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Open Access Highly Accessed Research article

Gaps in universal health coverage in Malawi: A qualitative study in rural communities

Gilbert Abotisem Abiiro12*, Grace Bongololo Mbera3 and Manuela De Allegri1

Author Affiliations

1 Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany

2 Department of Planning and Management, Faculty of Planning and Land Management, University for Development Studies, Wa, Ghana

3 Research for Equity and Community Health Trust (REACH Trust), Lilongwe, Malawi

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BMC Health Services Research 2014, 14:234  doi:10.1186/1472-6963-14-234

Published: 22 May 2014

Abstract

Background

In sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities’ perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage.

Methods

We conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers.

Results

The results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers’ attitudes, distance and transportation difficulties, and perceived poor quality of health services.

Conclusions

Moving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.

Keywords:
Universal health coverage; Financial protection; Access to health care; Gaps in coverage; Geographical inequities; Community perspective; Qualitative study; Malawi