COMPARISON OF HEALTH SYSTEMS OF MALAWI WITH OTHER COUNTRIES
A health system, also known as health care system or
healthcare system, is the organization of
people, institutions, and resources that deliver health care services to meet the health needs of target
populations.
Often health system has been defined with a reductionist perspective. Some authors, (Frenk J, 2010),
have developed arguments to expand the concept of health systems, indicating additional dimensions
that should be considered:
Health systems should not be expressed in terms of their components only, but also of their
interrelationships;
Health systems should include not only the institutional or supply side of the health system but
also the population;
Health systems must be seen in terms of their goals, which include not only health improvement,
but also equity, responsiveness to legitimate expectations, respect of dignity, and fair
financing, among others;
Health systems must also be defined in terms of their functions, including the direct provision of
services, whether they are medical or public health services, but also "other enabling
functions, such as stewardship, financing, and resource generation, including what is probably
the most complex of all challenges, the health workforce (Frenk J,m 2010)."
The World Health Organization defines health systems as follows:
A health system consists of all organizations, people and actions whose primary intent is to promote,
restore or maintain health. This includes efforts to influence determinants of health as well as more
direct health-improving activities. A health system is, therefore, more than the pyramid of publicly
owned facilities that deliver personal health services. It includes, for example, a mother caring for a
sick child at home; private providers; behavior change programmers; vector-control campaigns; health
insurance organizations; occupational health and safety legislation. It includes inter-sectorial action
by health staff, for example, encouraging the ministry of education to promote female education, a
well known determinant of better health (WHO, 2007).
According to the World Health Organization (WHO), the directing and coordinating authority for health
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within the United Nations system, healthcare systems' goals are good health for the citizens,
responsiveness to the expectations of the population, and fair means of funding operations. Progress
towards them depends on how systems carry out four vital functions: provision of health care services,
resource generation, financing, and stewardship (WHO, 2000: World Health Report 2000 - Health
Systems: improving performance. Geneva, WHO). Other dimensions for the evaluation of health
systems include quality, efficiency, acceptability, and equity. They have also been described in the
United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness (John
Hopkins, 2007). Also, continuity of health care is a major goal.
This document will compare Malawi's health systems, with the health system of the following
countries: Uganda, Bangladesh, Tanzania, Ethiopia, India, Kenya, Ghana, South Africa, Sudan and
Pakistan, on the basis that it is provided by the government or not.
HEALTH CARE SYSTEM IN MALAWI
Health Services in Malawi are provided by public, private for profit (PFP) and private not for profit
(PNFP) sectors (Makwero, Martha T., 2018). The Ministry of Health (MOH) is responsible for
overseeing health care in Malawi. Statistically, approximately 63% of health services are provided by
the government, 37% are provided by the Christian Heath Association of Malawi (CHAM), and a small
fraction of the population receive health services through the private sector. Private doctors and
non-governmental organizations (NGOs) offer services and medicines for a nominal fee (Kalinga, Owen,
2012). In simple terms, the government of Malawi has a national healthcare service which is
government funded, and free to all Malawians at the point of delivery. Government
healthcare is
provided in three forms: Health Centers at the local level, Regional or Rural Hospitals one level up,
and District Hospitals at the highest level.
HEALTH SYSTEM OF BANGLADESH AND MALAWI
Bangladesh is one of the most populous countries in the word, as well as having one of the fastest
growing economies in the word (Shah, Jahangir. 2011). Consequently, Bangladesh faces challenges and
opportunities in regards to public health.
Bangladesh has a pluralistic healthcare system. This healthcare system is highly decentralized. As a
result, it is regulated and controlled by for-profit companies, NGOs, the national government and
international welfare organizations.
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The Human Rights Measurement initiative (2022) finds that Bangladesh is fulfilling 89.3% of what it
should be fulfilling for the right to health based on its level of income. When looking at the right to
health with respect to children, Bangladesh achieves 95.0% of what is expected based on its current
income. In regards to the right to health amongst the adult population, the country achieves only
94.2% of what is expected based on the nations level of income. Bangladesh falls into the "bad"
category when evaluating the right to reproductive health because the nations is fulfilling only 78.8%
of what the nation is expected to achieve based on the resources (income) it has available.
