Stakeholders’ Perceptions Towards the Anticipated Introduction of the National Health Insurance Scheme in Malawi

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Implementing the NHIS plays a crucial role in advancing toward UHC and has the potential to strengthen health systems. This study aimed to explore stakeholders' perceptions regarding the anticipated introduction of the NHIS in Malawi. Methods The study employed an exploratory qualitative study design. A purposive sampling technique was used to select 20 participants who were involved in in-depth interviews. All the interviews were recorded and transcribed verbatim. Data was analyzed using thematic content analysis with NVIVO software. Results The study findings revealed that most participants demonstrated knowledge of the NHIS and its benefits to Malawi. Generally, the findings showed that the anticipated NHIS aligned with the participant’s positive expectations and was seen as a critical step towards making advancement in efforts to generate domestic health funding and lessen the reliance on foreign donor assistance, and enhance self-sufficiency in addressing the healthcare needs of people in Malawi. However, the study identified several challenges to the feasibility of implementing the NHIS in Malawi, including a weak economy, stakeholder conflicts of interest, contradictory regulations and policies, and insufficient stakeholder engagement. Additional barriers include political obstacles, corruption, insufficient human resources, inadequate technology infrastructure, high poverty and low literacy levels, pervasive myths/misconceptions, community resistance, and reliance on free public health services. These challenges complicate the establishment, implementation, and sustainability of the NHIS. Conclusion These findings will help to build momentum and consensus for the readiness and willingness among diverse stakeholders, prompting the government to prioritize and invest in NHIS to strengthen the health system. They also highlight that the introduction of NHIS relies on intricate factors in the policy making process, aiding policymakers and stakeholders in making informed decisions. National Health Insurance Universal Health Insurance Universal Health Coverage Malawi Developing Countries Introduction As countries are striving to achieve Universal Health Coverage (UHC) targets of 2030, Malawi through its Health Sector Strategic Plan (HSSP) III emphasizes the importance of promoting financial risk protection through the introduction of a well-set governed architecture for financial mobilization which is a National Health Insurance (NHS) [ 1 ]. Health outcomes in many developing countries, particularly Sub-Saharan African (SSA) countries such as Malawi, remain poor [ 2 ]. Globally, 400 million people lack access to quality essential health services because of insufficient health budget allocations [ 3 ]. This leads to an unequal distribution of healthcare services, inadequate infrastructure, and inadequate supply of drugs, particularly in rural areas, resulting in poor health outcomes [ 3 ]. The introduction of a national health insurance scheme (NHIS) has emerged as a potential solution to address poor health indicators and achieve both UHC and Sustainable Development Goals (SDGs) [ 4 ]. The public sector dominates the Malawian health system, accounting for 68% of free healthcare services. However, the total health expenditure of 8.4% aligns differently with the formulated health strategies [ 5 ]. Dependence on donor aid is a significant aspect of the health system, constituting 54.5% of the total health budget [ 5 ]. In recent years, the donors have reduced support from 57.6% (2017/18 fiscal year) to 54.5% in 2023 [ 6 ]. The health budget must adequately provide quality health services as outlined in the proposed strategies. For instance, HSSP III sets forth priority-planned activities for achieving UHC by 2030, with an estimated budget of 4 billion dollars for 2024–2025. However, the budget was trimmed to a mere $ 537.1 million, significantly insufficient compared to the ambitious 11-game charger priority reforms aimed at improving health status, financial risk protection, and client satisfaction. Consequently, the available health funds will need to be more adequate to fulfill the vision outlined in HSSP III, leading to the inability to execute various planned activities due to insufficient funds [ 1 ]. Countries adopt varying designs and implementation plans for their NHIS based on the local context agreed upon by stakeholders [ 7 ]. NHIS in African countries is predominantly driven by the government, with voluntary enrolment being the norm. Government-led schemes do not exhibit fragmentation in pooling, except in a few countries, such as Kenya, where NHIS is divided into formal (civil servants), informal, and general. In Sudan, the NHIS comprises 18 schemes, each corresponding to a state. Some countries, such as Ghana, have implemented NHIS with compulsory enrolment and contributions [ 8 ]. Despite differences in income earning, universal contributions have been observed between the rich and the poor in other countries, such as Algeria and Rwanda [ 8 ]. However, NHIS does not provide evidence of achieving UHC, as even implementing countries like Ghana and Nigeria have not yet attained a 100% UHC index score [ 2 ]. Stakeholders often need to agree on key aspects such as implementation and design, including contribution fees, identifying the poor population, selecting the health facility providers for the scheme, pooling models, mechanisms for pooling revenues from the informal sector, and the scheme's objectives [ 9 ]. Drawing lessons from Benin, interested countries are encouraged to thoroughly consult and engage all stakeholders, ensuring their interests are respected and agreed upon, to gain full support and participation in successfully introducing NHIS [ 10 ]. Despite these positive attributes, certain factors negatively impact NHIS policies and implementation plans. For example, the NHIS faced challenges in Benin after the ruling government lost parliamentary seats following its first term, leading to its suspension due to stakeholders’ conflicting ideas [ 10 ]. Research studies reveal that the challenges of NHIS primarily originate at the policy formulation level, driven by economic constraints, social factors, political power dynamics, inadequate stakeholder consultation and engagement, poor collaboration between government sectors, over-reliance on international decision-making, limited community and local authority involvement, and insufficient utilization of evidence-based decisions [ 11 ]. Another area for improvement in the policy environment is poor criteria for identifying poverty, with some countries relying on international standards [ 12 ]. This study therefore sought to explore stakeholders' perceptions' on the anticipated introduction of NHIS in Malawi. Methods Study Design and Setting This study utilised an explorative qualitative study design and was conducted in Lilongwe district, of Malawi between October 2023 and January 2024. Lilongwe was selected due to its status as the capital city and the concentration of key stakeholder offices, which facilitated easy allocation and accessibility of stakeholders. Study Population The study targeted a diverse group of health stakeholders with knowledge, expertise, and involvement in formulating and implementing health strategies and policies in Malawi. These included health policymakers from Ministry of Health and Population (MoHP), health managers, Health Development Partners (HDP) and Health Donor Groups (HDG), private medical insurance schemes, academic and research institution managers, Civil Society Organizations (CSOs), local authority leaders from Lilongwe Council, private hospital representatives, and representatives from the Christian Health Association of Malawi. Sample Size The study involved 20 participants who were selected using a purposive sampling technique. The investigator used a stakeholder mapping analysis matrix to select the study participants. Data Collection and Analysis Data collection was conducted through in-depth interviews using an interview guide consisting of open-ended questions, simultaneously it was in the English language as all stakeholders were proficient. The interview guide was developed solely for the study and is attached as a supplement document. The lead author conducted the data-collection process, as part of her master’s thesis. Before the interviews, the participants provided written and verbal consent. On average, each interview was scheduled for 45 min per participant. The last author (supervisor) reviewed the interview guide before actual data collection, ensuring the trustworthiness and accuracy of the interview guide. Pretesting of the interview guide was done in Blantyre city with two conveniently selected stakeholders to assess the validity and reliability of the interview questions to identify errors and unclear questions. The pretest aimed to help refine the interview guide by collecting identified mistakes and accurate for clear data. All interview was recorded and transcribed verbatim. Interview recordings and transcriptions were kept on a password-protected Google Drive, while transcribed notes and signed consent forms were locked away in a safe cabinet. NVivo 12 software was used to analyze the transcribed data using a thematic analysis approach. The data analysis focused on four policymaking components: content, context, process, and actors. The policy-making triangle conceptual framework enabled a comprehensive understanding of the various dimensions influencing the policymaking and formulation processes. Results Demographic characteristics of the study respondents. A total of twenty respondents participated in the study. Table 1 presents the demographic and professional characteristics of the participants. Table 1 Socio-demographic and Professional characteristics of respondents CHARACTERISTICS NUMBER OF PARTICIPANTS Gender Male: 14 Female: 6 Years of experience More than 2 years: 18 Less than 2 years: 2 Position held at the organisation Seniors: 14 Deputies: 6 Sector of origin Private: 12 Public: 8 Cadres/Professions positions by organisation Academia (University Registrar) = 1 CHAM hospital director = 1 Private hospital director = 1 Health Donor Group Partners = 5 private health insurance manager = 1 CSOs managers = 2 CHAM secretariat administrator = 1 MoHP managers = 2 Ministry of Finance manager = 1 Local authority manager = 1 Health Manager(public hospitals) = 3 Local Research Committee = 1 Participants’ Knowledge of NHIS Knowledge of NHIS was assessed by asking the participants to explain what they knew about NHIS. With regards to the definition of NHIS, some participants defined the NHIS as a government-led medical scheme initiative, while others defined it as one of the UHC initiatives aiming to achieve the SDGs by 2030 and were quoted as follows: "I think it's a universal health coverage initiative to make health services accessible, affordable to all without people spending much money or failing to access services at the point of need.” (Participant 11, Private Insurance Company). "It's a public insurance scheme where in countries implemented the public can receive health services paid by their insurers.” (Participant 18, Health Donor Group). “I just heard some rumours about it that government will want to introduce, at the hospital through MASM medical scheme.” (Participant 2, Academia) Participants were further asked to give their view in how the envision the implementation process for the HHIS. Most participants explained that NHIS in Malawi would be implemented in the following ways: civil servants will pay through their payroll, others said that forms were filled with those only willing, only those living below the poverty line will be subsidized 100%, the insurance will be responsible for hospital bill payments, and that it aims to cover every Malawian. Some of the participants were quoted as follows. “… if possible in the future the government wishes to introduce medical insurance just like MASM so that if you visit a hospital you should receive health services as with MASM beneficiaries. So the bills will be going to government insurance.” (Participant 1, CHAM facility). "I've just heard that the government wants to introduce a system that is going to subsidize here the services to people that are below the poverty line and also introduced some funds that are not disclosed so that the people that are above it can contribute as a way of boosting the health finance budget.” (Participant 7, Local Authority). "We will be given forms to fill out by the HR department.” (Participant 8, Research Committee). Participants’ were further asked to share their knowledge about NHIS in other countries. Most participants explained that different countries introduced NHIS in different models, whereas in other countries, the agreed premiums are subsidized to the beneficiaries. Other participants also explained that other countries are in the process of introducing the scheme, whereas others give examples of countries implementing the NHIS and its policy content. Other participants explained that Malawi did not have an NHIS. Below are some quotes that support this view. “From the way I understood it from the different countries, it takes different models.” (Participant 11, Private Health Insurance). "I've heard about it as South Africa is about to introduce to its citizens but for Malawi, I don't think we have that scheme.” (Participant 10, Health Donor Group). Furthermore, participants were asked about the sources of their information regarding the NHIS. They mentioned several sources, including international newspapers, workplace meetings, research articles, government meetings, and briefings with human resources officers during the civil servant scheme with MASM. Other sources included the launch of the Health Sector Strategic Plan (HSSP) and research presentations when seeking support letters. Some participants noted that they had not heard of the NHIS until the invitation for the interview. A few participants were quoted as follows: “No, not yet until I read from that consent form you gave to me.” (Participant 15, MOH Health Manager). "I have read it in certain articles I think it was a paper but not here in Malawi. It says that it is a policy to be implemented by the government of the South where people will be able to access health services at hospitals including private by contributing a certain amount because they want to improve the availability of healthcare services to all South Africans.” (Participant 13, Private Hospital). Reasons for Introducing the NHIS in Malawi Participants were asked to provide reasons for introducing in Malawi. They cited various reasons, including increasing access to health services, enhanced fund mobilization, promotion of equality in healthcare services, health systems strengthening, improving quality care, and reducing financial hardship. Some of the participants were quoted as follows. "It aims to mobilize funds, improve quality services, and expand it to the entire population for universal quality health care access.” (Participant 16, MOH). "Assist individuals that have that have different financial backgrounds so that they can access the same healthy services.” (Participant 12, Health Donor Group). "Through the understanding as any other health scheme is that it gives you security in terms of your health needs when you are sick and helps you so that you don't have a problem in accessing healthcare at the point of need without fear of fee since you already paid.” (Participant 5, CHAM). Stakeholder’s Roles in Introducing the NHIS in Malawi The study explored the views of stakeholders’ or actors' roles in introducing the anticipated NHIS in Malawi, covering aspects from policy formulation to implementation, expansion and sustainability of the scheme. Most of participants described their proposed roles as involving the provision of resources, funding, data management, trainings and education sessions, and ensuring access to target populations. Additionally, they propose roles also included providing advisory support, advocacy for broader participation, raining public awareness, regulating professional ethics, facilitating policy and reforms, and promoting collaboration among stakeholders. Additionally, they mentioned, harmonizing various initiatives towards a common goal, delivering direct health care, conducting research, protecting human rights, ensuring patient satisfaction, sharing experiences, supporting other sectors in their NHIS related duties, initiating benchmarking with other countries, serving on management teams, pay premiums for those unable to do so, coordinating all health systems