Monday, August 17, 2009

Towards improved governance in public health care delivery system

It begins with pain in one Molar or pre-Molar tooth.
Twenty-four year old Jonathan Banda invested hugely in dental care
over the years but finally, on Wednesday July 22, 2009, succumbs to
the beck and call of toothache and decides it was time he lived
without the tooth, anyway.
He underrates the medical services offered at Zingwangwa, Ndirande or
Chilomoni Health Centres in Blantyre and goes direct to the referral
Queen Elizabeth Central Hospital (QECH) where he is made to pay K200
for his pains in the public section.
He paid, yes, and wanted two things in return: no more pain as well as
taking the removed tooth (a Molar) home because 24 years are too long
a time to just pat like that. In addition, he hates the way people pat
with their teeth at the hospital- the patient goes home with some
cotton where once resided a tooth, and the troublesome tooth remains
in the bin at the hospital. Just like that.
“After removing the tooth, they gave me painkillers. I, then, asked if
I was free to go home, and they said ‘yes’. When I asked for my tooth,
they said no. Is that fair?” queries Banda.
Banda says some people love whatever they share a life-time with and
are not willing to easily pat ways with some of their body parts at
the hospital. He is talking about ‘unperishable’ organs such as teeth.
“We really need answers on what these people do with some of our body
parts. Some say they use them for study purposes at medical and health
science schools. Some say they throw them away. Only few people know
exactly what happens with their parts,” says Banda.
But, that is just the beginning: it ends with the pocket. Where does
the money (K200) that Banda paid go and, except for Ministry of Health
officials, how can the ordinary villager get hold of this revenue
The Malawi Health Equity Network (MHEN) has been fighting for this,
and many more, patient rights. According to MHEN National Coordinator,
Martha Kwataine, it is in the interest of transparency and
accountability in the public health care delivery system that people
ought to now about what happens with their what.
“This will instill a sense of confidence in our health care system and
improve the relationship between patients and the system,” says
The question of good governance in the health care service delivery
system has been a recurring theme, a theme that has resonated across
regional health forums and meetings.
Governance, according to one of the MHEN members- People’s Federation
for National Peace and Development Executive Director, Edward Chaka-
revolves around six key parameters.
“Broad participation, transparency, open responsiveness, consensus
based performance, equity and inclusion, and accountability, among
other notable factors,” says Chaka.
Not all members of the general public can have a say in this, he
acknowledges, hence the need for a more organized mechanism through
civil society groups such as MHEN.
Chaka indicates, in one of the papers presented at a MHEN (Southern
region) Regional Health Forum, that this can be achieved by
understanding the historical, social and cultural context of a given
society or community.
“This is especially true for hospitals. The essence of governance is
that an organization becomes accountable to those who will be affected
by its decisions or actions, and our hospitals, though trying, have
largely failed to make the mark. In deed, where do our teeth go? Don’t
we have the right to take them home? How are the finances run? Is
there no way of making them public, and timely?” he says.
Chaka acknowledges that, while good governance was ideal, it has
always been a challenge to achieve it in its totality. Very few
countries, including in the Western world, have mastered it. It is an
on going, continuous struggle.
To Kwataine, this struggle includes the need for a comprehensive
review of the health allocation formula. Her analysis of inequities in
health, service delivery and financing points to the gloomy conclusion
that our formula is not based on health needs.
This could be achieved by reshaping the formula to reflect an ‘Equal
access for equal need’ model, developing a needs based formula,
accommodating district specific cost and donor funding differences as
well as soliciting communitarian views on weightings in formula.
“(This will mean that) Population weightings include (s) age, gender,
residence, income, HIV status and performance criteria like in-patient
services,” says Kwataine.
The Malawi National Health Accounts (NHA)’s sub-accounts for HIV and
AIDS, Reproductive Health and Child Health, indicate that the Southern
region dominates in both health expenditures and facilities.
Between 2002 and 2004, for example, the South got 47 per cent of
health expenditures while the North and Centre got 17 per cent and 36
per cent, respectively. The South had a 47 per cent share of health
facilities, with the Centre and North sharing 35 per cent and 20 per
cent respectively.
Recent developments point to improved trends, however. It is also
intimated that K23 billion allocated to the Ministry of Health during
the 2009/10 fiscal year will go a long way in bringing equity in
health resources home.
Another factor includes the need to develop human resources and
capacity within the health sector. A Human Resources/Capacity
Development within the Health Sector Needs Assessment Study (Final
Report) released in April 2007 shows the need for more staff
recruitment and replacement.
The rate of attrition due to resignation, dismissal, redundancy and
death from 1990 to 2005 has been high, though it started to go down
between 1994 and 1995.
It started with a below-30 people figure in 1990, reached 320 in 1993
before going level at 200 workers between 1994 and 1995. Since then,
the number has been increasing, reaching 500 in 2005, up from 400 in
Ministry of Health officials blame it on the brain drain that
continues to hit many African countries including Malawi. Bilateral
donors, including Britain through its Department for International
Development, have tried to intervene with incentive-filled packages
and the trend seems to be slipping down into the record books.
Local Nurses and Midwives advocate, Dorothy Ngoma, says while the
biggest tide seemed far off the coast for now, conditions for health
workers remained pathetic in the country.
A paper by Prof. Cam Bowie (of the College of Medicine) indicates that
there have been staff inadequacies in both Ministry of Health and
Christian Hospitals Association of Malawi facilities between 2003 and
Except for Health Surveillance Assistants, positions for doctors,
nurses and+ technical personnel hardly filled the half-way mark. Many
more health experts continue to be lost to retirement, too.
The number of those lost to retirement now hovers above 50 annually,
raising the black flag even higher.
There is hope, however. Recent studies, including assessments
conducted by MHEN, seem to suggest that Public Private Partnerships in
health could be the answer. This will see private players deliver
health services on behalf of the public sector/government.
This recognizes the fact that, while the core business of the Ministry
of Health is to deliver the Essential Health Package (EHP), this is
hampered by poor coverage and access to the EHP services.
More hope lies in the fact, also, that health facilities such as QECH
have begun to open up to public scrutiny.
QECH, according to Felicia Chilipaine- Principal Nursing Officer,
Medical Unit, and a member of the hospital’s Suggestion Box Committee-
was now waking up to the notion of public responsiveness through such
strategies as suggestion boxes.
Chilipaine, who was speaking with the permission of Acting QECH
Administrator, said suggestions from the public were helping in
shaping the face of services delivery.
“It is also one way of achieving good governance and promoting
transparency and accountability,” said Chilipaine.
The public, through the ambitious initiative, now have the right to
demand quality services. Not only quality services but a timely
service, too, says Chilipaine.


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