Review of national AIDS councils in Africa: findings from five countries.

National AIDS councils (NACs) were established in many African countries to co-ordinate the multi-sectoral response to HIV/ AIDS. Their main mandate is to provide strategic leadership and co-ordinate activities geared to fight against HIV/AIDS. This study sought to understand the extent to which NACs have achieved their goals and the challenges they face. Best practices were identified and shared among countries involved, so as to enhance their efforts. This review is crucial given that the fight against HIV/AIDS is far from being won. Data for this study were collected from five countries: Ghana, Tanzania, Kenya, Zimbabwe and Lesotho. A qualitative study approach was employed by conducting individual in-depth interviews with senior staff members of NACs. We also collected important NAC documents that are used in achieving their mandates. The NAC documentation seemed to be in order in all countries visited, and there was a good understanding of the NACs' mandate and their functioning. There were numerous constraints and challenges that need to be addressed in order to make NACs perform their activities better. NACs need to operate independently of the usual government bureaucracy. Additional work is still needed by governments in making NACs responsible for the multi-sectoral response in sub-Saharan Africa.

Review of national AIDS councils in Africa: Findings from five countries

National AIDS councils (NACs) were established in many African countries to co-ordinate the multi-sectoral response to HIV/AIDS. Their main mandate is to provide strategic leadership and co-ordinate activities geared to fight against HIV/AIDS. This study sought to understand the extent to which NACs have achieved their goals and the challenges they face. Best practices were identified and shared among countries involved; so as to enhance their efforts. This review is crucial given that the fight against HIV/AIDS is far from being won. Data for this study were collected from five countries: Ghana; Tanzania; Kenya; Zimbabwe and Lesotho. A qualita- tive study approach was employed by conducting individual in-depth interviews with senior staff members of NACs. We also collected important NAC documents that are used in achieving their mandates. The NAC documentation seemed to be in order in all countries visited; and there was a good understanding of the NACs' mandate and their functioning. There were numerous constraints and challenges that need to be addressed in order to make NACs perform their activities better. NACs need to operate independently of the usual government bureaucracy. Additional work is still needed by governments in making NACs responsible

How do countries regulate the health sector? Evidence from Tanzania and Zimbabwe.

The health sectors in many low- and middle-income countries have been characterized in recent years by extensive private sector activity. This has been complemented by increasing public-private linkages, such as the contracting-out of selected services or facilities, development of new purchasing arrangements, franchising and the introduction of vouchers. Increasingly, however, experience with the private sector has indicated a number of problems with the quality, price and distribution of private health services, and thus led to a growing focus on the role of government in regulation. This paper presents the existing network of regulations governing private activity in the health sectors of Tanzania and Zimbabwe, and their appropriateness in the context of emerging market realities. It draws on a comparative mapping exercise reviewing the complexity of the variables currently being regulated, the level of the health system at which they apply, and the specific instruments being used. Findings indicate that much of the existing regulation occurs through legislation. There is still very much a focus on the 'social' rather than 'economic' aspects of regulation within the health sector. Recent changes have attempted to address aspects of private health provision, but some very key gaps remain. In particular, current regulations in Tanzania and Zimbabwe: (1) focus on individual inputs rather than health system organizations; (2) aim to control entry and quality rather than explicitly quantity, price or distribution; and (3) fail to address the market-level problems of anti-competitive practices and lack of patient rights. This highlights the need for additional measures to promote consumer protection and address the development of new private markets such as for health insurance or laboratory and other ancillary services.

Do they work? Regulating for-profit providers in Zimbabwe.

The experience of low- and middle-income countries (LMC) with respect to regulation and legislation in the health sector is in marked contrast to that of Canada and Europe. It is suggested that the degree to which regulatory mechanisms can influence private sector activity in LMC is quite low. However, there has been little work done on exploring just how, and to what extent, these regulations fail. Through the use of stakeholder interviews, this study explored the effectiveness of regulations directed at the private-for-profit sector (general practitioners, private clinics and hospitals) in Zimbabwe. The study found that there was limited and asymmetric knowledge of basic regulations among government bodies and private providers. However, there was a clear feeling that regulations are not being implemented and enforced effectively. A variety of opportunistic practices have been observed among private providers, including: practices of self-referral, where patients are sent to other services the provider has a financial interest in; over-servicing; doctor-patient collusion to collect health insurance payments; and the use of unlicensed staff in private facilities. Key factors limiting effectiveness of regulation in the health sector include the over-centralization and lack of independence of the regulatory body, the absence of legal mechanisms to control the price of care, and the lack of knowledge by patients of their rights. The study also identified a number of potential strategies for improving the current regulatory environment. For example, in order to improve monitoring, 'informal' arrangements between the centralized regulatory body and local authorities developed. There is a need to develop ways to formalize the role of these authorities. In addition, professional associations of private providers are also identified as key players through which to improve the impact of regulation among private providers. Increasing consumer access to information and knowledge is another potential way to improve information within the regulatory process as well as implementation.

