Providing Health Services for all

I have been amazed at what major Western Nations spend on health services. The US and the UK are world leaders in this field and treat health delivery as a major part of State finances, certainly several times what they spend on defense and security. It is no wonder that modern economies generate over half – perhaps as much as 70 per cent of national GDP from services. Despite this, millions of people, even in the most wealthy of States, suffer from poor health services and unaffordable treatment.

In Africa we are supposed to follow certain budgetary guidelines and to treat health as a real priority. But there is much more to health delivery than just making sure we allocate sufficient funds in the budget. The simple harsh reality is that there never is enough money for our needs.

But it is not always about money. When I employed over 2000 Zimbabweans in my business group, we often chose to send our staff to Mission Hospitals for treatment. They were always treated as real human beings and the facilities clean and well run. Very often we were astonished to find young European and American doctors in residence with real skills and knowledge. The equipment was often old – maybe second hand, but it worked. Treatment was often free.

State hospitals by contrast are renowned for poor service and demands for money before help. Staff attitudes are very poor and the quality of service leaves a great deal to be desired. When my driver was in an accident and broke his legs, he was admitted to a major regional State hospital and while we were satisfied with his treatment we did not get a bill for two years and when finally we paid what was due it was completely destroyed in value by inflation. Good for business, bad for the health service.

Health care provision is a business at its core and it is this aspect that needs close attention as we seek to create a system that can deliver a reasonable standard of health care to all our people. Increasingly countries are working to create health centers that can attract patients (clients) from all over the world. I would like to see the numbers for India which seem to be making a special effort in this regard. Today I have friends who have had procedures done at a much lower cost that they could expect here or in South Africa. Heart defects, new hips, knee surgery and eye surgery all seem to attract clients who can afford the trip, to hospitals and clinics in India and even Malawi and Zambia.

We spend much more than we think on health care even in this country’s terrible economic and political conditions. Our health budget is minimal at about 8 per cent of the total spend. But international donors double this with direct grants for HIV/Aids and other communicable diseases. Even so the biggest contribution comes from Medical Aid schemes – all of which are privately run and service about 8 per cent of our population or one million individuals. These schemes offer assistance that varies from very basic State managed services to top of the range health care with flights to neighboring States in an emergency. This must consume about double the national budget allocations plus donor aid or something over US$800 million a year.

If we add all this together we must be spending about US$2 billion a year on health care in Zimbabwe – that is 14 per cent of GDP. It is only because we are such a poor country that this does not enable us to deliver any sort of real health care to all our Citizens. We do not do badly in the circumstances but our low life expectancy, high maternal and infant mortality rates tell the real story without embellishment.

My personal medical aid scheme is called Northern and is restricted to local companies and their staff. The last time I looked at the annual accounts they spent 7 per cent of the total revenue of the scheme as administration cost. Their Board is made up of all volunteers and they do an exceptional job. My scheme has both a local element to cover local routine costs and an insurance component that is managed from Ireland. This covers major needs. At less than US$150 a month for two of us this is excellent value for money anywhere. They are not all like this – the Premier Medical Aid Society had half their annual revenue stolen by the senior staff leaving perhaps 400 000 people without cover.

So what do we do to avoid the mistakes of other countries, use scarce resources effectively, attract and retain top skills and give everyone access to medical services when they need help? I think we have to tackle this challenge from many different angles at the same time.

First we need to treat the provision of medical services as a business. Let’s create a competitive environment for companies to provide medicines at least cost, doctors to attract clients by their quality of service and skills. Hospitals, no matter what their funding, (Church, State or private), to be forced to compete for clients who would pay full cost for services and on the basis of which they must meet their costs.

We need to maintain our present system of grading our hospitals and clinics and then setting their charges for procedures based on their costs and margins. If you then chose a category A hospital or clinic you will be charged top rates for service and treatment. Category B and C likewise and I would assume some private hospitals would go for the top ranking while State and faith based facilities would go for B and C classification where service levels would be lower and cost appropriate but still competitive.

Then we need to be able to guarantee access and this should be achieved by a system of Medical Aid Schemes which would all offer what I get from my scheme – managed administrative overhead, annual General Meetings of Members and Audited accounts that are made public. All such schemes would belong to medical insurance schemes – private or public which would meet emergency needs and the cost of major procedures. The entire system should be administered on a “not for profit” basis but be subject to Community or Membership control and management.

Medical Aid contributions would be set on a cost recovery basis according the system selected – A, B or C. If any individual was unable to pay this fee from a means point of view then the State would provide the required top up on a monthly basis to the Medical Aid Scheme. The top up would be reviewed annually.

Government would no longer employ medical staff or run medical institutions – all State owned facilities would be handed over to Communities or local Authorities and be managed by Boards elected annually. I believe that medical staff may not be the right people to manage the health care system and that this role should be filled by a new class of professional managers with special knowledge and skills. To meet this need we should establish at least one major Business School at a local University – preferably one teaching medicine, and this would grant an MBA specifically designed to meet the needs of managing hospitals and clinics at all levels.

Is this an impossible dream? I do not think so and in my view this would address many of the problems I hear about with other systems – the huge costs of the American system, the inaccessibility of the NHS in the UK, the corrupt and unfriendly service at State funded and managed institutions. The ideal is the faith based system where dedicated, selfless individuals make great personal sacrifice to provide medical services to the poor. But I am realistic enough to recognise that that is simply not possible on the scale required.

What I am quite convinced of is that the present system simply does not work for everyone and cannot do so unless we change what we are doings and how we are doing it.

Eddie Cross
Harare, 28th December 2016