Conflict of interest vs conflict of incentives: rethinking dual practice in light of Malawi’s Presidential Executive Order No. 1 of 2026

Abstract

Background
Dual practice—where health professionals simultaneously participate in public and private healthcare markets—is common in many health systems but presents complex governance challenges. In 2026, the Government of Malawi issued Presidential Executive Order No. 1 of 2026, prohibiting public health workers from soliciting informal payments in public facilities and restricting their ownership or financial interests in private healthcare establishments. The policy has generated significant national debate regarding its implications for health system governance and workforce incentives.
Objective
This commentary examines the policy rationale and potential implications of the Executive Order, focusing on the tension between addressing conflicts of interest and maintaining appropriate incentives for health workforce retention.
Discussion
Drawing on international literature and comparative policy experiences, the commentary situates Malawi’s reform within the broader global discourse on dual practice regulation. Evidence from multiple health systems indicates that physician ownership of private facilities can introduce structural conflicts of interest that undermine public sector performance through patient diversion, reduced public sector effort, and erosion of public trust. However, outright restrictions on private sector engagement may also carry unintended consequences in settings where public sector remuneration is limited and specialist workforce shortages are acute. International experiences demonstrate that successful regulation of dual practice requires careful alignment of governance mechanisms, workforce incentives, and health system accountability.
Conclusion
Malawi’s Executive Order represents a decisive attempt to strengthen the integrity of public healthcare delivery by addressing ownership-based conflicts of interest. Its long-term effectiveness will depend on balanced implementation, transparent regulatory guidance, and complementary reforms that address workforce incentives and health system capacity. The current debate offers an opportunity to move beyond polarized narratives and instead focus on building a governance framework that simultaneously protects public trust and supports a sustainable health workforce.