When Ruth Kasau discovered she was expecting her first child in 2014, her initial joy was quickly turned to despair. She and her husband, both farmers, faced the daunting reality of unaffordable maternity care.
Residing in Ndindi village in Dedza district, in central Malawi, about 30 kilometres from a free government health facility, their options were few and far between. The couple were left with the only nearby clinic, Kaundu Health Centre, a non-profit facility run by the Christian Health Association of Malawi (CHAM). The clinic charges a service fee and was about an hour's journey from their home.
"It was not easy at all. I had to go to the hospital for routine prenatal visits, which was quite costly for my husband and I, both in terms of transport and medical expenses," Kasau recalled. "Somehow, we managed to sail through it all during my pregnancy and gave birth to my son."
Three years later, during her second pregnancy, Kasau's fears gave way to relief when she learned about a new community-based health insurance scheme introduced at Kaundu Health Centre. She joined without hesitation, as the financial burden of her care during her pregnancy had been a concern for the couple.
"I got the perfect care I needed and only paid 800 Kwacha ($0.46) for delivery," she said with a beaming smile. Without the scheme, Kasau and her husband would have faced a fee of about K10,000 ($5.79) -- a sum far beyond the reach of many in rural Malawi, where half of the population survives on $1 daily or less.
Out-of-pocket expenses are a barrier to accessing health services in Malawi, especially in rural communities where only fee-for-service health facilities exist. A report by BMC Health Services Research indicated that non-profit organisations like CHAM provide 29% of the country's health services, but charge service fees. The report further highlighted that 15% of Malawians were unable to meet their healthcare needs, with cost frequently cited as the primary obstacle.
Dedza is particularly vulnerable to common illnesses such as malaria and diarrhoea. To address this challenge, Kaundu Health Centre, which serves a population of more than 20,000 people, launched a community-based health insurance scheme in 2017 to make healthcare more affordable for residents in eight villages in the district. Recognising that many community members could not afford to contribute to the scheme, the health centre initially provided seed funding to help them start small businesses, enabling them to use the profits to fund for their health insurance coverage.
When the scheme was introduced, community members contributed K300 (equivalent to $0.17) per month, however with the recent currency depreciation, the monthly contribution has increased to K1,000 ($0.57) per individual in a household. These pooled funds are used to reduce out-of-pocket costs for accessing healthcare services at the centre.
How the scheme works
Community health workers associated with the clinic oversee the day-to-day operations of the insurance scheme. Each participating village has a health insurance committee led by an elected chairperson. The committee comprises of community members, traditional leaders and community health workers. Their main responsibilities include raising awareness about the scheme, registering new beneficiaries, collecting monthly premiums and transferring the funds to the health centre. In addition, committee representatives meet monthly with the staff at the health facility to review the scheme's progress and discuss the initiatives' effectiveness.
When a scheme member falls ill, they get a receipt from their village committee chairperson. This receipt serves as proof of membership and enables the patient to access healthcare services at a reduced cost at the health centre.
According to Mathews Simbi, Senior Surveillance Health Assistant at Kaundu Health Centre, the scheme has not only reduced out-of-pocket payments for its members, but has also played a crucial role in addressing long-standing challenges, such as medicine shortages at the facility.
"We often struggled with the availability of medical drugs, but since the scheme, the money members contribute has been used to procure essential medicines such as paracetamol and azithromycin," Simbi said.
In 2018, the health centre was able to employ two nurses through the scheme, according to Simbi. Data from the health centre showed that the scheme has reduced the out-of-pocket payment to 20% of the total service cost.
Prior to the scheme, the facility handled an average of 15 to 20 deliveries per month, however, between 2017 and 2018, this number doubled to 40 per month. During the same period, the use of health services by children under five increased from 40 to 50 visits per month to 100 to 150.
For 44-year-old Teresa Seleson, the scheme has helped her to get proper treatment for her children. "Before the scheme, when one of my children fell ill, I would often just assume they needed medication based on the symptoms without taking them to the hospital because I was afraid of the hospital charges," the mother of four said.
A few complexities
Since 2020, the scheme has experienced a sharp decline in membership. Initially covering eight villages, it now serves only four. In 2020, the scheme had an estimated 6,302 beneficiaries, but this number has plummeted to just 129 in 2024. Simbi attributed this significant decline to the discontinuation of the seed funding provided to beneficiaries when the scheme was first introduced and to climate change, which has left already vulnerable Malawians food insecure.
Between 2023 and 2024, the health centre recorded 20 deliveries and 72 visits by children under five suggesting a significant decline compared to previous years.
"Many members now opt to spend money on maize flour to feed their families rather than investing in the scheme," he said. "The misuse of the insurance funds from committee members in some villages has also led to this reduction in number," Simbi added.
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In response, Simbi says health workers at the facility are working together with local leaders from participating villages to engage those in communities who are no longer part of the insurance scheme or were never involved, aiming to rebuild and expand membership.
"It's challenging to persuade people of the long-term benefits of investing in the scheme, especially when they are struggling to meet basic needs," Simbi said. "Some feel it is a waste to invest their money in the scheme when they are not even sick. Changing this mindset requires continuous effort, and we're doing our best, considering it is an independent initiative," Simbi explained.
Village Headman, Lackson Kaliati of Josophat village in Dedza, says he actively encourages his community to diversify their crops to increase yields and use the income to invest in the scheme. "By doing this, no one will have to struggle to access medical care when they fall ill," he noted.
For Kasau, her wish is to see more people in her village join the scheme and for its reach to extend beyond Kaundu Health Centre.
"Since Kaundu Health Centre is a small facility, patients with complicated conditions are often referred to Mua Mission Hospital, where medical bills are hard for people like us to afford," she said. "This sort of initiative should be replicated in villages across the country -- it is a lifesaver."