under CHAM and representing them to the NHIS policy discussions, enforcing evidence-based research practices, advocating for vulnerable populations, and conducting monitoring and evaluation activities. Below are some quotes that illustrate these points. "People will easily accept it as they will act as advocates for awareness, with resources for example WHO help us with funds so it will not be hard for them to provide support to reach every Malawian.” (Participant 20, Health Donor Group). “If they can involve big companies like the bank institutions, Illovo, with an idea that these are informal sectors with workers. So they can be part of this by allowing to pay the premiums on behalf of their workers directly to national health insurance which will make it easy to collect contributions from the private sector. Also, these big companies can support the introductory part and sustainability with resources, expertise, and even awareness because they have already a community under their influence. So, consider all those big and small non-government profit companies in the informal sector that way it will not be easy to mobilize premium from the huge informal sector.” (Participant 2, Academia). Participants were further asked to provide reasons for their proposed roles. Most participants viewed their roles as beneficial, as they would help Malawi achieve UHC goals by 2030, while other participants believed that their contribution would aid in improving health outcomes. "My role is to mobilize others so that they can join the scheme because other medical schemes are expensive and as an individual, I will make sure to be part of the development to be able to access better services when I am sick.” (Participant 17, MoH Health Manager). "We would be able to cover more hospitals as of now we cover few district hospitals. But then when we have the scheme of equity we will be able to cover also support our services as you we focus on people with a particular character in terms of health so will also be in touch with those in private or CHAM hospitals universally, so we will be able to reach out to more hospitals as well for the scheme will make us work with various sectors to improve health goals in the country.” (Participant 12, Health Donor Group). Other participants’ roles will depend on various conditions; namely, if private medical schemes are involved, their interests will be included, and how they will be introduced. Some participants were not sure which roles they would take regarding their institution’s complex activities. The attached quotes support this statement. “I think we may not have a direct role as pay say but a variety of roles. When it comes to national health insurance, there are a couple of issues that we are already doing indirectly. We are currently covering the universal care agenda, where its role is to protect the poor. What it focuses on is ensuring that healthcare services are affordable to the poor; we are empowering communities with resources, education, awareness campaigns, and even fighting for human rights. So, national health insurance when it comes to us we will work to protect the public.” (Participant 18, Health Donor Group). “Not directly sure if we as private will be incorporate, it will depend from the private hospital job description indicated on its policy.” (Participant 13, private health institution). “It depends on how the government puts it or tries to enrol it. Thus, the role of private insurers is not clear, but it may become supplemental in the sense that those benefits that are not covered by the government then probably??? Private health providers will come in as supplemental, but it depends on how well the government will enrol it and what the national health insurance will constitute to whether it would be comprehensive or basic. Thus, the actual role of private health insurance is known, depending on how the government enrols the nation's health insurance. Therefore, it is difficult to say what role med health will play because it is not yet known what the provision in the initiative insurance will take as comprehensive or basic. Therefore, for now, it is a little bit difficult to speculate what the role of private health insurance will be unless it will be involved and our interests too are met because we are a private company we need money to run we have no donors as the government is therefore our interest is our priority thing in any partnership.” (Participant 11, Private Health Insurance). The private and other government sectors were not sure which roles to assume, as they stated that their duties followed job descriptions. Thus, they perform any role that will be stated in their job description, as supported by the quotes below: “I think as a government institution our role will be described during the policy formulation but for now will continue doing our role as a ministry carrying our duties as usual but since we are the main driver to the proposed national scheme we will work together with other sectors to make this happen because the intervention to be on strategic plan means it has gone under scrutiny and proved to be the best idea.” (Participant 9, Public Sector). "OK my role on the scheme though am not sure but I believe as a health worker and managers we will continue with our daily duties of direct provision of care, education, informing, communicating, advocating, manage. There are so many, but I will also ensure that this scheme is followed appropriately, and that the policies concerning the scheme are implemented. As a leader will make sure my fellow health workers work within our job description jurisdiction.” (Participant 15, MoH Health Manager). Proposed Stakeholders or actors for the NHIS in Malawi Participants were asked to proposed the key actors for NHIS in Malawi. The participants suggested that the following actors or stakeholders should be involved in introducing NHIS in Malawi: health donor groups, academia, business people and companies, the community, existing private medical schemes, government sectors, NGOs, politicians, private health facilities, the private sector, regulatory bodies, religious health institutions, and religious leaders. The following are quotes that support this information. "This scheme will be the major reform ever in the history of Malawi a lot will happen and conflicts are anticipated therefore as long as they are here in Malawi are responsible for making it happen whether being in the field of marketing, agriculture, you know even crypto-currency system I believe will have an impact so all sector representatives will be incorporated.” (Participant 9, Public Sector). "I can say like most of the community leaders because the community leaders can help in making an awareness to their people that are surrounding their villages to encourage them to participate to the medical schemes, even the religious groups, because mostly the religious groups, we have different beliefs, these group of leaders naturally are listened to they make an impact on influence, I remember in our projects back then on net use and fertility, men were refusing so we had to ask the chief in our second village to speak to their people before we interview them, I can tell how they were responding even others were waiting and following us for interview.” (Participant 10, Health Donor Group). When probed on which stakeholders they perceived to be at the forefront of the scheme to succeed, one participant responded to the government, specifically the MoH sector, as explained in the quote below: “So, I think the government should be the main stakeholder so that its policy can be passed easily in parliament to allocate more support and resources.” (Participant 20, Health Donor Group). Anticipated challenges with suggested actors Some participants explained that there is a need to anticipate collaboration and engagement challenges because of the large number of stakeholders from various institutions that may be involved in the introduction of NHIS in Malawi. The following quote shows how the participant explained the anticipated challenge. "I can foresee this because companies are looking for customers so with providing services across the larger capacity in terms of customers I can see conflicts and disagreements. Yes, private like xxx, xxx they will fight because they will be in completion not favouring them.” (Participant 17, MoH Health Manager). Perceptions on Power dynamics When participants were asked about their anticipation regarding power dynamics, several responded affirmatively for various reasons. These included conflict of interest among stakeholders, issues related to corruption, the complexity of health determinants as perceived by stakeholders, the influence of government powers and politics, the classification of services, or packages for those receiving 100% subsidies, negative perceptions of private hospital— as they are perceived to attract more customers than public facilities, and concerns about how roles will be allocated, the stakeholders involved and a general fear of unknown among stakeholders. This is illustrated by the following statements: "Conflicts are anticipated due to different business ideas and interests. Private insurance companies are there for profits and the government is trying to bring in an NHI initiative and try to leverage the access to this for the poor trying to balance the inequity formula that everyone else should have access equally to health services.” (Participant 11, Private Health Insurance). "Yes, yes in Malawi we have a lot of stakeholders who don't agree mostly with matters of health due to the complexity of factors affecting health , you know we work in isolation everyone immersed in their ideas which they think will work.” (Participant 12, Health Donor Group). Some participants stated that the anticipated power dynamics are anticipated to occur for various reasons at different stages during the introduction of the scheme and are deemed to fail if they are not properly managed, as explained in the following quotes: "It is anticipated even the government knows. Cause if we are talking about National Insurance, you have given an example of the private medical insurance that is in Malawi, and they are therefore for value of money. However, If National Insurance is being introduced, the government needs to ensure that their services are also a bit equal to the services that are provided in the private facilities to match the standards and that they also benefit from the products of the scheme.” (Participant 10, Health Donor Group). "I think there would be some power conflicts from the first time especially at the beginning.” (Participant 12, Health Donor Group). Some participants were unsure, and others denied the existence of power dynamics among stakeholders during the introduction of the NHIS for other reasons, as stated in the quote below. "I don't think so. Maybe when we start because we are already working with these stakeholders and the strategic plan was developed with their input so they cannot back-fire the decision made by them maybe power influence will be noted after it starts, but for now, I do not think so.” (Participant 16, MoH Health Manager). "I don't think there will be differences in power because I believe they will be a mechanism to spread equal power.” (Participant 2, Academia). When asked about interventions to prevent and reduce the anticipated power dynamics, some participants suggested several measures. These included the development of policies to guide the NHIS's operation, the establishment of a task force or committee, benchmarking practices and equitable distribution of roles among all stakeholders. They emphasized that the committee should be chosen by the stakeholders themselves and ensure equalization in terms of health service quality among public and private health facilities, as well as balanced power among stakeholders. Additional recommendations included raising vibrant awareness, creating terms of reference or memorandum of understanding to guide stakeholder interactions, formulating a comprehensive roadmap, establishing effective communication channels throughout the process, incorporating the NHIS within legal documents in Malawi for legal backing, and developing strategies to address the needs of all stakeholder. Below are some of the quotes reflecting the participants’ responses. "As I already said the equal share of responsibility by the committee or task group should be located at all levels. Centrally, leaders going to the district committee should be presented at all levels, from central offices to the community, with all stakeholders being presented. This influences accountability and response abilities. On sharing the roles, you know every member of the scheme you know will abide by their role as being responsible for serving Malawi people at the same time strengthening the system of health.” (Participant 6, CSOs). "Before it is introduced, it is necessary to clarify what and how it will be run. Because some of the needed representatives are from private institutions, if this is going to be a government mandatory insurance without them benefiting it means they will not be involved, meaning another failure; therefore, they need to clarify what will be the role of other stakeholders; however, I believe roles automatically will be distributed, for example health workers they provide services, educate, etc.” (Participant 9, Public Sector). Stakeholder engagement and collaboration Participants were asked to share their views on how the stakeholders will be encouraged to engage and collaborate for the scheme’s success. Some participants responded by stating that there is a need to utilize Memorandum of Understanding (MOU), NHIS policy, and NHIS committee or task force to enforce fairness, rules, and guidance on how conflicts will be averted or dealt with. Some participants suggested that benchmarking, continuous engagement of stakeholders at all levels, awareness, and broader consultation will help develop ways to avert problems or conflicts among stakeholders. The quotes below explain how the participants responded to the question. "For such an initiative to go out, we need to have a steering team to facilitate the activities and share responsibilities altogether. The team should have all sectors representative. The government should be a member equally on decisions as other institutions. Fairness when it comes to decision and respect will be enforced through the steering team.” (Participant 17, MoH Health Manager). "Since this is something that is going to be done nationwide, that means it needs to have TORs that are terms of reference on how best each stakeholder can perform their various roles. If my role is predefined, that means everyone will be working according to what they are supposed to do. For example, there will be no overstepping on others, as stated in the MOUs. Accountability will be enforced and will be equal if we want this to gain more support you know stakeholders are drivers like an engine to every intervention so need to be respected equally so that collaboration will be 100% and engagement will follow.” (Participant 19, Health Donor Group). Proposed Policy Process for the NHIS in Malawi Participants were asked to explain the process how the NHIS policy should be formulated in Malawi. Participants mentioned four main aspects which should be considered i.e. policy content, challenges, and interventions and adoption. Policy content Participants responded to the question by stating that the following aspects need to be considered and included in the anticipated NHIS policy content in Malawi. Some participants stated that issues with bordering countries and refugees need to be addressed. Other participants said that the policy's main priority areas on what to include should focus on contribution fees, different packages, governance issues, collection of revenue, incentives for health workers, identification criteria for poverty, and eligibility criteria. Other participants recommended that the policy should include issues on the resources to run the scheme, other vulnerable populations such as the elderly and children, safety issues, referral systems, stakeholders, and where the collected funds will be kept. The following quote supports the above data: "What I can say essentially is concerning policy, it needs to state clearly in the design who to benefit, the amount to be paid, who will be paying. Where do access services like good referral paths not everyone should come? For example, at xxx, it will exhaust us even at central hospitals only for severe cases with specialist needs. Otherwise, if not written, who, where, and how will we be drained out of resources by people not fit to receive them? In addition, it should not include an age limit