Understanding informal payments in the health sector in Malawi: results of a multidistrict household survey

In Malawi, health services are officially free at the point of use, but patients often make informal payments to access services or obtain medicines. These payments undermine equity and trust in the health system. This study examined for the first time the prevalence, types, and determinants of informal payments among Malawians who had recently used health services. We conducted a multi-district cross-sectional household survey in four districts chosen to reflect urban and rural Malawi. Households containing someone who had been hospitalised in the previous six months were interviewed using a structured questionnaire. Descriptive analyses identified the types and prevalence of informal payment, while multivariable logistic regressions identified factors associated with informal payments. Overall, 17% of respondents reported paying for services that are officially free. Informal payments are most often for medicines (52%), consumables (24%) and consultations (24%). Female respondents and those living in urban areas were significantly more likely to report giving informal payments, while those with higher levels of education were less likely. Participants with a good or very good financial situation were more likely to make such payments. Significant geographical variations were observed, with higher probabilities in Mchinji and Mzimba than in the Blantyre district. Nearly one in five Malawians reported making informal payments to access health services, questioning the formal policy that these are free. These findings highlight the need for governance reforms, greater accountability and community awareness to reduce informal payments and promote equitable access to care.