Why public hospitals are congested

Why is there congestion at our public healthcare institutions? Patients take long hours before they are attended. 

The challenges facing referral hospitals are a direct result of existing economic circumstances. The referral system, user fees and access have put unbearable pressure on the main referral hospitals, which are Parirenyatwa, Harare, Mpilo, Chitungwiza, and United Bulawayo hospitals.

Whether the problem lies with perceived or real inefficiencies or inadequate resource allocations is anyone’s guess but there are structural problems that should not be ignored. Zimbabwe is currently operating within very tight healthcare budgetary constraints and this in general terms affects health delivery.  

Part blame has been shifted to the absence or shortage of enough hospitals at lower levels that ensure central hospitals purely undertake their referral function. 

In the midst of all these conversations this paper attempts to answer the extent to which our current economic circumstances have contributed to pressure at our central referral hospitals like Parirenyatwa, Harare, Mpilo and others. 

This is by no means to suggest that more cannot be done by way of improved efficiencies and healthcare management. This is so because careful budgeting and planning, monitoring and evaluation in resource allocation and utilisation in central hospitals can help to improve output. In fact on the basis of studies done elsewhere improvements of 30 to 39 percent were realised from better and more efficient use of available resources including training and capacity building.

Although there are no universal models for good service delivery, there are some well-established and tested basic requirements. A health system must deliver effective, safe, good-quality personal and non-personal care to those that need it, when needed, with minimum waste. Suffice to say the services be they prevention, treatment or rehabilitation must be affordable whether being delivered in the home, within the community, the workplace or in health facilities.

Effective delivery requires trained staff working with the right medicines and equipment, and with adequate financing. 

The World health report 2000 defined overall health system outcomes or goals as improving health and health equity, in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources.

Zimbabwe’s hospital referral plan, the first level is the primary level constituting mainly rural clinics and other rural healthcare centers. According to the Zimbabwe National Health Strategy (2016-2020) every primary health has at least two qualified nurses, an Environmental Health Technician services 59 percent of administrative wards and 60 percent of villages have access to a village health worker.

The next level is district (secondary level) hospitals, which provide general inpatient services, accepting referrals from urban and rural health centers (RHCs) and clinics that constitute the primary level. 

Every district must have at least two doctors. WHO estimates 500 000 people per district hospital which should perform general operations that do not require a specialist doctor. 

Provincial or tertiary level hospitals receive patients referred from district or secondary level hospitals and provide general specialist services. 

Quaternary level hospitals in the major urban centres serve as national referral facilities and provide specialist and sub-specialist services. 

Parirenyatwa hospital in Harare designed for 900 beds but now accommodating much more functions as a teaching hospital and should just be a referral centre for patients from secondary and tertiary hospitals in the country and possibly the region. For example just in the physicians bay a cubicle supposed to hold six beds now holds about double that number. The hospital offers specialist and general outpatient and inpatient services and is at times overwhelmed. 

To date there is no intermediate hospital between the primary level and Parirenyatwa to which patients could have been admitted. The absence of these district hospitals has created the current congestion at Parirenyatwa. 

Reasons emanate from a dysfunctional referral system together with issues around council clinic user fees and charges by the private sector clinics and hospitals. Many go seeking initial care at the Parirenyatwa casualty department when they could have received such care at a secondary or primary level healthcare facility elsewhere.

There is also a school of thought as to whether Parirenyatwa hospital should not be split into two with one wing catering as a secondary or district hospital. Some thought must also be given to Harare hospital in terms of the whole referral value chain system. But it does not end there. Harare’s population is estimated at about 1.6 million and 2.5 million including surrounding areas. This demands an additional 3 hospitals.

The ministries of health and public construction and national housing have not built a hospital in the last 20 years in Harare. 

Success also requires an organisational environment that provides the right incentives and remuneration to both providers and users. This must be sustained over time and across different health conditions and locations. The issue of location is critically important, especially given Zimbabwe’s current economic circumstances in the context of our established but weak referral system.

Government adopted the primary healthcare approach in 1983. We have four basic levels of care and a well-defined package of health services provided by appropriately trained health care workers at each level. Competition for resources is not only between referral hospitals, district hospitals, clinics and other primary level care centers. 

