Promoting universal financial protection: contracting faith-based health facilities to expand access – lessons learned from Malawi

Abstract

BackgroundPublic-private collaborations are increasingly being utilized to universalize health care. In Malawi, the Ministry of Health contracts selected health facilities owned by the main faith-based provider, the Christian Health Association of Malawi (CHAM), to deliver care at no fee to the most vulnerable and underserved populations in the country through Service Level Agreements (SLAs). This study examined the features of SLAs and their effectiveness in expanding universal coverage. The study involved a policy analysis focusing on key stakeholders around SLAs as well as a case study approach to analyse how design and implementation of SLAs affect efficiency, equity and sustainability of services delivered by SLAs.MethodsThe study employed both qualitative and quantitative research methods to address the research questions and was conducted in five CHAM health facilities: Mulanje Mission, Holy Family, and Mtengowanthenga Hospitals, and Mabiri and Nkope Health Centres. National and district level decision makers were interviewed while providers and clients associated with the health facilities were surveyed on their experiences. A total of 155 clients from an expected 175 were recruited in the study.ResultsThe study findings revealed key aspects of how SLAs were operating, the extent to which their objectives were being attained and why. In general, the findings demonstrated that SLAs had the potential to improve health and universal health care coverage, particularly for the vulnerable and underserved populations. However, the findings show that the performance of SLAs in Malawi were affected by various factors including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate human and material resources, and lack of systems to monitor performance of SLAs, amongst others.ConclusionsThere was strong consensus and shared interest between the government and CHAM regarding SLAs. It was clear that free services provided by SLAs had a great impact on the impoverished locals that used the facilities. However, lack of supporting systems, inadequate infrastructure and shortage of health care providers affected SLA performance. The paper provides recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalization policy.

Perceptions and experiences of community members on caring for preterm newborns in rural Mangochi, Malawi: a qualitative study

“…Actually, it has been acknowledged that poverty undermines maternal, newborn and child health through numerous pathways, including reduced care-seeking and access to health care services [ 40 , 41 ]. In order to mitigate the impact of poverty on maternal and infant health, there is a policy in Malawi that allows free access to services at CHAM hospitals with a focus on maternal and neonatal interventions [ 42 ]. However, the CHAM hospital in the catchment areas was not yet a beneficiary at the time of data collection.…”

Ghana’s National Health insurance scheme and maternal and child health: a mixed methods study

“…Such an approach enabled us to obtain a richer and more comprehensive understanding of individual behaviors and community and contextual dynamics related to insurance, than a single method alone [ 23 ]. Mixed-methods approaches are increasingly being used in the study of diverse models of health insurance across Africa, reflecting the need to integrate multiple perspectives and sources of information to understand the complex determinants of insurance uptake and the relationships between insurance and outcomes [ 21 , 24 , 25 ].…”

Expanding Health Care Provision in a Low-Income Country

“…This is evident from a series of studies commissioned by the Ministry of Health, the College of Medicine, and other partners. A more recent study by Chirwa et al (2013) observes that SLAs have the potential to improve health and UHC, particularly for vulnerable and underserved populations. Using data from the CHAM Secretariat and the Ministry of Health, we observe that 76 of the existing 175 CHAM health facilities had active SLAs by the end of 2014.…”

“…The major challenges with regard to SLAs include late payment of bills, lack of transparency, poor communication, and lack of systems to monitor SLA and health worker performance (Chirwa et al 2013). A study by Tambulasi (2014) reveals that MoH is often accused of delaying payments to CHAM providers.…”