discussing each other’s views outside
seeking care, health workers were included in the study as the FGD setting. Also, to make it less possible for respon-
key informants to enhance the credibility of the findings, by dents’ views to be easily linked to their personal iden-
cross-checking their responses with the answers provided tities, we did not record the names of the respondents.
by community residents [38]. The health workers were The RATS guidelines for reporting qualitative research,
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modified for BioMed Central instructions to authors, they do the test, you pay…you pay for everything”
have been adhered to. (FGD05: Female).

Data analysis Health workers in CHAM and private facilities confirmed

Thematic analysis was done to identify the community’s that geographical disparities in population coverage result
perception of gaps in universal health coverage [38]. from the operational ineffectiveness of the SLAs. None of
Analysis began with an independent reading, coding, the private for-profit health facilities identified in the study
and categorizing themes of the transcripts by all three area was under the SLA. Health workers interviewed at
authors. The first author coded the entire material using private-for-profit facilities reported either failing to meet
the NVivo 9 software. The second and last authors the criteria for an SLA or being afraid that accepting an
manually analyzed two-thirds of the material. All ana- SLA may raise expectations among their clients that all
lysts approached the material inductively, letting codes services should be provided free of charge. Similarly,
and categories emerge as they worked through the tran- due to irregular reimbursement by the government, health
scripts [38]. At a later stage, the three analysts brought workers in the sampled CHAM facilities reported providing
together the results of their analyses to identify overarching only maternal and neonatal services under an SLA.
themes. Codes were re-categorized into broad and sub-
themes, reflecting the various dimensions of universal “It is only maternity side whereby we have a service
coverage and the context specific issues raised in the level agreement with the government …. In the past,
data, respectively. Discrepancies in interpretations across we used to have services agreement on pediatrics…but
the three authors were reconciled by returning to the text that service level agreement was cut off because they
and to notes taken during data collection for further ana- (government) were not paying us regularly”
lysis. Findings are presented along the three-dimensional (Nurse/mid-wife, CHAM hospital).
UHC framework: universal population coverage; financial
protection; and access to health care. To avoid redundancy, Gaps in financial protection
affordability as a dimension of access has been reported Out-of-pocket medical expenditure
under financial protection. Poignantly chosen quotations All community residents who participated in the FGDs
from the qualitative transcripts have been included in the reported being charged no formal or informal fees for
results section to illustrate our key findings, in order to give the treatment received at public facilities. However, they
a voice to our respondents. consistently reported incurring substantial out-of-pocket
payments for medical treatment at CHAM/private health
Results facilities and/or when purchasing drugs at private pharma-
Gaps in population coverage cies. Despite their awareness of and experience with free
The FGDs with community residents did not reveal healthcare provision at public facilities, respondents re-
systemic exclusion of population groups on the basis of ported frequently being compelled by circumstances to
socio-economic status in the coverage of public tax seek care at CHAM/private facilities and thus, incur
funding. Community residents unanimously reported a substantial out-of-pocket payments. They justified their
sense of entitlement to free provision of the EHP at need to do so in regards to a number of shortcomings in
public facilities. public health service provision, namely: shortages of
medicines and health workers, insufficient health facilities
“Where we live the hospitals that we go are free for and equipment, poor access to emergency services, long
everyone, when you are admitted and when you are distance and transportation difficulties, poor attitude of
treated you just leave without paying anything” health workers, overcrowding and perceived poor quality
(FGD05: Female) of care, among others.

Further analysis of the FGDs, however, revealed geo- “The government hospital … can be overcrowded and
graphical exclusion of residents from certain rural without drugs, so if other people help you with money,
communities from effective EHP coverage. In communi- you go to private hospital” (FGD08: Male)
ties where only private or CHAM facilities are located,
FGD participants argued that it is practically not possible Both community respondents and health care providers
to access the EHP free of charge, since services offered by consistently reported high expected out-of-pocket payments
such facilities are paid on an out-of-pocket basis. to be the main barrier to seeking care at CHAM/private
facilities. As a consequence of financial unaffordabil-
“When you go to Adventist (CHAM hospital), you pay ity, community respondents reported delays in seeking
first to see a doctor and then if you want to test, before care, refusing hospital admissions, demanding early
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discharge or being detained in the hospitals for non- “Whenever there is a patient, we do call for an
payment of bills. ambulance from the district but it doesn’t come in
time. (so) I just ask the patient, if they can manage to
“There are times when the doctor (at CHAM) tells you go using the public transport” (Medical Assistant,
to be admitted, but due to shortage of money in your public health center)
pocket you can’t allow that, because admission is a bit
expensive” (FGD10: Male) As the direct consequence of high transport costs, some
community residents reported often deliberately foregoing
“People are not able to pay for all the services so or delaying seeking care.
