Zimbabwe and other African countries need to invest more in health if they are to reverse the brain drain that has resulted in the shortage of doctors and other specialists, Cimas CEO Vulindlela Ndlovu has said.
Ndlovu (VN) told Alpha Media Holdings chairman Trevor Ncube on the platform, In Conversation with Trevor, that African countries were not investing in healthcare and there was need to find urgent solutions to the crisis.
Ndlovu also spoke about the two-month long strike by doctors at public hospitals, challenges facing medical aid societies and the state of Zimbabwe’s health sector.
TN: Let us start from the fact that you are a chartered accountant, a former partner at KPMG, you are an ex-banker and also dabbled into private equity. How was the transition from banking, private equity into running a medical aid society?
VN: I think the advantage was that obviously, I had worked in different sectors including publishing by the way, as a part of my career. The thing with health is that it is something that touches us every day, whether it’s through childbirth, or through parents or even yourself from when you are young and as you get older. So there is always that curiosity.
It’s almost like the hotel industry where we all kind of think we know what is always going on in there, but it is curiosity.
TN: What has been the biggest surprise for you from the move?
VN: I think the main thing has been just to understand the depth of it and also to realise what kind of an opportunity it is particularly for our country and interacting with various people, usually very brainy people doing great things.
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TN: Interesting, I have spent some time looking at your 2017, 2018 and 2019 financials and I see growth in revenues and growth in membership, which is a commendable progress given the current environment that we are operating in right now, can you unpack for us what has contributed to that growth both in membership and in your revenues?
VN: Okay, I think even since that year end of December 2018, there has been further growth in our membership numbers. By end of 2018 we were on something like 197 000 to 198 000, but we are now well over 200 000 to 207 000. I think it’s the awareness of the brand in the market but also I am starting to think that as things are getting difficult in our economy, people start wanting a safe place to be in.
TN: Let us talk about the current doctors’ strike, do you have a view as the leader of one of the biggest medical aid societies, what impact has that had in your service provision and to your members and generally to the health delivery system in the country.
VN: I think the biggest thing for me, and I look at it from a continental point of view, and from a developing countries’ point of view — the challenges that we are facing are quite common in the developing countries. We know that the current dispute is about remuneration and in Africa generally there are issues and conflicts around remuneration.
I was looking at some study that was done sometime last year about remuneration across Africa.We are talking about US$1 500 for a doctor in countries like Lesotho and Swaziland.
While in South Africa it’s a bit higher around US$3 400 but in the rest of the continent, the figures are really shocking with the likes of Nigeria getting under US$500 a month and so forth. For me, that is worrying because it means that as a continent, we do not retain those skills and what it calls for is I think all of us in the industry’s leadership to look for solutions to make sure that we progress in terms of health.
TN: So Nigeria stands at US$500 every month, where does Zimbabwe stand?
VN: Well in Zimbabwe, I think we all know the figures, which are now a bit difficult to say their values because of the movement of the currency and it would be misleading for me to quote any figure at this point. But you know things were stable during dollarisation period. I think we were staking around where most Sadc countries are, where it was around US$1 200 to US$1 500. There are also countries that we would have expected to be better like Egypt.
Egypt has got one of the lowest figures on the continent, which is pretty low, going under US$500, actually. For me, it is now time for us to start looking for solutions around that area.
TN: What could be the solutions to that?
VN: I think it is more about getting our government to invest more in health. For example, if you look at Zimbabwe or Africa, we have been guided by the Abuja Declaration which says 15% of our budget allocation should be directed to health, but in the recent years we seemed to be going upwards, but you know with the budget reallocation early this year, we are down to like 7%.
It is actually encouraging us to actually to start putting more money in health as a country. Some of it will come from our own pockets because when we talk about medical aid, it is people actually deciding that they want to save for their health. So it is about bringing that awareness because if we cannot raise that money, be it in the private sector or public sector, then we will not retain those skills.
TN: And as they say that a nation that does not take care of the health of its people is a dying nation. Let us move on to the next issue, which is the doctor patient ratio, which is also raised by the current doctors’ strike. Where do we stand and what would be the ideal place to be?
VN: You see even on that, despite the fact that we have actually upped our training of doctors in the last decade, we are still at quite a miserable ratio.
With the numbers that we have, we are looking at 0,16 doctors per
1 000 patients and the World Health Organisation benchmark is one doctor per thousand patients. We have got countries that are progressing in the West like the likes of Germany, Netherlands and the United States of America. Their ratios are ranging from two to four doctors per thousand patients. So it shows you the kind of gap that we have.