GHANA
In Ghana, most health care is provided by the government, but hospitals and clinics run by religious
groups also play an important role. Some for-profit clinics exist, but they provide less than 2% of
health services. Health care is very variable through the country. The major urban centers are well
served, but rural areas often have no modern health care. Patients in these areas either rely on
traditional medicine or travel great distances for care. In 2005, Ghana spent 6.2% of GDP on health
care, or US$30 per capita. Of that, approximately 34% was government expenditure. The kind of
health system that Ghana has is a Universal health care system, National Heath Insurance Scheme
(NHIS), and until the establishment of the National Health Insurance Scheme, many people died
because they did not have money to pay for their health care needs when they were taken ill. The
main challenges faced by Ghana healthcare system include poor hygiene and sanitation, inadequate
financial health investments or limited workforce and facilities.
SOUTH AFRICA
In South Africa, parallel private and public systems exist. The public system serves the vast majority
of the population, but is chronically underfunded and understaffed. The wealthiest 20% of the
population uses the private system and are far better served. This division in substantial ways
perpetuates racial inequalities created in the pre-apartheid segregation era and apartheid era of the
20th century. In 2005, South Africa spent 8.7% of GDP on health care, or US$437 per capita. Of that,
approximately 42% was government expenditure.
UGANDA
Uganda's health system is composed of health services delivered to the public sector, by private
providers, and by traditonal and complementary health practitioners. It also includes community based
health care and health promotion activities. The health system depends heavily on international donor
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support. Many healthcare facilities are run by the government, donors, or through NGOs, including
faith based organizations.
Uganda’s health system is comprised of decentralized healthcare services, overseen by district health
teams
across
112
districts
and
the
central
ministry
of
health(http://www.molg.go.ug/local-governments ). The decentralized district is the local level of
decision-making for health services delivery, including the planning and implementation of human
resources for health policies, budgeting for medicines, supplies, sundries, infrastructure and
amenities such as electricity and water(MoH 2010). The district health team is led by a District Health
Officer who works with a team of 7 health managers. Alongside other district departments such as
education, agriculture, water and sanitation and community development, they report to the Chief
Administrative Officer. These technical departments are governed by the political arm of government
headed by the Local Council V chairperson, assisted by District Councilors. Each district has
sub-districts, which are lower-levels of policy-making and monitoring of health services at the
sub-county levels.
Each district often has a General Hospital, and referral level Health Centre IVs at the health
sub-districts. Each Health Centre IV at the health sub-district supervises a number of Health Centre
IIIs, which often have maternal health services in addition to ambulatory care. Below the Health
Centre IIIs are dispensaries labelled Health Centre IIs. At the community level, are Village Health
Teams who provide day-to-day referral of patients from the community.
In Uganda’s rural setting, most healthcare services are provided by the public and the private
not-for-profit (PNFP) sector, the latter involving mainly faith-based Catholic, Protestant and Muslim
Medical Bureaus( Barugahara PM, Everd. Mugisha, J Francis, 2008). Both primary and secondary care
is provided at referral level health facilities; Health Centre IV and hospitals whereby workforce teams
include physicians, non-physician clinicians (NPCs), nurses and midwives, laboratory technicians,
dispensing staff and records personnel. Clinicians are scarce, particularly physicians, therefore the
backbone of the workforce consists of nurses and midwives, NPCs and the unqualified providers such
as the nursing assistants who have undergone certificate training for less than nine months.
Since,
2008, unqualified cadres are being phased out of the health workforce structures, through prohibiting
recruitment, and replacement of retired staff.
ETHIOPIA
Ethiopia's health care service includes primary health centers, clinics and hospitals. The current
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Ethiopia health care financing strategy focus on financing of the primary health care services in a
sustainable manner.
