The public/private mix in the health care system in Malawi

Transcription

1 HEALTH POLICY AND PLANNING; 9(1): Oxford University Press 1994 The public/private mix in the health care system in Malawi ELIAS E NGALANDE BANDA AND HENRY PM SIMUKONDA Chancellor College, University of Malawi, Zomba, Malawi The makings of a mixed health care system in Malawi go back to the time before independence when Mission Hospitals coexisted with Government District Hospitals. This public/private mix is what has defined health care provision in Malawi from about the 1930s to the end of the 1980s. Recent changes in policy towards private health care provision, dating back mostly to the 1987 Medical Practitioners and Dentists Act, have opened the flood-gates to another form of private provision: that by private for-profit providers. For a long time since independence, the government stifled the growth of this subsector through legislation and requirements on registration. Now, thanks to liberal registration of medical practitioners, the relaxation of policies restricting private practice by government doctors, and early retirement, the subsector is fast expanding. Occurring simultaneously with these policy shifts have been other developments, among them the emergence of a health insurance industry and the expansion of drug outlets. These developments are mutually re-enforcing in that each relies on the success of the other. Recognizing the benefits to be gained from a properly coordinated health care system, the Ministry of Health is reaching out to the other private providers - be they for-profit or not-for-profit - in order to tap into their resources. The paper discusses some of these developments and examines the future of health care in Malawi. Some future needs are identified if this 'boom' in private practice is to benefit consumers of health care. Introduction The health sector in Malawi can be broadly divided into two subsectors: the modern and the traditional. For most of Malawi's pre-independence experience, the traditional subsector was the most utilized by the Malawians, particularly those in the rural areas. Although quite a number of hospitals existed, the prominence of the traditional sector was due to a combination of two factors: poor transport infrastructure making access to health facilities difficult, and traditional views, attitudes and practices which favoured traditional healing (Simukonda 1992). Independence brought about greater efforts to improve access to modern health facilities through improved transportation, increased numbers of health centres and an intensive health campaign encouraging the use of modern medicine. These efforts were initiated by the government while an increased role for the nongovernment sector was being encouraged. Missionaries initiated modern health care and education at a time when the colonial government was busy trying to develop the structure of a modern state centring on political, administrative and economic aspects which favoured settler interests. It was perhaps because of the pressure for a state role in the provision of social services from both missionaries and Africans organized in Native Associations that government entered this field. By the 1930s, the government had embarked upon a programme of setting up district hospitals. Thus by independence (1964) there had emerged a dual mode of provision and Financing of health services, consisting of the government and the churches.

2 64 Elias Ngalande Banda and Henry Simukonda Soon there arose the need to properly coordinate activities between the missionary providers and the government on the one hand, and among the church providers themselves, on the other. This led to the formation of the Private Hospital Association of Malawi (PHAM); this was renamed the Christian Health Association of Malawi (CHAM) in February While PHAM sought primarily to serve the interests of member providers vis-a-vis the government, it also worked as an instrument for sharing the experiences, insights and difficulties of its member organizations, in order to chart ways of bringing improvements which were in their common interest (see Msukwa and Simukonda 1982). Within the modern subsector, there are also what we can call the private for-profit (PFP) health care providers. These are largely individual practitioners who operate private surgeries mostly in the urban centres, although to these may be added some mission hospitals not affiliated to CHAM. The PFP providers have increased in number because of recent policy changes on the part of the government allowing doctors to practise privately, and because of the emergence of a health insurance industry. The traditional subsector has also undergone some changes. From being called 'witch doctors', the practitioners in this subsector now have the rather elegant names of traditional healers or herbalists, traditional birth attendants, and health counsellors. They are soon to have their own association (The Herbalists Association), which, with the pledged assistance of the USAID-SHARED Project, will have its own secretariat. This organizational structure is important for the dissemination of ideas, and to enable cooperation between the herbalists and the government in referrals and policy. It is not necessarily intended as a control mechanism. However, it may play a crucial role in the efforts to monitor the activities of the traditional subsector. Already, there are areas of cooperation between the government and the herbalists such as through the traditional birth attendants (TBAs) and health counsellors (who advise on traditional and cultural health, and moral practices). The idea is to develop a mechanism whereby the modern and the traditional subsectors can rely on one another. In sum, we see that there are three major categories of providers in the modern subsector: the government, CHAM and private for-profit. In the traditional subsector, there are the herbalists, traditional birth attendants and health counsellors. Documentation is strong on the government and CHAM providers but there is very little on the private for-profit. To these categories must be added the