like other medical insurance, which does not allow other age groups like the elderly because it will be readmitted to the hospital at a certain time. They need to include these vulnerable people, and the rest cannot access everything unless they pay.” (Participant 13, Private Health Institution). “I don't see as a priority thing here with policy everything is crucial, you know to convince the public and sectors is not easy. So to me regard everything as crucial. We need to have some limits too to avoid abusers so control needs to be included in the policy. On packages as it is done with SLAs we have priority cases like RDS and maternity, so nowadays the trend is that non-communicable diseases are the ones killing a lot of people like BP, sugar so these common diseases should be put in those packages so that the most needed services are always given. Also, there is a need to include availably of resources that is sustainable because we can be talking about premiums while resources are always out of stock so procurement and sustainability of resources.” (Participant 2, Academia). “The people need to decide what they want the policy to include if they want it to be introduced what they want to see on the policy like packages, fees; the needs and those suggestions should be the ones to be enforced and made clear in the policy. Stakeholders can make decisions from those views only to suit the scheme, and it can be easily implemented as communities will understand it; it will act as a reference. Otherwise, minus that, I think it will be just a waste of time.” (Participant 17, MoH Health Manager). Policy process challenges and interventions Some of the respondents mentioned that the stakeholders’ differences regarding their interests, economic status to provide resources to run the policy, and large numbers of public health facilities will be the main cause of conflicts and misunderstanding during the policy formulation process, as supported by the quotes below. “Yes, yes in Malawi we have a lot of stakeholders who don't agree mostly with matters of health due to the complexity of factors affecting health; you know we work in isolation everyone is immersed in their ideas which they think will work. As such, without the reading team chosen by them to enforce the agreed policy, it will be chaos.” (Participant 12, health donor group). “As already hinted, different institutions have different interests and mechanisms on how to achieve goals.” (Participant 11, Private Health Insurance). The following interventions were gathered when probed on how to deal with these challenges so that the scheme could meet its intended goals. These include community awareness, adoption from other policies from existing medical scheme models, benchmarking, enforcing all stakeholders to voice their needs and concerns, equalizing the quality of health systems building blocks match in private and public, modifying and strengthening existing partnerships and structures, developing strategies to avert power dynamics, running the NHIS as a privately owned company, formulating a simple and clear policy, equalizing power between small and big institutions in decision making, harmonizing the NHIS goals to align with local and international health agendas, including vast kinds of stakeholders with different specialties, removing politics, respect, understanding, and appreciating the existence of different perceptions from different stakeholders, letting people owner it through constant engagement, being pro-active with challenges by anticipating shot falls and how to avert them, avoiding bias with the stakeholders involved, utilizing other existing structures and integrating services, and ensuring that existing job descriptions are progressing. The quote attached below supports this information. "Let it be managed like a company. Like how ESCOM is for example, ESCOM is a statutory organization with directors, so national health insurance should run the same. It will need to have directors and its management team; maybe the government should influence the appointments of directors. To understand how the Blantyre water board is run, when we want the water board or ESCOM to repair our faults, we do not go directly to the central government; we go to the institution knowing that it is well established with all its departmental roles well established so that if we have let us say faults with electric poles, we go directly to the poles department. Therefore, if national health insurance needs to be run in a well-distributed manner, everyone will be accountable and responsible for fulfilling their roles in customer satisfaction. Even for the government, I do not think the DC will receive many burdens from people's complaints concerning small matters with insurance; hence, the DC will be able to work within its job description regardless of the insurance scheme, as it is its primary job description. Thus, they will be the proper channel of communication so that issues with registration people can visit that department directly. So it needs to be run like a company well registered with a management team well capable of sustaining it.” (Participant 2, CHAM facility). Policy Adoption Under this sub-theme, participants were assessed to name local and international medical schemes, describe them, and identify areas that would need to be adopted if Malawi introduced the NHIS. Most participants described MASM as their choice of the medical scheme because of how it operates, its technical and strategic, its availability of different packages, its clear policy, started small and is scaling up, innovative ways of coming up with new ways of scaling, involvement with different partners, and expanding their scheme to more hospitals and in remote areas. Some of the participants’ quotes are attached below: "For me, I think national health insurance should adopt and modify existing models like MASM. They need to adopt strategies and technical know-how using these existing schemes. In addition, we need to change the models we currently use to run health facilities; therefore, public health facilities need to be paid for not free access. Therefore, if a person visits Chiradzulu DHO, for example, the hospital needs to produce an invoice, and that bill goes to national health insurance, where the insurance will be paying the Chiradzulu DHO. We will not hear those hospitals suffering and proclaim that we are suffering because we lack funding, and shortages of drugs for the hospitals will be able to generate funds through their services. Same now we are losing as a government, do you know that even people covered by the MASM access health services for free while covered schemes? If the hospital was able to produce this invoice, the scheme could be paying the hospitals.” (Participant 1, CHAM facility). Few participants were able to name international medical schemes but failed to explain how they work and what aspect the Malawi NHIS policy will adopt, as stated by the participant below: "I'm, I'm not sure I think but I heard the one in the UK. I am not sure correctly about its name.” (Participant 12, Health Donor Group). Other participants stated that Malawi needs to develop its policy without adopting existing medical schemes for the following reasons: all medical schemes known receive criticism, most Malawians in urban areas are aware of only MASM, while those in rural areas have no idea about medical insurance, international medical schemes require more funds for it to run, Malawi has few people on private schemes as compared to other countries, and most of the known local private schemes have narrow benefit packages, as explained in the quote below. "Unfortunately, the ones that I read about or appeared on, mostly do get negative reviews for example in the health insurance in the US because, for a person to access most medical services in the US you need medical insurance, and for those who are not covered under this health insurance, it's really difficult for you to get any access to healthcare, especially people who are immigrants and all that. So the positive is I haven't heard of it yet in detail, because I know there are countries like Canada where everyone can access services, but they don't have health insurance. Thus, it's free like Malawi, but it's much better than Malawi because they have the resources to do that. But for us to adopt a system like the one that they're using in the US I don't know what we have to work it out, how we're going to help the people who will not be covered by the insurance.” (Participant 14, Health Donor Group). Existing Policies and Regulations which can support or hinder the Introduction of NHIS in Malawi Most of the participants believed that existing HSSP III, gender policies, Malawi 2063, Malawi poverty reduction policies, MGDS, SDGs, SLA, UHC policy, and those policies that stand for vulnerable populations like children and the elderly will have a positive impact on the introduction of NHIS in Malawi backed up with quotes attached below. “First of all, I would say about the policies that focus on the vulnerable like the elderly and children because these populations are dependent. Moreover, most times children do not receive adequate care at a tender age, they end up having developmental problems when they grow up. The elderly also need more health care because their bodies are weak.” (Participant 4, CSOs). "The 2063 agenda, health, agriculture, manufacturing, security, finance, or I can say all sectors have policies that will be remodelled to fit the scheme as long as these sectors are for the citizens so is the scheme. I cannot say that this policy or that but all policies and regulations whether being it private or public sector, the scheme is eligible and they are the implementers so am sure already that all will suit it not against.” (Participant 7, Public Sector). Some participants explained that the free health care policy negatively affected the introduction of the NHIS introduction. These participants also came up with strategies for overcoming existing policy and regulation challenges, including awareness, reforms of existing parallel policies, aligning the NHIS goals to existing national and international policies, inclusion of the less privileged people like prisoners, aligning the NHIS policy with women championed policies, safe motherhood initiatives, taking advantage of existing structures like NRB, harmonizing all public and private initiatives through the one plan, M&E and budget, and strengthening of local authorities. These data were supported by the participants’ quotes attached below. "The government has been struggling to provide free services to individuals. Therefore, the most expensive service in the world is health, which affects every sector. Thus, providing it for free is a loss to a country. If everybody is made to pay through this insurance, it will return money to the government to procure and provide quality health services.” (Participant 11, Private Health Insurance). "Exactly I wanted to say let's utilize the national ID, the partnership with local and international institutions, the coalition with other countries, inter-sector collaboration, and this called one M&E as said in the strategic plan, we receive a lot of donations in health but we end up duplicating projects lets learn to work as a team and aligning to our strategic plan because the strategy is made for us to achieve the global agendas.” (Participant 19, Health Donor Group). One of the participants believed that there is no existing policy or regulation to negatively influence the NHIS in Malawi, as most policies align positively with each other, as quoted below. "There are policies and regulations that have a lot of positive when it comes to health. Agreements and partnerships with several organizations have increased access to people in remote areas to access healthcare. We obtained funds and resources from institutions such as the WHO, funding, and donations. Human rights civil organizations. They are rules that empower them to protect and support the vulnerable, such as the elderly, and refer to us. Those policies that empower these will make this insurance succeed because the scheme is in support of what is already done only this it for the whole Malawi, not specific community.” (Participant 17, MoH Health Manager). Few participants explained that no policy or regulation will have an influence as reforms will be made before the introduction of NHIS and the reforms will be easily enacted with the incorporation of the NHIS in Malawi's strategic plans, as quoted below. “I don’t think a government can put policies against each other probably if at all slight differences like the one of free services policy by the time the national insurance will be introduced it will be reformed completely.” (Participant 10, Health Donor Group). "I don't think so because most of our policies and regulations always support each other and are made in that way. So, they are strengthening each other, so they are no such to only strengthen one another by the time this scheme will be implemented, and I tell all regulations or policies will be inline.” (Participant 2, Academia). Context and environmental factors Factors to promote NHIS feasibility The study revealed that awareness, benchmarking, disaster preparedness, contingency plans, donor support, subsidization of poor people, harmonization of modern medicine and traditional medicine, incorporation in long-run agendas like MW 2063, mindset and behavior change, strengthening stakeholder involvement and support, supporting poor people to start small businesses, strengthening referral systems, taking advantage of existing structures and initiatives, and introducing complex strategies of contacting people from the informal sector. Below are some of the participants’ quotes in support of this information. "But at first, we need a lot of awareness campaign and we have to let the people know why we are doing that. I think it’s good, it can be a really good initiative if it is handled well.” (Participant 14, Health Donor Group). “But let me give you this I'm looking at this at an average Malawian and right now everything is going up with price. Everything is going up. Then, we introduce another medical fee to them, which will be more burdensome. Yeah. However, we look at job creation and economy in both ways. Thus, if we introduce it, we can win another battle. This is when diverse stakeholders are needed. Experts in various fields and sectors. That's why I said there will be no power inequality because every stakeholder will benefit. There is a lot to win if we implement it.” (Participant 16, MoH Health Manager). NHIS feasibility challenges The study revealed several feasibility challenges that are discussed below. Firstly, it was about the weak economy which was also revealed from a feasibility study that was conducted in 2019 and from other countries who are struggling to introduce and sustain it. The scheme will require new technology infrastructure, additional human resources, and finance to enhance community awareness to curb community resistance and low literacy levels, however with a poor economy the success is doubtable. In addition, due to the poor economy, a large number of people depend on free health care services provided by the public sector which will affect contribution and resistance to reform. Another challenge is poor stakeholder representation and engagement in most of the public policy formulation and decision-making. These resulted in unsuccessful implementation due to resistance by uninvolved stakeholders to support the proposed intervention as their interests are not incorporated hence failure. Furthermore, the uninvolved stakeholders do not support it as their interest contradicts existing regulations and policies. Further, the scheme is proposed to mobilize revenue from all populations which will be not feasible in Malawi. The reason is that a lot of people are from the informal sector where identification for the exempted and techniques for contribution mobilization will be doubted. Political obstacles were also raised to be another barrier. Most politicians include free access to most social amenities like health in their manifestos to win more votes yet the scheme will require universal contributions by citizens. Furthermore, the elected politicians are the ones that pass policies in parliament hence if their agenda is free access then the scheme will be a failure as it will oppose to their interest. Lastly, corruption was deemed to be a hindrance factor. This was noted in people trusting the authorities responsible as corruption cases are high with public firms hence gaining less community involvement. Additionally, high poverty and low literacy levels, and pervasive myths/misconceptions were minor