Limits of neoliberalism: HIV, COVID-19, and the importance of healthcare systems in Malawi

ABSTRACT

Countries in sub-Saharan Africa have been seriously affected by HIV and now face a new pandemic – COVID-19. How have prior experiences with managing HIV prepared countries for COVID-19? To what extent has the structure of the global health field enabled or constrained countries’ ability to respond? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi’s health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection.

KEYWORDS:

• HIV/AIDS
• Africa
• COVID-19
• neoliberalism
• health systems

Introduction

The HIV pandemic has had a major impact on many countries in sub-Saharan Africa. While the global response was devastatingly slow at first, there are now major global health initiatives and immense resources poured into addressing HIV (Benton, 2015; Whiteside & Smith, 2009). Today, the world faces a new pandemic – COVID-19. What effect it will have on African countries is not fully known. Past experiences with HIV and existing structures from HIV programmes may be resources that help governments and communities face the new pandemic. But the spread of COVID-19 also raises pressing concerns. Low-income countries struggle with under-resourced healthcare systems; and people often live in close quarters and face economic pressures to work, which can make it difficult to follow public health recommendations (El-Sadr & Justman, 2020). While the quick response from the African Union as cases first emerged may have minimised the severity of the first wave of COVID-19, most countries in the region have now experienced a more severe second wave with higher rates of infections and deaths (Salyer et al., 2021). As the pandemic unfolds, uncertainties remain – variants of concern continue to spread and access to recently developed vaccines remains limited in many African countries (Ghebreyesus, 2021; Mwai, 2021).

Thinking about countries’ ability to effectively respond to COVID-19 raises broader questions about the structure of the global health field itself. Today, donors tend to prioritise certain disease programmes, such as HIV, malaria, and tuberculosis, and often rely on non-governmental organisations (NGOs), rather than governments, to design and implement programmes (McCoy et al., 2009; Morfit, 2011; Shiffman, 2006; Watkins et al., 2012). This way of conceptualising healthcare – as discrete illnesses that are best addressed by non-state agencies – should not be taken for granted. Instead, it reflects the influence of neoliberalism on the global health field, which emphasises the role of the market and private sector in distributing health and other social goods (Centeno & Cohen, 2012; Keshavjee, 2014; Pfeiffer & Chapman, 2010). As COVID-19 spreads, this is a moment to reflect on the ideological underpinnings of global health and how current structures shape countries’ responses to the pandemic.

How have prior global health initiatives, in particular for HIV, prepared countries in sub-Saharan Africa for COVID-19? To what extent has the structure of the global health field enabled or constrained countries’ ability to effectively respond to the pandemic? I draw on fieldwork in health centres, provider interviews, and recent ethnographic journals written by Malawians to examine the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi’s health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing services to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection.

Neoliberalism in global health

Neoliberalism has had important implications for the global health field. Broadly defined, neoliberalism ‘stresses the necessity and desirability of transferring economic power and control from governments to private markets’ (Centeno & Cohen, 2012, p. 318). Proponents emphasised the role of the free market with minimal involvement from the government and other political institutions. They believed that market competition would not only improve economic outcomes, but also be the most effective and efficient way of allocating social resources (Birn et al., 2016; Keshavjee, 2014; Packard, 2016). The development of neoliberalism and its impact on society has been studied from several vantage points, for instance, as an economic debate, a political strategy, and an ideology (Centeno & Cohen, 2012). In this paper, I focus on neoliberalism as an ideology and practice. Neoliberal ideas have shaped the structure of the global health field and its logics persist in global health practice, becoming embedded within policies, programmes, and routine activities.

Research on neoliberalism in global health has examined its historical rise and continued impact on healthcare. Neoliberal ideas started to take hold in the 1970s and continued to gain strength into the 1990s and 2000s (Centeno & Cohen, 2012). One of the major changes that ensued was the declining role of the state in providing health and social services. Structural adjustment policies in the 1980s and 90s from the International Monetary Fund (IMF) and World Bank led to decreased state investments in healthcare (Pfeiffer & Chapman, 2010). Based on neoliberal ideas, these policies included conditions such as currency devaluation, eliminating government subsidies, and reducing overall spending to ‘stabilize economies.’ To meet loan conditions, governments often cut funding to their own health sector (Birn et al., 2000; Pfeiffer, 2013; Rowden, 2009). For instance, government healthcare spending in Malawi dropped from 7.35% of gross domestic product in 1978 to 5.59% in 1988 (Kalipeni, 2004). The costs in terms of human experience were severe. In Malawi, and other countries with structural adjustment policies, patients were burdened by user fees, clinics faced stockouts of drugs and supplies, and many healthcare workers left the field as they saw their salaries drop (Foley, 2009; Kyaddondo & Whyte, 2003; Wendland, 2010). Moreover, the expansion to privatise medical care starved the public sector at a particularly devastating time when the HIV/AIDS epidemic was taking hold (Comaroff, 2007).

The declining role of the state also occurred through donor financing of NGOs. In line with neoliberal efforts, critics of development aid called for privatised health systems and to reduce the role of government, which was seen as inefficient and sometimes corrupt (Packard, 2016). NGOs rose to the forefront as part of a paradigm shift from government-led to private-led development (Brass, 2016; Kamat, 2004). Since the 1990s, an increasing amount of donor funding has gone to NGOs (Koch et al., 2009; McCoy et al., 2009; Morfit, 2011). While there were just over 9,000 NGOs recognised by the United Nations in 1980, there were nearly 28,000 by 2006; and these numbers do not include the array of smaller NGOs that operated locally in many countries (Packard, 2016). Ferguson and Gupta (2002) use the term ‘transnational governmentality’ to describe how neoliberalism had a ‘de-stating’ effect both through directly imposed policies, like structural adjustment, and indirectly through the financing of international and local NGOs (see also Ferguson, 2006).