It is also between prevention and treatment; between professional groups; between public and private players e.g. pharmacies over foreign exchange; between those engaged in efforts to treat one condition versus another e.g. HIV/AIDS and Cancer; between capital and recurrent expenditures. This demands the need to strengthen health system evaluation and monitoring to achieve best choices and health outcomes.

Changes to public policy and administration, particularly decentralisation, makes    

new demands on local authorities and may change fundamentally the role of central health ministry and how the current referral system should be operationalized. A continuous review of our health delivery system is necessary to ensure its goals are met. 

Economic growth and poverty reduction have direct positive impact on health delivery. The opposite is true. Zimbabwe is a case in point. Our experiences of the 1980s and 1990s as compared to the post 2000 need no further elaboration. In Africa Rwanda is an example of what economic growth can do to healthcare. 

Between 1990 and 2000 Thailand reduced its level of child mortality and reduced by 50 percent inequalities in child mortality between the rich and the poor. The results were attributed to substantial economic growth and reduced poverty over the period. But these were not the only reasons. 

In the matrix were increased health insurance coverage and more equitable distribution of primary health care infrastructure and intervention coverage. A series of pro-poor health insurance schemes improved health service coverage. The initial step was to waive user charges for low-income families.

This was followed by subsidised voluntary health insurance, then the extension of the government welfare scheme in the 1990s to all children under 12, the elderly and disabled, and to universal coverage from 2001. 

Health infrastructure and services were scaled up with emphasis on primary healthCare and community hospitals targeting the poorer, rural populations. Increased financial incentives and educational strategies led to a more equitable allocation of doctors in rural areas. This combination led to increased utilization of health services. For example, vaccination coverage rose from 20 to 40 percent in the early 1980s to over 90 percent in the 1990s, skilled birth attendance rose from 66 percent to 95 percent between in the 1980s and 1990s.

The same strategy is still possible in Zimbabwe if economic growth comes to fruition. Already some of these initiatives are already taking shape although some challenges remain. The role of government and medical health insurance has weakened over the years.

The loss of confidence in the medical aid system is a major concern. Medical health insurance is provided by Medical Aid Societies (MAS), covering mainly the formally employed and their dependents and collecting premiums through employers. Job losses have negatively affected these collections resulting in many medical aid societies collapsing or failing. Owing to multiple challenges medical aid societies sometimes fail to pay service providers on time. This has rendered medical aid unacceptable to some service providers. 

This has resulted in some members seeking help from public healthcare institutions ahead of private ones. Exorbitant shortfall even for those on medical aid has simply the scheme difficult to use.

Estimates reveal that about a million beneficiaries comprising eight to 10 percent of the population out of a national population of 16 million are on medical aid. About 80 percent of income to private health care providers in Zimbabwe comes from Medical Aid Societies and they contribute more than 20 percent of the country’s total health expenditure. 

The reality is that the high share of private health insurance spending is not reflected in equally significant coverage rates because the 20 percent covers less than 10 percent of the population. 

There presently is no fully fledged national health insurance scheme in Zimbabwe meaning most of the population is not insured for health needs and cannot access the expensive private sector health facilities. This puts pressure on the public health delivery system especially the main referral hospitals.

In addition when out-of-pocket spending represents a large share of health expenditure the pooling of private resources is negatively affected. 

This demands that households produce funds at the time of seeking care. This is a barrier to accessing healthcare and can threaten families into deeper poverty. Changes in user fee policy during the 1990s early 1991 and the enforcement of user fee collection at all health facilities at the start of ESAP in 1992 to present has to a large extent limited access to health care. 

Changes involving the retention of user fee revenues at the facility and district level, reinstitution of user fees at some rural mission hospitals, withdrawal of health grants for local authorities and municipalities, higher than average increase in user fees charged by municipal health facilities in the late 1990s. All these emanating from the challenges of reduced government expenditure on health. 

At present, specialised services in the public sector such as cancer care, dialysis, and advanced imaging are not always affordable for patients. This is a major concern. The challenges facing referral hospitals are a direct result of the economic circumstances facing us.

The issues of a dysfunctional referral system, user fees and access and cost of medicines together with poor antiquated equipment continue to put pressure on the main hospitals. When the full circle is drawn it comes back to the state of our economy.