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Decongestion of Zomba Central hospital_Final

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Decongestion of Zomba Central hospital_Final

  1. 1. [Type text] [Type text] [Type text] Implications of Decongesting Central Hospitals on Gate Clinics: Case study of Zomba Central Hospital in Malawi ` Zomba Central Hospital GREVASIO MCHIGULUPATI CHAMATAMBE 100237367 A dissertation submitted in partial fulfillment to the requirements for the Award of Master Degree in Strategic Management By University of Derby 30th September, 2012
  2. 2. 1 Abbreviations ART Antiretroviral therapy BP Blood Pressure CIP Capital Investment Plan CO Clinical Officer DA Dermatology Assistant DIP District Implementation Plan DHO District Health Office(r) DHMT District Health Management Team DRG Diagnosis Related Group DT Dental Therapist EC European Commission GTZ German Technical Co-operation GIZ German International Co-operation HIV Human immunodeficiency virus HMIS Health Management Information System HSSP Health Sector Strategic Plan HTC HIV Testing and Counseling IMF International Monetary Fund LA Lumefantrine Artemther LT Laboratory Technician MA Medical Assistant MCH Maternal and Child Health MIM Malawi Institute of Management MOH Ministry of Health NPM New Public Management OCO Ophthalmology Clinical Officer OECD Organisation for Economic Co-operation and Development OPD Outpatient Department UK United Kingdom UNDP United Nations Development Programme
  3. 3. 2 SWAp Sector Wide Approach WBR World Bank Report WHO World Health Organization PMTCT Prevention of mother to child transmission RDTs Rapid Diagnostic Tests RN Registered Nurse RTA Road Traffic Accident TQM Total Quality Management
  4. 4. 3 Table of Contents Abbreviations........................................................................................................................... 1 Figures...................................................................................................................................... 5 Tables ....................................................................................................................................... 5 Acknowledgement ..................................................................................................................... 6 Executive Summary................................................................................................................... 7 Chapter 1: Introduction 1.1 Overview........................................................................................................................ 10 1.2 Background.................................................................................................................... 10 1.3 Problem statement......................................................................................................... 12 1.4 Aim of the Study ............................................................................................................ 12 1.5 Research questions....................................................................................................... 13 1.6 Road Map ...................................................................................................................... 14 Chapter 2: Literature Review 2.1 Overview........................................................................................................................ 15 2.2 Public sector reform....................................................................................................... 15 2.3 Health Sector Reforms ................................................................................................ 16 2.3.1 Universal Coverage health reforms....................................................................................... 16 2.3.2 Cost control reforms ............................................................................................................ 17 2.3.3 Improving quality of health services.................................................................................. 17 2.3.4 Multi-skilling of health manpower ...................................................................................... 19 2.3.5 Centralization of hospitals .................................................................................................. 20 2.3.6 Decentralization.................................................................................................................... 20 2.3.6.1 Decongestion ................................................................................................................ 22 2.4 Critical lessons from the literature.................................................................................. 22 2.5 Way forward................................................................................................................... 23 Chapter 3: Methodology 3.1 Overview........................................................................................................................ 25 3.2 Introduction to research ................................................................................................. 25 3.3 Research Paradigm/Philosophy..................................................................................... 26 3.4 Research Approach ................................................................................................................... 27 3.5 Research strategy.......................................................................................................... 27
  5. 5. 4 3.6 Research Purpose......................................................................................................... 27 3.7 Research Design ........................................................................................................... 28 3.8 Research methods......................................................................................................... 28 Chapter 4: Findings and Analysis 4.1 Overview........................................................................................................................ 31 4.2 Limitations of the study.................................................................................................. 31 4.3 Strategic direction in decongesting central hospitals ..................................................... 31 4.4 Customer/community perspective.................................................................................. 33 4.4.1 Location................................................................................................................................. 33 4.4.2 Health conditions that respondents presented at Zomba Central Hospital................ 34 4.4.3 Factors that prompted respondents to seek OPD service from central hospital ....... 35 4.4.4 Rating of Zomba Central Hospital and Health centres .................................................. 37 4.4.5 Respondents’ approval of transferring (closing out) outpatient services for general public to primary health care level..................................................................................... 39 4.5 Business processes perspective.................................................................................... 40 4.5.1 Workload of outpatient department................................................................................... 40 4.5.2 Stock out days of essential drugs...................................................................................... 42 4.5.3 Infrastructure......................................................................................................................... 