widespread practice of self-medication on which little research has been done. Organization of the health sector The health sector is primarily organized around the activities of the Ministry of Health (MOH) which has the primary responsibility for the development of policies, and planning strategies and programmes for health care in Malawi. Besides the MOH, the CHAM Secretariat formulates operational policies in the interests of its representative church organizations, in consultation with the MOH. The Ministry of Local Government also participates in health care provision as do other agencies such as the army, police, industries, and estates, to specific target groups. These other agencies provide health care with varying degrees of autonomy. For some, like clinics belonging to some estates, their activities have to be overseen by the MOH. This mostly involves conducting outreach clinics jointly with those clinics, as well as supervising the level and delivery of services. In terms of the shares of health care provision as measured by in-patient days and out-patient attendances, the MOH provides about 60% of health services (National Statistical Office 1987). Various churches under CHAM provide approximately 30% of services while local authorities provide about 3%. The remaining 7% is provided by the other agencies listed above (MOH 1992:iv). These shares do not include the traditional health sector, which is estimated to include about traditional healers and about 5000 traditional birth attendants. There are five levels of services in the country: the community level, health centres and rural hospitals, district hospitals, central hospitals, and special hospitals. The emphasis of this hierarchy is on the referral role of each level, so that patients would first contact the health centre

3 and then get referred up the ladder if a level was unable to provide adequate care. In practice, this has not happened, for at least two reasons. The first is that CHAM and local government facilities do not neatly fall into this hierarchy, so that those who wish to go from these facilities to MOH facilities often prefer to go direct to the central hospitals. The second is that poor staffing and availability of drugs and equipment at the lower levels has encouraged their by-pass in preference for the better staffed and equipped central hospitals. These problems have resulted in overcrowding at the highest referral levels, with the consequence that the quality of care has suffered. Within CHAM itself, there is a policy of noninterference with its members. This is because CHAM is an umbrella organization for health institutions belonging to religious groups with different spiritual philosophies. There is therefore no single fee-schedule for CHAM institutions, just as there is no sharing of responsibilities on the basis of specialization. The private sector (particularly commercial organizations) has viewed the provision of modest clinical services as a cost-effective way of keeping its employees in good health. Many companies who have not set up their own clinics have nonetheless subscribed to some health insurance programmes on behalf of their employees. The Medical Aid Society of Malawi, to which many of these organizations have subscribed, is the largest, though not the only, health insurance scheme in Malawi. (Besides MASM there is FIDE Insurance, which has been in medical insurance for about one year, as well as other independent parastatal medical schemes.) The small private for-profit subsector of providers has perhaps the weakest link to the government. The practitioners have varied degrees of autonomy depending on their area of operation and the supervising agency under which they operate. In order for the government to keep abreast of their operations, they are required to submit regular reports to the District Health Officer (DHO). The 'monthly returns', as they are called, are filed by each practitioner at the end of every month and they give the total number of out-patient visits broken down into Public/private mix in Malawi 65 major disease categories (such as malaria, pneumonia, measles, etc.). These reports are used by the DHO largely for monitoring disease patterns and population shifts rather than as a control mechanism over the private practitioners. By the mid-1980s there were only 35 private doctors who practised independently (MOH 1987). The MOH has been at the forefront of providing health care to ensure that there is even regional distribution of facilities. This was the reason why private practice was, for a long time, discouraged for those in active public service. However, casual observation suggests that health care services are most readily available in urban centres. This applies to both public and private health care providers, but more so to the latter. The most important explanation for the spread of private for-profit providers is the presence of the ability to pay among their clientele. For referral hospitals, they tend to locate where there is a concentration of both the population and other supporting facilities. Mission hospitals, for historical reasons, have tended to be more evenly spread throughout the country. For the most part, they have been driven by their spiritual objectives to locate in rural areas where the least privileged or the more disadvantaged reside. To encourage the patronage of public facilities, health care has been free at the point of consumption. Even in those facilities where there are paying departments, there is no effort to determine ability to pay so as to charge wealthier consumers for the service. Those who can afford to pay for health care are at liberty to demand a free service at these facilities. Health financing and expenditure The public sector is the single most important source of finance for health (MOH 1983). Closely behind is the CHAM as a major receiver of direct private payments. While voluntary bodies do not put in a lot of funds, they do generate funds through direct private payments which are ploughed back into services. In any case, the three major sources of financing are the public sector, direct private payments and foreign aid (in that order for most providers). Contributions from the private sector (insurance intermediaries,