patients are discharged early because they don’t have
enough money. They may require staying in the “I was injured and went to…the health center where
hospital for 7 days……but they stay in the hospital for the doctors (medical assistant) referred me to Thyolo
three days…they are asking to be discharged just (district hospital), but I had no access to transport. As
because they can’t pay for that” (Medical Doctor, CHAM). a result, I went home hunting for money and after two
days that I was able to raise money for transport but
To meet the cost of seeking the much needed care at it was too late and I had several complications at
private/CHAM facilities, community residents reported Thyolo” (district hospital) (FGD01: Female)
reliance on sales of farm produce, borrowing, and con-
tributions from family members. These are all implicit Gaps in universal access
indicators of gaps in financial protection. Shortcomings in public health service provision
The gaps in public provision which expose community
“Relatives contribute or we borrow from friends to pay residents to financial risk, by compelling them to seek
at private facilities” (FGM08: Male) care at private facilities, obviously represent the main
gaps when considering the access dimension of universal
Four out of the eight health workers interviewed had health coverage. These gaps - shortages of medicines and
additional private health insurance coverage through the health workers, insufficient health facilities and equipment,
Medical Aid Society of Malawi (MASM). This enabled overcrowding, poor access to emergency services, long dis-
them to access services at no direct cost, even from private/ tance and transportation difficulties, poor attitude of health
CHAM facilities that normally charge fees. At the time of workers, and hence perceived poor quality of care - are
the study, none of the FGD participants had any functional further explored under the following thematic topics.
additional health insurance coverage, whether private or
public. Similarly, only a few of the FGD participants had Availability and accessibility of health services
ever even heard of the concept of health insurance. Frequent drug stock outs dominated the discussions in 8
out of the 12 FGDs and in all the interviews with health
Travel expenditure workers in public facilities. FGD participants suspected
Irrespective of where care is sought, community residents that drugs were being badly managed and/or purposely
reported transport as an important additional burden. redirected towards private provision by the same pro-
Transport costs challenging residents’ ability to pay in- viders serving at the public facilities. Health workers in
cluded: public transport from the patient’s home to distant public health facilities, however, attributed the shortages
health care facilities; public transport from the community to inadequate supplies from the national drug provision
level facility to the district hospital, in case of referral; and system, which is heavily dependent on external donors.
at times, calling or fueling a government-owned ambu-
lance, in case of referral. The latter was perceived as an “The problem is that they (health workers) are selling
unexpected source of exposure to financial risk, given that these government drugs to owners of the groceries
emergency transport is supposed to be provided free of around” (FGD06: Male)
charge. All health workers confirmed the communities’
views and reported additional difficulties due to insufficient “In the past, I think things were better but now things
availability of public ambulances. have really deteriorated. As we speak now, this month,
we only got half of the medical supplies that we
“These days, they (health workers) tell us that the require per month.” (Medical doctor, public hospital)
patient should get his/her own transport to the district
hospital, always they say they do not have fuel Public sector health workers indicated that they cope
(for public ambulances)…….so a poor lady like me where with drug shortages by postponing treatment, by refer-
will I get the money at that time” (FGD12: Female) ring to a private pharmacy, and/or by referring clients to
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another health facility. Yet again, this confirms how gaps “due to long distance which we travel to the hospital
in public provision feed gaps in financial protection, as (public), we reach the hospital very late as a result we
described in the section above. are being chased away by the doctor or being told that
the drugs are finished, so most of the times we come back
“Sometimes they (health workers) tell us to buy the drugs home without getting any health care” (FGD03: Female).
ourselves yet …there are times when you don’t have even
10 Kwacha to buy panado, so in situations like these, the Acceptability and accommodation related gaps
patient stays without taking drugs” (FGD12: Female) Community respondents further complained of poor at-
titudes and behavior on the part of public providers and
“We just advise them to check on the coming week if poor quality of health services. These complaints indi-
we do have some drugs” (Medical Assistant, public cate the existence of additional gaps in access, pertaining
health centre) specifically to the acceptability and accommodation di-
mensions, respectively.
