Our health system in Zimbabwe; Time to think outside the box
By Dr Brighton Chireka
Doctors in Zimbabwe continue to be betrayed by their funders, as demonstrated by the latest strike by practitioners employed by PSMI. As a doctor, I do not take striking lightly, but I must say the status quo must not be allowed to continue and doctors must do something about their current plight. Waiting for government and funders to do something has failed dismally, so we now need change of tactics .
These new tactics call for serious reflection by all doctors and patients because, in the current situation, both are victims . The government and funders by controlling the resources means that doctors and patients will always be on the receiving end . Several calls have been made for funders to make the resources available where there are needed most, but that call has fallen on deaf ears .
The funders do not have financial discipline and do not care at all about patients and doctors. Their priorities are misplaced in that they pay hefty salaries to board members, who have other well-paying jobs such that they can forego their allowances for now until when the funders such as PSMAS are more fiscally buoyant. One fails to see the wisdom of paying bonuses and huge allowances to board members, when the doctors and patients are suffering. The Minister of Health, Dr David Parirenyatwa, is alleged to have been paid an advance of $77k in May last year, so it is likely that there will be little political will to address the problem of financial indiscipline.
There are calls, rightly so, for the minister to resign because what he did makes his position untenable . Having said, that we must not forget this minister was given this money in May 2014, 18 months ago now. It can be assumed that the minister must have seen enough patients to cover the money he was paid. If he has not done so then he must attend to all these patients who are affected by the current strike of doctors from PSMI. All we can do, unfortunately is speculate here, as we do not know the exact details . As members of the public, we deserve to know these issues involving our politicians.
We have a Parliamentary Health Committee, chaired by Dr Ruth Labode. This committee should summon the minister to give his side of the story and make it clear that if he is guilty of abusing his office, then he will have to decide whether remaining in office is possible or not. Dr Parirenyatwa has lost the confidence of his colleagues who are suffering. The name Parirenyatwa is a great name in the Zimbabwean medical field and many of us doctors still respect it. We all know that in life we do get things wrong and make error of judgement. When we do make those mistake, we can save our reputation by admitting our mistakes and leave office with dignity, instead of resorting to being fired and humiliated. I patiently wait for the outcome of the Parliamentary Health Committee meeting with the minister.
The government and funders have been controlling our health system without the contribution of doctors and patients . The government has been doing the right thing of appointing health professionals to head the Ministry of Health. The same trend has been adopted by funders, who have picked a few doctors to be on their boards . They have also gone further to form companies that are employing some of the doctors.(currently on strike). Furthermore, I am reliably told that some funders are now funding the post graduate training of specialists with an aim of “bonding” those doctors when they finish their training. This is a sad development as it means that these funders can now just ignore private doctors , they are owing millions of dollars in unpaid claims.
The situation was going to reach a breaking point because doctors thought that closing their private practices and going to work for these funders was a positive career move . This turned out to be an imprudent move, because it allowed these funders to continue their reckless financial management of limited resources. The funders just ignored the doctors they owed money to because some of the same doctors had agreed to become employees instead of remaining private contractors. Now the doctors that agreed to become employees for these funders have gone for several months without pay, and have gone on strike. This shows that doctors are being treated as worthless by these funders.
One funder in the press for all wrong reasons is PSMAS, which is rightly blaming the government for delayed payments. My question to PSMAS is; why aren’t you implementing your Plan B or C and stopping the unnecessary suffering and death of patients? Surely, you cannot be talking of having at least a Plan B for such a situation without implementing it. The government has not paid you for several months, but you have managed to meet not only your executives and board members’ hefty allowances, but also the Minister of Health’s $77k advance. My message to PMSAS is; stop playing games with people’s lives . We need genuine action, which starts with the board members and all the executive teams . Can the board members and executive teams also go for months without salaries or allowances? This is only fair, as patients and doctors are already without payment for several months. The little resources that will be realised by these measures should be channelled to the doctors, so that they can continue to see patients whilst other solutions are explored.