perceived barriers that may hinder the anticipated scheme’s success by participants. The following quotes support this information. "And a lot of people are not contributing anything even they're doing something because we don't have a way of gathering taxes from informal jobs. So, it can be introduced, but I do not see it succeeding for a few years. It will take time for us to adapt that unless we have good mechanisms to identify informal jobs and make way on how to collect the fees because we have a large informal sector.” (Participant 20, Health Donor Group). "Yes. I think the illiterate level is why I said earlier that community awareness and civic education are needed. This imitative will need a mindset, or I can say behavior change. Our culture, especially those deep in remote areas, believes in herbalists so it will not be easy to convert them and join the scheme unless you said the herbalist will also be part of the scheme then fine and good.” (Participant 15, MoH Health Manager). Discussion This study has revealed that most of the participants had knowledge about the NHIS and its benefits which is crucial to the successful design and implementation of NHIS policy because it helps to understand, analyze, and formulate an effective policy to meet population needs and achieve policy agendas [ 13 – 18 ]. Additionally, adequate knowledge curb resistance to existing policy reforms[ 29 ]. Different studies [ 13 – 18 ] have identified that stakeholders needed to understand the NHIS benefits, costs, and how different countries are implementing the scheme for the success of the NHIS [ 18 – 24 ]. However, it was noted that the majority of participants had inadequate understanding, while one participant had no knowledge due unavailability of common information source and it was those in senior position through meeting attendances. The studies that was conducted in Nigeria, Ghana, Kenya and Benin revealed partial or no knowledge of NHIS among stakeholders had a negative influence on policy designing and implementation which led to the suspension of the scheme and low subscription [ 10 , 17 – 26 ]. However, community awareness must be vibrant to curb low education levels because having adequate knowledge of NHIS among stakeholders before implementation does not necessarily translate to a successful introduction of the NHIS and sustainable implementation [ 27 ]. A diverse representation of stakeholders fosters collaboration, support, and respect towards their interests and benefits to the anticipated introduction of NHIS [ 26 ]. These results are similar to those of another study conducted in Ghana and South Africa, which explained NHIS stakeholders' diversity for successful policy design and implementation [ 23 – 24 , 28 ]. The participants suggested key stakeholders for the anticipated introduction of NHIS and most had already existing partnerships with the MoHP like donor health groups (WHO/UNICEF). whereas some recommended non-direct health institutions such as business companies and estate agencies, and assumptions were made that they should be from both the local and international institutions irrespective of size and influence using stakeholder analysis tools that will ease identification and management [ 22 ]. Further, the study revealed the anticipation of power dynamics among stakeholders due to disagreements on policy implementation as a large number of stakeholders will be involved. These findings resonate with other studies that were conducted in South Africa, Ghana, and Afghanistan where conflicts among stakeholders were due to having different interests and perceptions of the agendas by making the NHIS meet their organizational goals [ 23 , 28 , 29 – 30 ]. The proposed solutions were equal power in decision-making, incorporation of every stakeholder's interests, implementing from a small scale, and scaling it up to mention a few. Adei et al. affirms the reason for Ghana's successful implementation while the study by Passchier South Africans’ delays in the introduction of NHIS due to conflict of interest [ 23 , 28 ]. Other studies show that continuous engagement among stakeholders, awareness, political will, policy reforms, and integration, utilization of existing structures, disaster preparedness, entrepreneurship, and innovation resulted in the successful implementation of an NHIS, and all studies likely resonate with them [ 9 , 13 – 15 , 17 , 21 , 31 – 33 , 29 – 38 ]. Drawing on the inductive approach of thematic analysis, the interpretative findings suggest that a successful NHIS policy design and implementation will depend on a complex interplay of factors, such as clear policy content, actors, community awareness, alignment with national strategic plans, and reliable financing [ 39 , 28 ]. The diversity of stakeholders prompts continuous support, collaboration, and engagement that will enhance good governance, resource mobilization, and expertise. The study conducted in Ghana identified poor stakeholder participation as a challenge for sustainability, and so did Agyepong et al who recommended that clear policy content [ 9 , 14 ]. The study recommends that Community awareness, improvement of quality health care, and equal decision-making among stakeholders have been suggested as interventions to address these challenges. These align with study results from Ghana’s experience and South Africa struggles for the introduction [ 9 , 30 – 34 ]. Benchmarking as a solution was controversial by participants as they argue that community context is key to policy design. This align to WHO and a study conducted in eight sub-Saharan countries (Gabon, Ghana, Rwanda, Benin, Kenya, and Nigeria), showed that NHIS policy should be designed according to the local community context, and having priority policy content taking into account existing health system structures as the implementation process with NHIS is costly [ 2 – 3 , 10 , 34 – 39 ]. However, studies conducted in NHIS-implemented countries align with Christmals et, which concluded that the policy process had no priority aspect area and most LMIC profiles are similar [ 8 – 10 , 13 – 14 , 17 – 18 , 20 ]. Study Limitations Some intended participants and institutions were unable to be part of this study due to their demanding working schedules during the data collection period, despite their initial agreement to participate in the study. Additionally, other institutions declined to participate for reasons known only to them. This may have resulted in the exclusion of certain views, experiences, and perceptions from stakeholders and institutions. However, the purposive sampling qualitative design of the study allowed for an in-depth understanding of the stakeholder perceptions in Malawi, as participants and institutions were substituted. Those with tight schedules delegated their responsibilities to individuals who met the study criteria. Therefore, there is no reason to believe that the study participants significantly differed and the validity of the study remains intact Conclusion Analyzing stakeholders' perceptions regarding the introduction of NHIS in Malawi has provided valuable insights into their perspectives, shedding light on the factors contributing to the anticipated success of the NHIS introduction and implementation. The NHIS had proven to strengthening health systems and facilitate the achievement of universal access to quality healthcare services in developing countries. The anticipated NHIS met participant’s optimism and was seen as a critical step towards mobilizing health funds and relieving nations from donor aid overdependence. These findings have leveraged to build momentum and consensus for the readiness and willingness of diverse stakeholder’s, hence encouraging the government to prioritise and invest in NHIS to bolster the health system. The study findings have also demonstrated that the introduction of NHIS is dependent on a complex interplay of factors surrounding the policy-making process. These will help policymakers and stakeholders navigate the complexity and make informed and effective policy decisions. In addition, the anticipated NHIS provides a role of strategic fund mobilization which demonstrates innovation for secure and sustainable health funding options. Further studies should be conducted with other specific types of groups on a larger scale, involving a wider range of stakeholders. Additionally, quantitative studies on the NHIS should be undertaken to complement the existing qualitative findings. Abbreviations CBHI: Community Benefit Health Insurance, CHAM: Christian Health Association of Malawi COMREC: College of Medicine Research and Ethics Committee, CHE: Catastrophic Health Expenditure, DPP: Democratic Progressive Party, HSSP: Health Sector Strategic Plan, KUHES: Kamuzu University of Health Sciences, LMICs: Low and Middle-Income Countries, MoHP: Ministry of Health and Population, NHA: National Health Accounts, NHFS: National Health Finance Strategy, NHP: National Health Policy, NHIS: National Health Insurance Scheme, OOP: Out of Pocket Expenditure, PPS: Purchaser Provider Split, SHIS: Social Health Insurance Scheme, SSA: Sub-Saharan Africa, THE: Total Health Expenditure, WB: World Bank and WHO: World Health Organisation. Declarations Acknowledgements The authors would like to thank all the participants for their contributions to this study. We would also like to acknowledge key informants from the Ministry of Health for their contributions. Author Information: LN conducted this study in partial fulfilment of her Master's Degree in Business Administration in Health Systems and Management at Kamuzu College of Health Sciences (formerly known as the College of Medicine, University of Malawi). IKC supervised the study. She is a health systems researcher and senior lecturer in the Department of Health Systems and Policy, School of Global and Public Health at Kamuzu University of Health Sciences Authors’ Contributions: LV conceived the research idea, designed methods for the study, collected and analyzed data, and drafted the manuscript. IKC supervised and directed the planning, and designing of study methods, data collection, and analysis. She also contributed to and supervised the writing of the manuscript. Both authors read and approved the final manuscript. Ethics approval and consent to participate: Ethical approval was obtained from the College of Medicine Research and Ethics Committee (COMREC) in Malawi; and was conducted following the declaration of Helsinki and the international guidelines for Good Clinical Practice (GCP). The ethics approval reference number is P.07/23-0157. Informed written consent was obtained from the study participants. The participants indicated their willingness to participate in the study by signing or placing their thumbprint on the informed consent sheet. Anonymity and confidentiality were ensured by using code names in the data collection materials. Privacy was ensured by conducting the interviews in a private place. Consent for publication: Not applicable. Data availability: Data is available upon request Conflict of interest: The authors declare that they have no conflict of interest. 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Health outcomes in many developing countries, particularly Sub-Saharan African (SSA) countries such as Malawi, remain poor [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Globally, 400\u0026nbsp;million people lack access to quality essential health services because of insufficient health budget allocations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This leads to an unequal distribution of healthcare services, inadequate infrastructure, and inadequate supply of drugs, particularly in rural areas, resulting in poor health outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The introduction of a national health insurance scheme (NHIS) has emerged as a potential solution to address poor health indicators and achieve both UHC and Sustainable Development Goals (SDGs) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The public sector dominates the Malawian health system, accounting for 68% of free healthcare services. However, the total health expenditure of 8.4% aligns differently with the formulated health strategies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Dependence on donor aid is a significant aspect of the health system, constituting 54.5% of the total health budget [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In recent years, the donors have reduced support from 57.6% (2017/18 fiscal year) to 54.5% in 2023 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The health budget must adequately provide quality health services as outlined in the proposed strategies. For instance, HSSP III sets forth priority-planned activities for achieving UHC by 2030, with an estimated budget of 4\u0026nbsp;billion dollars for 2024\u0026ndash;2025. However, the budget was trimmed to a mere \u003cspan\u003e$\u003c/span\u003e537.1\u0026nbsp;million, significantly insufficient compared to the ambitious 11-game charger priority reforms aimed at improving health status, financial risk protection, and client satisfaction. Consequently, the available health funds will need to be more adequate to fulfill the vision outlined in HSSP III, leading to the inability to execute various planned activities due to insufficient funds [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCountries adopt varying designs and implementation plans for their NHIS based on the local context agreed upon by stakeholders [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. NHIS in African countries is predominantly driven by the government, with voluntary enrolment being the norm. Government-led schemes do not exhibit fragmentation in pooling, except in a few countries, such as Kenya, where NHIS is divided into formal (civil servants), informal, and general. In Sudan, the NHIS comprises 18 schemes, each corresponding to a state. Some countries, such as Ghana, have implemented NHIS with compulsory enrolment and contributions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite differences in income earning, universal contributions have been observed between the rich and the poor in other countries, such as Algeria and Rwanda [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, NHIS does not provide evidence of achieving UHC, as even implementing countries like Ghana and Nigeria have not yet attained a 100% UHC index score [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Stakeholders often need to agree on key aspects such as implementation and design, including contribution fees, identifying the poor population, selecting the health facility providers for the scheme, pooling models, mechanisms for pooling revenues from the informal sector, and the scheme's objectives [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Drawing lessons from Benin, interested countries are encouraged to thoroughly consult and engage all stakeholders, ensuring their interests are respected and agreed upon, to gain full support and participation in successfully introducing NHIS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these positive attributes, certain factors negatively impact NHIS policies and implementation plans. For example, the NHIS faced challenges in Benin after the ruling government lost parliamentary seats following its first term, leading to its suspension due to stakeholders\u0026rsquo; conflicting ideas [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Research studies reveal that the challenges of NHIS primarily originate at the policy formulation level, driven by economic constraints, social factors, political power dynamics, inadequate stakeholder consultation and engagement, poor collaboration between government sectors, over-reliance on international decision-making, limited community and local authority involvement, and insufficient utilization of evidence-based decisions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Another area for improvement in the policy environment is poor criteria for identifying poverty, with some countries relying on international standards [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This study therefore sought to explore stakeholders' perceptions' on the anticipated introduction of NHIS in Malawi.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study utilised an explorative qualitative study design and was conducted in Lilongwe district, of Malawi between October 2023 and January 2024. Lilongwe was selected due to its status as the capital city and the concentration of key stakeholder offices, which facilitated easy allocation and accessibility of stakeholders.