Challenges to effective governance in developing health systems: a qualitative study in Malawi

Abstract

Effective governance is vital in maintaining and improving health systems but has received little attention in research, especially in developing countries. All United Nations (UN) members have committed to Universal Health Coverage (UHC) by 2030. Malawi, a member and one of the five poorest countries in the world, is highly dependent on donor contributions. Recent poor governance of government-funded healthcare saw donors withdraw funding, limiting services and resources. The government identifies the need for better oversight to improve health system efficiency and achieve UHC. This study contributes to a better understanding of the relationship between governance and health systems in developing countries moving towards UHC by identifying stakeholder perceptions of the challenges in this area, using Malawi as a case study.Interviews were conducted with 22 representatives of non-government organisations, civil society groups, local government and government-funded organisations and governance bodies and the transcripts and field notes were analysed using inductive thematic analysis.Four main issues emerged: accountability; resource management; power dynamics; non-government actors. We conclude that political, structural and financial challenges are seen as barriers to effective health governance at all levels (national, local, service provider). These include little monitoring of health policy implementation, little accountability of the government to the public on health policies and spending decisions, and poor resource management, especially in the drug supply chain. In response to the government's perceived disinterest, non-government initiatives (often supported by donors) advocate for greater governance and monitor the health sector, including progress towards UHC. Poor governance adversely affects health system functioning and may prevent developing countries achieving UHC by 2030.