While healthcare in Malawi’s public facilities is free and the country is a leader in the fight against HIV, it remains heavily dependent on international donors. Strengthening domestic revenue streams is crucial to avoid an impending funding crisis.
Maintaining momentum in Malawi towards universal health coverage hinges on unlocking more sustainable approaches to health financing. Photo: Josephine Chinele
In 1995, Lilian Dindi Kumwenda was diagnosed with HIV while caring for her critically ill husband, who also had the virus. At the time, Malawi’s public health facilities had no provision for antiretroviral drugs, which stop the virus from replicating in the body. Kumwenda managed to purchase the medication from a private facility, but at MWK3750 (US$2.1) per month, the cost was too high to sustain for both of them.
“I was still strong, unlike my husband, so I prioritised him [and let him] use this drug. But it was sadly too late and he died two weeks after starting the medication,” Kumwenda says.
She then decided to proceed without the medication after resigning from her stable banking job, as she could not afford to pay for it with income from the business she ran with her husband. Years later, Kumwenda became very sick. “I was at the point of death,” she says. In 2008, she was initiated on free government antiretrovirals.
Kumwenda is now 66 years old and has lived 29 years with HIV. She speaks highly of the free treatment and care provided by Malawi’s health system. Essential healthcare—such as vaccines, treatment for malaria, management of childhood illnesses, and HIV treatment—is provided free of charge in all public health facilities. “It has allowed people living with HIV to prolong their lives and care for their families—unlike in the past, when many people died and left kids orphaned,” says Kumwenda, who has four children and five grandchildren.
Lilian Dindi Kumwenda is on free antiretroviral therapy (ART) and has lived with HIV for 29 years. Photo: Lilian Dindi Kumwenda
Out of its population of 21 million, Malawi is home to an estimated 980,000 people living with HIV (PLHIV). Kumwenda is among the country’s 900,000 PLHIV on antiretroviral therapy (ART), the majority of whom depend on free government treatment, which in turn relies on funding from The Global Fund and other partners. The National AIDS Commission says widespread availability of ART has averted new HIV infections in Malawi, which have been reduced by 88% since the peak in 1993.
Maintaining momentum across the country for HIV treatment, and towards universal health coverage (UHC) targets more broadly, hinges on unlocking more sustainable approaches to health financing—and reducing reliance on external donor funding.
HIV treatment progress supports universal health coverage
Latest figures from the Population-based HIV Impact Assessment (PHIA) Project, which conducts nationally representative surveys to capture the state of the HIV epidemic in the most affected countries, show that Malawi has made tremendous progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 target—that by 2025, 95% of all people living with HIV will know their HIV status, 95% of all people with diagnosed HIV infection will receive HIV treatment, and 95% of all people receiving treatment will have viral load suppression (VLS).
Evidencing Malawi’s strong treatment programs, a 2022 report reveals 88% of Malawian adults living with HIV were aware of their HIV-positive status, 97.9% were on ART, and among adults on ART, 96.9% had suppressed viral loads. A 2024 report by Malawi’s National AIDS Commission reveals the country has achieved 97-97-95, with new infections and AIDS-related deaths in constant decline.
George Jobe, chairperson of the Universal Health Coverage Coalition in Malawi and executive director for Malawi Health Equity Network (MHEN), says the country has made great strides reducing mortalities related to HIV and AIDS because of enhanced availability of ART. “There was a time when testing positive for HIV would almost ignite feelings of death in someone—people would be afraid,” he recalls.
“Donors such as The Global Fund have saved us in fighting against tuberculosis, malaria, and HIV. But we can’t continue to be living in a comfort zone. We are sitting on a time bomb because all our hope is in the hands of donors.”
The challenge now is to maintain and further these successes in the years to come—a task made more difficult given development partners such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund’s support for Malawi’s HIV and AIDS response. Over 95% of the country’s HIV and AIDS financing comes from external partners.
Across the healthcare sector more broadly, even though it received the second largest allocation after education and agriculture in the 2024–25 Malawi national budget, 56% of this funding came from donors, including The Global Fund, the United States Agency for International Development (USAID), the Department for International Development (DFID), and the Clinton Health Access Initiative.
The National AIDS Commission report found that “the country faces barriers that would jeopardise and derail the national response. The main one being heavy reliance on external financing from international development partners.” External disruptions like the covid-19 pandemic and large conflicts “may affect external resource flows”, it says.
Health budget provides inadequate support
HIV treatment and the expansion of ART coverage is a significant component of Malawi’s broader movement towards UHC. It aligns with Sustainable Development Goal (SDG) 3, which aims to promote good health and wellbeing for all, including access to safe, effective, and affordable essential medicines and vaccines.
The Malawi Health Sector Strategic Plan III 2023–2030 focuses on several key areas that address both immediate healthcare needs and long-term goals for Malawi’s sustainable health system. This plan focuses on reforming for UHC, which includes strengthening health system resilience, improving financial protection, promoting quality of care, and mobilising resources.
A UNICEF 2024–25 budget analysis notes that Malawi’s health budget is inadequate to support the country’s efforts to accelerate progress in achieving UHC targets by 2030.
Yet a UNICEF 2024–25 budget analysis notes that Malawi’s health budget is inadequate to support the country’s efforts to accelerate progress in achieving UHC targets by 2030. It says the World Health Organization (WHO) recommends an annual per person expenditure of US$86 to effectively improve the UHC targets, and the current on-budget per person expenditure of US$16 is far too low to strengthen the health systems and improve healthcare outcomes extensively.