Neoliberal ideologies also indirectly contributed to a renewed focus in global health on ‘vertical’ or disease-specific programmes. While debates between ‘vertical’ and ‘horizontal’ programming have long been part of the field, the 1970s were a moment when global enthusiasm for a broad rights-based conceptualisation of health was at a high – the 1978 Alma-Ata conference, which brought together 134 countries and 67 international organisations, affirmed a commitment to primary healthcare as well as supportive public health measures like promoting safe water and food supply (Basilico et al., 2013). The rise of neoliberalism, along with the 1980s debt crisis and consolidation of conservatism in the US and UK, contributed to a political economic context that favoured a focus on targeting specific diseases in a cost-effective way (Brown et al., 2006; Cueto, 2004). After much debate, most agencies shifted away from broadly defined goals for primary healthcare toward a market-based approach of ‘selective’ primary healthcare that focused on low-cost technical interventions for specific diseases (Cueto, 2004). Donors preferred short-term projects with clear budgets and measurable outcomes that maximised returns on investment (Birn, 2018).

Over time, neoliberal agendas have become less overt. But as scholars have noted, its logics remain and are consequential for global health programmes. NGOs have continued to proliferate over the past three decades and have become deeply incorporated into the development process (Brass et al., 2018). For instance, nearly 90% of World Bank projects in 2018 involved the participation of an NGO compared to just 21% in 1990 (Brass et al., 2018). Nguyen (2009) has described humanitarian responses as ‘government-by-exception’ – it is large donors and international organisations, rather than the state, that define health priorities, design interventions, and regulate public health. Similarly, in Dionne’s (2018) principal-agent model of global health, donors are the international ‘principals’ at the top of the global hierarchy, who then contract work to a multitude of ‘agent’ organisations within countries. NGOs also play a key role in providing healthcare, especially for donor priorities like HIV. Some argue that the reliance on NGOs creates a fractured healthcare system, where instead of one standard package of care that exists through the government, there are an array of different NGO programmes, each working to recruit members and provide services (Prince & Otieno, 2014; Sullivan, 2011). In this landscape, new forms of citizenship emerge – rather than citizens exercising a right, patients become more like clients or consumers of a healthcare product (Whyte et al., 2013). NGO programmes commodify beneficiaries and place some of the poorest populations in competition to access programme benefits (Krause, 2014). With HIV, for instance, patients must not only demonstrate belonging to a target population, but in some cases also perform an illness narrative that appeals to NGOs (Burchardt, 2015; Meinert et al., 2009; Nguyen, 2010).

Market-based logics also continue to shape various aspects of global health programmes. Scholars have argued that neoliberal ideas are embedded within various healthcare analyses and metrics that implicitly commodify health as a market good (Adams, 2016; Erikson, 2016). Disease priorities are often determined through cost-effectiveness analysis, which follows an economic logic that emphasises funding diseases that yield maximum returns with measurable reductions in morbidity and mortality (Birn, 2009; Sparke, 2017; Storeng, 2014). The emphasis on value-for-money can also shape programme activities. For instance, NGOs sometimes narrow their goals to focus on targeted interventions – e.g. from maternal health to drug treatments for postpartum hemorrhage – because economic value is more easily calculated, thus making the programme easier to ‘sell’ to donors (Storeng & Béhague, 2014). In addition, health metrics, like DALYs, QALYs, and MMR, which are necessary for monitoring health outcomes, implicitly place value on human life in market terms (Adams, 2016). As Wahlberg and Rose (2015) note, calculations are a ‘governmentalization of living’ where social and personal experiences are transformed into numerical indicators that function like a monetary instrument. Rather than a public good, health has become tied to market accountability.

Research shows how neoliberalism has historically influenced the global health field and the ways its logics remain, though perhaps in more subtle ways. Building on this body of work, I examine how neoliberal ideas have become routinized where they are embedded in the structure of healthcare and everyday clinical practices. I show how neoliberalism’s influence on global health is manifest in the parallel NGO system of care for donor priorities like HIV; while NGO and government providers work alongside one another, their clinical practices and the resources they have access to differ significantly. In the context of COVID-19, I also explore how the neoliberal underpinnings of global health may shape and constrain countries’ ability to respond to new pandemic threats.

Potential effects of HIV interventions

HIV is a good case to understand how neoliberalism affects public healthcare and its implications in the context of new pandemics. HIV was a novel disease and is often considered exceptional in its severity, long-term impact, and unique challenges it poses to public health (Benton, 2015; Whiteside & Smith, 2009). Today, it is the largest disease programme in the global health field, with global annual funding for HIV programmes reaching over US$19 billion (UNAIDS, 2020). On a broad scale, HIV redefined what was possible in global health. Prioritising HIV shifted the entire field from focusing on low-cost interventions toward bigger budgets and more audacious visions (Brandt, 2013; Messac & Prabhu, 2013; Ravishankar et al., 2009). Development assistance for health has now reached over US$31 billion, which is 5.5 times larger than in 1990, with about 75% of growth occurring since 2002 (Dieleman et al., 2014).

It is possible that resources for HIV transfer to cross-cutting issues in the healthcare system and to addressing emergent diseases. In the past, family planning programmes in the 1970s laid the groundwork for HIV interventions, where financial resources, technical skills, and community-based distribution were translated to address the then emerging HIV epidemic (Robinson, 2017). Similarly, HIV programmes and clinics today often have full-time staff, modern facilities, trained community health workers, and a robust referral network, which have the potential to be adapted for emergent diseases (Messac & Prabhu, 2013). In addition, within the HIV field, there has been growing interest in improving the conditions of public healthcare. Major donors, such as PEPFAR and the Global Fund, have made commitments to use HIV programmes to support broader efforts for ‘health systems strengthening,’ which is meant to address systemic issues that affect services for all conditions (Packard, 2016).

