MoH MYR 2014-2015 Hospital Reforms

Central Hospital Reform in Malawi 1

Establishment of Public Trust Hospitals in Malawi:Expert Panel on Reforms

Report

Ministry of Health

SWAp mid-year Review meeting

27th April 2015


Outline of presentation Introduction Findings by Consultancy on Establishment of Public Trust

Hospitals (What has been done / Progress on Reforms) Challenges Why Reforms Proposed Reforms

Efficient & Effective Central Hospitals (QECH, KCH, MCH, ZCH)

Efficient & Effective District Health Services - (Blantyre, Lilongwe, Mzuzu & Zomba

Considerations Conclusions


Introduction Hospital Reforms were initiated in Malawi health system

(National Health Policy Framework) – 1995 (20 years to-date)

Starting 1997, the MOH Working Group on Hospital Autonomy prepared a draft policy which proposed goals and strategies for hospital autonomy including the decentralisation of hospitals and new roles for hospital boards, management and the MOH. – 4th National Health Plan, and– Program of Work, both made provision for reforms.

– Program implemented by PHR Plus and from early 2003,

– Program implemented by MSH (both funded by USAID).


2015 - Key Findings

Only Gate way clinic established in Blantyre operated by DHO – KCH (efforts made)

Assessment of Blantyre health facilities done – Ndirande, Bangwe, Chilomoni & Zingwangwa (to look at report

Selected systems in place i.e. HMIS system in QECH

By pass fee in place in QECH & KCH

Special paying ward in KCH

Hospitals accessing funds from paying services (60%?)


Challenge

• ‘The inability of central hospitals to provide equitable access to tertiary quality health care to all Malawians’ • (Draft Hospital Reform Policy: September 2006 and

Cabinet Paper on Reforms: 2004)

• Central hospitals’ failure to deliver their core functions - including provision of quality specialist care, professional training, research and district support


Challenges• All urban (City) districts including Blantyre, Zomba, Lilongwe

and Mzuzu do not have district.

• Urban districts have very large populations served by very limited hospital services including Central hospitals, CHAM and private hospitals / clinics - 4 central hospitals, 2 Mental hospitals, 23 district hospitals, 37 community hospitals and 21 CHAM hospitals.

• Most CHAM hospitals and community hospitals are not operating at optimum capacity. CHAM hospitals are affected by funding / resources while community hospitals have serious lack of equipment, and human resources


Why Reforms?

• Need to make the hospitals run more effectively and efficiently

• Giving more control to the hospitals to manage their own affairs

• That the hospitals will have greater power to manage themselves

• That the hospitals can appoint their own staff directly

• That the hospitals can manage their own finances


Why Reforms?

Inadequate policy, regulatory and institutional framework

Gross under-management of public central hospitals

An inefficient health referral system

MSH 2007


Why Reforms? HR situationCentral hospital QECH KCH ZCH MCH

Medical Doctors 16 31 4 4

Intern Medical Doctors 79 61 1 2

Paediatrician 1 1 0 0

Specialist[3] // Surgeons 3 4 2 2

Internal Medicine 0 1 0 0

Obstetrics & Gynaecology 3 2 0 0

Ophthalmologist 1 2 1 0

Pathologists 0 0 0 0

Dental Specialist 1 0

Radiologist 0 1 0 0

Oncologist 1 0 0 0

Orthopaedic Surgeon 0 0 0 0

104 104 8 8

Source: Hospitals Staff Returns - 2015


Mzuzu Central Hospital

Grade Staff CategoryAuthorized Posts

Filled Posts

Vacant Posts

D Chief Specialists / Hospital Director 15 2 13E Principal Specialists /Deputy Hospital Director 36 1 35

FSpecialists /Chief Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant 53 13 40

GPrincipal Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant, Medical Doctors 66 12 54

HSenior Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant, Medical Doctors 54 5 49

IOfficers - Clinical, Nursing, Clinical Support, Administrator, Accountant 97 72 25

J Senior Technicians - Clinical, Nursing, Clinical Support 112 22 90K Technicians - Clinical, Nursing, Clinical Support 223 179 44

