Research: Clinic Visits, Diagnoses Increase When Patients Access Free Care in Malawi

A mother recently carried her feverish 3-year-old boy two hours into Dambe Health Center in the hills of the remote district of Neno in southern Malawi. She left with medication for his new diagnosis, one Malawians hear often: Malaria. They’d caught it early this time.

If the boy had been sick several years earlier, before the clinic’s opening, the scenario would have played out much differently. The mother might not have been able to take her son to the doctor in the first place. It would’ve taken her an entire day to walk to the nearest free care at Neno District Hospital and back home, and that’s if she could’ve afforded to miss a day’s labor. 

On average, Malawians live on just $586 a year, one of the lowest per capita incomes in sub-Saharan Africa. For the more than 170,000 people living in Neno, one of the poorest regions of the country, it’s even lower. 

“Mothers will often wait until a child has a seizure from cerebral malaria,” says Dr. Luckson Dullie, executive director of Abwenzi Pa Za Umoyo, as Partners In Health is known in Malawi. That’s because families must travel long distances to clinics and fear the potential cost of care. Yet Dullie knows that a child faces a 70 percent chance of death when care is delayed. 

Families shouldn’t have to debate whether they can afford to seek care for sick children. There is a better way, backed by common sense and solid research.

Research published by a team of PIH staff in Malawi and collaborators at the University of Warwick details how poor patients suffer when faced with long distances to care and the prospect of paying high user fees. Simply put, when health care is a morning’s walk away and care is free, exponentially more patients arrive at clinics and diagnoses rise for infectious diseases, such as malaria, HIV, and tuberculosis.

While Malawi has resisted international pressures and provided free public health care since 1964, about one-fourth of its health centers are operated privately and still charge user fees. In Neno there were four such centers when PIH began supporting the Ministry of Health in 2007. At that time, there was no district hospital, and the 10 health centers had fallen into disrepair. 

Over the past 12 years, PIH built Neno District Hospital, a community hospital, and two health centers, and revitalized two more centers. Clinicians have focused on reducing maternal deaths, treating severely malnourished children, and providing preventative care and treatment for HIV, tuberculosis, malaria, and noncommunicable diseases (NCDs). Meanwhile, staff have provided financial support to Neno’s most vulnerable patients by helping them access safe housing, pay for children’s school fees, and train for local jobs. 

Since 2007, PIH-supported clinicians at health centers and the district hospital have tended to a steady flow of patients eager to access free services. As in other communities around the world where PIH works, patients arrive when facilities are staffed, well-stock with essential medicines, and provide reliable quality care.

Seeing these results, Dullie and his team realized they had a natural experiment in their backyard. They wanted to see whether their belief was true: that user fees discouraged patients from seeking services. If they analyzed historical data from the district health system, where some health centers have required fees and others haven’t, they knew they could test their hypothesis.

The team compared outpatient attendance and new diagnoses of HIV and malaria between July 2012 and October 2015 across health centers that charged fees and those that did not. Sure enough, there had been a 70 percent drop in attendance when patients were charged fees and a 50 percent reduction in HIV diagnoses in the district. When the fees were subsequently removed at these centers, the team documented a 350 percent increase in outpatient visits, and a case identification for malaria saw a similar increase. 

Dullie and his colleagues carefully chronicled how charging patient fees obstructed access to health care, particularly for sick children. The lack of affordable care has a way of proliferating the spread of disease, which in Neno and many poor settings includes HIV, malaria, and tuberculosis, putting especially infants and mothers at high risk of preventable death.

Following the paper’s publication three years ago, Dullie and his team worked with the Ministry of Health to remove user fees in three of four health care centers still charging the equivalent of a few dollars for each visit. The continued advocacy has resulted in the removal of user fees in all four of the privately operated facilities in Neno.

“Now, without user fees, patients can come in every time they have an issue,” he says. “Parents don’t wait too long and kids come in with less severe forms of illness.”

The study also helped Dullie and his team see a vast need for care in the remote, rural region of Dambe. They advocated for building a new health center to meet potential patient demand. And their work prevailed. 

In 2016, Dambe Health Center opened to great local fanfare and large crowds. Luckily, for the toddler with malaria and his mother who visited recently, it was ready to receive them with a cure.