However, scholars have also been critical of the extent to which HIV programmes can address other issues. HIV’s exceptional status may detract attention from other illnesses and reinforce disparities between donor-funded programmes and public healthcare (Benton, 2015). For instance, HIV receives more funding than diseases with a similar impact on illness and death (Esser & Bench, 2011; MacKellar, 2005; Shiffman, 2006). And, by focusing on a specific disease, fewer resources are committed to government budgets for cross-cutting issues, leaving national healthcare systems to struggle with resource constraints (Biesma et al., 2009; England, 2007; Ooms et al., 2007). While donors have made financial commitments for ‘health systems strengthening,’ what that means in practice often varies (Storeng, 2014). Marchal et al. (2009) find that organisations interpret health systems strengthening in different ways; many agencies take a selective approach that addresses systemic issues like drug procurement and distribution but only for the specific diseases they focus on. Similarly, Hafner and Shiffman (2013) note that aggregate funding for health systems strengthening has not grown rapidly since 2005, which may suggest that the policy community is fragmented or that commitments shift based on funding constraints and the long-standing pendulum swings between vertical and horizontal approaches in global health.

Moreover, the HIV field itself may be becoming more targeted. Responses to HIV since the beginning of 2010 have been framed by declarations that an AIDS-free generation is possible. Kenworthy et al. (2018) argue that this ‘end of AIDS’ discourse encrypts a neoliberal policy agenda that favours cutting costs by solely promoting biomedical treatment expansion as the means to halt the epidemic, while limiting broad-based efforts like health systems strengthening and community-based care and prevention projects. These trends dovetail with a general ‘biomedical turn’ in the global health field, where donors and international organisations embrace privatised, technological solutions for achieving new eradication and elimination goals for diseases like polio, malaria, and Guinea Worm (Allen & Parker, 2011; Cueto, 2013; Moran-Thomas, 2013). The financial crisis in 2008 has also ushered in a new era of austerity – funding has stagnated, and major donors like PEPFAR have narrowed their focus on specific countries and target populations (Whitacre, 2019). In the context of COVID-19, experience with managing HIV could be a resource, but the concerns that scholars have raised about commitments to health systems strengthening and the field’s biomedical turn may suggest limited support. My findings will provide empirical analysis on whether and how HIV programmes can support responses to emergent pandemics.

Context of Malawi

Malawi is a small country in sub-Saharan Africa that has been severely affected by the HIV epidemic. The country has the 9th highest prevalence rate in the world, with an estimated 9% of the population infected (World Bank, 2020). Malawi is often considered a ‘donor darling’ for HIV interventions. For instance, since the early 2000s, the Global Fund has committed over US$ 700 million for HIV treatment and other programmes for prevention and education (The Global Fund, 2021). NGOs are also a significant part of the healthcare landscape, with HIV organisations making up about half of the entire development field (Morfit, 2011).

Malawi is now dealing with the COVID-19 pandemic. Rates of COVID-19 remained relatively low throughout 2020. On October 14, 2020, there were 5,827 reported cases and 181 deaths (Ministry of Health, 2020). Like other countries in the African Union, the Malawi government responded early, mandating face covering in public places, closing markets and businesses, and banning public gatherings such as weddings (Masina, 2020). However, in January 2021, Malawi experienced a second wave. As of May 5, 2021, there have been 34,123 confirmed cases of COVID-19 and 1,149 deaths reported to the WHO (2021a). These numbers may be an underestimate – there have been challenges with testing (Ferree et al., 2021; Munharo et al., 2020), and emerging seroprevalence data from countries in sub-Saharan Africa suggest greater community transmission than reported from laboratory-confirmed cases (Usuf & Roca, 2021). Malawi’s trends are like other countries in Africa, where most had experienced a second wave that was more severe than the first (Salyer et al., 2021). Malawi received its first shipment of COVID-19 vaccines (Astra-Zeneca) in March 2021 from COVAX, a global partnership that aims to bridge the vaccine gap between high and low- and middle-income countries. As of May 5, 2021, 307,218 vaccine doses have been administered in Malawi (WHO, 2021a). But the future of the pandemic remains uncertain as variants of concern continue to spread (Mwai, 2021), and vaccine supplies are still limited in low-income countries like Malawi (Ghebreyesus, 2021).

Methods and data

To understand the impact of HIV interventions on healthcare in Malawi, I draw on fieldwork and in-depth interviews with healthcare providers (N=37) from three health centres in Lilongwe during 2014–2015. My research took place primarily at prenatal and ART clinics. As Malawi was implementing their Option B+ policy, which provided HIV-positive pregnant and breastfeeding women with immediate and lifelong antiretroviral therapy (ART), these departments became key sites to observe both HIV interventions and routine healthcare services. I observed a range of services, such as health education lectures, prenatal services, HIV testing and counselling, ART initiation, and enrolment into NGO programmes. Lilongwe is Malawi’s capital city and has several NGO headquarters and private HIV clinics located there. While the high concentration of NGOs provides a unique opportunity to contrast NGO and state-led care, observations from my field sites are less generalisable to rural regions where NGO presence is less concentrated. My interviews included Ministry of Health nurses and clinicians (N = 16) and NGO community health workers (N = 21). Interviews lasted about 1 h and covered topics such as providers’ work responsibilities, interactions with patients, resource constraints at the facility, and feelings towards their work. As a foreign researcher who had previously collaborated with one of the NGOs at the health centre, my positionality may have influenced providers, especially those working for the NGO, to give more positive assessments of the programme and their work with patients (Bergen & Labonté, 2020). However, the combination of observations and interviews helps to triangulate responses and see whether there is a difference between what people say and what happens in practice at the clinic. Ethical approval was granted by the author’s institution and the University of Malawi – College of Medicine.