Throughout the 1990s, the government, as part of its reconstruction program, devoted ever-increasing
amounts of funding to the social and health sectors, which brought corresponding improvements in
school enrollments, adult literacy, and infant mortality rates. These expenditures stagnated or
declined during the 1998–2000 war with Eritrea, but in the years since, outlays for health have grown
steadily. In 2000–2001, the budget allocation for the health sector was approximately US$144 million;
health expenditures per capita were estimated at US$4.50, compared with US$10 on average in
sub-Saharan Africa. In 2000 the country counted one hospital bed per 4,900 population and more than
27,000 people per primary health care facility. The physician to population ratio was 1:48,000, the
nurse to population ratio, 1:12,000. Overall, there were 20 trained health providers per 100,000
inhabitants. These ratios have since shown some improvement. Health care is disproportionately
available in urban centers; in rural areas where the vast majority of the population resides, access to
health care varies from limited to nonexistent. As of the end of 2003, the United Nations (UN)
reported that 4.4 percent of adults were infected with human immunodeficiency virus/acquired
immune deficiency syndrome (HIV/AIDS); other estimates of the rate of infection ranged from a low of
7 percent to a high of 18 percent. Whatever the actual rate, the prevalence of HIV/AIDS has
contributed to falling life expectancy since the early 1990s. According to the Ministry of Health,
one-third of current young adult deaths are AIDS-related. Malnutrition is widespread, especially
among children, as is food insecurity. Because of growing population pressure on agricultural and
pastoral land, soil degradation, and severe droughts that have occurred each decade since the 1970s,
per capita food production is declining. According to the UN and the World Bank, Ethiopia at present
suffers from a structural food deficit such that even in the most productive years, at least 5 million
Ethiopians require food relief.
In 2002 the government embarked on a poverty reduction program that called for outlays in education,
health, sanitation, and water. A polio vaccination campaign for 14 million children has been carried
out, and a program to resettle some 2 million subsistence farmers is underway. In November 2004, the
government launched a five-year program to expand primary health care. In January 2005, it began
distributing antiretroviral drugs, hoping to reach up to 30,000 HIV-infected adults.
INDIA
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In India, the hospitals and clinics are run by government, charitable trusts and by private
organizations. The public clinics in rural areas are called Primary Health Centers (PHCs). Public
hospitals are free for all and entirely funded through taxes. Major hospitals are located in district
headquarters or major cities. At the federal level, a national health insurance program was launched
in 2018 by the Government of India, called Ayushman Bharat. This aimed to cover the bottom 50% (500
million people) of the country's population working in the unorganized sector (enterprises having less
than 10 employees) and offers them free treatment even at private hospitals. For people working in
the organized sector (enterprises with more than 10 employees) and earning a monthly salary of up to
Rs 21000 are covered by the social insurance scheme of Employees' State Insurance which entirely
funds their healthcare (along with pension and unemployment benefits), both in public and private
hospitals. People earning more than that amount are provided health insurance coverage by their
employers through the many public or private insurance companies. As of 2020, 300 million Indians
are covered by insurance bought from one of the public or private insurance companies by their
employers as group or individual plans. Unemployed people without coverage are covered by the
various state insurance schemes if they do not have the means to pay for it. In 2019, the total net
government spending on healthcare was $36 billion or 1.23% of its GDP. Patients generally prefer
private health clinics. These days some of the major corporate hospitals are attracting patients from
neighboring countries such as Pakistan, countries in the Middle East and some European countries by
providing quality treatment at low cost. In 2005, India spent 5% of GDP on health care, or US$36 per
capita. Of that, approximately 19% was government expenditure.
SUDAN
Outside urban areas, little health care is available in Sudan, helping account for a relatively low
average life expectancy of 57 years and an infant mortality rate of 69 deaths per 1,000 live births, low
by standards in Middle Eastern but not African countries. For most of the period since independence
in 1956, Sudan has experienced civil war, which has diverted resources to military use that otherwise
might have gone into health care and training of professionals, many of whom have migrated in search
of more gainful employment. In 1996 the World Health Organization estimated that there were only 9
doctors per 100,000 people, most of them in regions other than the South. Substantial percentages of
the population lack access to safe water and sanitary facilities. Malnutrition is widespread outside
the central Nile corridor because of population displacement from war and from recurrent droughts;
these same factors together with a scarcity of medicines make diseases difficult to control. Child
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immunization against most major childhood diseases, however, had risen to approximately 60 percent
by the late 1990s from very low rates in earlier decades. Spending on health care is quite low – only 1
percent of gross domestic product (GDP) in 1998 (latest data). The United Nations placed the rate of
human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) infection in late
2003 at 2.3 percent for adults, quite low by regional standards. The United Nations suggested,
however, that the rate could be as high as 7.2 percent. Between 400,000 and 1.3 million adults and
children were living with HIV, and AIDS deaths numbered 23,000. As of late 2004, some 4 million
persons in the South had been internally displaced and more than 2 million had died or been killed as
a result of two decades of war. Comparable figures for Darfur were 1.6 million displaced and 70,000
dead since fighting began there in early 2003.