LSenior - Ward / Data Clerks/Nurse Auxilliaries / Clerical Officers / Catering / Accounts Assistants 43 10 33

MWard / Data Clerks/Nurse Auxilliaries / Clerical Officers/ Catering / Accounts Assistants 100 41 59

N Operators /Hospital / Patient Attendants 29 8 21O Hospital / Patient Attendants 42 76 -34P Guards 154 38 116

1024 479 545


Queen Elizabeth Central Hospital - As of December 2014

Grade Staff CategoryAuthorized Posts Filled Posts Vacant Posts

D Chief Specialists / Hospital Director 17 6 11

E Principal Specialists /Deputy Hospital Director 34 10 24

FSpecialists /Chief Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant 58 23 35

GPrincipal Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant, Medical Doctors 71 28 43

HSenior Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant, Medical Doctors 60 111 -51

I Officers - Clinical, Nursing, Clinical Support, Administrator, Accountant 110 150 -40

J Senior Technicians - Clinical, Nursing, Clinical Support 122 32 90

K Technicians - Clinical, Nursing, Clinical Support 235 339 -104

LSenior - Ward / Data Clerks/Nurse Auxilliaries / Clerical Officers / Catering / Accounts Assistants 50 21 29

MWard / Data Clerks/Nurse Auxilliaries / Clerical Officers/ Catering / Accounts Assistants 120 87 33

N Operators /Hospital / Patient Attendants 42 58 -16

O Hospital / Patient Attendants 48 209 -161

P Guards 164 162 2

Q Cooks 12 10 2

R Ground Labourer 15 10 5

1158 1256 -98


Why Reforms? Patients seen in Central Hospitals

Q1 (Jul-Sep 13) Q2 (Oct - Dec 13) Q3 (Jan - Mar 14) Q4 (Apr - Jun 14) Q5 (Jul - Sep 14) Q6 (Oct -Dec 14)0

10000

20000

30000

40000

50000

60000

KCH Attendance

OPD attendance Seen by Specialist Admissions all Discharges - tot


Why Reforms? HR situation

• Number of Specialists very low (Grades F- D)

• Highest number of staff are subordinates employees and professional staff grades – (M to I) – not the required staff for Central Hospitals

• Numbers of Doctors high where there are Interns

• Translating into poor quality of care and limited specialist services


Why Reforms? District Support function

• One of the critical roles for public trust hospitals is to provide district support to ensure provision of quality clinical care in all districts in the country.

• The ability by public trust hospitals to attract and retain well - qualified personnel including Medical Specialists, Specialist nurses and para-medicals will have the potential of revitalizing the Malawi health system through this function.

• Enabling districts receive technical support from those that are responsible for managing cases that the districts refers– Undertaking Specialist visits for district specialist clinics– Mentorship and clinical couching visits– Organizing clinical camps in public trust hospitals for district staff, – Providing referrals feedback– Making recommendations and identifying potential district staff for Specialist training– Facilitating clinical and Specialist trainings are the important functions that the public

trust hospitals are to undertake.


Why Reforms? Strengthening urban health services

Construction of district hospitals - Long term Establishment of City / Urban District Health Offices /

integrate the office with the Directorate of Health and Social Services for the City Councils

Up grading of urban health centres to become urban (community) hospitals:

Construction of Gate Way Clinics and urban health centres Establishment of Urban Health Outreach programs Urban (City) District Health offices agreements with CHAM

to operate district hospitals services in CHAM hospitals Promote Public – Private Partnerships (Community Health

Partnerships).

Central Hospital Reform in Malawi

EPOS 2010

GIBSON MASACHE


Proposed Reforms

Recommended change in Policy:Governance structure change through

establishment of Public Trust Hospitals

Legal precedents are National AIDS Commission (NAC), Malawi Blood Transfusion Service (MBTS), Small Medium Entrepreneur Development Institute (SMEDI), Central Medical Stores Trust (CMST)


Proposed Reforms

Recommended change in Policy:Governance structure change through

establishment of Public Trust Hospitals

Legal precedents are National AIDS Commission (NAC), Malawi Blood Transfusion Service (MBTS), Small Medium Entrepreneur Development Institute (SMEDI), Central Medical Stores Trust (CMST)