In addition, I draw on recently collected ethnographic journals to understand how the COVID-19 pandemic is experienced in Malawi. The journal entries are part of the Malawi Journals Project – a longitudinal collection of ethnographic journals on local responses to the HIV epidemic, and more recently, to COVID-19. I draw on journals written by two people, one man and one woman, when COVID-19 was starting to spread in Malawi. There have been 15 entries on COVID-19 since June 2020. The journalists are secondary school graduates living in the Balaka township, though they also travel for work and family obligations. They have both contributed to the Malawi Journals Project in previous years, and like the prior journals, they were asked to write about conversations they have had or have overheard on COVID-19; they were not asked to conduct interviews or do other forms of research (Kaler et al., 2015). The journals are written in English and Chichewa (with English translations), and they are anonymized before being archived online (Ashforth & Watkins, 2015).

The journals form a kind of ‘insider ethnography’ as people write about their own lives. The settings vary, from their home, trading centre, markets, work, hospital, and so on. This is unique data that allows for research on everyday conversations in natural settings without the presence of an outsider ethnographer or interviewer (Kaler, 2004; Watkins & Swidler, 2009). They capture collective meaning-making and cultural understandings of illness that are constantly negotiated. The journal entries during the early stages of COVID-19 in Malawi provide valuable insight into people’s reactions and understandings of the pandemic as it unfolds. The combination of fieldwork, interviews, and journals allows us to understand the perspectives of both the providers working within the healthcare system and the users of healthcare. Data were coded in Atlas.ti, and themes were developed throughout the process of data collection, analysis, and writing.

HIV care as exception

HIV care was distinct from other forms of healthcare in several ways. Donor-funded HIV programmes were ‘grafted’ onto the public healthcare system (Pfeiffer, 2013). For HIV care, there were separate supply chains, management, data systems, and service providers. While Malawi’s public healthcare facilities offered HIV services, NGOs and private companies bought, stored, and distributed HIV test kits, treatment, and other commodities. A supervision team also monitored HIV supplies at healthcare facilities on a quarterly basis to ensure that donor-funded goods were properly managed (Schouten et al., 2011). NGOs were also ‘grafted’ onto healthcare facilities, working within or alongside government hospitals and health centres to provide care to their target populations. At my field sites, there were two NGO programmes dedicated to preventing mother-to-child transmission of HIV. The findings primarily discuss my work with one of the NGOs, which used community health workers (CHWs) to provide various HIV services at the clinic and follow up with clients at home. I find that while the parallel NGO-based system had benefits for the delivery of HIV care, support for the healthcare system was selective and focused on bolstering disease-specific goals.

NGO workers provided dedicated staff for HIV testing, counselling, and treatment support. Staff members often conducted HIV testing at the prenatal clinic as well as at voluntary counselling and testing centres (VCT). Women who tested positive received extensive one-on-one counselling. CHWs would often spend 30 min or more with someone who was newly diagnosed. They explained that it was not easy for women to receive both an HIV diagnosis and prescription for lifelong treatment in one day. One CHW said: ‘you could really tell that this person is desperate, they don’t actually ask questions. But you can tell, so what you need is to give a comforting message’ (CHW007, 8/13/2015). For women who joined the NGO programme, they were assigned a CHW who would visit them at home on a monthly basis and monitor their experience with treatment. CHWs checked women’s ART adherence by counting pills and discussed any challenges they were facing. In addition to home visits, CHWs saw their clients when they came to the health centre for early infant diagnosis (EID) and medication refills at the ART clinic. Over the roughly 2 years that women were in the programme, they received continuous HIV services and treatment support. The regular communication that CHWs had with their clients helped in some cases to build a stronger provider-client relationship. One CHW explained: ‘it’s us who go to their homes. Sometimes they feel comfortable with us, rather than the nurses, so they go back home and express their feelings to us’ (CHW007, 8/13/2015).

The benefits of having a separate structure for HIV care sometimes spilled over to the healthcare facility. At the health centres, NGOs had taken over a large portion of HIV services. This alleviated government providers of some duties they had previously been responsible for. Government providers described the ability to task-shift HIV testing and counselling to NGO workers as a major benefit. One nurse described:

In the past, if you are in the ANC [antenatal clinic], you were there, you were alone. You will do everything alone … You have a talk about HIV, from there you go to group counselling. From there, you have to test them and to give results. It was a long process, but now we share the job. (N005, 9/16/2014)

In addition, government providers expressed that NGOs extended their capabilities for providing HIV care. For instance, while they saw patients at the health centre, they were not able to individually follow-up with them at home or carefully monitor their treatment. One doctor said: ‘Here in the office, I don’t go to the village to assure those clients and have a pill count … It’s a relief, and that’s why we see so many clients coming with their babies here, receiving the drugs correctly, because of this [programme]’ (D001, 8/24/2015).

NGO workers also provided infrastructural support to government providers who were prescribing ART and seeing patients with clinical concerns. The ART clinic was busiest on the day that HIV-positive women and children were scheduled for their regular appointments. While CHWs often visited their clients during the day, almost the entire team would stay at the health centre when it was ‘clinic day’ for women and children. Within the ART clinic, I often observed one or two government nurses seated in a room to prescribe ART refills, and surrounding them would be a team of CHWs from the NGO. The CHWs entered patient data into computers, organised the flow of patients into the room, and matched patients’ health passbooks – a booklet of personal health records that patients keep – with clinic files. Outside, there would be more CHWs taking vital signs for women and children and distributing nutritional supplements. In this case, NGOs provided additional staff for the ART clinic to help government providers complete the numerous tasks that were necessary for routine HIV services.

