In the past couple of weeks the shortages of medicines in Malawi’s public health facilities has caused a public outcry. Several facts have emerged that draw attention to governance of the medicine sector, and to some of the reasons why shortages, which became worse during Bingu wa Mutharika’s term of office, continue in spite of attempts by government and donors to fix the problem.
On 23 January 2013 15 medical professionals at Kamuzu Central Hospital in Lilongwe wrote to President Joyce Banda to complain about the ‘worsening shortage of essential and basic medications and supplies’. They added that the situation is the ‘same in all public hospitals’ and that in spite of physicians providing their own funds to buy supplies, people are dying as a result of shortages (The Nation, 28 Jan 2013).
A day later JournAIDS in Lilongwe took up the same theme in an open letter to the ‘Head of State’ demanding that she ‘act’ on the shortage of diabetes drugs. It is one of several drugs that are in critically short supply, along with malaria medicines (particularly needed now, during the rainy season). What the President needs to do, the letter said, is to ‘convene a meeting for all health stakeholders to discuss the shortages’. Staff from the Central Medical Stores Trust (CMST) were expected to attend to explain why there are drug stockouts, and why there was a misprocurement (oversupply) of bandages in storage. The letter asked that the President convene a special commission of inquiry on drug stockouts, and that the media investigate and hold the CMST accountable. (JournAIDS, Policy Brief Series 17, Jan 2013).
Letters to the press and pronouncements made on social media are becoming more common in Malawi, and are evidence of the spreading belief by citizens that they have a right to demand better services. This is a good thing, and shows that the population is awakening from 30 years of H Kamuzu Banda’s rule when dissent was severely punished, and from Mutharika’s second term when public criticism was violently crushed by the police and the President’s youthful loyalists.
That Malawians believe it is up to a president to fix any and all of the country’s ills is not so good, but is still typical of the society. Further, it parallels the recentralisation of power in the presidency that has been ongoing, off and on, since the 1994 transition to democracy. It also demonstrates a focus on personalities in power rather than on the institutions of governance that are charged with delivering public services. Taken together these trends show how little entrenched democratic norms really are.
President H Kamuzu Banda shaped the presidential mould when he (through his single-party system) directed all activities and oversaw all initiatives. He also took a personal interest in punishing anyone who broke the rules. This tendency is evident now in the way the President interferes in many issues that her ministers and civil servants ought to be managing – most recently, in directing the award of tenders to specific pharmaceutical companies (Weekend Nation, 12 Jan 2013). Similarly, ruling party loyalists are often expected ‘to eat’ as a result of their allegiance while those who belong to other parties don’t expect to access scarce public goods. This ‘single-party mentality in a multiparty regime’ is typical of Malawi.
Second, decentralisation policy was pushed by donors and adopted by government in the 1990s, but has been implemented only partially. In 2010 Mutharika rolled back advances made earlier when changing the law on council membership and elections, and the appointment of district commissioners. Further, presidents are still overly powerful vis-à-vis parliament and chiefs, and their political parties, which they often literally own.
Finally, the fixation on the father-mother president who is expected to solve the family-country’s problems demonstrates a lack of awareness of the role of formal institutions in delivering services. In this case, the CMST is supposed to be restructuring and recapitalising in order to ensure it can deliver drugs from mid-year when the emergency-drug supply programme (supported by donors) is meant to expire. That it hasn’t money enough from Treasury to procure drugs is a policy (and perhaps a technical) issue, not one that a meeting with the President should address. Far too often presidential (and other politicians’) interference in what should be institutionalised processes, has undermined the development of a strong, technocratic public service with the space to do its job.
As a result it would be much better had civil society, the ‘concerned physicians’ and anxious citizens addressed the CMST and Ministry of Health and Treasury to fix the systems that are meant to ensure that basic medicines reach health facilities.