June 24, 2014

I strongly believe in the importance of context for understanding one’s individual experiences. Therefore, as a helpful exercise, I hope to organize my understanding of Malawian Healthcare from a big picture perspective prior to digging into personal observations. Of course, the description that follows is by no means error-free or truly encompassing; however, I hope you all find it somewhat informative.

Brief Overview of Health Care in Malawi

Healthcare is provided either in government-run settings (62%), missionary hospitals/clinics as part of the Christian Health Association of Malawi (CHAM) (37%) or the private sector (1%). The administration of healthcare occurs at three levels, primary, secondary and tertiary (basic to advanced), which are connected by a referral system. Overall, the first point of contact with the system for most Malawians, involves the primary tier of rural health centers/hospitals. In fact, the vast majority of rural care is provided by CHAM rural hospitals (the category that St. Gabriel’s falls into). In order to provide the above services, healthcare in Malawi is financed through three main methods: government expenditure (21%), foreign aid (60%) and private (19%) – largely out-of-pocket (OOP) – payments (2006 statistics). Overall, while still largely foreign aid dominated, the Malawi gov’t has increased expenditures in health care and private payments (out-of-pocket) as a percentage have decreased (note: private (OOP) was 45% of all financing in 1999).

St. Gabriel’s Hospital Background

St. Gabriel’s Hospital was founded by Luxembourg Carmelite Sisters in 1959 and has been servicing the Namitete area for many years. As mentioned earlier, the church falls under the missionary hospital category. Thus, it charges a fee to inpatient/outpatient services unlike government hospitals that are free of charge upon referral (Note: Many activities are free of charge – ex. outreach vaccination, but not quite sure of other). Check out the picture and website to get a sense of the services provided and amounts of patients served. From what I’ve heard this hospital is definitely above average for rural hospitals in its cleanliness/resources/organization.

Personal Observations on Doctor-Patient Relationship

Compared to the interaction between physician and patient in the States, it felt like a complete different experience at St. Gabriel’s Hospital. There is a more obvious difference in power between the two. This wider gap, dominated by a patient’s greater deference to the physician, may stem from their overall lower educational status and the higher societal position of the doctor. The patients do not speak until spoken to, whether that’s stating their symptoms/complaints or a simple greeting. This phenomenon can also be an extension of the high patient load that physicians face; there may simply be a lack of time to engage in more thorough interactions. However, from what I gather, this silence is not from fear, but respect. I’ve seen multiple instances where the patient provides a gift to the clinician for his therapeutic help. Another interesting aspect I noticed was the limited “host-like” atmosphere of clinical encounters. For example, the physician does not greet the patients at the door during outpatient clinics, instead the patient simply comes to a seated doctor. The emphasis and effort isn’t about providing the patient a good experience, but treatment (except in inpatient palliative care patients, where comfort is highly sought).

Another facet of this relationship is the patient’s expectation for cure, not treatment. This difference is subtle, but important to recognize. I was often told by health personnel in pediatrics that patients’ guardians strive for discharge as soon as improvement is felt/observed, but if discharged, the patients frequently return with the same illness, possibly worsened. To mothers, an extra day beyond feeling better – “cure” – is more money owed; however, to the physician it is viewed as medically necessary to ensure dose completion and confirmed return to normal health. Mothers often tell their children not to say anything, to put on a show of wellness. There exists a divide on how treatment occurs and what “cure” actually consists of. There are limited initiatives for patient education to bridge this knowledge gap.

Weekend Trip to Cape Maclear (Lake Malawi)

From the car ride surmounting mountains to the pristine, awe-striking beach, Lake Malawi was quite the beauty. Not to mention, the lodging, which was quite cheap, had a resort-like ambience and provided the most pleasant experience. We actually met up with the five other Rice students from Blantyre and their two British physiotherapist friends. (We also happened on two current medical students from Rice! – It was quite the group.) On Saturday, we took a boat and island hopped across the lake and then closed it with some nice dinner, great company and two excellent world cup matches. Though I must say, my personal favorite was simply sitting by the coast with a nice book in hand. By the way, if interested, the next post will revolve around pediatric measurement and Babymetrix. Anyways, enough with the text – enjoy the pictures!