Malawi’s Healthcare Crossroads: Can Public-Private Partnerships Deliver Long-Term Gains?

Public-Private Partnerships in Malawi, particularly through CHAM in Mzimba, have improved rural healthcare access but face critical challenges like delayed government payments, staff shortages, and donor dependency. Sustainable reforms in governance, financing, and infrastructure are essential to ensure long-term impact.

In a collaborative study led by The Copperbelt University in Zambia and the Synod of Livingstonia Health Department in Malawi, researchers explored the impact of Public-Private Partnerships (PPPs) on healthcare delivery in Malawi, focusing on CHAM (Christian Health Association of Malawi) facilities in the Mzimba district. These partnerships, formalized through Service Level Agreements (SLAs), are intended to bridge the gap between Malawi’s overstretched public healthcare system and its underserved populations, especially in rural areas. Under the SLAs, CHAM provides essential services such as maternal and child healthcare, while the government reimburses them for the cost of delivering these services, allowing patients to access them free of charge. In theory, this model has expanded access and saved lives. But the research reveals a far more complex reality—one where policy, payment delays, infrastructure limitations, and mistrust undermine the full potential of these partnerships.

Delayed Payments, Inflated Costs, and Strained Trust

Despite their advantages, PPPs in Malawi suffer from chronic delays in government payments to CHAM facilities, leading to cash flow crises and service disruptions. CHAM officials report borrowing money just to stay afloat while also having to work around inflexible government-imposed pricing for essential items such as delivery kits, gloves, and medicines—many of which are not reimbursed. These tensions are aggravated by what the study frames as "principal-agent" conflicts. Government representatives often accuse CHAM of overcharging and submitting inflated usage data, while CHAM officials argue that underfunding and the lack of government-provided supplies force them to spend from their own constrained budgets. The resulting mistrust is not merely theoretical—it affects every level of healthcare delivery, from budgeting to frontline patient care.

Meanwhile, District Health Management Teams (DHMTs) express their own frustrations. While they acknowledge that CHAM facilities are essential to reaching remote populations, they raise concerns about accountability and financial transparency. Instances were reported where CHAM charged up to MWK 80,000 for bed space or billed the government for utilities and prescription services, which DHMTs argue could be more economically handled within public health facilities. Some healthcare professionals even raised concerns about misuse of funds for infrastructure improvements rather than patient services. This distrust is compounded by staff shortages, overworked personnel, and outdated or insufficient medical equipment—conditions that make it hard for health workers to maintain the quality of care expected under PPPs.

Patient Voices: Gratitude, Confusion, and Long Walks

From the patient's perspective, the elimination of user fees under PPPs has undeniably improved healthcare access. In a country where poverty is widespread, free maternal and child health services can be life-saving. Many patients expressed appreciation for these services, but they also highlighted persistent frustrations: long wait times, inconsistent availability of drugs, and confusion over what services are actually free. One expectant mother shared how she had to leave and return to the facility the next day because of the overwhelming queues. Another woman described a chaotic delivery experience, where a nurse was attending multiple laboring women at once, compromising patient care.

Moreover, access still depends on physical proximity. In Malawi’s vast rural landscapes, many must walk for hours to reach the nearest CHAM facility. Transport and food costs remain substantial barriers for the poorest families, particularly when guardians must accompany patients and stay overnight without proper accommodations. While PPPs have lifted financial barriers at the clinic door, other social determinants continue to limit true accessibility and equity in healthcare.

Case Studies Reveal Common Struggles Across Facilities

The study’s deep dive into five CHAM facilities in Mzimba reveals common threads: increased patient utilization following PPP implementation, but also overstretched resources and administrative hurdles. Facilities located far from the district hospital experienced surges in maternal health service use, often without the corresponding increase in staffing, medical supplies, or physical infrastructure. In one case, a facility had to suspend child health services altogether because of overdue payments from the government. Another recorded only a marginal rise in service utilization, owing to inadequate staff and limited diagnostic tools.

All five facilities reported challenges in keeping up with patient volumes, managing service delivery under financial stress, and navigating unclear government guidelines. These local struggles paint a national picture of a health system trying to innovate through partnerships—but falling short on the operational basics needed to support them.

Sustainability at Risk Without Structural Reforms

While the study confirms that PPPs have expanded healthcare access in Malawi, particularly in rural districts like Mzimba, it also raises serious questions about sustainability. Much of the funding and technical expertise behind these partnerships comes from international donors. This donor dependency poses a significant risk if foreign support diminishes or shifts priorities. Moreover, PPPs remain largely donor-driven, with limited ownership from government officials, many of whom view them as externally imposed rather than nationally integrated efforts. This lack of buy-in threatens the long-term institutionalization of PPPs in the country’s health framework.

For PPPs to thrive in Malawi, the researchers argue, systemic reforms are essential. These include better contract design with flexible, inflation-adjusted terms; stronger regulatory oversight; improved infrastructure and staffing; more transparent financial reporting; and, crucially, a shift toward national ownership of the PPP model. Without such interventions, the risk is not just that these partnerships will falter, but that communities who’ve come to rely on them will be left without reliable care.

The study paints a vivid, sobering picture of how PPPs are simultaneously transforming and straining Malawi’s health sector. The potential is clear but so are the risks. For a nation striving toward universal health coverage, these partnerships could be part of the solution—if only they are given the robust, sustainable foundation they need to endure.