Child mortality in Malawi – Authors' reply
Authors: Tim Colbourn, Melisa Martinez-Alvarez, Spy Munthali, Jennifer Bryce, Jo Borghi
Journal: The Lancet Global Health (2016)

We thank Rob Yates for his letter and agree that Malawi's consistent absence of user fees in public facilities will have probably facilitated access to care and financial protection, which might have benefited health outcomes. Indeed, a recent analysis by Manthalu and colleagues1Manthalu G Yi D Farrar S Nkhoma D The effect of user fee exemption on the utilization of maternal health care at mission health facilities in Malawi.Health Policy Plan. 2016; (published online May 11.)https://doi.org/10.1093/heapol/czw050Crossref PubMed Scopus (27) Google Scholar found positive effects of user fee removal on access to antenatal and delivery services in private facilities in Malawi. An analysis by Leone and colleagues2Leone T Cetorelli V Neal S Matthews Z Financial accessibility and user fee reforms for maternal healthcare in five sub-Saharan countries: a quasi-experimental analysis.BMJ Open. 2016; 6: e009692Crossref Scopus (35) Google Scholar also found a positive effect of user fee removal on institutional deliveries in Burkina Faso and Ghana. Given the absence of user fees in the vast majority of facilities throughout the period of our study, we were unable to assess the impact of removing user fees on the achievement of Millennium Development Goal 4 (MDG4) in Malawi, but in a forthcoming district-level analysis, we will report on the relationship between out-of-pocket payment levels and mortality of infants younger than 5 years. New studies are needed to explore the effect of removing user fees on the achievement of MDG4, and its speed. Such studies should control for the effect of other financing mechanisms, and consider mediating and moderating factors, when possible. We also thank Kate Mandeville and Adamson Muula for their letter and agree with the need to ensure resources are available to fund salaries for newly trained doctors and other health workers to allow these workers to be absorbed into the under-resourced Malawian health system. The doctors' salary cap in Malawi is intended to increase macroeconomic stability. However, recruiting staff will improve capacity for service delivery, ensuring better health, and thus enhancing economic growth. If health workers have been trained—using scarce resources—they need to be hired. Austerity is unlikely to lead to a financially sustainable (or effective) public sector now, or in the long term, because it will prevent a prosperous Malawi in future.3Ostry JD, Prakash L, Furceri D. Neoliberalism: oversold? Finance & Development (Washington DC), June, 2016: 38–41.Google Scholar The International Monetary Fund needs to learn the lesson the World Bank did with user fees 10 years ago4Yates R Universal health care and the removal of user fees.Lancet. 2009; 373: 2078-2081Summary Full Text Full Text PDF PubMed Scopus (163) Google Scholar and reverse its public sector wage cap edicts.3Ostry JD, Prakash L, Furceri D. Neoliberalism: oversold? Finance & Development (Washington DC), June, 2016: 38–41.Google Scholar, 5Mwansambo C. Funding for impact: global financing for maternal and newborn health. Session at the Global Maternal and Newborn Health Conference; Mexico City; Oct 21, 2015.Google Scholar The Government of Malawi should also increase its spending on health to 15% of gross domestic product in line with the Abuja target to help ensure the funds are available to hire all health workers who have been trained, and develop a sustainable health financing strategy to address the new ambitious health-related Sustainable Development Goal targets and the Global Strategy for Women's, Children's, and Adolescents' Health. We declare no competing interests. Child mortality in MalawiIt is encouraging to read in the Article by Mercy Kanyuka and colleagues (March, 2016)1 about Malawi's success in reducing child mortality, but I fear the authors might have missed one of the key factors contributing towards this great achievement. Specifically, that Malawi is unique in sub-Saharan Africa in having never charged user fees in public health facilities, apart from a brief experiment in 1964, which the President soon abandoned after protests by the population.2 Full-Text PDF Open AccessChild mortality in MalawiWe read with interest the study by Mercy Kanyuka and colleagues1 on Malawi's achievements in Millennium Development Goal 4. The authors identified several major health-system barriers to replicating this success throughout all districts in Malawi, the foremost being low numbers of health workers. The authors point out that massive investment in the health workforce will be needed to reach the minimum densities recommended by WHO.2 Unfortunately, these standards do not take into account the financial burden to the public sector associated with expansion of the health workforce. Full-Text PDF Open Access