BY Dr Lasting K Kachingwe
There are so many facets to health system reform that it would be difficult to cover them all in one instalment. The word reform is often used with reference to the change or amendment to something that is defective in one way or another in order to make it better. The aim of reforming anything could be to make it more efficient. Restructuring, like reform, implies organising something differently, resulting in changes to the structure or practice. Since reform, basically, implies change, those undertaking reforms should have the requisite change-management skills. They must, in particular, be prepared to manage a whole host of emotions among the stakeholders, which can be summed up under the phrase: “What’s in it for me?”
On August 13, 2020, local media was awash with reports of the round-the-country tour by the newly-appointed Health minister, Vice-President Constantino Chiwenga. According to the reports, the minister was not happy with, among other issues, those hospitals that were said to be demanding Covid-19 clearance certificates from people seeking medical services as well as those taking advantage of the Covid-19 pandemic to charge fees that were viewed as exorbitant. The minister announced that the government was soon to embark on a “restructuring and reforming” exercise of the health delivery system. He added that weaknesses had been identified in the current health system and “things will never be the same again . . .”.
The structural changes, he stated, were to be effected throughout the health system from the “village, district, provincial to referral hospitals.” Subsequent announcements by the minister were made, expressing the desire by government that citizens have “equitable access to health care services of sufficient quality”. The announcements were made in the backdrop of strikes by public health sector staff, inclusive of nurses, medical doctors and the allied health professionals. The specific objective of the reform of the Zimbabwe health care system has been reported as to develop a new structure of the Ministry of Health and Child Care, with three phases as outlined below:
l addition of a new top layer to the national health delivery system.
l the development of an organised strategic department in the ministry.
l (i) development and adoption of a sustainable funding model for the national health care system. (ii) develop conditions of service for the health staff to perform functions in the new structure. The VP Chiwenga has since announced that the first phase of the restructuring has been accomplished through the addition of “the fifth level or the quaternary hospital which is a high level research and development hospital.”
It is important to, on the outset, define what a health system is. The World Health Organisation (WHO) definition is that a health system is,“all the organisations, institutions, resources and people whose primary purpose is to improve health.” It is noteworthy that the efforts of individuals in a public or private work environment have the over-arching goal of improving the health status of individuals or communities. The actors in a health system, therefore, include the patients or clients, communities, the health regulatory entities, the service providers as well as the institutions responsible for health financing. It is anticipated, therefore, that a health system will equitably meet the expectations of individuals and communities regardless of their socio-political or economic status. Issues of equity have serious implications for the principle of justice and embedded in this principle is the aspect of fairness.
The reform of the health system normally refers to fundamental and purposeful change at all levels of the system. Such change, in essence, is holistic in nature and it is typified by the implementation of comprehensive or global structural changes, involving amendments to health policies and institutional arrangements. This is quite distinct from a situation where piecemeal changes are made in the structure. The ultimate aim of health system reform/restructuring is to enhance the performance of the health system. The health system must be fit for purpose, which is to improve the health of citizens or communities. As is the nature of systems, whatever happens to one part of the system will affect other parts of the same system, either positively or negatively. Sight should not be lost of the relationships and interconnections of the different parts that form the health system. Reformers of a health system, therefore, need to think of the possibility of unintended consequences, and not just the results that they aim for.
It is necessary to briefly describe the structure of the Zimbabwe health system, since although there maybe similarities, the structures tend to differ from country to country, even for countries in the same region. Without going into the finer details of the network of institutions, both public and private, in the system at each level, suffice to state that the structure has been, hitherto, besides the headquarters, been characterised by four levels, that is, the primary, secondary, tertiary and quaternary. The primary, as the term suggests, is the basic level where institutions include the clinics/rural health centres, the secondary has district hospitals as the most distinct institutions, the tertiary has provincial hospitals and the quaternary level is where are found the central hospitals. Each lower level, ideally, refers patients to the next higher level, if necessary, for more specialised care. The greater proportion of the health services are provided by the public health sector and these are complemented by the private health sector, that is, the private-for-profit, including private surgeries and hospitals and the private not-for-profit such as missions health facilities.
The literature reveals that the following list, though not exhaustive, constitutes some of the common reasons for governments to undertake health system reforms:
i) cost of providing health services exceedingly high to the extent of being unsustainable.
ii) radical political and economic changes, normally related to the arrival of a new political administration rather than the objective identification of dysfunctionalities of the existing system
iii) the need to expand access to health care by the population.
iv) the quest to address inequities in the distribution of health care.
v) addressing inefficiencies in the health delivery system.
A discussion of the problem in the health system should not detract from the commendable work that is being done by the majority of the health workers.
Although the Zimbabwe health system, at independence, was the envy of many countries in the region and far afield, over the years, the following have been some of the system weaknesses:
l Inadequate allocation of financial reources to the health sector. (Abuja Declaration target of 15% of annual national budget to be allocated to health sector is still elusive)
l Imbalance in distribution of health resources. The greater proportion of the Zimbabwean population is still in rural areas but staff and financial resources are still disproportionately allocated to urban areas.
l Shortage of medicines and other medical sundries in health facilities.