It also gets worse in the specialist disciplines where in Zimbabwe we are at 0.03 per 1 000 patients.
South Africa is not any better at all, at 0.09 per 1 000 patients and yet there are countries like Turkey and Chile, who are already at 1/1 000 for specialist doctors.
TN: And is this all because of the under investment by government into the health infrastructure, training of doctors and nurses and that kind of stuff?
VN: I would also think the brain drain from our continent into those places. There are a lot of African doctors practising in Canada, Europe and Australia and so on.
TN: Linked to that is also the cost of medicine and in our environment this is worsened by the currency and what it is doing. What has been your experience in terms of your members and patients around the impact of foreign currency on the cost of medicine on medical provision?
VN: The last 12 months have really been testing for us because we saw the cost of medicine going up drastically, mainly because we import the bulk of our medicines and again it is something that is not peculiar to our country alone because South Africa is also in the same situation.
Our manufacturing capacity has been decimated. We are importing everything, but in the case of our country, we also find that our buying is fragmented. So we are not able to negotiate in bulk. So there are many people importing and not getting the best prices.
TN: So we are not taking advantage of bulk buying that would result in the prices being reduced. But the bottom line is we are not manufacturing, why is that not happening?
VN: I think in our case it is something that we should really introspect about because if you think about it, 30 to 40 years ago, we were doing some serious manufacturing in this country.
It may not have been efficient, but you know the situation post the Unilateral Declaration of Independence, what we did not do was to invest and re-equip our industries.
I think in the long-term we really should be looking at sectors like health because we did have the competence before and those are the sectors we should be looking into for investment.
It all starts with the public sector. If they are not able to afford then there is no customer because health really is largely a public sector responsibility.
So we need to get to a state whereby our public sector is well financed for a start, but also grow our private sector to complement the public sector.
TN: And give people an option — those that can afford private can go that way and those that cannot — go to the public health service sector.
I have been looking at your report on the growth of your business.
I am led to believe that you must be commended for having taken advantage of the collapse in service delivery by government.
You have moved into spaces, which are not traditional medical aid services and I want us to talk about that right now on how you have aggressively moved into investing in the health sector and if you could outline the sectors you have invested in and the impact that you have had.
VN: I think one of the advantages that we have is that some of us came into an organisation with a very long history. We had to study the history of medical aid in this country and the first one came in 1933 and that was PSMAS, followed by Cimas in 1945.
We were quite advanced in terms of what we were doing.
If I tell you that South Africa started having regulation of medical aid (as much as they had had medical aid before), that only started in 1966.
So we had moved somewhat in terms of our medical aid services, but what then happened was that going into service provision, our first foray in terms of medical aid services provision was in 1985 when we bought medical laboratories and that was at the request of the industry when the then pathologists were emigrating and there was nobody who had the capacity to take over the laboratory. We have since expanded into about eight laboratories countrywide, but it is certainly one of the largest in terms of marketing and one of the first to be ISO accredited.
What then happened is in 2003 we started having a problem in the country and that is when there was hyperinflation and there was no agreement between the medical aid industry and the health service providers on the medical tariffs.
As inflation went up, we found out that our members had no places where they could access service particularly on the lower side of the scale and hence our new clinics were born.
We then went into primary healthcare, which for me I think was a very good foresight on the part of my predecessors, because primary health care is at the core of health care services and if you get that right, everything else follows.
We have 12 clinics countrywide and they have in-house dispensaries, which by the way came in very handy during the crisis that I highlighted earlier on when things started getting out of control and medicines were not that available and our members were able to access those medicines in the pharmacies and are still doing that.
TN: And dialysis units.
VN: The clinics started in 2003, I should have mentioned the dialysis, in 1999, for the same reasons, when we found out that while the public sector had put up dialysis facilities, they were not enough, they were not adequate and hence we put up a Harare haemodialysis centre in 1991.
It was a huge lifesaver to a lot of our members and patients, some of whom had been on it for a decade and provides a very high quality service.
TN: Are there plans for a dialysis centre in the southern region of Zimbabwe?
VN: Yes, we certainly have that in our plans because we have patients sometimes commuting to Harare. One or two others have opened up since then. We really think that it is necessary that we spread our wings so that as many people can access the health service.
Talking about the expansion, not only did we have primary health care clinics, we also went into dental health service provision as well and we also entered into ambulances and air rescue.
Ambulances services are very interesting to talk about because we noticed that the ambulance services that were there were not coping. So we feared that the first hour is very critical, especially after an accident.
We have a long way to go because people need to have an ambulance when they need it particularly in light of accidents.
Going into that sector we are discovering a lot of things including the ambulance service, which has been well received.
