A responsive health system must have mechanisms in place that ensure it is accountable to those it serves. Patients in Malawi have to overcome many barriers to obtain care. Many of these barriers reflect weak accountability. There are at least 30 mechanisms through which Malawian patients in the public sector can assert their rights, yet few function well and, as a consequence, they are underused. Our aim was to identify the various channels for complaints and why patients are reluctant to use them when they experience poor quality or inappropriate care, as well as the institutional, social and political factors that give rise to these problems. The study was set in the Blantyre district. We used qualitative methods, including ethnographic observations, focus group discussions, document analysis and interviews with stakeholders involved in complaint handling both in Blantyre and in the capital, Lilongwe. We found that complaints mechanisms and redress procedures are underutilized because of lack of trust, geographical inaccessibility and lack of visibility leading to limited awareness of their existence. Drawing on these results, we propose a series of recommendations for the way forward.