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

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