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study targeted a diverse group of health stakeholders with knowledge, expertise, and involvement in formulating and implementing health strategies and policies in Malawi. These included health policymakers from Ministry of Health and Population (MoHP), health managers, Health Development Partners (HDP) and Health Donor Groups (HDG), private medical insurance schemes, academic and research institution managers, Civil Society Organizations (CSOs), local authority leaders from Lilongwe Council, private hospital representatives, and representatives from the Christian Health Association of Malawi.\u003c/p\u003e\n\u003ch3\u003eSample Size\u003c/h3\u003e\n\u003cp\u003eThe study involved 20 participants who were selected using a purposive sampling technique. The investigator used a stakeholder mapping analysis matrix to select the study participants.\u003c/p\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cp\u003eData collection was conducted through in-depth interviews using an interview guide consisting of open-ended questions, simultaneously it was in the English language as all stakeholders were proficient. The interview guide was developed solely for the study and is attached as a supplement document. The lead author conducted the data-collection process, as part of her master\u0026rsquo;s thesis. Before the interviews, the participants provided written and verbal consent. On average, each interview was scheduled for 45 min per participant. The last author (supervisor) reviewed the interview guide before actual data collection, ensuring the trustworthiness and accuracy of the interview guide. Pretesting of the interview guide was done in Blantyre city with two conveniently selected stakeholders to assess the validity and reliability of the interview questions to identify errors and unclear questions. The pretest aimed to help refine the interview guide by collecting identified mistakes and accurate for clear data. All interview was recorded and transcribed verbatim. Interview recordings and transcriptions were kept on a password-protected Google Drive, while transcribed notes and signed consent forms were locked away in a safe cabinet.\u003c/p\u003e \u003cp\u003eNVivo 12 software was used to analyze the transcribed data using a thematic analysis approach. The data analysis focused on four policymaking components: content, context, process, and actors. The policy-making triangle conceptual framework enabled a comprehensive understanding of the various dimensions influencing the policymaking and formulation processes.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eDemographic characteristics of the study respondents.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of twenty respondents participated in the study. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic and professional characteristics of the participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and Professional characteristics of respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHARACTERISTICS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNUMBER OF PARTICIPANTS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale: 14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale: 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 2 years: 18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than 2 years: 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePosition held at the organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeniors: 14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeputies: 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSector of origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate: 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublic: 8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eCadres/Professions positions by organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcademia (University Registrar)\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHAM hospital director\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivate hospital director\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Donor Group Partners\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eprivate health insurance manager\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSOs managers\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHAM secretariat administrator\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoHP managers\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMinistry of Finance manager\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal authority manager\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Manager(public hospitals)\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLocal Research Committee\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u0026rsquo; Knowledge of NHIS\u003c/h2\u003e \u003cp\u003eKnowledge of NHIS was assessed by asking the participants to explain what they knew about NHIS. With regards to the definition of NHIS, some participants defined the NHIS as a government-led medical scheme initiative, while others defined it as one of the UHC initiatives aiming to achieve the SDGs by 2030 and were quoted as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I think it's a universal health coverage initiative to make health services accessible, affordable to all without people spending much money or failing to access services at the point of need.\u0026rdquo;\u003c/em\u003e (Participant 11, Private Insurance Company).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It's a public insurance scheme where in countries implemented the public can receive health services paid by their insurers.\u0026rdquo;\u003c/em\u003e (Participant 18, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I just heard some rumours about it that government will want to introduce, at the hospital through MASM medical scheme.\u0026rdquo;\u003c/em\u003e (Participant 2, Academia)\u003c/p\u003e \u003cp\u003eParticipants were further asked to give their view in how the envision the implementation process for the HHIS. Most participants explained that NHIS in Malawi would be implemented in the following ways: civil servants will pay through their payroll, others said that forms were filled with those only willing, only those living below the poverty line will be subsidized 100%, the insurance will be responsible for hospital bill payments, and that it aims to cover every Malawian. Some of the participants were quoted as follows.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eif possible in the future the government wishes to introduce medical insurance just like MASM so that if you visit a hospital you should receive health services as with MASM beneficiaries. So the bills will be going to government insurance.\u0026rdquo;\u003c/em\u003e (Participant 1, CHAM facility).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I've just heard that the government wants to introduce a system that is going to subsidize here the services to people that are below the poverty line and also introduced some funds that are not disclosed so that the people that are above it can contribute as a way of boosting the health finance budget.\u0026rdquo;\u003c/em\u003e (Participant 7, Local Authority).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We will be given forms to fill out by the HR department.\u0026rdquo;\u003c/em\u003e (Participant 8, Research Committee).\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; were further asked to share their knowledge about NHIS in other countries. Most participants explained that different countries introduced NHIS in different models, whereas in other countries, the agreed premiums are subsidized to the beneficiaries. Other participants also explained that other countries are in the process of introducing the scheme, whereas others give examples of countries implementing the NHIS and its policy content. Other participants explained that Malawi did not have an NHIS. Below are some quotes that support this view.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;From the way I understood it from the different countries, it takes different models.\u0026rdquo;\u003c/em\u003e (Participant 11, Private Health Insurance).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I've heard about it as South Africa is about to introduce to its citizens but for Malawi, I don't think we have that scheme.\u0026rdquo;\u003c/em\u003e (Participant 10, Health Donor Group).\u003c/p\u003e \u003cp\u003eFurthermore, participants were asked about the sources of their information regarding the NHIS. They mentioned several sources, including international newspapers, workplace meetings, research articles, government meetings, and briefings with human resources officers during the civil servant scheme with MASM. Other sources included the launch of the Health Sector Strategic Plan (HSSP) and research presentations when seeking support letters. Some participants noted that they had not heard of the NHIS until the invitation for the interview. A few participants were quoted as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;No, not yet until I read from that consent form you gave to me.\u0026rdquo;\u003c/em\u003e (Participant 15, MOH Health Manager).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I have read it in certain articles I think it was a paper but not here in Malawi. It says that it is a policy to be implemented by the government of the South where people will be able to access health services at hospitals including private by contributing a certain amount because they want to improve the availability of healthcare services to all South Africans.\u0026rdquo;\u003c/em\u003e (Participant 13, Private Hospital).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReasons for Introducing the NHIS in Malawi\u003c/h3\u003e\n\u003cp\u003eParticipants were asked to provide reasons for introducing in Malawi. They cited various reasons, including increasing access to health services, enhanced fund mobilization, promotion of equality in healthcare services, health systems strengthening, improving quality care, and reducing financial hardship. Some of the participants were quoted as follows.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It aims to mobilize funds, improve quality services, and expand it to the entire population for universal quality health care access.\u0026rdquo;\u003c/em\u003e (Participant 16, MOH).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Assist individuals that have that have different financial backgrounds so that they can access the same healthy services.\u0026rdquo;\u003c/em\u003e (Participant 12, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Through the understanding as any other health scheme is that it gives you security in terms of your health needs when you are sick and helps you so that you don't have a problem in accessing healthcare at the point of need without fear of fee since you already paid.\u0026rdquo;\u003c/em\u003e (Participant 5, CHAM).\u003c/p\u003e\n\u003ch3\u003eStakeholder’s Roles in Introducing the NHIS in Malawi\u003c/h3\u003e\n\u003cp\u003eThe study explored the views of stakeholders\u0026rsquo; or actors' roles in introducing the anticipated NHIS in Malawi, covering aspects from policy formulation to implementation, expansion and sustainability of the scheme. Most of participants described their proposed roles as involving the provision of resources, funding, data management, trainings and education sessions, and ensuring access to target populations. Additionally, they propose roles also included providing advisory support, advocacy for broader participation, raining public awareness, regulating professional ethics, facilitating policy and reforms, and promoting collaboration among stakeholders. Additionally, they mentioned, harmonizing various initiatives towards a common goal, delivering direct health care, conducting research, protecting human rights, ensuring patient satisfaction, sharing experiences, supporting other sectors in their NHIS related duties, initiating benchmarking with other countries, serving on management teams, pay premiums for those unable to do so, coordinating all health systems under CHAM and representing them to the NHIS policy discussions, enforcing evidence-based research practices, advocating for vulnerable populations, and conducting monitoring and evaluation activities. Below are some quotes that illustrate these points.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"People will easily accept it as they will act as advocates for awareness, with resources for example WHO help us with funds so it will not be hard for them to provide support to reach every Malawian.\u0026rdquo;\u003c/em\u003e (Participant 20, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If they can involve big companies like the bank institutions, Illovo, with an idea that these are informal sectors with workers. So they can be part of this by allowing to pay the premiums on behalf of their workers directly to national health insurance which will make it easy to collect contributions from the private sector. Also, these big companies can support the introductory part and sustainability with resources, expertise, and even awareness because they have already a community under their influence. So, consider all those big and small non-government profit companies in the informal sector that way it will not be easy to mobilize premium from the huge informal sector.\u0026rdquo;\u003c/em\u003e (Participant 2, Academia).\u003c/p\u003e \u003cp\u003e Participants were further asked to provide reasons for their proposed roles. Most participants viewed their roles as beneficial, as they would help Malawi achieve UHC goals by 2030, while other participants believed that their contribution would aid in improving health outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"My role is to mobilize others so that they can join the scheme because other medical schemes are expensive and as an individual, I will make sure to be part of the development to be able to access better services when I am sick.\u0026rdquo;\u003c/em\u003e (Participant 17, MoH Health Manager).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We would be able to cover more hospitals as of now we cover few district hospitals. But then when we have the scheme of equity we will be able to cover also support our services as you we focus on people with a particular character in terms of health so will also be in touch with those in private or CHAM hospitals universally, so we will be able to reach out to more hospitals as well for the scheme will make us work with various sectors to improve health goals in the country.\u0026rdquo;\u003c/em\u003e (Participant 12, Health Donor Group).\u003c/p\u003e \u003cp\u003eOther participants\u0026rsquo; roles will depend on various conditions; namely, if private medical schemes are involved, their interests will be included, and how they will be introduced. Some participants were not sure which roles they would take regarding their institution\u0026rsquo;s complex activities. The attached quotes support this statement.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think we may not have a direct role as pay say but a variety of roles. When it comes to national health insurance, there are a couple of issues that we are already doing indirectly. We are currently covering the universal care agenda, where its role is to protect the poor. What it focuses on is ensuring that healthcare services are affordable to the poor; we are empowering communities with resources, education, awareness campaigns, and even fighting for human rights. So, national health insurance when it comes to us we will work to protect the public.\u0026rdquo;\u003c/em\u003e (Participant 18, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Not directly sure if we as private will be incorporate, it will depend from the private hospital job description indicated on its policy.\u0026rdquo;\u003c/em\u003e (Participant 13, private health institution).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It depends on how the government puts it or tries to enrol it. Thus, the role of private insurers is not clear, but it may become supplemental in the sense that those benefits that are not covered by the government then probably??? Private health providers will come in as supplemental, but it depends on how well the government will enrol it and what the national health insurance will constitute to whether it would be comprehensive or basic. Thus, the actual role of private health insurance is known, depending on how the government enrols the nation's health insurance. Therefore, it is difficult to say what role med health will play because it is not yet known what the provision in the initiative insurance will take as comprehensive or basic.