Relying on NGOs had benefits for HIV care, in particular, with providing consistent access to testing, counselling, and treatment. But it was not perfect. Women could only benefit from NGO programmes for a limited time while they were pregnant and breastfeeding. And the extensive counselling and pill counts could be seen as a form of surveillance and ‘responsibilization,’ where NGOs use disciplinary techniques to pressure women on treatment adherence (Mattes, 2011; Vernooij & Hardon, 2013). At the health centres, NGOs supported government nurses and doctors but in selective ways. For NGOs, supporting the healthcare system meant supporting aspects of it that were relevant for programmatic goals, which is understandable since they are accountable to funders to meet their targets for HIV service provision and patient outcomes (see Swidler & Watkins, 2017). Donor’s parallel supply chain and reliance on NGOs show neoliberal ideology in action, where funding, medical supplies, and personnel for HIV are separate from state institutions. Support for public healthcare is limited to issues that are related to donor priorities, while those not directly related often go unaddressed.

Healthcare system left behind

The impact of neoliberal policies on the public healthcare system was evident in Malawi’s health centres. Earlier structural adjustment policies as well as the ways that donor resources continue to bypass the state meant that public healthcare facilities were under-resourced and struggled with shortages of medications, supplies, and staff. Outside of donor priorities, these shortages structured the work of government healthcare providers and made it difficult for them to provide what they considered to be adequate care. Prenatal services at the health centres were a stark contrast to the donor-funded NGO services that HIV-positive women received.

While resources for donor priorities like HIV went through separate channels for procurement and distribution, other medical commodities were managed by the Malawi government. Essential medicines – drugs meant to ‘satisfy the priority healthcare needs of the population’ (WHO, 2020) – were seen as the government’s responsibility and received little donor assistance except during emergencies. Malawi’s Central Medical Stores Trust (CMST) faced numerous challenges with managing their drug supply chain, including cumbersome World Bank procurement procedures, shortages of qualified staff, poor warehousing, lack of space, and insufficient funds to purchase buffer stocks of drugs (Mueller et al., 2011). In a survey of facility managers, 31% said they had to refer patients to a higher-level clinic because drugs were not available (Mueller et al., 2011). During my fieldwork, I found similar issues with shortages of certain medications and supplies. For instance, I had observed: providers complaining that they had run out of amoxicillin, a common antibiotic; providers unable to run certain tests because they did not have the reagents for them; laboratory technicians usable to use microscopes because the light bulbs were broken; and a physician in-charge deciding whether to shut down certain procedures because the medical equipment steriliser had broken. While NGOs rarely had a problem with the supply of HIV commodities, government providers regularly encountered stockouts of the medicines and supplies they needed.

Government providers also struggled with shortages of staff at the health centres. This is a widespread problem in the country. In 2018, Malawi reported having 0.019 doctors and 0.283 nurses and midwives per 1,000 population, which falls below the WHO ‘critical shortage’ threshold of 2.28 doctors, nurses, and midwives per 1,000 population (Bickton & Lillie, 2019). While NGO workers did support government providers by taking on HIV services, task shifting did not solve the overarching problem of staff shortages. Government providers described feeling stretched thin from their work since each individual had to take on multiple responsibilities across various departments. One nurse described:

Yea, shortage of staff really affects the work because there will be so many people to attend to alone … It’s a challenge because for you to complete your work, you become very tired. Because if you were alone, you do things maybe that would have been done by three people. (N011, 9/3/2015)

Respondents mentioned how even having one more provider, so that there could be at least two nurses in each department, would feel like a great relief. In this environment, many felt burnt out and dissatisfied with their work.

In addition, providers worked in conditions where physical space and basic infrastructure were limited. During my fieldwork, it was not uncommon to see patients sharing spaces. Women at the maternity ward, for instance, shared beds when the room exceeded its capacity. Nurses sometimes shared rooms for women’s prenatal consultations, even though they knew this was not ideal for privacy. In the waiting areas, there would often be large crowds of patients with lines that extended around the building. One nurse explained:

You know our facility was built so many years ago in 1979 … But maybe the population has doubled, you know, from 1979 to 2015. The population has changed. So, the infrastructure itself is not adequate. That’s why we have another problem. (N012, 9/4/2015)

The health centres also did not have consistent electricity and water. These infrastructural issues affected all services, including those for donor priorities. For instance, the coordinator for HIV services at one health centre showed me their new CD4 machine (which measures robustness of the immune system), but providers could only use it on a limited basis because of power outages that lasted about 4–5 h each day. When there were water shortages, providers across the facility would need to fill buckets and keep them next to the sinks so that they could clean their hands and equipment.

In this healthcare setting, patient care for conditions outside of donor priorities suffered. While HIV-positive women could benefit from enrolling in NGO programmes, pregnant women without HIV did not have similar access to specialised programmes through the state. Unlike the continuity of care between NGO staff and their clients, prenatal care was often impersonal and cursory. Because of staff shortages, nurses felt pressured to move quickly in order to see all of the women who came for prenatal services. One nurse explained that she could only spend about 3–5 min with each patient. She said:

I wish it can be longer, but the problem is I’m the only one working ANC. You’re with the client inside while some huge number is waiting for you … so I try to minimize, to speed up so that people can get their help in a hurry. (N001, 8/21/2014)

With shortages of medical supplies, providers were also limited in the kinds of prenatal services they could provide. Nurses often did palpations (checking the status of the pregnancy by massaging women’s abdomens), listened for a fetal heartbeat, and provided anti-worm and malarial medication for women. But other aspects of prenatal care, such as taking blood pressure, measuring hemoglobin and urine protein levels, and testing for syphilis were not always provided because supplies were not available. One doctor explained:

I don’t know if I can call it a mistake, but there are gaps … I want that person to be checked for HB [hemoglobin], and that person goes to lab, but there are no reagents for HB. There is no electricity around … I can say they are more challenges, which are making our work difficult. (D002, 9/15/2015)

What took place within Malawi’s healthcare facilities reflects neoliberal influences on the global health field. The legacy of structural adjustment policies and continued de-emphasis on funding the state meant that local healthcare facilities struggled with numerous resource constraints. In this context, government providers often become disillusioned with their career choices (Wendland, 2010), and they sometimes look to NGOs for more appealing job prospects (Van de Ruit, 2019). For patients, care outside of donor priorities was left to government providers, who often did not have the resources to provide comprehensive services. The challenges providers described with medical supplies, staffing, and infrastructure are fundamental aspects of care that cut across numerous health issues. In the next section, we see how the neoliberal influence on global health makes new pandemic threats particularly concerning.