TN: What have you discovered?
VN: We have discovered a lot of gaps throughout the country, in remote areas, on our highways, and this is something, which as a country, we need to come up with a solution for.
TN: Is this an opportunity for Cimas?
VN: Yes, I think this is an opportunity for Cimas but it is also for the public sector and those who are entrusted with our roads to rise to the occasion. Here I am talking about the likes of Zinara and we really need to do something about the highways.
TN: On the dental side, how many dental units do you have at the moment?
VN: So far we have one with two more planned in the next year or so and that one is in Harare.
TN: That is interesting, you have gone in as a response to government not providing the services but in 2017 you have government proposing a Medical Aid Societies Regulatory Authority Bill, which to me looks like is going to punish you for all the creativity and innovations you have had going into places where government has not been able to invest in.
Government is raising the issue of conflict of interest. You are arguing self-regulation, this is obviously a dark cloud hovering over what you are trying to do, what is your position on that?
VN: Firstly I would like to say that we are open and welcome any improved new regulation.
So far we were being regulated by the Ministry of Health in terms of the Medical Services Act and the medical aid regulations of 2000.
Yes, there is this debate around that and we know that there is an intension of bringing the Medical Aid Societies Regulatory Authority Bill.
We welcome this because if we have got a strong regulatory environment, it means that our business can grow undeterred and we can compete on an equal footing as an industry.
But more importantly, medical aid is about the ability to pay and financial ability, good governance, and all those things, which are things that as Cimas we pride ourselves on.
When this talk of stopping medical aid societies from being in service provision comes, we just think it is an unnecessary destruction for a variety of reasons.
One is that there would be a conflict of interest.
First of all the regulations that I cited say you cannot direct a member to a particular facility, that’s catered for there, but also if you look at the Competition Act, there is a lot of safeguards in there and indeed when you are found doing the wrong thing, that Act will deal with you.
What are we talking about here? In substance are we not trying to entrust the same thing that we are trying to get rid of because we are now saying that service provision is the preserve of health practitioners only. But is that not also creating a monopoly in that regard?
In fact, we are always talking about the issue that there is no common tariff between medical aids societies and service providers. It is also an outdated concept.
People should not sit down and agree on prices, there could be a guide on tariffs going forward, any prices should be business to business relationship.
TN: The issue of conflict of interest is one that to me appears might be legitimate and that it might need to deal with that. What is your view on that? How does the industry address the concern that the industry might be having some conflict that you might be directing some of your clients, who you supply medical aid services to say you go to our dentists, you go to our clinics. How do you give comfort to those pushing against that?
VN: In terms of existing regulation it is illegal to do that for a start but also, it is not good business practice to actually say to somebody, join me and if you join me this is what you want. People want choice and we as a business understand that people want choice. It is about customer experience.
When we put up these clinics and other facilities out there, they should just compete with what is in the market so that patients can choose where to go and members can choose where to go to.
Our view is that as long as you are not penalising people for going to a particular service provider over your own then I do not see where the conflict really comes from.
TN: Has there been an initiative by industry to practise self-regulation to give comfort to the authorities that we can self-regulate?
VN: I think as the dialogue on the new regulatory bill comes, we have put this on the agenda to say, to literally say let us strengthen our own self-regulation.
There are industry bodies that look after medical aid societies, maybe not actively self-regulating but there is room to build on that going forward. TN: What do you consider to be the major challenges being faced by medical aid societies in the country?
VN: At the moment I think it is access to services, which comes from the fact that members are facing significant shortfalls and this arises from the fact that the cost of services has gone up, sometimes in sympathy with the depreciation of the currency, particularly in the early days, while the contributions have not.
In the recent month or two there has been a bit of pull back in the sense of the extent of the increase of the cost but there is still a discrepancy where maybe medical contributions have gone up at least three times whereas sometimes the cost of services has maybe gone up at least 10 times. That for me is the challenge we face at the moment.
It also comes down to pharmaceuticals for example because the inputs are also foreign and the cost of running a hospital to some extent there is a significant foreign component and then problems that I talked about earlier that those are skill based activities.
Some people have the skills and, therefore, would want their remuneration protected.
Even as medical aid practitioners, we cannot point fingers at service providers and say you are being unreasonable because at the end of the day it is fair pay for them as well.
TN: Less that 10% of the population are covered by medical aid. How does that figure look like compared to the rest of the world?
VN: Like I said earlier, in terms of Africa we really have challenges. Even in South Africa it’s no better either, but the Sustainable Development Goals talk about universal health and wellbeing for all by 2030, giving people healthier living by 2030.
