Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 1 | 9 ORIGINAL RESEARCH Improving access to health services in Malawi Robert Msokwa1 1 Dedza District Hospital, Ministry of Health, Malawi; Corresponding Author: Robert Msokwa (BSC, MBBS - College of Medicine); Address: Dedza District Hospital, Ministry of Health, Malawi; Email: m201650043380@stud.medcol.mw mailto:m201650043380@stud.medcol.mw Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 2 | 9 . Abstract Background: Timely access to health care can substantially reduce mortality. The United Na- tions Sustainable Development Goal 3, target eight recommends provision of quality care to all must include usually underserved groups by 2030. Universal access to healthcare remains una- vailable particularly in rural areas, due to a shortage of labor, a lack of basic health-facility infra- structure, poor management practices, and insufficient financing In Malawi, universal access to healthcare remains unavailable particularly in rural areas, however, no data is available from vil- lagers themselves on improving access to health services. The aim of the study was to find ways of improving access to health services in Malawi with focus on people staying in rural areas. Methods: Quantitative cross-sectional study. Simple random sampling. Face to face interview was conducted. Results: The survey included 126 people, 97(77%) were women and 29 (23%) were men. 52 % participants were farmers, 7% of participants were employed, and 5% attainted tertiary educa- tion. Common barriers to access health services which participants (35%) mentioned were lack of drugs and medical equipment, shortage of health personnel (25%), another 25% complained of long distance to nearest health facility. 10 % of participants fail to access health services due to poor design of hospitals and 5% failed to access health services due to rudeness of health workers. Accessibility of health services in Malawi can be improved by increasing number of clinics which was suggested by 28% of participants, 25% of study participants suggested training more health workers, 23% suggested of setting up of community fund to transport patients in cases of emergency, 20% of participants suggested of introducing mobile clinics and 4% sug- gested of designing of tricycle to be used for transport in rural areas. Conclusion: Access to health services in Malawi can be achieved by Training more health work- ers, introducing community funds, empowering local people to own the health facilities, increas- ing number of health facilities, designing tricycle which could travel in rural areas and improve drug supply and quality of medical equipment through increased funding from central govern- ment Keywords: World Health Organization, Health Care Workers, United Nations, Tuberculosis, Acquired Immune Deficiency Syndrome, Human Immune Virus, Christian Health Association of Malawi, Barriers, Health services, Health care access, Sub-Saharan Africa Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 3 | 9 Introduction ‘Universal health coverage is defined as en- suring that all people have access to needed health services (including prevention, promo- tion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship’ (1). The United Nation through Sustainable Development Goal 3 recommends universal access to health services. This translates equal access to health services no matter you are rich or poor. Every human being has a right to life by having access to universal health services [2]. Nobody must die due to failure to access health services. Death may only occur after doctors have tried all means to save life, but all available interventions have failed. According to the United Nations (UN) Sustainable Development Goal 3, tar- get eight, recommends ‘the provision of qual- ity care to all must include underserved groups’, however studies had unveiled that most countries do not meet the world body recommendations. At least half of the world’s population does not get essential health ser- vices (3). According to a new report from the World Bank and WHO, each year 100 mil- lion of people are being pushed into poverty extreme because they must pay for health care out of their own pockets, forcing them to survive on just $1.90 or less a day. ‘Cur- rently, 800 million people spend at least 10 percent of their household budgets on health expenses for themselves, a sick child or other family member’ (3). Other continents are bet- ter in terms of access to health services as compared to Africa. In Africa, accessibility and coverage of essential health services are very low (4). ‘Physical access to emergency hospital care provided by the public sector in Africa remains poor and varies substantially within and between countries’ (5). Africa ac- counts for almost half of the world’s deaths of children under five and has the highest ma- ternal mortality rate, HIV /AIDS, TB, and Malaria (7). People in sub-Saharan Africa have the worst health on the average in the World. It has only 3% of the World health workers [6].Three countries (Malawi, the Philippines, and Tanzania) saw deteriorations in both service coverage and financial protec- tion (7). Malawi as one of Sub-Saharan coun- tries, health care provision is difficult be- cause the population is largely rural, and 15 percent of Malawians were unable to attend to their medical-health needs (8). Malawi health care is also dispersed across the coun- try. According to USAID report 2019, Ma- lawi has a high unmet need for family plan- ning services (26%), with acute needs among young people [9]. In Malawi almost one mil- lion people live with HIV, and about 34,000 new cases every year, 37 percent of Mala- wian children suffer from chronic malnutri- tion and a large of malaria cases with an ‘in- cidence rate of 332 cases annually per every 1,000 people and approximately 4.8 million episodes of malaria per year. Over