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTherefore, for now, it is a little bit difficult to speculate what the role of private health insurance will be unless it will be involved and our interests too are met because we are a private company we need money to run we have no donors as the government is therefore our interest is our priority thing in any partnership.\u0026rdquo;\u003c/em\u003e (Participant 11, Private Health Insurance).\u003c/p\u003e \u003cp\u003eThe private and other government sectors were not sure which roles to assume, as they stated that their duties followed job descriptions. Thus, they perform any role that will be stated in their job description, as supported by the quotes below:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think as a government institution our role will be described during the policy formulation but for now will continue doing our role as a ministry carrying our duties as usual but since we are the main driver to the proposed national scheme we will work together with other sectors to make this happen because the intervention to be on strategic plan means it has gone under scrutiny and proved to be the best idea.\u0026rdquo;\u003c/em\u003e (Participant 9, Public Sector).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"OK my role on the scheme though am not sure but I believe as a health worker and managers we will continue with our daily duties of direct provision of care, education, informing, communicating, advocating, manage. There are so many, but I will also ensure that this scheme is followed appropriately, and that the policies concerning the scheme are implemented. As a leader will make sure my fellow health workers work within our job description jurisdiction.\u0026rdquo;\u003c/em\u003e (Participant 15, MoH Health Manager).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProposed Stakeholders or actors for the NHIS in Malawi\u003c/h2\u003e \u003cp\u003eParticipants were asked to proposed the key actors for NHIS in Malawi. The participants suggested that the following actors or stakeholders should be involved in introducing NHIS in Malawi: health donor groups, academia, business people and companies, the community, existing private medical schemes, government sectors, NGOs, politicians, private health facilities, the private sector, regulatory bodies, religious health institutions, and religious leaders. The following are quotes that support this information.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"This scheme will be the major reform ever in the history of Malawi a lot will happen and conflicts are anticipated therefore as long as they are here in Malawi are responsible for making it happen whether being in the field of marketing, agriculture, you know even crypto-currency system I believe will have an impact so all sector representatives will be incorporated.\u0026rdquo;\u003c/em\u003e (Participant 9, Public Sector).\u003c/p\u003e \u003cp\u003e\u003cem\u003e\"I can say like most of the community leaders because the community leaders can help in making an awareness to their people that are surrounding their villages to encourage them to participate to the medical schemes, even the religious groups, because mostly the religious groups, we have different beliefs, these group of leaders naturally are listened to they make an impact on influence, I remember in our projects back then on net use and fertility, men were refusing so we had to ask the chief in our second village to speak to their people before we interview them, I can tell how they were responding even others were waiting and following us for interview.\u0026rdquo;\u003c/em\u003e (Participant 10, Health Donor Group).\u003c/p\u003e \u003cp\u003eWhen probed on which stakeholders they perceived to be at the forefront of the scheme to succeed, one participant responded to the government, specifically the MoH sector, as explained in the quote below:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So, I think the government should be the main stakeholder so that its policy can be passed easily in parliament to allocate more support and resources.\u0026rdquo;\u003c/em\u003e (Participant 20, Health Donor Group).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAnticipated challenges with suggested actors\u003c/h2\u003e \u003cp\u003eSome participants explained that there is a need to anticipate collaboration and engagement challenges because of the large number of stakeholders from various institutions that may be involved in the introduction of NHIS in Malawi. The following quote shows how the participant explained the anticipated challenge.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I can foresee this because companies are looking for customers so with providing services across the larger capacity in terms of customers I can see conflicts and disagreements. Yes, private like xxx, xxx they will fight because they will be in completion not favouring them.\u0026rdquo;\u003c/em\u003e (Participant 17, MoH Health Manager).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions on Power dynamics\u003c/h2\u003e \u003cp\u003eWhen participants were asked about their anticipation regarding power dynamics, several responded affirmatively for various reasons. These included conflict of interest among stakeholders, issues related to corruption, the complexity of health determinants as perceived by stakeholders, the influence of government powers and politics, the classification of services, or packages for those receiving 100% subsidies, negative perceptions of private hospital\u0026mdash; as they are perceived to attract more customers than public facilities, and concerns about how roles will be allocated, the stakeholders involved and a general fear of unknown among stakeholders. This is illustrated by the following statements:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Conflicts are anticipated due to different business ideas and interests. Private insurance companies are there for profits and the government is trying to bring in an NHI initiative and try to leverage the access to this for the poor trying to balance the inequity formula that everyone else should have access equally to health services.\u0026rdquo;\u003c/em\u003e (Participant 11, Private Health Insurance).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Yes, yes in Malawi we have a lot of stakeholders who don't agree mostly with matters of health due to the complexity of factors affecting health\u003c/em\u003e, \u003cem\u003eyou know we work in isolation everyone immersed in their ideas which they think will work.\u0026rdquo;\u003c/em\u003e (Participant 12, Health Donor Group).\u003c/p\u003e \u003cp\u003eSome participants stated that the anticipated power dynamics are anticipated to occur for various reasons at different stages during the introduction of the scheme and are deemed to fail if they are not properly managed, as explained in the following quotes:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"It is anticipated even the government knows. Cause if we are talking about National Insurance, you have given an example of the private medical insurance that is in Malawi, and they are therefore for value of money. However, If National Insurance is being introduced, the government needs to ensure that their services are also a bit equal to the services that are provided in the private facilities to match the standards and that they also benefit from the products of the scheme.\u0026rdquo;\u003c/em\u003e (Participant 10, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I think there would be some power conflicts from the first time especially at the beginning.\u0026rdquo;\u003c/em\u003e (Participant 12, Health Donor Group).\u003c/p\u003e \u003cp\u003eSome participants were unsure, and others denied the existence of power dynamics among stakeholders during the introduction of the NHIS for other reasons, as stated in the quote below.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I don't think so. Maybe when we start because we are already working with these stakeholders and the strategic plan was developed with their input so they cannot back-fire the decision made by them maybe power influence will be noted after it starts, but for now, I do not think so.\u0026rdquo;\u003c/em\u003e (Participant 16, MoH Health Manager).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I don't think there will be differences in power because I believe they will be a mechanism to spread equal power.\u0026rdquo;\u003c/em\u003e (Participant 2, Academia).\u003c/p\u003e \u003cp\u003eWhen asked about interventions to prevent and reduce the anticipated power dynamics, some participants suggested several measures. These included the development of policies to guide the NHIS's operation, the establishment of a task force or committee, benchmarking practices and equitable distribution of roles among all stakeholders. They emphasized that the committee should be chosen by the stakeholders themselves and ensure equalization in terms of health service quality among public and private health facilities, as well as balanced power among stakeholders. Additional recommendations included raising vibrant awareness, creating terms of reference or memorandum of understanding to guide stakeholder interactions, formulating a comprehensive roadmap, establishing effective communication channels throughout the process, incorporating the NHIS within legal documents in Malawi for legal backing, and developing strategies to address the needs of all stakeholder. Below are some of the quotes reflecting the participants\u0026rsquo; responses.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"As I already said the equal share of responsibility by the committee or task group should be located at all levels. Centrally, leaders going to the district committee should be presented at all levels, from central offices to the community, with all stakeholders being presented. This influences accountability and response abilities. On sharing the roles, you know every member of the scheme you know will abide by their role as being responsible for serving Malawi people at the same time strengthening the system of health.\u0026rdquo;\u003c/em\u003e (Participant 6, CSOs).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Before it is introduced, it is necessary to clarify what and how it will be run. Because some of the needed representatives are from private institutions, if this is going to be a government mandatory insurance without them benefiting it means they will not be involved, meaning another failure; therefore, they need to clarify what will be the role of other stakeholders; however, I believe roles automatically will be distributed, for example health workers they provide services, educate, etc.\u0026rdquo;\u003c/em\u003e (Participant 9, Public Sector).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStakeholder engagement and collaboration\u003c/h2\u003e \u003cp\u003eParticipants were asked to share their views on how the stakeholders will be encouraged to engage and collaborate for the scheme\u0026rsquo;s success. Some participants responded by stating that there is a need to utilize Memorandum of Understanding (MOU), NHIS policy, and NHIS committee or task force to enforce fairness, rules, and guidance on how conflicts will be averted or dealt with. Some participants suggested that benchmarking, continuous engagement of stakeholders at all levels, awareness, and broader consultation will help develop ways to avert problems or conflicts among stakeholders. The quotes below explain how the participants responded to the question.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"For such an initiative to go out, we need to have a steering team to facilitate the activities and share responsibilities altogether. The team should have all sectors representative. The government should be a member equally on decisions as other institutions. Fairness when it comes to decision and respect will be enforced through the steering team.\u0026rdquo;\u003c/em\u003e (Participant 17, MoH Health Manager).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Since this is something that is going to be done nationwide, that means it needs to have TORs that are terms of reference on how best each stakeholder can perform their various roles. If my role is predefined, that means everyone will be working according to what they are supposed to do. For example, there will be no overstepping on others, as stated in the MOUs. Accountability will be enforced and will be equal if we want this to gain more support you know stakeholders are drivers like an engine to every intervention so need to be respected equally so that collaboration will be 100% and engagement will follow.\u0026rdquo;\u003c/em\u003e (Participant 19, Health Donor Group).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eProposed Policy Process for the NHIS in Malawi\u003c/h2\u003e \u003cp\u003eParticipants were asked to explain the process how the NHIS policy should be formulated in Malawi. Participants mentioned four main aspects which should be considered i.e. policy content, challenges, and interventions and adoption.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePolicy content\u003c/h2\u003e \u003cp\u003eParticipants responded to the question by stating that the following aspects need to be considered and included in the anticipated NHIS policy content in Malawi. Some participants stated that issues with bordering countries and refugees need to be addressed. Other participants said that the policy's main priority areas on what to include should focus on contribution fees, different packages, governance issues, collection of revenue, incentives for health workers, identification criteria for poverty, and eligibility criteria. Other participants recommended that the policy should include issues on the resources to run the scheme, other vulnerable populations such as the elderly and children, safety issues, referral systems, stakeholders, and where the collected funds will be kept. The following quote supports the above data:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"What I can say essentially is concerning policy, it needs to state clearly in the design who to benefit, the amount to be paid, who will be paying. Where do access services like good referral paths not everyone should come? For example, at xxx, it will exhaust us even at central hospitals only for severe cases with specialist needs. Otherwise, if not written, who, where, and how will we be drained out of resources by people not fit to receive them? In addition, it should not include an age limit like other medical insurance, which does not allow other age groups like the elderly because it will be readmitted to the hospital at a certain time. They need to include these vulnerable people, and the rest cannot access everything unless they pay.\u0026rdquo;\u003c/em\u003e (Participant 13, Private Health Institution).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I don't see as a priority thing here with policy everything is crucial, you know to convince the public and sectors is not easy. So to me regard everything as crucial. We need to have some limits too to avoid abusers so control needs to be included in the policy. On packages as it is done with SLAs we have priority cases like RDS and maternity, so nowadays the trend is that non-communicable diseases are the ones killing a lot of people like BP, sugar so these common diseases should be put in those packages so that the most needed services are always given. Also, there is a need to include availably of resources that is sustainable because we can be talking about premiums while resources are always out of stock so procurement and sustainability of resources.\u0026rdquo;\u003c/em\u003e (Participant 2, Academia).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The people need to decide what they want the policy to include if they want it to be introduced what they want to see on the policy like packages, fees; the needs and those suggestions should be the ones to be enforced and made clear in the policy. Stakeholders can make decisions from those views only to suit the scheme, and it can be easily implemented as communities will understand it; it will act as a reference. Otherwise, minus that, I think it will be just a waste of time.\u0026rdquo;\u003c/em\u003e (Participant 17, MoH Health Manager).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePolicy process challenges and interventions\u003c/h2\u003e \u003cp\u003eSome of the respondents mentioned that the stakeholders\u0026rsquo; differences regarding their interests, economic status to provide resources to run the policy, and large numbers of public health facilities will be the main cause of conflicts and misunderstanding during the policy formulation process, as supported by the quotes below.