4 66 Elias Ngalande Banda and Henry Simukonda private enterprises and voluntary bodies) come in as a distant fourth source of funding. Ministry of Health institutions MOH services and institutions are fundamentally free and depend on government funding. Hospital budgets are largely set on the basis of historical trends and any future changes to be made. No account of the population to be served is made. Available data reveal that the bulk of the MOH vote is spent on health institutions and a little under half is spent on the two central hospitals and one General Hospital. We can note then, that there is great emphasis on specialist hospital-based care (though these hospitals also fund health centres in their districts, as do district hospitals). Upwards of 85% of the MOH budget is spent on hospitals and their associated health centres, with another 3 to 5% on training institutions. Administration takes up the lion's share of the remainder with the rest going to other programmes such as child spacing, maternal and child health programmes, etc. (basically, preventive care). Table 1. Sources of revenue for private unit* - PHAM (%) Type of unit Government While all three tertiary hospitals are equipped with paying departments which charge for the services they deliver to patients, only about 2 or 3% of total expenditure is generated by these departments (Ngalande Banda 1989). These funds, which are far below operating costs, are surrendered to the Treasury where their distribution is irrespective of the institution that generated them. Public hospitals in Malawi therefore do not aggressively pursue fee collection. In addition, in at least one of these central hospitals, the fee-paying department is underutilized (as measured by bed-occupancy), largely because it is seen by the parent hospital as a department that does not add anything to the hospital. Consequently the hospital regards it as an unnecessary drain on its financial and manpower resources. Financing of private hospitals (CHAM) Compared to the MOH hospitals' two sources of funds, CHAM hospitals have four (Table 1): they obtain subsidies from the government and the churches to which they belong, they charge fees, and receive donations from overseas. These sources contribute to varying degrees each year; funds from the churches and overseas can be very unreliable. In general the government accounts for more than a third of the funds of all types of CHAM units taken together. Most of the help given by the government is in the form of local staff salaries. Another third of the funds is generated from fees. Overseas funds come in as the distant third source. The fourth source accounts for less than 10%; this is mainly local donations from mother churches. Within CHAM, the institutions differ in the extent to which they rely on the four different sources (Tilak 1989; Ngalande Banda 1989), though government grants and fees tend to provide similar shares. A fundamental difference between the running of MOH institutions and the running of CHAM institutions is that while all MOH institutions are accountable to the MOH headquarters, where all their revenues have to be sent, revenues Fees Overseas Others Total Hospitals Primary health centres Health centres Health sub-centres Special units Others Average all Source: Cited in MOH report on Health Financing Survey, 1983, p.26.

5 generated in CHAM hospitals are often retained by the institution for the provision of its services. There is therefore an incentive to collect the fees in CHAM hospitals, unlike in the MOH hospitals. Financing of private for-profit services The private for-profit sector obviously relies on user charges for the bulk of its running costs. While this is so, we should note that with the low levels of income in Malawi, the consultation fees charged by these facilities, which range from MK10.00 to MK27.00 excluding drug charges (roughly 1.20 to 3.24), are not within the comfortable reach of most Malawians. The backbone of the viability of the private surgeries is the insurance industry. When this industry suffers as it is currently (thus forcing an increase in premiums), the private surgeries experience a sharp drop in patient attendances. The traditional subsector is cushioned against these economic swings by its acceptance of payments in kind and in instalments. The setting up of MASM can be seen as an answer to the problems of paying for services rendered by the private clinics. It can also be seen as an incentive to private sector health care, particularly of the higher quality and costly type. On the one hand, MASM reduces the pressure upon the government to provide services for free in its own units; on the other hand, it facilitates the financing of the private for-profit health delivery system. Despite these implications of MASM, there has not been a move on the part of the government to legislate in favour of compulsory health insurance coverage. MASM is privately owned by Trustee Directors and is managed by the National Insurance Company (NICO), itself another private company. Being the largest health insurance scheme, MASM boasts of having all doctors and hospitals in the country registered with it. For the doctors, a monthly fee of MK9.00 per patient is paid, whether or not the patient has consulted the doctor. MASM also pays for all the prescriptions, while the rate of reimbursement varies with the type of coverage chosen. As of September 1992, MASM had over subscribers, of whom 792 were organizations or firms. The premium ranged from MK per adult per month for basic coverage to MK per adult per month for the comprehensive scheme. Each Public/private mix in Malawi 67 member of the family has to be separately covered by paying the appropriate premium. From this, it can be easily inferred that even for the basic scheme, most Malawian households cannot afford complete family coverage. The government's role in determining and regulating the public/private mix Policies relating to the private sector The MOH has neither the manpower nor the material