BLANTYRE, 3 June 2011 (IRIN) - After several years of fragile gains, Malawi's healthcare sector is facing major setbacks following a decision by its largest international donor, the UK's Department for International Development (DFID), to freeze its aid to the impoverished nation.

The UK provided about US$122 million annually to Malawi, of which $49 million went to funding Malawi's public health sector, but DFID made its final aid disbursement in March and has decided not to renew a six-year funding commitment which ends in June.

"We have already started feeling the pinch," said Martha Kwataine, a policy analyst with the Malawi Health Equity Network. "There is going to be a regression in the progress we have made with DFID in improving health services in the country."

The UK's decision not to renew its aid to Malawi followed the expulsion of its top envoy Fergus Cochrane-Dyet by the Malawian government for allegedly writing in a leaked memo that Malawian President Bingu wa Mutharika was "ever more autocratic and intolerant of criticism".

Drug shortages

Malawi's health sector is nearly entirely donor-funded with foreign aid covering about 90 percent of the costs of all medicines.

"[The cuts] will really make a difference because we don't have the means to buy most drugs ourselves," Kwataine told IRIN.

However, drug shortages and stock-outs were a problem even before DFID's funding freeze. Anti-retrovirals (ARVs), for example, are provided entirely by the Global Fund to Fight AIDS, Tuberculosis and Malaria but their distribution to HIV patients across the country is the responsibility of the Ministry of Health's HIV Unit. Often, the drugs are not available where they are needed.

At a health clinic in southern Malawi run by Dignitas, a Canadian NGO which supports the development of local health care, Dr Belete Assefa has been dealing with inconsistent supplies of ARVs for the past two years.

"It's a problem of the supply chain. It might be available in the country, but it's the way they are distributed. There might be a lot of drugs at one health centre and no drugs at another," he said.

Cuts to the health budget resulting from the withdrawal of UK aid are likely to deepen inefficiencies in the distribution of ARVs. In Blantyre's suburb of Ndirande, one of the poorest urban areas in Malawi, ARV clinician Eddie Manda said drug shortages had already worsened in recent weeks.

"Normally when we request ARVs, we are supplied within two or three days. Now it has been three weeks," he said.

Demoralized doctors

The drugs shortage means that Manda spends hours each day driving to other health centres to pick up a supply of ARVs that will last for a few days. It also means he can only prescribe patients with a two-week supply of ARVs instead of enough for a month. This is no small problem in Malawi where many people struggle to afford the transport costs to distant health centres. "It's not supposed to be like this," he said. "My work as a clinician is compromised."

Assefa faces the same problem at the Dignitas clinic. Because of widespread fuel shortages in the country, he is sometimes forced to send patients out on their own to search for ARVs when the supply at his clinic runs out.

"Patients have had to go up and down to different clinics looking for drugs. For medical professionals, this is very discouraging. This will affect the morale of healthcare workers," he said.

The problem of low morale has contributed to a critical shortage of health workers in Malawi, with many migrating to South Africa and elsewhere in search of better pay and working conditions. A DFID-sponsored programme was making huge strides in improving working conditions for doctors and had helped increase the doctor to patient ratio from 1 to 60,000 in 2004, to the current ratio of 1 to 46,000. These gains are now at risk as health workers become increasingly frustrated by a lack of resources.

Diplomatic stalemate

It seems unlikely that the UK and Malawi will be re-establishing ties any time soon. In an emailed response to questions from IRIN, DFID communications officer Andrew Massa said the UK was "reviewing its relations with Malawi, including DFID's aid programme" and that no new aid would be committed until this review was completed.

"We and other donors have urged the [Malawian] government to finalize a new 5-year national health strategy to accelerate progress. Without this, donors cannot begin the process of considering what support they will provide," he added.

A London spokesperson with DFID wrote: "We have raised concerns with the Government of Malawi on a number of occasions and it is right that we should review our aid programme. We have to ensure that British taxpayers' money delivers a better life for the poor of Malawi.''

While the UK's aid freeze may have been meant as a political retaliation, Kwataine said it was not the country's leadership who would pay the price if the freeze continues. "Whatever decision they make, they need to know that it's the ordinary man and woman who will suffer," she told IRIN.

President Mutharika responded to the withdrawal of UK support by announcing in his State of the Nation address on 23 May a "zero-deficit" budget that will necessarily entail increased taxation. Meanwhile, Finance Minister Ken Kandodo told Reuters he plans to introduce a host of austerity measures to deal with the gap in the country's budget.

Kwataine worried that such measures could include shifting the burden of healthcare costs to Malawians, a move that would only aggravate poverty levels in a country where 74 percent of the population are already living on less than US$1.25 a day. "The poorer you are, the more likely you are to have poor health indicators," she pointed out.