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, yes in Malawi we have a lot of stakeholders who don't agree mostly with matters of health due to the complexity of factors affecting health; you know we work in isolation everyone is immersed in their ideas which they think will work. As such, without the reading team chosen by them to enforce the agreed policy, it will be chaos.\u0026rdquo;\u003c/em\u003e (Participant 12, health donor group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;As already hinted, different institutions have different interests and mechanisms on how to achieve goals.\u0026rdquo;\u003c/em\u003e (Participant 11, Private Health Insurance).\u003c/p\u003e \u003cp\u003eThe following interventions were gathered when probed on how to deal with these challenges so that the scheme could meet its intended goals. These include community awareness, adoption from other policies from existing medical scheme models, benchmarking, enforcing all stakeholders to voice their needs and concerns, equalizing the quality of health systems building blocks match in private and public, modifying and strengthening existing partnerships and structures, developing strategies to avert power dynamics, running the NHIS as a privately owned company, formulating a simple and clear policy, equalizing power between small and big institutions in decision making, harmonizing the NHIS goals to align with local and international health agendas, including vast kinds of stakeholders with different specialties, removing politics, respect, understanding, and appreciating the existence of different perceptions from different stakeholders, letting people owner it through constant engagement, being pro-active with challenges by anticipating shot falls and how to avert them, avoiding bias with the stakeholders involved, utilizing other existing structures and integrating services, and ensuring that existing job descriptions are progressing. The quote attached below supports this information.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Let it be managed like a company. Like how ESCOM is for example, ESCOM is a statutory organization with directors, so national health insurance should run the same. It will need to have directors and its management team; maybe the government should influence the appointments of directors. To understand how the Blantyre water board is run, when we want the water board or ESCOM to repair our faults, we do not go directly to the central government; we go to the institution knowing that it is well established with all its departmental roles well established so that if we have let us say faults with electric poles, we go directly to the poles department. Therefore, if national health insurance needs to be run in a well-distributed manner, everyone will be accountable and responsible for fulfilling their roles in customer satisfaction. Even for the government, I do not think the DC will receive many burdens from people's complaints concerning small matters with insurance; hence, the DC will be able to work within its job description regardless of the insurance scheme, as it is its primary job description. Thus, they will be the proper channel of communication so that issues with registration people can visit that department directly. So it needs to be run like a company well registered with a management team well capable of sustaining it.\u0026rdquo;\u003c/em\u003e (Participant 2, CHAM facility).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePolicy Adoption\u003c/h2\u003e \u003cp\u003eUnder this sub-theme, participants were assessed to name local and international medical schemes, describe them, and identify areas that would need to be adopted if Malawi introduced the NHIS. Most participants described MASM as their choice of the medical scheme because of how it operates, its technical and strategic, its availability of different packages, its clear policy, started small and is scaling up, innovative ways of coming up with new ways of scaling, involvement with different partners, and expanding their scheme to more hospitals and in remote areas. Some of the participants\u0026rsquo; quotes are attached below:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"For me, I think national health insurance should adopt and modify existing models like MASM. They need to adopt strategies and technical know-how using these existing schemes. In addition, we need to change the models we currently use to run health facilities; therefore, public health facilities need to be paid for not free access. Therefore, if a person visits Chiradzulu DHO, for example, the hospital needs to produce an invoice, and that bill goes to national health insurance, where the insurance will be paying the Chiradzulu DHO. We will not hear those hospitals suffering and proclaim that we are suffering because we lack funding, and shortages of drugs for the hospitals will be able to generate funds through their services. Same now we are losing as a government, do you know that even people covered by the MASM access health services for free while covered schemes? If the hospital was able to produce this invoice, the scheme could be paying the hospitals.\u0026rdquo;\u003c/em\u003e (Participant 1, CHAM facility).\u003c/p\u003e \u003cp\u003eFew participants were able to name international medical schemes but failed to explain how they work and what aspect the Malawi NHIS policy will adopt, as stated by the participant below:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I'm, I'm not sure I think but I heard the one in the UK. I am not sure correctly about its name.\u0026rdquo;\u003c/em\u003e (Participant 12, Health Donor Group).\u003c/p\u003e \u003cp\u003eOther participants stated that Malawi needs to develop its policy without adopting existing medical schemes for the following reasons: all medical schemes known receive criticism, most Malawians in urban areas are aware of only MASM, while those in rural areas have no idea about medical insurance, international medical schemes require more funds for it to run, Malawi has few people on private schemes as compared to other countries, and most of the known local private schemes have narrow benefit packages, as explained in the quote below.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Unfortunately, the ones that I read about or appeared on, mostly do get negative reviews for example in the health insurance in the US because, for a person to access most medical services in the US you need medical insurance, and for those who are not covered under this health insurance, it's really difficult for you to get any access to healthcare, especially people who are immigrants and all that. So the positive is I haven't heard of it yet in detail, because I know there are countries like Canada where everyone can access services, but they don't have health insurance. Thus, it's free like Malawi, but it's much better than Malawi because they have the resources to do that. But for us to adopt a system like the one that they're using in the US I don't know what we have to work it out, how we're going to help the people who will not be covered by the insurance.\u0026rdquo;\u003c/em\u003e (Participant 14, Health Donor Group).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eExisting Policies and Regulations which can support or hinder the Introduction of NHIS in Malawi\u003c/h2\u003e \u003cp\u003e Most of the participants believed that existing HSSP III, gender policies, Malawi 2063, Malawi poverty reduction policies, MGDS, SDGs, SLA, UHC policy, and those policies that stand for vulnerable populations like children and the elderly will have a positive impact on the introduction of NHIS in Malawi backed up with quotes attached below.\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;First of all, I would say about the policies that focus on the vulnerable like the elderly and children because these populations are dependent. Moreover, most times children do not receive adequate care at a tender age, they end up having developmental problems when they grow up. The elderly also need more health care because their bodies are weak.\u0026rdquo;\u003c/em\u003e (Participant 4, CSOs).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The 2063 agenda, health, agriculture, manufacturing, security, finance, or I can say all sectors have policies that will be remodelled to fit the scheme as long as these sectors are for the citizens so is the scheme. I cannot say that this policy or that but all policies and regulations whether being it private or public sector, the scheme is eligible and they are the implementers so am sure already that all will suit it not against.\u0026rdquo;\u003c/em\u003e (Participant 7, Public Sector).\u003c/p\u003e \u003cp\u003eSome participants explained that the free health care policy negatively affected the introduction of the NHIS introduction. These participants also came up with strategies for overcoming existing policy and regulation challenges, including awareness, reforms of existing parallel policies, aligning the NHIS goals to existing national and international policies, inclusion of the less privileged people like prisoners, aligning the NHIS policy with women championed policies, safe motherhood initiatives, taking advantage of existing structures like NRB, harmonizing all public and private initiatives through the one plan, M\u0026amp;E and budget, and strengthening of local authorities. These data were supported by the participants\u0026rsquo; quotes attached below.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"The government has been struggling to provide free services to individuals. Therefore, the most expensive service in the world is health, which affects every sector. Thus, providing it for free is a loss to a country. If everybody is made to pay through this insurance, it will return money to the government to procure and provide quality health services.\u0026rdquo;\u003c/em\u003e (Participant 11, Private Health Insurance).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Exactly I wanted to say let's utilize the national ID, the partnership with local and international institutions, the coalition with other countries, inter-sector collaboration, and this called one M\u0026amp;E as said in the strategic plan, we receive a lot of donations in health but we end up duplicating projects lets learn to work as a team and aligning to our strategic plan because the strategy is made for us to achieve the global agendas.\u0026rdquo;\u003c/em\u003e (Participant 19, Health Donor Group).\u003c/p\u003e \u003cp\u003eOne of the participants believed that there is no existing policy or regulation to negatively influence the NHIS in Malawi, as most policies align positively with each other, as quoted below.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"There are policies and regulations that have a lot of positive when it comes to health. Agreements and partnerships with several organizations have increased access to people in remote areas to access healthcare. We obtained funds and resources from institutions such as the WHO, funding, and donations. Human rights civil organizations. They are rules that empower them to protect and support the vulnerable, such as the elderly, and refer to us. Those policies that empower these will make this insurance succeed because the scheme is in support of what is already done only this it for the whole Malawi, not specific community.\u0026rdquo;\u003c/em\u003e (Participant 17, MoH Health Manager).\u003c/p\u003e \u003cp\u003eFew participants explained that no policy or regulation will have an influence as reforms will be made before the introduction of NHIS and the reforms will be easily enacted with the incorporation of the NHIS in Malawi's strategic plans, as quoted below.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t think a government can put policies against each other probably if at all slight differences like the one of free services policy by the time the national insurance will be introduced it will be reformed completely.\u0026rdquo;\u003c/em\u003e (Participant 10, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I don't think so because most of our policies and regulations always support each other and are made in that way. So, they are strengthening each other, so they are no such to only strengthen one another by the time this scheme will be implemented, and I tell all regulations or policies will be inline.\u0026rdquo;\u003c/em\u003e (Participant 2, Academia).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eContext and environmental factors\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eFactors to promote NHIS feasibility\u003c/h2\u003e \u003cp\u003eThe study revealed that awareness, benchmarking, disaster preparedness, contingency plans, donor support, subsidization of poor people, harmonization of modern medicine and traditional medicine, incorporation in long-run agendas like MW 2063, mindset and behavior change, strengthening stakeholder involvement and support, supporting poor people to start small businesses, strengthening referral systems, taking advantage of existing structures and initiatives, and introducing complex strategies of contacting people from the informal sector. Below are some of the participants\u0026rsquo; quotes in support of this information.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"But at first, we need a lot of awareness campaign and we have to let the people know why we are doing that. I think it\u0026rsquo;s good, it can be a really good initiative if it is handled well.\u0026rdquo;\u003c/em\u003e (Participant 14, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;But let me give you this I'm looking at this at an average Malawian and right now everything is going up with price. Everything is going up. Then, we introduce another medical fee to them, which will be more burdensome. Yeah. However, we look at job creation and economy in both ways. Thus, if we introduce it, we can win another battle. This is when diverse stakeholders are needed. Experts in various fields and sectors. That's why I said there will be no power inequality because every stakeholder will benefit. There is a lot to win if we implement it.\u0026rdquo;\u003c/em\u003e (Participant 16, MoH Health Manager).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eNHIS feasibility challenges\u003c/h2\u003e \u003cp\u003eThe study revealed several feasibility challenges that are discussed below. Firstly, it was about the weak economy which was also revealed from a feasibility study that was conducted in 2019 and from other countries who are struggling to introduce and sustain it. The scheme will require new technology infrastructure, additional human resources, and finance to enhance community awareness to curb community resistance and low literacy levels, however with a poor economy the success is doubtable. In addition, due to the poor economy, a large number of people depend on free health care services provided by the public sector which will affect contribution and resistance to reform. Another challenge is poor stakeholder representation and engagement in most of the public policy formulation and decision-making. These resulted in unsuccessful implementation due to resistance by uninvolved stakeholders to support the proposed intervention as their interests are not incorporated hence failure. Furthermore, the uninvolved stakeholders do not support it as their interest contradicts existing regulations and policies.\u003c/p\u003e \u003cp\u003eFurther, the scheme is proposed to mobilize revenue from all populations which will be not feasible in Malawi. The reason is that a lot of people are from the informal sector where identification for the exempted and techniques for contribution mobilization will be doubted. Political obstacles were also raised to be another barrier. Most politicians include free access to most social amenities like health in their manifestos to win more votes yet the scheme will require universal contributions by citizens. Furthermore, the elected politicians are the ones that pass policies in parliament hence if their agenda is free access then the scheme will be a failure as it will oppose to their interest. Lastly, corruption was deemed to be a hindrance factor. This was noted in people trusting the authorities responsible as corruption cases are high with public firms hence gaining less community involvement. Additionally, high poverty and low literacy levels, and pervasive myths/misconceptions were minor perceived barriers that may hinder the anticipated scheme\u0026rsquo;s success by participants. The following quotes support this information.