resources to fulfil its mandate of raising the health of all Malawians by reducing the incidence of illness and death in the population 'through the development of a sound service delivery system capable of promoting health, preventing, reducing and curing disease, protecting life and fostering general well-being and increased productivity' (Malawi Government 1986). It is for this reason that the government has sought partnership through the incorporation of the private sector. The government's health institutional policy can best be characterized as flexible in that it has allowed participation by different governmental organizations (MOH, local government, army, police, etc.), non-governmental organizations (private agencies, CHAM, estates, industries, licensed practitioners, etc.) and the traditional health practitioners. It should be noted once more that part of thisflexibilityis for historical reasons in that traditional healing and Christian Missions preceded the government sector in the provision of expanded health care, and have thus remained a significant part of the health care system (Simukonda 1992). The government has recognized that the private sector is substantial and can therefore play a positive role with respect to the provision of health care. Further, the private sector is quite varied, with different organizations having different philosophical objectives, interests and capabilities. These differences are largely accepted by the government in so far as they do not detract from its economic objectives, and they reflect the needs of the various sections of the population. However, the government is wary of what an unregulated private sector could do to its policy objectives and the fulfilment of the health needs of the population.

6 68 Elias Ngalande Banda and Henry Simukonda It is for this reason that the Medical Practitioners and Dentists Act of 1987 (Malawi Government 1987) was put into place. Through this Act, the government is able to define the various categories of practitioners and the qualifications they should have in order to practise. The Act also spells out other procedural matters that must be followed during registration. Most importantly, the government is able to influence the conduct of the health sector through the Medical Council of Malawi (see later). Private practice Recent shifts in government policy, as evident in the 1987 Act, may be seen as an attempt to relieve the government of some of its reponsibilities. The government encourages the private sector in a number of ways. First, the government now permits serving medical personnel in its facilities to set up private surgeries (where they can practise 'after official duty hours') and allows them to retire early so as to go completely into private practice. So far, all of the private surgeries are established outside government hospital premises (perhaps to avoid confusion over when to pay, and when not to). Second, the government allows those without professional medical qualifications (e.g. paramedics) to set up a health care business for minor health complaints. The 1987 Act lists 24 licensed paramedical and allied health professionals in private practice. Third, the government encourages parastatal organizations to adopt a medical scheme (health insurance programme) for their employees. All parastatals currently have some form of medical scheme for their senior staff, while a number operate clinics for their junior staff. Such clinics in areas such as Blantyre and Lilongwe are sometimes run by the private doctors, who come on selected days of the week. The expansion of private practice can be viewed as having both positive and negative effects. Malawi is already short of medical personnel who can deliver health care at an affordable price for the majority of the population. Private practice is bound to short-change the poorest within the population. On the positive side, the escalating cost of curative care may be just what the government needs to get its preventive programmes widely accepted. Another plus in the expansion of the private sector is that it may act as a magnet to attract the numerous Malawian doctors currently practising outside the country. The policy shift was partly embraced in order to address this problem of the brain drain. It would seem that the government now admits that it is better to have many doctors within the country even if the majority are practising privately. Specific policies relating to CHAM The interface between CHAM and the MOH does not extend to the control of the former by the latter, as already stated. In fact, beyond the payment of staff salaries, CHAM is free to manage its institutions without interference from the government. But this is about to change so that the two major providers can cross-refer their patients and share management techniques since the CHAM institutions seem to be better managed. The procedure for sharing management techniques has already been discussed and the method recommended is to divide the country into 39 Health Delivery Areas (HDAs) to be headed by 15 CHAM hospitals, 21 Government District hospitals and the three District Health Offices in Blantyre, Zomba and Lilongwe (where the tertiary hospitals are located). These HDA hospitals would then be reponsible for the administration of all health services and activities in their areas (MOH 1992:viii). Through this hierarchy, CHAM should be able to exert some management influence, as some of the health services and activities will include those under the government. Similarly, this arrangement would also afford the government an opportunity to directly supervise CHAM activities falling within its HDAs. With regard to the establishment of new units, CHAM has for some time been required to seek approval from the MOH. On its part the latter would not build any unit near an existing CHAM unit. This policy is intended to discourage an uneven distribution of health facilities within the country. The dilemma this poses is that certain areas are served only by CHAM units whose services are not free. This has led to persistent calls for the establishment of MOH units in those areas.