a third of established positions in the health sector are vacant and there is a perpetual shortage of qualified health workers in facilities across the country’ (8). Universal access to healthcare remains unavailable particularly in rural areas, due to a shortage of labor, a lack of basic health-facility infrastructure, poor management practices, and insufficient financing (7). Methods The study design was a quantitative cross- sectional study, and the study setting was Chitipa, Dedza and Mangochi Districts in Malawi. The study was conducted between March and July 2020.The sampling strategy was simple random sampling. People who met the preferred age group were inter- viewed. The sample size was determined by Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 4 | 9 assessing the number Table of numbers was used in coming up with sample size. From population of three hundred twenty five peo- ple in three selected areas, a sample had 126 participants for ±7% precision level and confidence level was 95% and P<0.5. About thirty-one patients were selected from Chi- tipa, forty-eight were selected from Dedza and ninety-five patients were selected from Mangochi. Local people aged between 18 years and above who use health services par- ticipated in the study. Data was collected us- ing a structured questionnaire with close – ended questions was formulated in English. Questions which were in cooperated in the questionnaire answer objectives of the study that was mainly focused on accessing univer- sal health services in Malawi.There after each participant was interviewed using a question- naire. Three clerks were trained to collect the data. Data management included question- naires being collected from study participants were checked for mistakes. Thereafter it was transported in a locked brief case to the house of the researcher. Upon arrival at home, it was kept safely and locked in drawer to pre- vent access by other people. To ease entry in the computer, coding was done to all ques- tions on a questionnaire. After finishing cod- ing, the data was entered in the computer us- ing excel database. Data analysis Data analysis was done using computer aided programs such as Microsoft excel and Epi info tables, pie charts and bar graphs were constructed using excel. Ethical consideration Consent was obtained from the District Com- missioner, Institutional Research Team, Tra- ditional Authority and Village leader before conducting the study. Consent was also be obtained from participants. Participants names were not indicated on the question- naire. Results The study was conducted in Chitipa, Dedza and Mangochi districts in Malawi. A total of 126 participants were interviewed in rural health centers. The target population are peo- ple aged 18 years and above (Table: 1). The majority of the participants (43%) were within the age group of 23-33 years, 1% of participants were in 83-93 age range. Most women (77%) participated in the study. 80% of the participants were married and 12% were single. 56% of the participants had at- tained primary education and 2% were illit- erate. 52% of participants were farmers and 3% earn their living by doing business. 27% of study participants were C.C.A.P. members and 2% were Muslims. Malawians have sev- eral barriers to access health services (Figure 1) according to the study findings; 35% of study participants said that lack of drugs and medical equipment was a barrier to access health services while 25% of participants said that shortage of health care workers was a barrier to access health services. Participants proposed several methods of improving ac- cessing to health services in their respective areas (Figure 2); 28% participants suggested that increasing number of clinics can improve access to health services which is seconded by 25% participants who suggested that by training more health care workers could im- prove access to health services. Table 1: Social demographic characteristics of the study population Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 5 | 9 CHARACTERISTICS VARIABLE NUMBER (N=126) PERCENT AGE SEX Female 97 77% Male 29 23% AGE GROUP 18-23 34 27% 23-33 54 43% 33-43 20 16% 43-53 4 3% 53-63 5 4% 63-73 6 5% 73-83 1 1% 83-93 2 1% MARITAL STATUS Married 101 80% Single 15 12% Divorced 5 4% Windowed 5 4% EDUCATION LEVEL Primary 71 56% Secondary 47 37% Tertiary 6 5% Illiterate 2 2% OCCUPATION Employed 2 7% Business 1 3% Farmer 16 52% Others 12 39% RELIGION C.C.A.P. 34 27% Catholic 26 21% Pentecostal 14 11% Muslim 3 2% Others 49 39% Figure 1: Common barriers to seek universal health services Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 6 | 9 Figure 2: Methods of improving health services to people Discussion The Universal Declaration of Human Rights of the United Nations states in article 3 that everyone has the right to life, liberty, and se- curity of person (12). Every human being at some point in his/her journey become sick., to restore normal human health some health 25% 35% 5% 25% 10% 0% 5% 10% 15% 20% 25% 30% 35% 40% BARRIERS TO SEEK HEALTH SERVICES 4% 25% 23% 20% 28% METHODS OF IMPROVING HEALTH SERVICES TRICYCLE TRAIN MORE HEALTH WORKERS COMMUNITY FUND MOBILE CLINICS INTRODUCTION INCREASING NUMBERR OF CLINICS Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 7 | 9 conditions requires to seek health services failing to do so result into loss of life. There- fore, access to health services is a human right. Contrary to United Nations recommen- dation, the study carried out in some parts of Malawi had revealed that people do not have access to right to health services. The study (Figure 1) has found several factors hindering people to access health services. In the study, 35% of participants fail to access health ser- vices due to lack of drugs and medical equip- ment. Malawi as developing country does not have sophisticated equipment to diagnose some diseases. Currently there