All the stakeholders need to put their heads together and address the state of affairs in our health system as a matter of urgency. This status quo cannot be allowed to continue and them and us attitude must stop. I call for genuine engagement of funders, providers and patients. Let bygones be bygones and start a new chapter that will respect the views of all parties and find a solution that will benefit everyone. We know that resources are scarce, so we need to innovate and work together to control wastage and cut costs. Patients have been patient for a long time, and their lives matters most . Patients cannot continue to pay high premiums yet not benefit from the schemes.
Currently, there is no clinical leadership in the government and among the private funders. Having a doctor heading the ministry or being part of board of private funders does not equate to clinical leadership. The biggest question is what are these clinicians bringing to the table? It is an open secret that undergraduate training for doctors does not involve leadership or business management courses. This means that if these clinicians in these positions are not offered further training then we continue to have the same problem. “Cosmetic” employment of doctors to positions must end . We need to monitor and evaluate what these clinicians are bringing to the system. We need clinical leadership whereby these clinicians use their skills to inform and shape the policies and decision making in the ministry of health or in private funders.We cannot allow them to abuse the system and benefit as individually instead of the whole system benefiting.
I cannot end this article without talking about patients. Most of you know I that I am an advocate for genuine patient engagement. I believe in ” nothing about me without me, ” so if it’s about patients, then they must have a voice in it. I call for patient participation groups which will select representatives that will be on the board of these funders and also that work with the ministry of health and providers such as hospitals and private doctors.
Patients have to do their part by living a healthy lifestyle and avoid unnecessary visits to the doctors or hospitals. Doctors must promote health lifestyles and be paid for keeping patients healthy. Also, hospitals must be paid for their quality service. Hospitals must not be paid to keep a patient for 2 weeks when the procedure can be done as a day case.
When funders work well with patients and doctors, there will be some savings that are made in the system. It would be unfair to go back to the old system of paying hefty bonuses to the top executives. Everyone must benefit, providers such as doctors must get bonuses or incentives for implementing successful medicine management systems that reduce the bill for funders. Also, patients, for adhering to their actions and taking ownership of their health, must also benefit by having low premiums and access to further expensive tests or discounts to join e.g. gyms and health and fitness classes.
The regulatory council of doctors in Zimbabwe need to help the situation but sadly it is currently engaged in a battle with these doctors working for funders. The regulatory board for doctors must not allow knee jerk-reactions to make the conditions of these doctors worse. Right now, these doctors on strike are also fighting another battle with their regulatory board. The regulatory board is run by mostly health professionals, and it’s sad that they are fighting among themselves without addressing the root cause. The debate is whether it is ethical to work for funders as they advertise for their services which is not allowed for doctors.There is nothing wrong with funders to work together with providers. The government is the biggest funder and largest employer of doctors, so the argument that doctors must not work for funders is not a practical one. I can understand where the regulatory board is coming from, but they must not make the lives of doctors worse. I call for an open debate about the advertising laws as they apply to the medical profession. The rest of the world has moved on as here in the UK doctors can have websites, but they have to follow certain rules as guided by the General Medical Council. The regulatory board in Zimbabwe should look at ways of addressing this issue of doctors working for funders or working with funders. Here in the UK, we have a scenario of general practitioners running Clinical Commissioning Groups (CCG) which are responsible for funding mostly hospital services for patients and some community services . There are strict laws that govern conflict of interests. So far, the system is working, as I can attest from experience. I am one of the board members of my local CCG. I am the Clinical Lead for Child health and Maternity services as well being a general practitioner provider services to the National Health Services (NHS).
For these suggestions to work there, is need for a committed and caring leadership that is open to new ideas and that is prepared to take calculated risks and think outside the box. If all the stakeholders are involved, then we can see some changes in our health system. The alternative, not doing anything, is simply unacceptable.
This article was compiled by Dr. Brighton Chireka who is a GP and a Patient Engagement Advocate (PEA) in Folkestone Kent, UK. You can contact him on firstname.lastname@example.org