When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi

Abstract

Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world's highest burdens of maternal mortality. Specifically, we analyse Malawi's recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services "fall apart" and are "fixed" is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

“…However, recent reduction of development partners' contribution to the Malawian total health budget has impaired the fee exemption mechanism with CHAM, resulting in certain facilities re-introducing user fees to cope with the financial setback. Such reduction is speculated to be related to internal political instability, scandals and poor governances [59,65]. Strategies that include fee-based, non-profitable health providers working in rural areas mitigates financial barriers to use of care and expands the options for higher-level health providers that poor remote dwellers are otherwise unable to use, thus shortening the travel time required to obtain and receive adequate care [66,67].…”

Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions

“…They are expected to exercise power in the implementation of policies that contribute to the achievement of organizational goals [52,56]. How healthcare managers exercise power in everyday decisions in health facilities shapes how health care is provided and determine the quality of care that clients receive [57][58][59][60].…”

Managing Malaria in Pregnancy Policy Interventions in A Challenging Environment: an Ethnographic Study of two Ghanaian Administrative Regions

“…Mintzberg (35), de nes power in organizations as "…the capacity to effect (or affect) organizational outcomes." How health managers and workers exercise power in everyday decisions on health care shapes health facilities' internal policies, which determine the quality of health care that clients experience (37)(38)(39)(40)(41). Managers are expected to exercise power in the implementation of policies that contribute to the achievement of organizational goals (42,43).…”

“…When power is exercised positively, clients develop trust in health providers and the health care system. Where power is exercised negatively clients distrust health providers (41,46). Trust has been de ned as "…the optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for the trustor's interests" (36).…”