A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services.

OBJECTIVE: To qualitatively assess the referral system at district level from the consumers' point of view and assess implications it had on efficiency and effectiveness of service delivery. DESIGN: Descriptive study. SETTING: Districts of Tsholotsho and Murewa. SUBJECTS: Subjects of the study included community members, ward health team members outpatient department (OPD). MAIN OUTCOME MEASURES: The nature and magnitude of the problem; health seeking behaviour; the perceived role of a hospital versus a health centre; knowledge on the referral system; user fees and the referral system and communication between the service and the community; and perceptions on the referral system. RESULTS: The community does not know the functional differences between a hospital and a clinic. What is clearly known is the physical differences that exist between the two. That is one of the reasons why the choice of a point of entry into the health care delivery system is not always correct. People do understand the mechanics of referring a patient to higher levels of care but they were not happy with the high hospital charges. Although the majority are eligible for free treatment the issues of high transport and other indirect costs were mentioned. There is no effective communication system between the service and the users. This manifested itself through the lack of knowledge or the existence and role of ward health teams or clinic committees. This lack of communication seems to be a major determinant in the failures of many a good policy. The impact of the new fee structure of January 1994 was minimal at district level because the communities felt that although referred patients do not pay hospital consultation fees, once admitted the patient still has to pay or at least prove that he/she is eligible for free services. The inconvenience of proving eligibility for free care still exists. CONCLUSION: In general, the community did not fully comprehend the purposes and intentions of the new user fees policy of January 1994 which was meant to rationalise the referral system. Generally, communities are seldom consulted in time to ensure effective policy implementation and realisation of the intended impact. Impressions generated on the impact of the problem of the referral system on resource use at hospital level show that it has been considerable, although this study did not quantify it. Unnecessary overloading of referral centres negatively affected the care of referral cases, which actually required hospital care, due to competition with primary care cases.

PIP: This exploratory study describes the nature and magnitude of the problem of health referrals, health-seeking behavior, perceptions, and knowledge at the district level in Zimbabwe. Data were obtained from focus groups with 159 persons in Tsholotsho and 132 persons in Murewa; from discussions with health personnel from the 6 health centers in Murewa and the 2 rural hospitals in Tsholotsho; and from records among a systematic sample of 400 new outpatients during October 1993 and March 1994 in Murewa district. Findings indicate that 71.8% in outpatient departments at Murewa Hospital had no access to a health center. 24.3% by-passed the health center for treatment at the hospital. 3.8% were referred by health centers. The absolute number of referrals did not change during 1991-93. However, the number directly accessing services from outside the district rose. Focus group participants reported their intention to use the nearest clinic for an illness. In Tsholotsho, people initially used the village community worker/headman. If illness was perceived as serious, patients would go to a hospital. For minor illness, people used traditional herbal remedies. If illness did not change after remedies, the clinic was consulted. Some illnesses were perceived as outside the realm of medicine. Most distinguished between a health center and a hospital, but were unaware of the important, superior functions of the health center. Most did not understand the logic behind the referral system, but appreciated referrals and not the cost of hospital treatment or transportation. The community was unaware of Ward Health Teams. Many did not understand the new fee policy introduced in 1994.

Improving the efficiency of district hospitals: is contracting an option?

