Moral hazards and Moral Economies: The Combustible Politics of Healthcare User Fees in Malawian History

The history of user fees in colonial Nyasaland and postcolonial Malawi demonstrates that public sector medical services have long had moral and political import. During the colonial era, British officials in the peripheral protectorate of Nyasaland provided free (if sparse) healthcare for Africans. This investment sought not only to improve labour supply and productivity, but also to address a growing concern that cosmologies of vernacular healing helped to mobilise political resistance. Biomedical services for Africans expanded after the mchape anti-witchcraft movement of the early 1930s, and again during World War II. In 1964 British demands for fiscal retrenchment as a condition of independence spurred Prime Minister Hastings Kamuzu Banda to institute user fees on the first day of Malawi's independence. Popular resistance to the fees contributed to a political crisis that resulted in the resignation of many of Banda's advisers. Postcolonial Malawi's persistent investment in hospitals over primary and preventive health services, its conciliatory foreign policy toward racist regimes in southern Africa, and its refusal to institute health fees for much of the neoliberal era are comprehensible only in light of this history. This moral and political genealogy of health financing challenges the tendency in health economics to ‘de-moralise’ politically combustible policies such as user fees.