Community residents identified poor access to emer- Community residents reported rudeness and favorit-
gency services as an additional gap in access, and de- ism as the main negative attitudes of health workers in
fined it in terms of lack of adequate equipment and staff public facilities, compared to attentiveness and courtesy
at public facilities. Specifically, residents complained that at private facilities. Respondents described not being lis-
compared to CHAM and private facilities, where service tened to and being prescribed the same kinds of drugs,
provision is generally rated adequate, public facilities irrespective of their medical condition. Respondents fur-
lacked basic resources, such as electricity and water, to ther indicated that these negative attitudes effectively limit
provide adequate care. They also noted that health staff access to services, since those community residents who
frequently resided far from the facility, hampering the cannot stand the discourteous attitudes of health workers
provision of services in a timely fashion. Health workers often avoid seeking health care at public facilities.
confirmed the veracity of community concerns, but at-
tributed shortages in both equipment and staff to cir- “With government hospitals… if you know the doctor
cumstances beyond their own control. Staff shortages or if you are his/her relative, that is when you are
were cited to explain the public facility overcrowding, given enough medicine, if not that is when you receive
resulting in long waiting times. just Panado or nothing” (FGD03: Female)

“Some of the wards have about 60 patients yet they “At government (health centers), they (health workers)
are being manned by two clinical officers maybe with do not listen to our explanations, they give us the
just two nurses, and the health centers that should prescription form to get medicine at the pharmacy
have at least three or four medical assistants and before we finish explaining” (FGD01: Female)
maybe 8 nurses, they are running on one medical
assistant and two nurses, so, we have a serious issue with FGD participants in all six FGDs with women further
human resources” (Medical doctor, public hospital). explained that they experience poor attitudes from health
workers more often when they are seeking maternal care:
“Doctors (health workers) stay far from the hospital
because there are no hospital houses as such when one “… During labor pains and delivery, the nurse used to
falls sick at night and goes to the hospital he cannot be shout and insult, she used to tell us not to cry because
assisted because there is no doctor who works at night” the time we were getting pregnant she wasn’t there…..we
(FGD01: Female). are bored and tired of those insults”. (FGD12: Female)

In addition, both the FGDs and the interviews revealed None of the four public health workers supported the
that accessibility gaps largely result from the uneven community’s views on their poor attitudes, stating that
geographical distribution of public facilities. FGDs revealed they provide the best possible care, given the conditions
that large portions of the population reside only in the in which they operate. Their colleagues in private facil-
proximity of CHAM/private facilities. If unable to seek ities, however, fully supported community perceptions
care at CHAM facilities due to the affordability concerns and confirmed the existence of important differences
described earlier, community residents are forced to travel in the provider-patient interaction between private and
long distance to receive care free of charge. Respondents public facilities.
reported that due to long distance and lack of adequate
transport, they often arrive at public facilities after standard “When a patient comes to a private institution, we
consultation hours and are therefore denied treatment. give him more time, we listen to his complaints…..
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because we have time to listen to their complaints as made considerable efforts towards UHC [17]. In prac-
compared to public institutions” (Clinical officer, tical terms, the existence of geographical inequities in
private clinic) population coverage confirms the assertion that universal
health coverage entitlements, as documented on paper
The cumulative effect of the deficiencies in public service and assumed to be offered to the population, often differ
provision is that community residents perceive services substantially in reality [4]. Also, the operational challenges
provided at the public sector as inappropriate and poor in in effectively implementing the SLAs at the local level,
quality, compared to those provided in the private sector. as evidenced in our study, supports findings from previ-
They, therefore, expressed a stronger preference for seeking ous studies on the Malawian SLA [26,36]. This, by im-
care at private facilities. plication, suggests a weakness in effectively extending
government’s purchasing and regulatory function to the
“We prefer to go to the private hospitals because we private health sector within a pluralistic health care sys-
get good services. The private doctors are also good tem like Malawi’s [41].
and understand our concerns. They know that visiting Furthermore, our findings clearly indicated that geo-
their facility, it means we are looking for good services” graphical disparities in population coverage have re-
(FGD12: Female) sulted in perceived inequities in financial protection.