A world-wide revolution in thinking about public sector management has occurred in recent years, termed the 'new public management'. It aims to improve the efficiency of service provision primarily through the introduction of market mechanisms into the public sector. The earliest form of marketization in developed countries has tended to be the introduction of competitive tendering and contracts for the provision of public services. In less wealthy countries, the language of contracting is heard with increasing frequency in discussions of health sector reform despite the lack of evidence of the virtues (or vices) of contracting in specific country settings. This paper examines the economic arguments for contracting district hospital care in two rather different settings in Southern Africa: in South Africa using private-for-profit providers, and in Zimbabwe using NGO (mission) providers. The South African study compared the performance of three 'contractor' hospitals with three government-run hospitals, analysing data on costs and quality. There were no significant differences in quality between the two sets of hospitals, but contractor hospitals provided care at significantly lower unit costs. However, the cost to the government of contracting was close to that of direct provision, indicating that the efficiency gains were captured almost entirely by the contractor. A crucial lesson from the study is the importance of developing government capacity to design and negotiate contracts that ensure the government is able to derive significant efficiency gains from contractual arrangements. In other parts of Africa, contracts for hospital care are more likely to be agreed with not-for-profit providers. The Zimbabwean study compared the performance of two government district hospitals with two district 'designated' mission hospitals. It found that the two mission hospitals delivered similar services to those of the two government hospitals but at substantially lower unit cost. The nature of the contract between government and missions was implicit rather than explicit and of long standing. On the whole the mission organizations felt the informal nature of the agreement was advantageous, though the government plans to introduce service contracts at district level with all hospitals, both government and mission. The paper concludes by identifying concerns raised by the case-studies that are of relevance to other countries considering the introduction of explicit contractual arrangements for district hospital provision.

A coverage plan for health centres in Murewa district in Zimbabwe: an example of action research.

Good access to health facilities providing good first-level health care remains problematic in many developing countries. It is a hindrance to effective and efficient functioning of the hospital, as outpatient departments become overcrowded with patients from areas without health centres. In many cases the quality of care delivered to these patients is poor because within the district health system the hospital is not the best place for the supply of comprehensive, integrated and continuous care. Eventually, high hospital involvement in first-level care can jeopardize the delivery of adequate referral care for those patients who desperately need the hospital's technology and expertise. This paper provides an account of the way this problem was investigated and managed by the district health management team in the Murewa district in north-east Zimbabwe. The design of a comprehensive 'master plan' or 'coverage plan' is presented as well as the problems and difficulties encountered. The Murewa experience highlights the relevance of a coverage plan for rational and coherent health infrastructure planning at district level. The approach followed by the Murewa team illustrates the use of action research as an integral part of the management of district health systems.

Contracting out of clinical services in Zimbabwe.

Contracting is increasingly recommended to developing countries as a way of improving the efficiency of the health sector. However, empirical evidence regarding its effectiveness in this respect is almost completely absent. In Zimbabwe, a long standing contract exists between the Ministry of Health and Wankie Colliery to provide clinical services in the Colliery's 400 bed hospital. This paper details a study of the Zimbabweans' experience with the contract. Its success is assessed using comparisons with a neighbouring government hospital of the price of services (vs the cost in the government hospital); the situation of hospital workers; and the quality of services delivered. The Colliery has established a monopoly position for hospital services in the district. However, it appears to offer services of at least as good quality at prices which are lower than the unit costs of the government hospital when capital costs are included. Nevertheless, the contract cannot be considered a success due to the failure to contain its total cost. Approximately 70% of provincial non-salary recurrent expenditure is consumed by the contract while only a minority of the province's population have access to the Colliery hospital. Screening patients, both with respect to their ability to pay and to their need for secondary level services does not take place with the result that utilization levels are not controlled. The study highlights a number of important issues affecting contracting in developing country setting: First, contracted institutions attain powerful bargaining positions if there are no viable competitors and the government does not itself retain capacity to offer an alternative service. Second, specific skills are needed for the management of contracts at all levels. If the process of contract development responds to a crisis driven agenda resulting from civil service retrenchment and public expenditure cuts, it is unlikely that adequate consideration will be given to the development of such skills and the retention of key personnel. If such details are neglected, otherwise feasible efficiency gains will prove elusive.

Cost analysis for rehabilitation services in Zimbabwe:a report prepared for the World Health Organisation

Like in most developing countries; there is paucity of cost data on the provision of rehabilitation services especially programme specific cost data in Zimbabwe. This study therefore endeavoured to test the WHO protocol on cost of heath services to cost rehabilitation services. The aim was to generate field information that would enable design of a protocol that can be effectively employed in other countries for costing rehabilitation services. The study is an economic study analysis of rehabilitation services which does not only look at financial costs but also social costs. An analysis of economics is a necessary pre requisite to the effective efficient expansion of rehabilitation services in Zimbabwe. Information on costs and possible simulations of changes in scale or organisational arrangements of community based rehablitation provides crucial baseline information for informed decision making