Child mortality in Malawi
Authors: Rob Yates
Journal: The Lancet Global Health (2016)

It is encouraging to read in the Article by Mercy Kanyuka and colleagues (March, 2016)1Kanyuka M Ndawala J Mleme T et al.Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e201-e214Summary Full Text Full Text PDF PubMed Scopus (85) Google Scholar 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.2Messac L Moral hazards and moral economies: the combustible politics of healthcare user fees in Malawian history.S Afr Hist J. 2014; 66: 371-389Crossref Scopus (2) Google Scholar The Countdown to 2015 case study reasonably attributes improved child health outcomes to increased coverage of effective preventive and curative interventions. However, in focusing on a scale-up of services (in other words the supply side) it appears to neglect Malawi's unique demand-side reform in the 1990s—to provide services for free. Removing this access barrier would have resulted in a higher consumption of effective services by children (especially poor children) in Malawi than in neighbouring countries. Proof of this proposed effect is provided by the numerous examples of countries that have removed user fees since 2000 and witnessed large increases in use of health care.3Yates 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 Also, it's noticeable that where user fees have become more entrenched in west Africa, due to the Bamako Initiative, child health indicators are now lagging behind the rest of the continent.4UNICEFCommitting to child survival: a promise renewed. Progress report 2013.http://www.unicef.org/publications/files/APR_Progress_Report_2013_9_Sept_2013.pdfGoogle Scholar It's true that the authors do mention, in passing, that services have been free at the point of delivery in Malawi, but only to mention that 10% of total health expenditure was still in the form of out-of-pocket payments. This proportion of health expenditure is actually very low for Africa5Leive A Xu K Coping with out-of-pocket health payments: empirical evidence from 15 African countries.Bull World Health Organ. 2008; 86: 849-856Crossref PubMed Scopus (286) Google Scholar and again shows that Malawi's free services policy has also been effective in providing financial protection. I declare no competing interests. Child 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 AccessChild mortality in Malawi – Authors' replyWe 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 colleagues1 found positive effects of user fee removal on access to antenatal and delivery services in private facilities in Malawi. An analysis by Leone and colleagues2 also found a positive effect of user fee removal on institutional deliveries in Burkina Faso and Ghana. Full-Text PDF Open Access