Attitudes towards access to and utilization of the formal healthcare sector in rural Malawi: A qualitative approach

Background: Despite the relative availability of a formal healthcare system, it remains under-utilized in Malawi. Methods: We applied a qualitative descriptive approach to explore community attitudes, perceptions, and experiences regarding the access and utilization of both traditional and formal healthcare systems in Mzimba, rural Malawi. We conducted 12 focus group discussions (n = 71) with community members and transcribed, coded, and analyzed data for major themes. Results: Average age was 40; 60% female; and 90% were married. Both formal and informal healthcare sectors, consisting of government and private facilities, and traditional healers and prophets, respectively, are widely used as complementary and not mutually exclusive. Majority reported that if one type of healthcare sector failed to address a health condition, an alternative healthcare sector or provider was sought out. Healthcare-seeking behavior is often governed by whether a disease is believed to be biological or spiritual/psychological in nature, the latter being best treated by traditional medicine. Common barriers in accessing the formal healthcare sector include lack of transportation, limited financial and social resources, and socio-cultural beliefs. Despite locally devised transport systems, such as bicycle ambulances, transportation to healthcare facilities was cited as a significant barrier, often directly linked to increased mortality.  Conclusions: Despite barriers, the formal healthcare sector is accepted among rural Malawians. Supporting local strategies to address transportation and its cost, structural approaches to improve quality healthcare and address financial burden, and community education reconciling traditional beliefs and modern medicine are needed to mitigate access issues and improve utilization of the formal healthcare system.