“Given the dire economic situation characterised by high inflation, climate mobility (El Nino and floods), and debt servicing costs, this expenditure will likely lead to diminishing access to essential healthcare services, particularly for vulnerable population categories like children,” reads part of the analysis, recommending Malawi’s Ministry of Health (MoH) prioritise investments in low-cost, high impact interventions, including expanding UHC through primary healthcare.
Urgent need for new approach to health financing
Health experts point to the urgency of Malawi doing more on health financing reforms and ensuring that the sector is well funded.
“At the moment, the role of donors [in progressing] towards UHC is still very important because Malawi can’t do this on its own,” says Maziko Matemba, executive director for the Health and Rights Education Program Malawi, an NGO with expertise in advocacy, policy, and research. He explains that although the country has made strides in reaching the UNAIDS 95-95-95 target, it still faces challenges providing Bactrim, an antibiotic used to treat infections, as part of HIV treatment.
Matemba suggests that for Malawi to sustain UHC without donors, it needs to intensify its domestic resource mobilisation efforts, including the collection of more taxes.
Jobe cites a proposal to establish a national health fund through funds collected from road toll gates and vehicle certificates of fitness, among other sources. “We are advocating for the generation of revenue for any activities affecting the health sector,” he says.
Matemba says Malawi’s incorporation of UHC in development strategies as part of the country’s commitment to improving access to healthcare and ensuring equitable, quality health services for all is a step towards this goal.
The Health Sector Strategic Plan III outlines strategies and interventions to improve health outcomes in Malawi. The National Health Policy (NHP) 2017–2030 also serves as the primary policy framework guiding Malawi’s health sector development over the long term and was developed to address the financing challenges in the health sector and support the UHC goal.
Health advocate Dingani Mithi says that there has been slow progress since the release of Malawi’s health financing strategy in January 2023, which sets out clear pathways through which the government will finance UHC policy activities. These include increasing the domestic revenue base, introducing a national health insurance scheme aimed at reducing out-of-pocket expenses for low-income people, and strengthening public-private partnerships (PPPs) to improve service delivery at public health facilities.
Mithi calls for political will to move forward. “We need to monitor and follow the health financing reforms by finding alternative sources required for domestic resource mobilisation,” he says. “Donors have their own problems that are savaging their economies…The war in Ukraine should be a wake-up call.”
Mithi says the country is wasting resources through corruption and over-spending on non-priority tasks. “Donors such as The Global Fund have saved us in fighting against tuberculosis, malaria, and HIV. But we can’t continue to be living in a comfort zone. We are sitting on a time bomb because all our hope is in the hands of donors. Should they cut aid, it would be a disaster for our HIV treatment program,” he says.
More work to be done despite government commitment
Dr Matthews Ngwale, chair of Malawi’s Parliamentary Committee on Health and Population, describes Malawi’s pursuit of UHC as still in its infancy. Despite the advances in HIV treatment, he says healthcare is not provided to everyone equally and there are gaps between people living in urban and rural areas. People often need to walk long distances to access medical care. “There is government commitment, but a lot more needs to be done,” Ngwale says.
There are calls for Malawi to construct more health facilities like those at Queen Elizabeth Central Hospital. Photo: Josephine Chinele
He explains that many people ask him to lobby for more funds to be allocated to the health sector budget. “But where does Malawi get the money from? [The] government gets money from a few people who are working. Not that much money is generated. We need to do something to earn more money. As an agriculture-based economy we could have mega-farms and export our produce, and also maximise on tourism,” he says.
Ngwale points out that Malawi needs to construct more health facilities and make all types of medicines—not only essential drugs as is the situation now—available at all public health facilities through the capacitation of central medical stores.
“We also have situations where facilities in rural areas have been built but not yet opened because there are no healthcare workers due to lack of staff houses. This is another area we need to work on,” Ngwale says.
Health financing challenges remain
Malawi’s Ministry of Health, however, believes the country is on track to achieve UHC by 2030.
“We are working towards achieving UHC. We recently recruited healthcare workers, and this is still work in progress. We want to have adequate personnel at every level, be it health posts, health centres, district and central hospitals. We want specialised healthcare workers at every level to provide quality healthcare,” says Ministry of Health spokesperson Adrian Chikumbe.
“We have had challenges such as cyclones and outbreaks that diverted our attention along the way,” Chikumbe continues, admitting that the ministry is resource-constrained as it needs to meet the demand for a growing population.
“That’s why we need donors,” Chikumbe says. “We are also eyeing public-private partnerships [between the government and well-financed individuals, institutions, or corporations] for health facility management, which we feel is also crucial for UHC.”
The Ministry of Health says it is also exploring options for having patients treated for ailments such as cancer within the country’s health facilities, rather than using government funds to send them abroad for treatment. “If treated within the country, funding meant for one patient externally could treat five or more people if treatment is accessed locally,” Chikumbe says.
Malawi’s journey to achieving UHC is fraught. If donors begin to reduce funds due to shifting global priorities, Malawi could face critical gaps in its healthcare services. This includes the gains in HIV treatment that people like Kumwenda are enjoying and could leave the most vulnerable without care. Malawi needs to strengthen domestic revenue streams and create a resilient health financing model to avert an impending crisis.
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