Global health in the time of COVID-19

As Malawi faces a new pandemic, limitations in the public healthcare system are particularly salient. Journals written during the start of COVID-19 show that while HIV provides a conceptual framework for making sense of the new pandemic, community members are concerned about the ability of government facilities to manage and treat infections and the effects of the pandemic on their livelihoods. The challenges described above add new uncertainties in the context of COVID-19. Not only is state healthcare constrained in its ability to provide services, but it also becomes a site of risk itself. The burdens on the public accumulate – the lingering effects of neoliberal ideologies, which shaped healthcare as well as national economics and other social sectors, create compounding disadvantages during the pandemic.

HIV as a framework for COVID-19

HIV has shaped everyday life in Malawi. Many people know someone with HIV or someone who has died from HIV; and with the involvement of foreign aid, HIV NGOs and public health campaigns have proliferated across the country (Dionne, 2018; Swidler & Watkins, 2017). In conversations, people often made sense of COVID-19 in light of their experiences with the HIV epidemic. Many noted similarities between the two conditions. For instance, Frank, one of the journalists, described a conversation with a man at a food stall, who said: ‘There is nowhere to run and hide. And this is similar in the way AIDS arrived and it killed many people before they received enough information about its prevention’ (6/2/2020). Others noted similarities with HIV stigma (see Ferree et al., 2021). Esther, another journalist, described a conversation at the hospital, where a guardian said: ‘In fact, this disease is the same as HIV in the first days, because stigma was there, though there was no isolation as it is happening to Corona Virus’ (6/15/2020).

While there were similarities between the two epidemics, people expressed more anxiety over COVID-19. They felt that they knew how to prevent HIV after being a part of numerous public health campaigns and community-based discussions (Kohler et al., 2007). But, while HIV infection seemed in the realm of personal control, COVID-19 was not – it felt like infection could happen at any time regardless of one’s actions. Frank described a conversation with friends at the trading centre:

He said that when you abstain from sex or other means of transmission – like never sharing razor blades, toothbrushes, touching some blood during accidents, being faithful to your own wife – then we can be safe from HIV … But not in the case of Corona … He said you can abstain, but still, one way or another you can come into contact with this COVID, either by a friend, relative or by yourself unknowingly. For example, coming into contact with someone on a minibus … you can also catch it by coming into contact with someone having the disease at the marketplaces, for example Thursdays here at the trading center. We all agreed. (6/13/2020)

COVID-19 was also perceived as more deadly. Fears around HIV mortality have declined over time as ART became increasingly available, and patients saw their health improve and that they could lead normal lives with sex, marriage, and childbearing (Conroy et al., 2013). In contrast, COVID-19 was like the early days of the HIV epidemic when infection meant a death sentence. People expressed that there was no way to manage COVID-19 – one’s survival was ‘in God’s hands.’ Frank described:

Another gentleman who sat adjacent to me added, saying that AIDS was more dangerous in the past and not now that we do take ARVs and live longer … Another said that AIDS is junior to Corona. Corona kills instantly and thousands of people just in a day. All agreed. (6/2/2020)

While these remarks highlight community members’ anxiety around COVID-19, the parallels made between HIV also demonstrate how the earlier epidemic provides a framework for understanding new conditions. The journals were written when COVID-19 first arrived in Malawi. Though there were few cases at the time, conversations suggest that people had a good understanding of what COVID-19 is, how it spreads, and its potential severity. Collective experiences and memories of HIV may have contributed to the seriousness seen in these public reactions to COVID-19. In addition, public health messaging around HIV as well as other infectious diseases like tuberculosis may have contributed to public knowledge about health and illness more generally. Unlike the early days of the HIV epidemic, when the illness was interpreted in more mystical terms, journals suggest that Malawians today more readily use a framework of infectious disease to make sense of COVID-19.

Government hospitals as a site of risk

However, as described earlier, HIV programmes provided limited support for the public healthcare system. While community members understood COVID-19 and its seriousness, they expressed fatalistic attitudes about whether their healthcare system could address the pandemic. In the context of COVID-19, the constraints that public facilities face gain renewed salience. Long-standing problems, like crowded conditions and inconsistent availability of soap and water, were not only resource constraints but also risk factors for COVID-19 infection. For instance, Esther described taking her niece to the hospital. There were no beds when they arrived, so they both slept on the floor until one became available. When they were admitted into the ward, she was disappointed at the condition of the room. She writes: ‘One bed had no mattress, and the other bed had a mattress, but it was looking dirty. The hospital attendants did not change the mattress … so everyone refused to use it’ (6/15/2020). With the room full of patients, there was little space for the family members who accompanied them. Esther and other guardians discussed how they felt vulnerable to COVID-19. One woman said:

Look at our room that we are staying in. Is this a room to be occupied by more than 20 people? The room is small. We have 8 beds for patients with different diseases, and we are more than 8 guardians here breathing on each other. Are we protected from COVID-19? (6/15/2020)

In addition to crowded spaces, hospitals lacked basic supplies to protect workers and patients. Esther described one guardian saying: ‘There is no water for people to wash their hands, and some people stole the tablets of soap as well as the hand sanitisers from the hospital’ (6/5/2020). Others said that soap and water were available ‘in the early days,’ but now the containers were often empty. Family members were also concerned about inconsistent supplies of personal protective equipment (PPE) at the hospital. They overheard nurses talking about how they ration their PPE, for instance, by wearing shorter aprons while keeping the longer ones in storage for suspected COVID-19 cases (6/15/2020). These hospital conditions did not make people feel safe from COVID-19 infection. As one guardian said: ‘If we get infected here, we carry the viruses back home and spread it to our families’ (6/15/2020). Another responded: ‘So if the nurse is worried about her life, yet she is a health worker, and she received other protecting resources including masks, aprons, and gloves, what about you and me who have nothing? Are we going to survive’ (6/15/2020)?