Proposed Reforms : Objectives of Public Trust Hospitals• Establish authority and accountability of public trust hospital boards and

management• Improve the quality and availability of public hospital care, especially for

priority conditions• Ensure equitable access to essential public hospital services • Establish an effective referral system• Ensure hospitals are accountable to the people they serve• Introduce modern hospital management practices for efficient care

delivery• Ensure sustainable public hospital financing • Provide support for training health workers and for research• Provide effective district support• Strengthen urban health services


Proposed Reforms : Features of Public Trust Hospitals Hospitals remain in public ownership therefore state assets

are not alienated

No change in fee policy

Public Trust Hospitals need necessary policies, procedures, systems and staff to implement decentralized management

Legislation


Proposed Reforms : Features of Public Trust Hospitals

Separation of Primary, Secondary & Tertially (central hospital) services

City Councils to be responsible for primary and secondary health services in cities

Public Trust hospitals be ‘National Resources’ and thus to become “Autonomous” Hospitals responsible to a Management Board


Proposed Reforms : Features of Public Trust Hospitals (2)

Decentralization of management controlled through a performance management agreement between MOH and hospital boards

Hospital focus on performance improvement measured by outputs as well as inputs

Introduction of a business management approach (commercial accounting system, business planning, marketing department, business IT system)


Proposed Reforms : Features of Public Trust Hospitals (3) New cadre of professional hospital managers:

– CEO

– Finance, HR, Physical Assets and Pharmaceutical Services Directors

Allowed to attract new sources of finance

- public – private partnerships

- grants & direct donations

- Fees (service, research, training etc.)

Continue to bid for Government capital funds (Purpose built paying units, Specialized OPD units, HDU etc.)


Proposed reforms: Roadmap for public trust hospitals reforms process

The Roadmap (14 steps outlined) :• Agree to the specific content for establishment of public

trust hospitals as outlined in this report• Identification of governing structure and board composition• Development of the advocacy and communication strategy

and communicating the objectives of the process• Drafting cabinet paper and seeking cabinet approval• Determining personnel policies and transition arrangements• Developing systems procedures and plans• Communication to stakeholders including staff and the

public


Proposed reforms: Roadmap for public trust hospitals reforms process

• Preparation of service plans• Registering public trust hospitals under public trust act• Developing service agreements and performance

management systems• Selecting and training key managers and board members• Start operating Public Trust Hospitals (1st July 2016)• Drafting legislation and obtaining parliament endorsement• Reviewing implementation of the preparatory phase (April

to June 2016), transition phase (July 2016 to June 2018) and final evaluation of the implementation period (after June 2020).


Proposed Reforms: Recommendations (Financing) Proposed mechanisms to fund Public Trust

hospitals:

Public Trust Hospitals FundTo benefit from Health Fund / Government funding

arrangementProposing 25% from Health Fund to finance the 5 PTH’s Independently managedSource additional Funding / get donationsGovernment funding based on Referral budgets for

Districts & CHAM Hospitals


Proposed Reforms: Recommendations (Financing 2)

Proposed mechanisms to fund Central hospitals:

By Pass fees (OPD I) – In-place In – Patient paying services – In placeCharges for training / student levy charged to

teaching institutions (per student)Charges for student research / student levy

charged to teaching institutions (per student)Charges for research / researchers levy charged to

individual researchers & research institutions


Proposed Reforms: Recommendations - Financing Proposed mechanisms to fund Public Trust

hospitals: Government ORT for management during

transitionTransition period (3 years)MOH support

Donor support - Financing of Independent facilitator for reforms

Finances managed / mobilized through the Public Trust Hospitals Fund


Challenges to address:

Problems with the term “autonomy”:negative public perceptionsequated with privatisation, fee for service,

limitation of access to central hospital services and alienation of public assets

none of these issues are fundamental to the policy on introduction of public trust hospitals


ConclusionsNeed to address a wide array of policy,

management and devolution issues

Considerable vested interests in status quo at all levels

Advocacy & Communication essential

Policy changes, systems strengthening and structural adjustments take time to develop and implement (facilitates preparations & acceptance)

Healthcare

MoH MYR 2014-2015 Hospital Reforms