PAKISTAN
Pakistan has a mixed health system that includes public, parastatal, private, civil society,
philanthropic contributors, and donor agencies. The health care delivery system in Pakistan consists
of public and private sectors mainly though. Under the constitution, health is primarily responsibility
of the provincial government, except in the federally administrated areas.
Pakistan's health indicators, health funding, and health and sanitation infrastructure are generally
poor, particularly in rural areas. About 19 percent of the population is malnourished – a higher rate
than the 17 percent average for developing countries – and 30 percent of children under age five are
malnourished. Leading causes of sickness and death include gastroenteritis, respiratory infections,
congenital abnormalities, tuberculosis, malaria, and typhoid fever. The United Nations estimates that
in 2003 Pakistan's human immunodeficiency virus (HIV) prevalence rate was 0.1 percent among those
15–49, with an estimated 4,900 deaths from acquired immune deficiency syndrome (AIDS). AIDS is a
major health concern, and both the government and religious community are engaging in efforts to
reduce its spread. In 2003 there were 68 physicians for every 100,000 persons in Pakistan. According
to 2002 government statistics, there were 12,501 health institutions nationwide, including 4,590
dispensaries, 906 hospitals with a total of 80,665 hospital beds, and 550 rural health centers with a
total of 8,840 beds. According to the World Health Organization, Pakistan's total health expenditures
amounted to 3.9 percent of gross domestic product (GDP) in 2001, and per capita health expenditures
were US$16. The government provided 24.4 percent of total health expenditures, with the remainder
being entirely private, out-of-pocket expenses.
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TANZANIA
Tanzania has a hierarchical health system which is in tandem with the political-administrative
hierarchy(Manzi, ie, 2012). The health services are delivered through a decentralized system. At the
bottom, there are the dispensaries found in every village where the village leaders have a direct
influence on its running. The health centers are found at ward level and the health center in charge is
answerable to the ward leaders. At the district, there is a district hospital and at the regional level a
regional referral hospital. The tertiary level is usually the zone hospitals and at a national level, there
is the national hospital. There are also some specialized hospitals that do not fit directly into this
hierarchy and therefore are directly linked to the ministry of health.
The government has several key plans and policies guiding healthcare provision and development. The
Health Sector Strategic Plan III (2009–15) is guided by the Vision 2015 and guides planning for health
facilities. The Big Results Now (BRN) was copied from the Malaysian Model of Development and
placed health as a key national result area and mainly was for priority setting, focused planning and
efficient resource use. There are many other policies aiming at improving the health system and
health care provision in Tanzania.
In addition to that, the leading causes of mortality in Tanzania include: HIV 17%, lower respiratory
infections 11%, malaria 7%, diarrheal diseases 6%, tuberculosis 5%, cancer 5%, ischemic heart
disease 3%, stroke 3%, STDs 3% and sepsis 2% and this shows the double burden of disease the
country has to bear.
KENYA
Kenya’s health care system is structured in a step-wise manner so that complicated cases are
referred to a higher level. Gaps in the system are filled by private and church run units. It is made up
of several systems: public, private, and faith based or NGO. About 48% are public and operate under
the Ministry of Health, 41% are in the private sector, 8% are faith based health services, and 3% are
run by NGOs.
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REFERENCES
White F (2015). "Primary health care and public health: foundations of universal health systems"
"Health care system". Liverpool-ha.org.uk. Retrieved 6 August 2011.
World Health Organization. (2000). World Health Report 2000- Health systems: improving performance.
Geneva, WHO
Frenk J (2010). "The global health system: strengthening national health system as the next step for
global progress."
Remarks by Johns Hopkins University President William Body: "Health Care '08: What's
Promised\What's Possible?"
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