Free primary health care for vulnerable social groups in low income settings : lessons from Malawi and Zambia


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Høgskolen i Oslo og Akershus. Fakultet for samfunnsfag

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Master in International Social Welfare and Health Policy


Due to the increased burden of poor health on poor and rural households, Malawi and Zambia waived user fees in health. Malawi introduced an Essential Health Package (EHP) in 2004 to address common causes of morbidity and mortality that disproportionately affect the poor. Zambia abolished user fees in health for rural households in 2006. Waving user fees was seen as an effective tool for bridging the socio-economic divide and improving health equity. These policies sought to reduce the national health burden, which falls more heavily on poor and rural households. Against this back drop, this study was formulated to review literature on the effects of the stated policies on access to health services by vulnerable social groups in both nations and investigate the challenges that constrain their implementation. The study focused on social protection in health for vulnerable groups using a social constructionist approach. The review found that access and utilization of health services have significantly improved in both cases. However, coverage of services is still limited. Services are free in principle but poor households still have to bear indirect costs to health services. Health centers and personnel are still disproportionately distributed between urban and rural areas and structural factors still threaten household accessibility to services. The analysis also finds the targeting strategies used in delivering services inadequate. Thus, both countries have not effectively extending coverage of services. Overall, Malawi’s EHP has produced better coverage than the Zambian waiver policy due to more coordinated implementation. However, the understanding of what the policies entail on the part of health managers at facility level is in both cases weak thus compromising implementation. Although intended to be supply-side both policies are in practice demand-side. Both nations suffer human resource and essential medicine shortages, poor distribution of health facilities and poor funding and coordination. Hence, health systems should be strengthened and remote areas targeted more. Both governments should increase social protection budgets. Donors should pool support to reduce coordination problems in implementation and a quasi-internal market in health care with a system of purchasers and providers of services should be introduced. Further inquiry on social impacts of the policies and not only cost effectiveness is necessary.


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