In addition to being a site of risk, people expressed concerns that government facilities would not be able to take care of COVID-19 patients. Government hospitals were often described as a ‘graveyard’ and a ‘place for people to die.’ While patients and providers in Malawi have long been critical of state healthcare (Wendland, 2010), COVID-19 becomes yet another reminder of inadequacies in care. Esther described a conversation with a woman at the market, who said to her:

We have nothing here, so if the disease is spread to us, I hope all of us can die within seconds because we have nothing to protect ourselves from the disease. And we have no money for building better hospitals for saving lives for patients with coronavirus. (6/1/2020)

Similarly, at the hospital, Esther and the other guardians discussed resource constraints. Some of the statements that people made included:

They are doing nothing because the hospitals have no resources for them to use when helping patients.

This is why we say that the hospital is a place for people to die and not for one to get healed.

A government hospital is a graveyard where people are buried when they die. We mostly come to government hospital to buy death and not to survive. (6/15/2020)

At the same time, it was not clear whether the international community could help. The journals describe conversations where people expressed skepticism that donor funding for COVID-19 would actually be put to use. Some felt that government officials were corrupt and keeping donor money for themselves. Additionally, wealthy countries appeared to be struggling with managing their own pandemic responses. If countries like the US, UK, and China were struggling, it seemed impossible for a country like Malawi to manage. Esther wrote that at the market, one person said to her: ‘If the disease is killing many people from the rich countries including America where they have a lot of money and are well equipped, what about Malawi – the poorest country in the world’ (6/1/2020)?

The concerns that people in Malawi expressed about COVID-19 are tied to the structure of the global health field. Hospitals were equated to ‘graveyards,’ in part, because neoliberal divestment from the public sector had left healthcare facilities severely resource constrained. While patients had long experienced problems like overcrowding, these issues in the healthcare system become doubly dangerous during the pandemic. Not only were government facilities limited in the services they provided, but they also became a site of risk itself.

Compounding disadvantages

The COVID-19 pandemic compounds disadvantages in an economically precarious context. In the journals, community members expressed concerns about whether they could afford protective measures for their family. Purchasing items, such as washing pails and soap, could stretch a family’s budget. For instance, Frank described a conversation with his wife: she told him that she bought a pail for their family to use outside of the toilet, but she could not afford the more expensive ones that have a tap to allow for running water. She also hid bars of soap to prevent others from stealing it. In addition, work had become more unstable during the pandemic. Frank’s wife told him about her conversation with a friend on the struggles of small businesses during the pandemic. He wrote:

She went on saying that with this era of COVID-19 things are worse. She added, saying that most of her friends, who were running small businesses at the trading center, saw their businesses collapse … She met the wife of Mavuto, who has just gone to South Africa, and left his wife with a small business of selling tomatoes. She said tomatoes used to be a good business because each and every day people want to eat Nsima [a staple food], and no one prepares Nsima without preparing relish first. And that requires tomatoes. She was complaining that she doesn’t see any difference compared to those who are just staying at home, running no business. (6/5/2020)

It was hard for community members to imagine how they could support themselves and their families when shelter-in-place and other public health measures are put into effect. Esther described someone at the market saying to her: ‘Every day we go to look for piece work for survival, so what will happen to us if we are in a lockdown situation’ (6/1/2020)? Moreover, with less work available, food security becomes a serious concern. Outside the village bank, one person said to Frank: ‘we eat through hand to mouth so, we cannot stay locked into our houses even for 3 days’ (6/12/2020). To prepare for the pandemic, Frank described how he and his wife tightened their budget. His wife suggested cutting out tea, sugar, cassava and sweet potato, which were now considered luxury items (6/5/2020). People were concerned about both health and economic suffering. One man at the bank said to Frank: ‘This COVID-19 is really and absolutely going to make people suffer a lot, not only suffering from the disease itself, but also we are going to be affected and severely hit by crucial poverty’ (6/5/2020).

While this article focused on the healthcare implications of neoliberalism, the effects of this ideological influence extend beyond. Structural adjustment policies in the long run did not strengthen economies, but instead contributed to their weakening, which exacerbated poverty, informal work, and food insecurity (Kolko, 1999). Additionally, the concerns that people expressed about their economic livelihoods may also be a result of misplaced donor priorities. While donors have focused heavily on HIV, which is indeed a major health issue, villagers in a survey responded that access to clean water and food security were some of their top priorities (Dionne, 2012). Like with public healthcare facilities, the social and economic issues that local residents feel have been unaddressed become more pressing in the context of COVID-19.

Conclusion

Neoliberalism has had a historical impact on global health and continues to shape the field as market-based approaches and reliance on private or non-governmental organisations have become taken-for-granted features of many programmes. This paper has shown that, on the ground, neoliberalism is manifest in the structure of healthcare facilities and the routine practices that take place within. In the case of HIV interventions, a parallel NGO system of care has become ‘grafted’ onto state healthcare (Pfeiffer, 2013), where there are separate procurement and distribution processes for HIV commodities and separate NGO programmes for HIV patients. While I find that HIV NGOs do support government providers, such as by providing staff to help manage the ART clinic, their support is limited to aspects that align with their programmatic goals. Outside of donor priorities like HIV, the conditions of public healthcare are largely left behind. In contrast to NGOs, government healthcare providers struggle with shortages of staff and medical resources as well as the limitations of their facility’s infrastructure. In the context of COVID-19, the conditions of public healthcare gain renewed and dire salience. People in Malawi face a set of compounded risks: risk of receiving inadequate care, risk of COVID-19 infection, and risk of economic devastation during the pandemic.

