Getting Our Priorities Right – Health

Source: Getting Our Priorities Right – Health – The Zimbabwean

Quality of life indices for humanity take many variables into account – access to education, water, energy, shelter but perhaps one of the most important is access to health services.


A nurse takes care of a cholera patient during a visit of Zimbabwe Minister of Health, at the cholera treatment centre of the Beatrice Infectious Diseases Hospital, in Harare, on September 11, 2018.
At least 18 people have died over the past week in the Zimbabwe capital Harare and scores fallen ill after a cholera and typhoid outbreak in some areas, authorities said on September 10, 2018. / AFP PHOTO / Jekesai NJIKIZANA

As is the case with all of the above, how we fund and manage the systems that must deliver these services to us, is a critical consideration, yet it gets very little attention. In the United States during the Obama era, the extension of the American Medicare system to all Americans was one of the most contentious issues he had to deal with. Trump is now trying to undo all that Obama achieved.

Americans spend an enormous amount of money on health care. No society on earth has ever had access to such a system and on the back of this system, many health care workers have become extremely wealthy. The industry itself makes massive profits out of the system and all the industries that service health care seem to make an inordinate amount of money. Yet tens of millions of Americans still have no access, simply because they cannot afford the cost.

The United Kingdom has a system which is supposed to offer all Citizens free access to a comprehensive health care system called the National Health Service. It is well funded, absorbs a very high proportion of the national budget and is truly national in character, yet, patients who need urgent attention have to wait months to get it, hospitals are overcrowded and service is often sloppy or insensitive – it could hardly be called a responsive system.

Then you get the situation in the rest of the world where the wealthy have access to systems that deal with their health needs very expeditiously and well and often attract patients from other countries whose systems are not so welcoming or effective. But often such systems are built on low wages for staff, even professionals and the not so well off must rely on a State financed and managed system of health care that is short of everything and riddled with corruption and exploitation. There are exceptions, but they are few and far between.

Here in Zimbabwe we have just such a situation – a small, well financed system of private medicine which is funded through a network of institutions called Medical Aid Societies. These collect a monthly contribution from their members based on what level of medical care you can afford and the Society then pays for medical procedures and needs – often leaving shortfalls to be paid directly by the client. I personally use one of the best – Northern Medical Aid Society, it spends 7 per cent of revenue on administration and the rest delivering health care to its members. We get excellent service and I can be admitted to virtually any hospital in the country without any delays related to who was going to pay.

Not all Medical Aid organisations are as efficient or reliable and some are downright bad with corrupt management and Board. Some are so badly run that their clients have difficulty in securing service. But they collect revenues of $1,2 billion a year and this constitutes the largest single source of funding for medicine in the country. The State provides an allocation that falls far short of half of that total and the international Community provide about half the national health budget, mainly for dealing with the major communicable diseases like Aids and Malaria.

One thing we can all agree on is that the professionals who work in the public health sector are inadequately remunerated. Sir Cornelius Greenfield, who was Secretary for Finance in the Federal Government, said to me once that public sector managers and professional should receive 80 per cent their private sector counterpart’s salary and benefits if we are to retain skills and experience. I think he was spot on.

We need to think about what we can afford and what system would deliver a satisfactory, if not first world, standard of health care to all our people. It requires some hard decisions but if approached properly we can avoid the costly mistakes made by many countries in this field. The first is to recognise that curative service is at the top of the cost pyramid of the medical industry. Therefore, we have to catch problems early and deal with the root causes wherever possible.

So for me the public health system is the top priority – this needs sound management and employs people with lower level skills. Generally, it is reckoned that we should spend 20 per cent of our medical budget on this system. The cost can also be spread across both Central and Local Government.

Secondly, we need to provide good primary health care centres in every community and every Ward – they might total 2200 to give us national coverage, in walking distance, across the country. Each of these should have all the basic services for health care – a few beds for patients, an outpatient’s facility, infectious diseases unit and maternity capacity capable of taking all normal births and managing child health care up to the age of 5 years. In addition, we should use modern communications technologies and solar energy to ensure all Clinics are connected. A national consultative centre in the Capital could then provide back up to local staff presented with complex problems that they cannot interpret.

Only when we have these two systems working properly should we then consider what we can afford in terms of curative facilities and medicine. I am afraid we might have to accept that there are limits to such medicine. What is different is response to medical emergencies such as accidents and I think a national fund to finance such response and care is long overdue. The question is how to manage and fund the whole system.

If we look at all sources of funding – the State, donor aid, the Diaspora, the Medical Aid Societies, missions and the Aids levy, I think we might be spending close to $2,5 billion on health care today. That is not an inconsiderable sum for a poor country like ours and shows just what we can do even given our economy and international relations. But it is less than $200 per capita per annum and is far less than the $2000 a head collected by the better Medical Aid Societies.

Of one thing I am certain is that how we manage what we spend is as important as how much we spend. Mission Hospitals have a much better track record than State hospitals and I have had experience in both. Patients are treated as humans in the Mission Hospitals which are often more poorly equipped than the State facilities. Inefficiencies in State institutions are legendary. The answer is to put all institutions under the control of the Communities they serve, that includes all Public Health programs, clinics and major health facilities like the referral Hospitals.

It is also clear we need a State assisted national Medical Aid and Insurance Scheme. My own ideas in this respect are to make all health institutions self-supporting from fees charged to patients. Then enable all Citizens to secure access and service based on a secure payments system administered by the Primary Health Care Centres with strong Community involvement. My own view is that such a system would work if we could raise $30 a month from each adult in the country (over 18 years). This would be made affordable using a means test system of support from the State.