Being located close to or seeking health care from pub-
Discussion lic facilities were perceived to be associated with oppor-
This study reveals the views and experiences of the res- tunities for greater financial protection than being
idents of rural Malawian communities in regards to the located only close to or having to seek health care from
existence of gaps on all three UHC dimensions (population private/CHAM facilities. This implies that the provision
coverage, financial protection and access to services). Its of the EHP has mostly been effective when considering
uniqueness lies in its explicit focus on reporting the per- the financial dimension (i.e. out-of-pocket payments) at
spective of community members, voicing the concerns public facilities. The existing literature reveals incidences
of those rural residents who are rarely given the opportun- of illegal or informal charges for medical services that
ity to actively contribute towards the health policy debate ought to be offered free, in some settings [9,42-44]. This
in their country. Community responses constitute an add- evidence has been reported within contexts where direct
itional source of evidence to inform current UHC discus- out-of-pocket payments were previously implemented in
sions and policy reforms in Malawi, advancing knowledge the public health sector [9,42-44]. This important financial
on gaps in UHC beyond what has already been reported protection gap was absent in our findings and the findings
in existing quantitative studies [16,18], expert opinions, of earlier published studies within Malawi [26,30,35]. This
and policy analyses [5,7,14,17]. possibly suggests that informal payments within the public
We acknowledge that this study was only conducted in sector are more likely to arise within contexts where free
two districts in rural Malawi and among a few purposively care or exemption systems exist parallel to out-of-pocket
sampled respondents, whose views may therefore not ne- payments, rather than in a system like Malawi which has
cessarily represent the opinions of all community residents never relied on user fees after independence [45].
and all health workers in Malawi. Due to this limitation, Nevertheless, even in the absence of formal and infor-
typical of qualitative research, findings from this study can- mal payments at public facilities, our findings indicated
not be generalized to other populations and contexts, since that communities perceived themselves to be exposed to
health system gaps are to a large extent context-specific. some financial risk due to out-of-pocket payments for
However, we trust that lessons from the results are transfer- medical treatment rendered at private/CHAM facilities,
able to other rural districts in Malawi where over 80% of transportation costs, and purchases of drugs at private
Malawians reside [23,37] and where there exist similar pharmacies. The majority of potential financial protection
health system characteristics [26,30,32,35,39], and at least barriers identified in this qualitative study are not likely to
partially transferable to other rural settings in SSA which be reflected in quantitative cost/expenditure studies. The
experience similar health system characteristics [38]. reason is that rural residents normally perceive such costs
Our study confirmed the existence of clear interrelated as substantially high, unaffordable and potentially cata-
gaps in the three main dimensions of UHC, as defined strophic, and hence, either completely avoid seeking health
by rural communities, indicating a synergy between care or adopt certain coping mechanisms to avoid incurring
community perspective on UHC and current global de- the cost. Our findings, therefore, support the widely docu-
bates [4,5,7,40]. In terms of population coverage, the mented evidence confirming such cost avoiding/coping
unanimous sense of entitlement to coverage of public strategies as very important indicators of gaps in financial
funds (tax revenue) at public health facilities expressed protection within poor settings [2,35,46]. The literature
by the study respondents, implies that the country has also acknowledges long distance to health facilities and
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transportation difficulties as barriers to accessing ser- governance, specifically the role and capacity of govern-
vices that are supposed to be offered for free [10,47,48]. ment to regulate the private health sector.