While findings contribute to our understanding of the impact of COVID-19 in Malawi, there are some limitations to note. The descriptions of HIV and prenatal care come from the perspective of healthcare providers, who may be more likely to give positive accounts of their work with patients (Bergen & Labonté, 2020). This study did not examine patients’ perspectives and experiences with healthcare, which, as other research suggests, likely differ from providers’ accounts (Mattes, 2011; Vernooij & Hardon, 2013). In addition, the heavy reliance on HIV NGOs described in this paper is more prominent in Malawi’s urban centres, where there is greater concentration of NGO programme headquarters and HIV clinics (Swidler & Watkins, 2017). In rural regions, where most people live, there is less concentrated NGO presence, which suggests that the contrast between NGO and state-led care will be less distinct. While entries from the Malawi Journals Project provide insight into people’s experiences during COVID-19, the data is limited – analysis has not reached saturation and results are not generalisable to the country. It is also possible that journalists were biased in the conversations they documented, choosing, for instance, events that they thought were more interesting (Conroy et al., 2013; Kaler, 2004). Future qualitative research, such as those drawing on in-depth interviews, can deepen our understanding of experiences during COVID-19. And quantitative surveys, some of which are already underway, can provide nationally representative findings on the impact of the pandemic (Banda, 2020; Kohler, 2020).

My findings lend support to scholarship on how neoliberalism continues to influence global health but in less overt ways. As others have noted, neoliberalism has become embedded in various healthcare metrics (Adams, 2016; Erikson, 2016; Wahlberg & Rose, 2015) and practices like using cost-effectiveness analysis to determine disease priorities (Birn, 2009; Sparke, 2017; Storeng, 2014). Building on this work, I show how neoliberalism has become routinized, where it shapes the structure and routines within healthcare facilities. The divide between NGO and state-led care is a part of everyday clinical practices, where NGO and government providers work side-by-side but in very different ways and with different implications for patients. Additionally, the challenges that government providers faced reflect both the historical and continued influences of neoliberalism. Structural adjustment policies in the 1980s and 90s damaged Malawi’s healthcare system, leading to decreased government spending on health, stockouts of drugs and supplies, and loss of healthcare workers (Kalipeni, 2004; Wendland, 2010). While these policies are no longer enacted, the role of the state continues to be diminished as donors rely on NGOs to design and implement health programmes. NGO-based case may lead to certain improvements in health, but it leaves fundamental aspects of public healthcare behind. The COVID-19 pandemic is a moment to think critically about neoliberal ideas in the global health field and to address the ‘programmatic blindness’ that has occurred around the foundations of care (Keshavjee, 2014).

There is still much uncertainty around COVID-19 and how it will impact countries in Africa. The WHO African Region reports over 3.3 million COVID cases and over 84,000 deaths as of May 2021 (WHO, 2021b). As Nachega et al. (2021) note, the HIV pandemic provides important lessons for responding to COVID-19, one of which is that ‘biomedical advances alone are insufficient to sustainably control a pandemic’ (p. 3). Public health interventions need to consider not only COVID-19 treatments and vaccines, but also health infrastructure, local epidemiology, and local concerns and beliefs. HIV organisations can and have already begun to contribute to these efforts, for instance, by assisting with emergency procurements of testing, PPE, and hand washing materials (Global Fund, 2020; Loembé et al., 2020; UNC, 2020). As vaccines are starting to roll out, it is possible for HIV community health workers to be trained to provide information and assist with vaccine distribution (Nachega et al., 2021). And, as my findings suggest, experience with HIV may also provide the public with a framework for making sense of and responding to COVID-19.

But the COVID-19 pandemic also brings into stark relief the importance of strong public healthcare systems. While acknowledging the growing commitments from donors to support health systems strengthening, my findings suggest that even more needs to be done. Healthcare facilities continue to struggle with resource shortages. In the context of COVID-19, it is understandable that community members worry about the ability of their healthcare system to treat patients and to protect staff, patients, and families from infection. Systemic issues, like shortages of staff and medicine, matter for a range of conditions as well as for addressing new disease threats. Other research findings raise similar concerns. The Malawi Emergency and Critical Care (MECC) Survey showed that supplies of ventilators and oxygen in public hospitals were extremely low – for instance, there were only 16 working ventilators across the four central (tertiary) hospitals in the country (Sonenthal et al., 2020). Additionally, Munharo et al. (2020) commented on how laboratory facilities in Malawi are struggling with COVID-19 testing because of poor infrastructure, irregular water supply, insufficient electricity, and lack of equipment and reagents (Munharo et al., 2020). As vaccines are distributed, infrastructural issues like inconsistent electricity may pose a challenge to storing certain vaccines, such as the mRNA-based Moderna and Pfizer-BioNTech, which require low-temperatures (Nachega et al., 2021). Without addressing systemic issues, solutions to new pandemic threats will necessarily be ad hoc and emergency measures. There is both urgent need for short-term interventions to minimise COVID-19 infections, treat patients, and distribute vaccines as well as rigorous long-term efforts to strengthen healthcare systems to improve population health and prepare for emergent diseases in the future.

Acknowledgements

This paper received valuable feedback at multiple stages of development from Elizabeth Bernstein, Karina Chavarria, Deisy Del Real, Nicole Iturriaga, Mirian Martinez-Aranda, Angela Simms, and Catherine van de Ruit as well as the anonymous reviewers for Global Public Health. Special thanks to the healthcare workers in Malawi who generously shared their experiences with me and to the journalists and organisers of the Malawi Journals Project for their work in documenting experiences during the HIV and COVID-19 pandemics.

Disclosure statement

No potential conflict of interest was reported by the author(s).