is only one Magnetic Resonance Imaging (MRI) for im- aging brain tumors). There is no Radiother- apy facility for cancer patients. As result some patients become disappointed with this and never return to the hospital for the second time when they are sick. The study findings correlate with USAID Report for 2019 which stated that Malawi has poor health services due to poor health financing although per- centages were not mentioned [9]. However, a study conducted by Institute of Public Opin- ion and Governance (7) found that 29% of Malawians cited the absence of necessary treatment as a reason for being unable to at- tend to their medical services which a bit lower than in our study. The difference may be due to the target population interviewed. The study had revealed the second barrier to access health services in Malawi as lack of health workers which was at 25%. USAID Global Health for 2019 reported similar re- sults. ‘Over a third of established positions in the health sector are vacant and there is a per- petual shortage of qualified health workers in Facilities’ across Malawi (8). Long distance of travel to visit the nearest is another barrier to seek health services which also at 25%. Most health facilities are dispersed especially in rural. A study conducted in Malawi by In- stitute of Public Opinion and Governance in 2016 reported similar findings. Another study conducted by Lancet Global Health across Africa revealed that hospitals in the continent are dispersed and people take long time to access health services to the nearest hospital. The investigator was interested in approaches of improving universal access to health services. Formulation of solutions for access to health services depends on the prob- lems identified. Different countries have dif- ferent barriers for access to health services. In the study conducted in Malawi by the re- searcher (Figure 2), participants came with several solutions of improving access to health services. The majority (28%) of partic- ipants suggested that access to health services can be improved by increasing number health facilities such as clinics in locations where people stay. Most participants said that health services must be brought closer to end users. The government must allocate more money to build health facilities according to the Abuja Declaration (10) and World Bank re- port of 2018 [11]. The study agrees with World Bank, Global Health Report for 2018 (13) which recommends at least 15% budget allocation to the health sector. Another group of participants (25%) suggested training of more health workers to work in hospitals could solve the problem. By training more health workers, will result improving quality of health services. The World Bank report for 2018 also recommends improving quality health services as one way of improving ac- cess to health services. Some participants (20%) reported introduction of mobile clinics can improve access to health services. Mobile clinics can help to screen some diseases, pro- vision of primary health care, and manage conditions associated with the elderly. Halina et al. (14) also recommends improving Pri- mary Health Care as one way to improve ac- cess to health services. Furthermore, univer- sal health services can be improved by pro- tecting all people from pandemics (12). Msokwa R. Improving access to health services in Malawi (Original research). SEEJPH 2021, posted: 26 April 2021. DOI : 10.11576/seejph-4383 P a g e 8 | 9 Conclusion The study found that common barriers to ac- cess universal health services are lack of drugs and medical equipment, long distance of health facilities from residential areas of patients, and shortage of health workers. Ac- cess to health services can be improved by improving drugs supplies, building more hos- pitals, empowering communities to own health facilities and training more health workers. References 1. WHO, "Universal health coverage," 4 May 2020. (Online). Available: https://www.who.int/healthsys- tems/universal_health_coverage/en/. (Accessed 31 July 2020). 2. UN, "The Universal Declaration of Human Rights," United Nations, New York, 1948. 3. W. &. W. Bank, "Tracking universal health coverage," World Health Or- ganization, Geneva, 2015. 4. M. Yoshizu, "Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses," WHO news letter, Tokyo, 2017. 5. S. Yaya, "Universal Health Coverage and Facilitation of Equitable Access to Care in Africa," Front Global Health, vol. 7, no. 02, p. 3, 2019. 6. L. G. Health, "Access to emergency hospital care provided by the public sector in sub-Saharan Africa in 2015: a geocoded inventory and spatial analysis," Lancet Global Health, vol. 6, no. 3, p. 4, 2018. 7. W. B. -IFC, "Health and Education," 16 June 2020. (Online). Available: https://www.ifc.org/wps/wcm/con- nect/REGION__EXT_Con- tent/IFC_External_Corpo- rate_Site/Sub-Saharan+Africa/Priori- ties/Health+and+Education/. (Ac- cessed 31 July 2020). 8. I. o. P. O. a. governance, "The Local Governance permonce index(LGPI) in Malawi: Selected findings on Health," Univesity of Gothenburg, 2017. 9. USAID, "IMPROVING THE HEALTH STATUS OF MALA- WIANS IN TARGETED DIS- TRICTS," 19 November 2019. (Online). Available: https://www.usaid.gov/ma- lawi/global-health. (Accessed 25 JULY 2020). 10. A. &WHO, "Abuja Declaration: Ten Years On," 2011. (Online). 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DOI : 10.11576/seejph-4383 P a g e 9 | 9 © 2021 Msokwa et al; This is an Open Access article distributed under the terms of the Creative Commons Attribu- tion License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and repro- duction in any medium, provided the original work is properly cited. health coverage for people with disa- bilities in Afghanistan: a multilevel analysis of repeated cross-sectional surveys," Lancet Global health, vol. 14, no. 6, 2017. ____________________________________________________________________________