This implies that UHC reforms, including support for Several implications for people-centered universal health
community residents to improve access to transport coverage policy reforms in Malawi, and similar SSA
during health care seeking, can facilitate progress towards contexts, can be drawn from our study. The clear illus-
universal health coverage in rural Malawi, and within other tration of an interrelationship of gaps in universal health
poor SSA settings. coverage implies the need for an integrated and inclu-
Interestingly, most of the reported gaps in financial sive approach to fill existing gaps [12]. To move towards
protection and population coverage are often triggered UHC in Malawi, the possibility of an effective public-
by access-related gaps in the public health sector. Af- private partnership needs to be explored, in order to
fordability of medical costs at private/CHAM facilities harness the potentials of the private sector to complement
and transport costs remain the main access barriers to the UHC efforts in the public sector [41,54,55]. The con-
seeking health care in rural Malawi. In line with earlier tracting arrangement under the SLA in Malawi, therefore,
studies in Malawi, supply side deficiencies, ranging offers great prospects for universal financial protection,
from drug shortages to perceived poor quality of care, if its implementation can be strengthened through gov-
were reported as the main barriers to accessing health ernmental commitment to regular payments of bills and
care in public facilities [26,30,34-36,39,49]. These per- expansion to cover all services under the EHP. Other
ceived access-related gaps, especially supply side defi- recommendations on how to strengthen the EHP outlined
ciencies in availability of medical products, equipment by Chirwa et al. [36] should also be considered. Given that,
and facilities, are also frequently reported by studies in Malawi, private/CHAM facilities provide approximately
within other SSA settings [50,51]. However, some studies 40% of health services, are perceived to provide the best
from Burkina Faso, for instance, revealed that, unlike what quality of care, and (especially CHAM facilities) are located
has been reported in our study, respondents had relatively mostly in rural areas [23,36], a strategy that completely
good perceptions about the attitude of their health care integrates both the public and private/CHAM sectors
providers [50,51]. This is probably due to contextual dif- will be essential for filling gaps in universal health
ferences between the two health systems or to underlying coverage. UHC can be achieved to the extent that com-
differences in expectations about what constitutes good munity residents perceive less difference in cost and
quality of care. In rural Malawi, these access-related gaps quality when seeking health care from any type of facil-
have led to low satisfaction with services provided by public ity. This could also imply reforms in the purchasing
facilities, and hence, a high preference for private/CHAM function of the health system, by introducing a third
facilities, as already reported in previous studies [32,35]. party purchaser, tasked to purchase EHP equitably from
This further widens gaps in financial protection, since the both public and private/CHAM facilities [17,56]. This
private/CHAM facilities collect out-of-pocket payments. It has the potential of reducing geographical inequities in
should be noted that although the community perceived population coverage of public funds, financial protec-
better quality of care at private facilities, in line with what tion and access to quality health care [2].
was reported in other studies within SSA settings [52,53], The above recommendation however, needs to be
the reality of such facilities actually providing high standard supported by improvement in the quality of services
quality of care may differ substantially. In rural Malawi, for and an expansion of the service provision capacity of
instance, probably only the CHAM facilities have a better the public health sector. However, directly overcoming
capacity in terms of infrastructure, medical equipment and the access-related gaps in the public health sector is a
personnel than most public facilities. The private-for-profit complex issue, since such gaps are also generally rooted in
facilities that exist in the study area are mainly individual the low economic development of the districts and of the
business organizations, with few staff, who lack the capacity country [57]. Insufficient funds to supply enough drugs,
to handle certain serious cases, such as maternal cases. It is train more health professionals and adequately motivate
not surprising, therefore, that these private-for-profit pro- them, provide sufficient health facilities, accommodation
viders do not qualify for SLAs with the government. The for health workers and enough ambulances, is one root
perception of a relatively low quality of care at public facil- cause of the supply side gaps [26]. Given the obstacles to
ities, therefore, mainly comes from the increased utilization raising additional domestic revenue from the traditional
rates in these facilities, which has been induced by commu- UHC revenue sources (taxes and insurance contributions)
nity desire to access health care free of charge. This has led within poor settings, overcoming these access-related gaps
to frequent shortages of medicines and increased providers’ in rural Malawi may require economic empowerment,
workload, and hence probably less attention spent on cli- increased external intervention and alternative innova-
ents. Again, this difference in quality of care between pub- tive mechanisms of raising additional revenue for the
lic and private health facilities borders on health systems health sector [2].
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Conclusions and field workers of Reach Trust, in particular Mr. Helecks Mtengo and Mrs.
This study has demonstrated the ability of rural communi- Miriam Matengula, Malawi, for their support during data collection. We are
also grateful to our professional proof-reader, Amy Rue.
ties to identify and define gaps in universal health coverage
through their own experiences and within their own local Author details
1
contexts. From the perspective of rural residents, there Institute of Public Health, Medical Faculty, University of Heidelberg,
Heidelberg, Germany. 2Department of Planning and Management, Faculty of
exists a unanimous sense of entitlement to coverage of Planning and Land Management, University for Development Studies, Wa,
public funds in Malawi. However, uneven distribution of Ghana. 3Research for Equity and Community Health Trust (REACH Trust),
public and private/CHAM facilities, ineffective public- Lilongwe, Malawi.

private services level agreements (SLAs), and several Received: 30 September 2013 Accepted: 6 May 2014
shortcomings or gaps in public service provision, have Published: 22 May 2014
resulted in geographical inequities in effective population
coverage, financial protection, and access to quality health
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