They go on to a lot of issues including one that affects us and that is sub-goal 3.8, which talks about universal health coverage, including financial inclusion.
In Africa that continues to elude us. We are far away from it and it comes back to challenges that I mentioned earlier on that as individuals we must start to invest in our health and not to wait for the rainy day to come, but also we must help our governments to put the things they need to put in place. The issue of the national health insurance that is topical in South Africa, those are useful discussions to have. I know right now we have got other pressing needs but then again let us take advantage of, we as the private sector, we need to invest in health.
TN : Is it on the table in Zimbabwe?
VN: Yes it is but obviously we have more pressing needs. It has been on the table…
TN: Should this be prioritised?
VN: Yes I think it should be prioritised in a holistic manner as we deal with other things in the country. We need economic stability for a start.
TN: Let us move to your discomforts with health service providers, the fact that sometimes people with Cimas cards get turned away and issues along those lines. Can you outline to us exactly the problems you are facing?
VN: I think for us some of the problems are perceptions more than reality. We are one of the largest in medical aid societies in the country and probably the largest in the private sector.
We have been around since 1945, the formula has been working for a long time and it is only when we stopped having agreed tariffs that the relationship didn’t seem to be going too well, but we are not deterred by that.
We are working very hard to improve that relationship, particularly the business to business relationship.
We are also working very hard because we understand the service providers are also just as good as our customers.
TN: And by service providers we are talking about doctors, hospitals and who else?
VN: It’s doctors, hospitals, laboratories, ambulances, and the like.
For us we see them as our partners, contrary to the view that you just cast and I think for now we think we enjoy cordial relations with them and they could actually improve.
A lot of them, believe it or not, they are actually taking our cards and they are increasingly taking it because we are slowly reaching an understanding and we know where they are coming from.
Some of the pressures are the pressures of the economy and they also have to invest in their lives and skills and that needs money.
TN: So you are finding each other somehow?
VN: I think we are making really good progress and we are very optimistic about the future of the relationship.
TN: Let us move now to talk about a lot of Zimbabweans going outside the country mainly in India for medical tourism, to receive medical attention, how big is that and what role does Cimas play in that?
VN: There are certain services that are not available in this country, like a lot of cardio procedures, some of the cancer treatments and even kidney transplants that we don’t do here, liver transplants and so forth.
India has advanced greatly.
They have trained super specialists. So since 2012 we have been sending patients to India to South Africa because we figured out that the country is also an expensive destination and yet in India we found out that the outcomes are great because they use the model of integrated health care where there is everything under one roof and use a group mentality where a number of specialists will come and look at patients and assist each other in that way.
For us it has been a learning point and we have been using it to our advantage but we have also been using it to learn as I said.
TN: So is India cheaper than South Africa when you add hotel accommodation?
VN: Yes. The problem in South Africa and the model that they are using is that when you go into a hospital, it is almost like a hotel and then the specialist comes with his own bill and it is also the model that we used here whereas in India the doctor is actually employed by the hospital.
So you get all expenses in one bill.
I actually visited India in December and had first-hand experience of this in practise.
TN: Tell me on average how many patients in a year do you refer to India?
VN: It is pretty small, we are talking about 2% of the people that claim.
More people had been to South Africa along the years.
Maybe for our size we are talking about the region of 200 to 300 people at any point in time whereas in India it has been a fraction of that. Maybe a quarter of that.
TN: Let us dwell on specialists and specialty services. Four cardiologists throughout the country.
VN: Yes we have four cardiothoracic surgeons in the whole country. Four cardiologists the whole country.
You can’t even do the hard procedures that you have to do here.
Mind you, when those super specialities come they also need the support staff that they need. We are really quite thin on specialists.
TN: What other specialists do we have?
VN: I think its right across all the specialists’ areas. Various surgery disciplines. Orthopaedic surgeons, it is improving.
You are talking about 14 neurosurgeons but the areas I have mentioned there are areas people need super specialities.
There is one that will worry you, paediatric surgeons, two in the whole country and is the other area where we have been sending patients to India. We need to plug that.
TN: How do we plug that? Is it the private sector, is it the public sector doing that, is it a combination? What initiative would we need to close that?
VN: I think it’s a combination. If the public sector can chip in the way we have done and I know that some of our fellow medical aid societies are also doing quite a lot in that area.
It helps address the gap.
But the public sector and also our universities, understanding that gap but also having structures where these people can work when they have gained all those super specialties.
That is where for us, it is a tragedy if medical aide societies were to be stopped from being service providers in those areas because we have an eye on those things to say let us start these facilities to address some of those areas.