7 Policies on co-ordination of public sector activities On co-ordination of public sector activities, the MOH has also taken the initiative with a collaborative effort being explored with the Ministry of Local Government. Although MOH and local government units were often side by side, they lacked a common policy, partly because MOH services are free while those of local government are chargeable. Although informally there was a sharing of staff and supplies, this will now be done at the formal level, by both parties acknowledging the presence of certain skills in the other. This will remove duplication of staff. Similarly, explorations are underway to see if supervision of health units can be organized regardless of ownership. The principle behind all these changes is to rationalize the utilization of scarce human and financial resources. Regulation of the health sector Specialized corporate bodies under MOH supervision have been set up to professionally regulate and/or encourage a sound system of health care delivery. Although not policy makers themselves, it is fair to say that these bodies do professionally advise the MOH. The most significant ones are the Medical Council of Malawi (MCM) and the Nurses and Midwives Council of Malawi. The MCM has the responsibility of registering and disciplining medical practitioners and dentists. It has also been charged with the responsibility of licensing the private practice of such persons, regulating the training of medical personnel, and controlling and regulating the medical profession and practice in Malawi. Although it has such wide-ranging powers, the composition of its membership of nine, which requires at least two representatives from the private sector, provides for the incorporation of the interests of the many management bodies. In cases that so require, the Minister of Health can nominate a further two non-voting members from the University of Malawi. The Medical Council is also empowered to register a wide range of health practitioners. There are some 21 recognized categories of health practitioners in the current register, ranging from medical practitioners on the temporary register Public/private mix in Malawi 69 to allied health professionals in private practice (Malawi Government Gazette, January 17th, 1992). The novelty of the current register is that it is allinclusive, that is, every possible category of practitioner is listed. This has several implications for the types of health care services available. Most important is the fact that the liberal registration policy encourages the delivery of health services under private practice of both modern and traditional types. In addition, it is clear that the other intention is to bring all health personnel under effective regulation and control since the Act specifies the requirements for each category of service and personnel, as well as the penalties for indiscipline and failure to register with the Council. With regard to private practice, only registered persons are allowed to practise, and only in licensed premises which are subject to inspection by the Council. The Council has the power to withdraw the licence at any time and no person is allowed to recover any charges for medical services rendered without an appropriate licence for private practice. The government has made no effort to regulate the setting of fees. This has the effect of encouraging some competition, especially amongst general practitioners within the private for-profit subsector. The problem arises though when specialist care is sought by the patient from the private sector. With the scarcity of specialists in the country, there is little competition of specialists at this level and the fees tend to be prohibitive. Drug outlets The Central Medical Stores supply drugs to public facilities, and CHAM is also permitted to purchase from them. Some private companies manufacture drugs for commercial sale. There is also a pharmacy chain (Malawi Pharmacies) which manufactures over-the-counter drugs and dispenses prescription drugs. As the private for-profit subsector expands and problems of maintaining adequate drug stocks in the public sector persist, commercial drug outlets will become ever more important. So far, there is

8 70 Elias Ngalande Banda and Henry Simukonda no policy one way or the other on the process of procuring drugs that should be followed by the private for-profit subsector, perhaps this is because both the subsector and the drug outlets are quite small in terms of their operational size. It is not clear at the moment how much of their business comes from over-the-counter drugs and how much from prescription drugs. Currently, there is some debate over the manner of dispensing drugs since most private doctors prefer to fill their own prescriptions. Doctors in public hospitals will only give prescriptions to be filled outside when the client demands it due to unavailability of the chosen drug. Pharmacists feel that this practice denies them some of their potential business while doctors respond that for other considerations, including payment by instalments, patients are better served when the drug is available from the doctor (Michiru Sun 1992). Prescription drugs are also available on the open market and dispensed illegally and informally. It is very difficult