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The evolving two tier systems in Malawi.

By Elvis Gama and Barbara McPake


Malawi is one of a few countries experiencing extreme crises of both human resources and HIV/AIDS, all of them in sub-Saharan Africa (McCoy et al., 2008). Overall expenditure on the health system has been rising, supported by a growing public sector in turn supported by growing external assistance (WHOSIS). \ud This has implications for the nature and shape of the public health system. It is highly stressed, in particular in relation to human resource availability. In principle it is focused on the provision of an essential health package (EHP), focused on mainly infectious diseases that account for the greatest burden of disease which is the priority of external funding channelled through the national sector wide approach process. Although only recently included in the EHP, much external assistance has been channelled to an antiretroviral treatment programme which has been considered an ‘island of excellence’ in an otherwise very basic public health system (McCoy et al., 2008 ). For relatively wealthy Malawians who are not HIV positive or currently eligible for antiretroviral treatment, the public health system is likely to offer little. \ud \ud WHOSIS data also indicate stagnation of private expenditure on health in international (purchasing power parity) dollar terms while other data indicate a growing private health care sector in Malawi. The number of private health services providers as recorded by the business registrar has increased from 40 in 1995 to 78 by the end of 2007. Similarly, a physical count of private health providers shows that the number of private providers has increased from 65 in 1995 to 138 by end of 2007(Business Registrar report,2007). This combination of observations is likely to imply a struggling private sector with providers moving in and out of the sector as they initially invest and often then fail to remain solvent, such as has been described in Tanzania (Tibandebage and Mackintosh, 2002 ). The implications of this category of private sector for the nature of two-tier provision are likely to differ from the implications of a more thriving and stable private sector. \ud \ud This paper will present evidence of the characteristics of private sector development and their consequences for the nature of two tier provision using available data concerned with: \ud \ud • Human resource distribution across the health system and implications for retention and motivation\ud \ud • Factor prices\ud \ud • Distribution of users of the tiers of the system in relation to income or wealth quintiles and disease profile\ud \ud • Distribution of benefit incidence across user groups \ud \ud comparing these, where internationally comparable data are available, with data from countries in which there appears a more thriving and stable private sector. The paper will inform the development of a research proposal focused on the implications of two tier provision for equitable access to health care in different types of settings

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