The highly informalised economy makes it difficult for the majority of people to be on medical aid. Often, health care providers refuse to accept medical aid payments from clients, due to delays in effecting payment by medical aid societies, seriously inconveniencing clients on medical aid. The poor and unemployed have a highly restricted access to health care. Also, there are still, in many parts of the country, long distances to be walked by people seeking medical care, inspite of the commendable work made after independence in 1980 to construct more health facilities.)
l Staffing issues: shortage of professional health staff, particularly in rural areas, and demotivated staff due to poor conditions of service including inadequate salaries.
l Poor maintenance of health infrastructure.
l Corruption (eg, in recuitment practices, procurement, abuse of medical aid schemes, etc)
The health system reform process, it is expected, should not be done just for the mere sake of having change in the manner in which the system has been functioning. The question to take into account is: what are the positives that Zimbabweans expect to see with the advent of the reform, notwithstanding the fact that some of the results of the reform may not be witnessed immediately? What are the tangibles that will show that the reform effort has paid dividends?
I find a useful guide to be the six building blocks identified by the WHO which serve as an analytical framework for assessing the performance of health systems. The building blocks, it has to be noted, are interdependent and do not exist as silos.
The blocks are:
i. Service delivery;
ii. Health workforce;
iii. health information systems
iv. access to essential medicines;
With the building blocks in mind, Zimbabweans across the board, therefore, expect the following from the health system:
1. Quality health services should be provided in an effective and safe manner at a minimum cost and readily available when needed. The number and distribution of health facilities should be re-visited, per given population with a view to increasing these as necessary and improving coverage. A comprehensive range of services should be provided, based on the needs of communities. The socio-economic and geographic barriers to health-seeking behaviour should be addressed.
2. A health workforce that is productive and responsive to the health needs of clients in spite of resource constraints is what clients expect. I believe the knowledge and skills of the Zimbabwean health workers are a good match for those of health workers in neighbouring countries. The main thorn in the flesh could be the lack of staff motivation due to poor conditions of service and financial remuneration in the form of salaries and allowances. Failure to decisively deal with this problem could lead to the continued migration of health workers to other countries. The extent to which health workers are equitably distributed within and across provinces also needs to be looked into. Health staff have long asked for the system to provide the tools required for them to carry out their duties effectively. It is yet to be seen how the government efforts to develop a new work ethic among its health workers will pan out. The vice-president has pledged that government will avail the requisite resources, including personal protective equipment for the health workers to perform their functions well.
Such pledges should be honoured.
3. A well-functioning health information system that provides reliable and timely information is critical for efficient and effective health service planning and management. A well-managed health information system will form the foundation for meaningful health policy development, research, data analysis,
The health information, if appropriately managed, will serve as an early warning system for health problems that may emerge. For the health information to be useful, however, the staff at the point of collection of the data will need to be motivated to analyse it and use it locally for decision-making, rather than simply go through the motions of pushing data collection forms, manually or electronically up the bureaucratic ladder.
4. Clients expect equitable access to essential medical products, vaccines and technologies of an appropriate quality to meet the health needs of the population. There is need for flawless supply, storage and distribution practices that are characterised by prudence in the procurement processes. To this end, the National Pharmacy needs to be capacitated to perform its central role of providing medicines and the related products to health facilities. Stockouts at the National Pharmacy translate into stock outs at the facility levels.
5. Recipients of health services expect a health financing system that avails adequate funds for health service provision. In the case of cost recovery, the health services should not be beyond the capacity of the clients to pay.
Concerted efforts have to be made by the government with regard to the provision of financial risk protection to societal members who face challenges of paying for health services. In any case, our constitution recognises access to health services as a basic human right.
6. Leadership and governance should enable the development of appropriate strategic health policies, achieving consensus in decision-making, team building and institutionalising accountability mechanisms at all levels of the health system. The management of health facilities should have the necessary authority and leeway to plan for health services and be accountable for the results of implementation. The consensus in health service planning and management should extend beyond the involvement of the subordinate health staff to include the recipients of health services through community participation. Indeed, the health professionals and civic society representatives need to be involved in the very process of health system reform. Recent media headlines such as, New Health Minister Dr Constantino Chiwenga fires warning shots at hospitals do not help in this regard. The reforms should not be seen as a witch-hunt. Should the health sector reform process be viewed as a mere imposition from above, the chances of it failing are high. We need to answer these questions:
1. What has necessitated the reforms and what are its objectives?
2. What specific components of the health system will be reformed?
3. What will be the nature and extent of the reforms?(incremental or radical?)
4. Who are the drivers of the reform process?
5. Who will be involved as participants in the reforms?
6. Who will be affected (either positively or negatively) by the reforms?
7. Are the requisite financial, personnel and material resources readily available to undertake the reforms?
8. Will the reform exercise result in the need for additional staff and, hence, an increased wage bill or not?