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"And a lot of people are not contributing anything even they're doing something because we don't have a way of gathering taxes from informal jobs. So, it can be introduced, but I do not see it succeeding for a few years. It will take time for us to adapt that unless we have good mechanisms to identify informal jobs and make way on how to collect the fees because we have a large informal sector.\u0026rdquo;\u003c/em\u003e (Participant 20, Health Donor Group).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Yes. I think the illiterate level is why I said earlier that community awareness and civic education are needed. This imitative will need a mindset, or I can say behavior change. Our culture, especially those deep in remote areas, believes in herbalists so it will not be easy to convert them and join the scheme unless you said the herbalist will also be part of the scheme then fine and good.\u0026rdquo;\u003c/em\u003e (Participant 15, MoH Health Manager).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study has revealed that most of the participants had knowledge about the NHIS and its benefits which is crucial to the successful design and implementation of NHIS policy because it helps to understand, analyze, and formulate an effective policy to meet population needs and achieve policy agendas [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, adequate knowledge curb resistance to existing policy reforms[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Different studies [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] have identified that stakeholders needed to understand the NHIS benefits, costs, and how different countries are implementing the scheme for the success of the NHIS [\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, it was noted that the majority of participants had inadequate understanding, while one participant had no knowledge due unavailability of common information source and it was those in senior position through meeting attendances. The studies that was conducted in Nigeria, Ghana, Kenya and Benin revealed partial or no knowledge of NHIS among stakeholders had a negative influence on policy designing and implementation which led to the suspension of the scheme and low subscription [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, community awareness must be vibrant to curb low education levels because having adequate knowledge of NHIS among stakeholders before implementation does not necessarily translate to a successful introduction of the NHIS and sustainable implementation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA diverse representation of stakeholders fosters collaboration, support, and respect towards their interests and benefits to the anticipated introduction of NHIS [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These results are similar to those of another study conducted in Ghana and South Africa, which explained NHIS stakeholders' diversity for successful policy design and implementation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The participants suggested key stakeholders for the anticipated introduction of NHIS and most had already existing partnerships with the MoHP like donor health groups (WHO/UNICEF). whereas some recommended non-direct health institutions such as business companies and estate agencies, and assumptions were made that they should be from both the local and international institutions irrespective of size and influence using stakeholder analysis tools that will ease identification and management [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther, the study revealed the anticipation of power dynamics among stakeholders due to disagreements on policy implementation as a large number of stakeholders will be involved. These findings resonate with other studies that were conducted in South Africa, Ghana, and Afghanistan where conflicts among stakeholders were due to having different interests and perceptions of the agendas by making the NHIS meet their organizational goals [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The proposed solutions were equal power in decision-making, incorporation of every stakeholder's interests, implementing from a small scale, and scaling it up to mention a few. Adei et al. affirms the reason for Ghana's successful implementation while the study by Passchier South Africans\u0026rsquo; delays in the introduction of NHIS due to conflict of interest [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Other studies show that continuous engagement among stakeholders, awareness, political will, policy reforms, and integration, utilization of existing structures, disaster preparedness, entrepreneurship, and innovation resulted in the successful implementation of an NHIS, and all studies likely resonate with them [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Drawing on the inductive approach of thematic analysis, the interpretative findings suggest that a successful NHIS policy design and implementation will depend on a complex interplay of factors, such as clear policy content, actors, community awareness, alignment with national strategic plans, and reliable financing [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The diversity of stakeholders prompts continuous support, collaboration, and engagement that will enhance good governance, resource mobilization, and expertise. The study conducted in Ghana identified poor stakeholder participation as a challenge for sustainability, and so did Agyepong et al who recommended that clear policy content [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The study recommends that Community awareness, improvement of quality health care, and equal decision-making among stakeholders have been suggested as interventions to address these challenges. These align with study results from Ghana\u0026rsquo;s experience and South Africa struggles for the introduction [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32 CR33\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Benchmarking as a solution was controversial by participants as they argue that community context is key to policy design. This align to WHO and a study conducted in eight sub-Saharan countries (Gabon, Ghana, Rwanda, Benin, Kenya, and Nigeria), showed that NHIS policy should be designed according to the local community context, and having priority policy content taking into account existing health system structures as the implementation process with NHIS is costly [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37 CR38\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, studies conducted in NHIS-implemented countries align with Christmals et, which concluded that the policy process had no priority aspect area and most LMIC profiles are similar [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eSome intended participants and institutions were unable to be part of this study due to their demanding working schedules during the data collection period, despite their initial agreement to participate in the study. Additionally, other institutions declined to participate for reasons known only to them. This may have resulted in the exclusion of certain views, experiences, and perceptions from stakeholders and institutions. However, the purposive sampling qualitative design of the study allowed for an in-depth understanding of the stakeholder perceptions in Malawi, as participants and institutions were substituted. Those with tight schedules delegated their responsibilities to individuals who met the study criteria. Therefore, there is no reason to believe that the study participants significantly differed and the validity of the study remains intact\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAnalyzing stakeholders' perceptions regarding the introduction of NHIS in Malawi has provided valuable insights into their perspectives, shedding light on the factors contributing to the anticipated success of the NHIS introduction and implementation. The NHIS had proven to strengthening health systems and facilitate the achievement of universal access to quality healthcare services in developing countries. The anticipated NHIS met participant\u0026rsquo;s optimism and was seen as a critical step towards mobilizing health funds and relieving nations from donor aid overdependence. These findings have leveraged to build momentum and consensus for the readiness and willingness of diverse stakeholder\u0026rsquo;s, hence encouraging the government to prioritise and invest in NHIS to bolster the health system. The study findings have also demonstrated that the introduction of NHIS is dependent on a complex interplay of factors surrounding the policy-making process. These will help policymakers and stakeholders navigate the complexity and make informed and effective policy decisions. In addition, the anticipated NHIS provides a role of strategic fund mobilization which demonstrates innovation for secure and sustainable health funding options. Further studies should be conducted with other specific types of groups on a larger scale, involving a wider range of stakeholders. Additionally, quantitative studies on the NHIS should be undertaken to complement the existing qualitative findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBHI: Community Benefit Health Insurance, CHAM: Christian Health Association of Malawi\u003c/p\u003e\n\u003cp\u003eCOMREC: College of Medicine Research and Ethics Committee, CHE: Catastrophic Health Expenditure, DPP: Democratic Progressive Party, HSSP: Health Sector Strategic Plan, KUHES: Kamuzu University of Health Sciences, LMICs: Low and Middle-Income Countries, MoHP: Ministry of Health and Population, NHA: National Health Accounts, NHFS: National Health Finance Strategy, NHP: National Health Policy, NHIS: National Health Insurance Scheme, OOP: Out of Pocket Expenditure, PPS: Purchaser Provider Split, SHIS: Social Health Insurance Scheme, SSA: Sub-Saharan Africa, THE: Total Health Expenditure, WB: World Bank and WHO: \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organisation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the participants for their contributions to this study. We would also like to acknowledge key informants from the Ministry of Health for their contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Information:\u003c/strong\u003e LN conducted this study in partial fulfilment of her Master\u0026apos;s Degree in Business Administration in Health Systems and Management at Kamuzu College of Health Sciences (formerly known as the College of Medicine, University of Malawi). IKC supervised the study. She is a health systems researcher and senior lecturer in the Department of Health Systems and Policy, School of Global and Public Health at Kamuzu University of Health Sciences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u003c/strong\u003e LV conceived the research idea, designed methods for the study, collected and analyzed data, and drafted the manuscript. IKC supervised and directed the planning, and designing of study methods, data collection, and analysis. She also contributed to and supervised the writing of the manuscript. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the College of Medicine Research and Ethics Committee (COMREC) in Malawi; and was conducted following the declaration of Helsinki and the international guidelines for Good Clinical Practice (GCP). The ethics approval reference number is\u0026nbsp;P.07/23-0157. Informed written consent was obtained from the study participants. The participants indicated their willingness to participate in the study by signing or placing their thumbprint on the informed consent sheet. Anonymity and confidentiality were ensured by using code names in the data collection materials. Privacy was ensured by conducting the interviews in a private place.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e Data is available upon request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was self-funded, therefore the funding declaration is \u0026ldquo;Not Applicable\u0026rdquo;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGovernment of the Republic of Malawi. Health Sector Strategic Plan III: Reforming for universal health coverage for 2023\u0026ndash;2030. Ministry of Health. 2022 [cited 7 June 2023]. 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Qualitative Res Psychol uqrp20. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"National Health Insurance, Universal Health Insurance, Universal Health Coverage, Malawi, Developing Countries","lastPublishedDoi":"10.21203/rs.3.rs-6368241/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6368241/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eMalawi through the Health Sector Strategic Plan III aims to introduce a National Health Insurance Scheme (NHIS) that will serve as a key health-financing mechanism for achieving Universal Health Coverage (UHC). Implementing the NHIS plays a crucial role in advancing toward UHC and has the potential to strengthen health systems. This study aimed to explore stakeholders' perceptions regarding the anticipated introduction of the NHIS in Malawi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study employed an exploratory qualitative study design. A purposive sampling technique was used to select 20 participants who were involved in in-depth interviews. All the interviews were recorded and transcribed verbatim. Data was analyzed using thematic content analysis with NVIVO software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study findings revealed that most participants demonstrated knowledge of the NHIS and its benefits to Malawi. Generally, the findings showed that the anticipated NHIS aligned with the participant\u0026rsquo;s positive expectations and was seen as a critical step towards making advancement in efforts to generate domestic health funding and lessen the reliance on foreign donor assistance, and enhance self-sufficiency in addressing the healthcare needs of people in Malawi. However, the study identified several challenges to the feasibility of implementing the NHIS in Malawi, including a weak economy, stakeholder conflicts of interest, contradictory regulations and policies, and insufficient stakeholder engagement. Additional barriers include political obstacles, corruption, insufficient human resources, inadequate technology infrastructure, high poverty and low literacy levels, pervasive myths/misconceptions, community resistance, and reliance on free public health services. These challenges complicate the establishment, implementation, and sustainability of the NHIS.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings will help to build momentum and consensus for the readiness and willingness among diverse stakeholders, prompting the government to prioritize and invest in NHIS to strengthen the health system. They also highlight that the introduction of NHIS relies on intricate factors in the policy making process, aiding policymakers and stakeholders in making informed decisions.\u003c/p\u003e","manuscriptTitle":"Stakeholders’ Perceptions Towards the Anticipated Introduction of the National Health Insurance Scheme in Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 18:02:57","doi":"10.21203/rs.3.rs-6368241/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-20T10:17:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T10:06:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-01-12T16:55:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-28T07:36:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-27T09:57:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19414051458760288035626948355030569766","date":"2025-05-26T21:09:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94648843207349407755611294243980606086","date":"2025-05-22T04:50:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51985832445089328244967680682625861120","date":"2025-05-18T09:11:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18339059881982843996796972808945318116","date":"2025-05-17T18:42:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-15T05:09:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-13T07:28:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-10T05:25:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-08T09:52:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-04-08T09:50:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5dfc6b18-0cc1-46d6-bb83-b72945ce1e87","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T12:24:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 18:02:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6368241","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6368241","identity":"rs-6368241","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}