to determine the size of this sector since it exists to offer drugs cheaply to people who know the drug they want but cannot afford it from the regular pharmacies. With respect to non-prescription drugs, practically all grocery shops stock them, including some standard drugs found in hospitals such as panadol, aspirin and chloroquine. Casual observation suggests that these outlets are commonly used for minor symptoms such as flu, colds and headaches. For traditional medicines, open market places are the major source. The future health system in Malawi The previous sections have indicated that the health system is undergoing several changes. These changes stem from the fact that health care resources are limited both at the material and personnel levels. In addition, there are budgetary constraints imposed by structural adjustment policies which require major shifts in financing of health care. A further reason is that lack of co-ordination among the various health care providers has created a duplication of services. To overcome resource limitations, the government is exploring ways of collaborating with other health care providers in areas of management, training, and the referral of patients. According to a recent study (Ministry of Health 1992), MOH facilities are heavily utilized while CHAM facilities are not as busy. In 1990, for example, 72% of out-patient attendances were made at MOH facilities while only 129/o were at CHAM facilities. This relative over-use of public health facilities is explained largely by the CHAM fees. If referrals are to be made between these two major providers, the issue of fees has to be addressed. The study recommends uniform fees between CHAM and MOH units. However, this may not be easy under the present constitution of CHAM since fees also vary within CHAM. With regard to the financing of health care, it is becoming increasingly apparent that for government units to provide quality care, they will have to strengthen their chargeable services in order to subsidize the free services. A model for doing this is already available from CHAM and the private for-profit subsector, where a sliding scale is sometimes used, and indigent patients are not necessarily denied treatment. Discussions on instituting some user charges within government health facilities are already in an advanced stage, and they may be introduced within the next financial year. References Malawi Government Statement of Development Policies (DEVPOL) OPC - Dept of Economic Planning and Development, Lilongwe. Malawi Government Medical Practitioners and Dentists Act. Cap.36.01, No. 17. Michiru Sun To dispense or not to dispense with medicines. Premier edition, August. Ministry of Health Report on health financing survey, June-December Lilongwe, Malawi. Ministry of Health The National Health Plan of Malawi, Lilongwe, Malawi. Ministry of Health Strengthening of health services in Malawi: Report of a study on co-ordination and collaboration between the Ministry of Health and the Private Hospital Association of Malawi. February. Lilongwe, Malawi. Msukwa L and Simukonda HPM Report on the evaluation of the Private Hospital Association of Malawi. Centre for Social Research, Zomba, Malawi. National Statistical Office Malawi Statistical Yearbook. Zomba, Malawi. Ngalande Banda EE Financial resource allocation and utilization, expenditure allocation and income generation of selected hospitals in Malawi. Report submitted to the World Bank (December).

9 Public/private mix in Malawi 71 Simukonda HPM The NGO sector in Malawi's socioeconomic development. In: Mhone G (ed). The economy of Malawi at a crossroads. SAPES Trust, Harare. Tilak JBG Financing and cost recovery in social sectors in Malawi. The World Bank (mimeo). Biographies Elias E Ngalande Banda, a lecturer in Economics at the University of Malawi, holds an MSc in Development Economics from Strathclyde University in Scotland, an MA in Political Economy and a PhD from Boston University in the USA. He has recently completed a Career Development Fellowship in health under the International Health Policy Program (IHPP). In addition to teaching the areas of macroeconomics and microeconomics, he has research interests in_healthreducation and agriculture. He has consulted in health and education for the World Bank, the World Health Organization and the Government of Malawi. Henry PM Simukonda, a Malawian, was Senior Lecturer and Head of the Public Administration Department at Chancellor College, University of Malawi. He has studied at the University of Malawi (BA Public Administration), University of Birmingham, UK (MSocSc Dev. Admin.) and the University College of Swansea, UK (PhD). His areas of research have included rural development policy planning and management and rural poverty, health sector organization and public drug use behaviour, public enterprise management, small scale indigenous enterprise development, and the NGO sector. He has contributed papers to a number of journals, books and official policy analysis documents, and carried out commissioned research for a number of organizations including VSO, WHO, the Christian Health Association of Malawi, and the Malawi Council for Non- Governmental Organizations. Correspondence: Dr EE Ngalande Banda, Chancellor College, University of Malawi, PO Box 280, Zomba, Malawi.