Healthcare financing in Malawi and the achievement of universal health coverage : paradoxical difficulties in its realization due to vertical programming and off-budgetary support to the NGO sector
Malawi’s public health sector is presently funded 54% by external financial contributions from donor partners, demonstrating an overreliance on such donor aid for effective service delivery. However, donor support is increasingly precarious as donor partners opt for non-budgetary support, which redirects funds towards international and local NGOs instead of governmental ministries. Priorities for NGOs and donors oftentimes are uncoordinated with governmental priorities, resulting in the duplication of service delivery and the wasting of donors’ funds. Additionally, NGOs preferentially support vertical programs that focus on specific health concerns, notably HIV/AIDS, to the detriment of non-prioritized health conditions, such as maternal health and non-communicable diseases, effectively fragmenting and debilitating the overall healthcare system. The former perpetuates Malawi’s continued dependence on foreign funds and inhibits the government’s ability to achieve targets such as the implementation of universal health coverage. Even though vertical programs have undoubtedly contributed to marked improvements in health during the 21st century, such achievements are neither sustainable over the long-term nor reflective of gains expected due to such high levels of funding. The present analysis, shaped by personal experiences and observations within a local Malawian NGO, examines the country’s healthcare system and the NGO sector. On one hand, concerning the healthcare system, the expansion and success of vertical programming in improving life expectancies at the expense of broader healthcare gains is critically analyzed. While on the other, the NGO sector is critiqued for its overdependence on volunteers for operations and economic sustainability, the presence of entrenched small-scale corruption, and the system of per diems, which incentivize remunerated activities over salaried obligations. Finally, I argue that vertical programming financed by donor partners have inhibited the realization of universal health coverage in Malawi and that donor partners should increase direct budgetary support to the Malawian government to enable an alignment between the government’s health priorities and the available financial resources.