Early one weekday afternoon in mid-July, the rows of wooden benches under a shaded awning at Nsambe Health Center are empty. In this, the outpatient waiting area of a remote mission clinic, all the day's patients have been seen. Yet only a few weeks earlier, at this hour the area would still have been crowded with sick patients seeking care. The clinician in charge of the department, Damiyano Nkhoma, reports that in May and June of 2013 he saw 100 to 130 patients a day. But since the start of July, the number of patients has plummeted to roughly 30 per day.
Biological and ecological factors could not explain this rapid change in clinic attendance. May, June, and July are all part of Malawi's cold, dry season, when malaria is at a nadir and the annual maize harvest leaves bodies well-fed and strong. Though the area has seen frightening outbreaks of epidemic disease like typhoid in recent years, this year has been quiet. The people, it would seem, are no less sick this month than before.
Both Nkhoma and the residents of Nsambe interviewed for this story claim that the reason for the drop in clinic attendance is the reintroduction of user fees. Since July 1, the clinic has charged each patient a set fee for consultation and additional fees for each drug dispensed or medical supply used during the visit. According to Nkhoma, "Paying does reduce attendance…because here you are talking of some who have and some who do not have."
At first glance, the sums involved can appear paltry. Including fees for drugs, supplies, and consultations, the average patient seeking treatment for a routine condition, like a headache or a GI infection, can expect to pay the equivalent of $3 or less. Seriously ill patients in need of intravenous fluids or admission for observation will be charged more. But in Malawi, one of the world's most impoverished countries, even the smallest fees can leave people outside the clinic doors. According to the World Bank, 82 percent of Malawians live on less than $2 per day.
Asked about the fees, Janet Saidi, a village health worker employed by the NGO Partners In Health, explains, "Yeah, it's a lot of money, because people here earn money through farming." In remote areas like Nsambe, where huts have dirt floors, battery-powered radios are luxuries, and the frostbitten harvest of Irish potatoes has been pitifully small, it is uncommon to have much cash ready at hand in the event of illness.
For at least the past decade, out-of-pocket health payments have fallen into disrepute among global health experts and policymakers. As early as 1997 a review of the academic literature by Lucy Gilson, a health economist at the London School of Hygiene and Tropical Medicine, revealed that health user fees rarely raised as much revenue as projected. In 2005, the World Health Organization estimated that out-of-pocket health payments push an estimated 100 million people into poverty every year globally. Citing this evidence, in May 2013 Dr. Jim Yong Kim, president of the World Bank Group (long a major institutional proponent of health user fees), called for the "elimination or sharp reduction of point-of-service payments."
Although many governments have moved away from fees at the point of care in recent years, independent mission clinics remain a significant exception to the trend. Nearly every one of Malawi's mission clinics charges user fees.
That Nsambe Health Center ever operated without user fees was the product of an anomaly. Six years ago, the Neno District Health Office entered into an agreement with Adventist Health Services, which administers Nsambe and 16 other health centers in Malawi. Under the terms of the agreement, funding from Partners In Health would help build new infrastructure (electricity, running water, new buildings) and supply essential medicines, while Adventist Health Services would abolish fees.
Following the global financial crisis, charitable donations to Partners In Health fell, forcing substantial budget cuts. Florence Chipungu, CEO of Adventist Health Services, said that many promised infrastructural improvements remained to be completed, and drug stock-outs were frequent. Adventist Health Services said the agreement was no longer in force and announced the reintroduction of fees.
Sitting in his Neno office in early August, Dr. Jonas Rigodon, Partners In Health country director, said the reintroduction of fees kept him awake at night. "We have seen people get sicker and sicker because they don't have the little they are asked to pay to get access to health care." For her part, Chipungu said she was also concerned about the impact of the fees, "but it is hard for us to provide that free service without support, because then we will not be able to sustain that service."
People near Nsambe are especially concerned about one product of the new fees: long walks. For years before the abolition of fees in 2007, many patients would journey 13 miles past empty waiting rooms in Nsambe to reach long lines for free services at the government hospital in Neno. Today, patients and health workers are reprising that painful sojourn for care. "In the past [before July 1] it was not very difficult," explained community health worker Janet Saidi, "because if I found a patient who was ill, I would take him to [Nsambe] to receive treatment, free of charge. But today if I see him, I will ask him if he has money. If he has no money, I can take him to Neno, but it is a long distance."
Local authorities in Nsambe have sent entreaties to all parties, seeking the return of free health care. In a letter sent in early July, local traditional authorities (chiefs charged with administrative duties) asked Partners In Health to help build a new government health center in Nsambe. This request is in line with recent statements by Ministry of Health spokesman Henry Chimbali, who has said that the Ministry aims to construct government facilities in areas previously only served by mission clinics. For his part, Nkhoma hopes the lapsed agreement will be revived soon so he can go back to treating all patients in need of care.