The dangerous accountability deficit in Malawi's health sector

By Annabel Raw

Malawi is one of the poorest countries in the world and is heavily dependent on aid. About 40% of its annual budget comes from international donors. However, following the revelation of a massive corruption scandal dubbed “cashgate”, donors have been slashing their disbursements. In October, the IMF also suspended loans to Malawi due to its failure to implement reforms and improve revenue collection.

The country is currently experiencing high inflation and currency depreciation and some are claiming that the economy is freefalling. At the same time, Malawi faces a looming famine. In January, floods destroyed some 27% of Malawi’s annual output for its staple maize. Recent statistics indicate that 2.8 million Malawians (about 17% of the population) face starvation. President Peter Mutharika is urgently appealing for additional humanitarian assistance.

The economic crisis has contributed to disastrous effects this year with some civil servants’ salaries being suspended and government cutting budgets across the board. The health sector has suffered from the squeeze with significant reductions in the 2015/2016 budget allocations. In the context of an already under-served population, this has resulted in additional cut-backs in ambulance services, food, basic supplies, equipment and medicines in healthcare facilities.

Outreach programmes have also been suspended, making patients in remote areas impossible to reach. Despite the already low doctor/patient ratio of 1 doctor to 80 000 patients and a critical shortage of trained nursing staff, government has also failed to hire medical and nursing graduates.

But even before the current economic crisis, Malawi struggled with frequent stock-outs of essential medicines. While government usually blames the inefficiencies of the central medical stores, large quantities of medicines are stolen from public health facilities and corruption in the healthcare sector is rife. Stolen medicines are often sold to private healthcare providers only to be re-sold to indigent patients seeking care at public facilities, where they are told to purchase medicines and basic supplies privately as the public facilities are out of stock.

While it appears that HIV/Aids funding remains viable in the short-term (and in fact Malawi has committed to scaling up treatment to the provision of ARVs to all HIV-positive patients irrespective of CD4 count from April 2016) donors in other crucial sectors of healthcare are threatening to pull funding if wide-spread theft and misappropriation of resources is not stopped.

There is a deep and troubling deficit of accountability in the healthcare sector. The consequence is that already thinly-spread resources continue to be misappropriated and external funding to retain basic services is being withdrawn. It is therefore disturbing that in the wake of a crisis where government desperately needs all hands on deck to ensure propriety and clean books in the healthcare sector, instead of improving accountability mechanisms, efforts are being made to shut down democratic oversight.

The Anti-Corruption Bureau, the Office of the Ombudsman and the judiciary have all seen their budgets reduced following the cashgate saga. In addition, in the face of increasing protests and discontent with declining services and supplies in the public healthcare sector, government recently issued a “gag order” against hospital spokespersons to prevent them from engaging with the media.

The absence of transparency and access to information in the healthcare sector threatens to undermine the government’s prospects of stemming graft in the system and undermines the opportunity to work with civil society to identify and rectify inefficiencies and develop solutions to improve health systems. When belts are tightening it is all the more vital that governments are careful and efficient with resources. If Malawi’s rhetorical commitment to improving accountability and healthcare are sincere, immediate efforts must be made to improve democratic oversight and transparency in the healthcare sector. An essential component of such transparency is enabling healthcare workers throughout the country to voice their concerns when problems arise that affect access to healthcare services.

Annabel Raw is a health rights lawyer at the Southern Africa Litigation Centre.