43 4.6 Financial allocation for renovating and refurbishing gateway clinics.............................. 43 Chapter 5: Conclusion and Recommendations 5.1 Overview........................................................................................................................ 45 5.2 Conclusion..................................................................................................................... 45 5.3 Recommendations......................................................................................................... 47 Chapter 6: Personal Reflection 6.1 Overview........................................................................................................................ 50 6.2 Major lessons learnt....................................................................................................... 50 6.3 Challenges..................................................................................................................... 51 6.4 Summary ....................................................................................................................... 52 Appendices Appendix 1: Participant Briefing and consent and withdraw letters........................................... 53 Appendix 2: Data collection tool 1: Individual questionnaire for OPD Clients .......................... 56 Appendix 3: Data collection Tool 2: Questionnaire for In-charges of Gateway clinics ......... 60 Appendix 4: Data collection tool 3a: Guiding questions for District Health Management Team...... 65 Appendix 5: Data collection 3b: Guiding questions for Ministry of Health Planning) ............ 67
  6. 6. 5 References .............................................................................................................................. 68 Figures Figure 1: Levels of health care services in Malawi Figure 2: Balanced scorecard Figure 3: Onion research layers Figure 4: Respondents’ health conditions Figure 5: Gateway clinics’ OPD Workload Figure 6: Clients at under-five OPD clinic Figure 7: Adult OPD patients waiting to register Tables Table1: shows reason for choice of data collection method/tool Table 2: closest public health facility to respondents Table 3: Reasons that persuade people seek OPD services at Zomba Central Hospital Table 4: Rating of Zomba Central Hospital Table 5: Health centre/gateway clinic rating Table 6: Do you approve closing of outpatient department to general public. Table 7: Status of Stock-out days of some selected essential drugs at Gateway Table 8: Staffing levels of gateway clinics
  7. 7. 6 Acknowledgement I would like first of all to thank my wife and youngest son, Kondwani Chamatambe for their encouragement and withstanding challenges encountered during the study; I therefore, dedicate the study to them. The author is indebted to Zomba Hospital Director, Dr. Martias Joshua, in development of the study and for authorizing the study to be conducted at his institution. The author acknowledges all participants in the study, the patients and clients at Zomba Central Hospital Outpatient department, health centre in-charges, Mr. Medson Semba, Zomba District Health Officer, and his DHMT members for support and responses given during the study. Without their support and cooperation the study would not have been successful. The author appreciates valuable input and guidance that was provided by Dr. Margaret Sikwese, the independent study supervisor. The author is also indebted to Dr. Dieter Koecher, former GIZ Health Coordinator, whose organization provided scholarship for the study. The author would like to thank Peter Makaula, Dr. Esther Ratsma, Mr. Macdonald Msadala, Sekelani Phiri, Wiseman Chimwaza and Peter Dickson who provided moral and material support during the study
  8. 8. 7 Executive Summary Central hospital is tertiary care health facility and supposed to provide highly specialized services to patients that have been referred from lower levels of care. Unfortunately, most central hospitals in the world including those in Malawi are providing services that are supposed to be provided by primary and secondary levels of care in addition to providing tertiary care services. Consequently, central hospitals are congested. Zomba Central Hospital is one of the four central hospitals in Malawi. Zomba Central Hospital is a referral health facility for six districts of Balaka, Machinga, Mangochi, Mulanje, Phalombe and Zomba in the South Eastern Region of Malawi. The central hospital is congested with minor health conditions which do not require specialist attention. There are a lot of self-referred clients and patients who seek primary health care services in both under-five and adult outpatient departments. People by-pass primary health care facilities and come directly to tertiary level facility without being referred. Decongestion of central hospitals is a deliberate arrangement intended to transfer out-outpatient services for general patients/clients to primary health care level facilities. This cross-sectional study was conducted to find out how these primary health care facilities were performing in decongesting Zomba Central Hospital. Both qualitative and quantitative research methods were employed in the study. Individual questionnaires were used to collect data from self-referred patients/clients at Zomba Central Outpatient department; and health centre in charges. In-depth interviews were used to collect data from District Health Management Team members and Ministry of Health. The research findings were presented following four perspectives of balanced scorecard. The balanced scorecard is a planning and management system, which is commonly used in both private and public sectors to present a comprehensive overview of how an organization is performing. The key findings were as follows: With regard to strategic direction, study findings indicate that Ministry of Health did not have three strategic documents (road map, human resource policy and minimum infrastructure requirements for gateway clinics) in place to guide the decongestion process of central hospitals. In addition, MOH did also not commit itself because the Capital Investment Plan for 2011 to 2016 did not contain financial allocation for renovating and extending gateway clinics. Zomba Central Hospital and Zomba District Health Office were implementing the reform process without policy guidance but rather implementation was based on gentleman
  9. 9. 8 agreement, good working relationship of the management teams of the two institutions. Unfortunately, absence of a clear strategic direction affected readiness of the four perspectives of balanced scorecard. The study findings further show there were two major factors that forced people to seek primary health services at central hospital. First, most respondents complained of persistent stock-outs of drugs at health centres and that many people had inadequate knowledge regarding the functions of central hospitals. Consequently, they regarded the central hospital as any health facility. With regard to business processes, the study revealed that the gateway clinics were not providing wide range of health services except Matawale Health Centre. The other clinics did not have capacity to offer some services due to shortage of human resource and equipment. The study further shows that all gateway clinics experienced stock-out of all tracer drugs except Tetanus Toxoid Vaccine, which was available throughout the year. Shortage of drugs was a leading factor that persuades people to seek services at the central hospital. Matawale Health Centre had the highest workload of outpatient attendance of 229% which signified that the facility was already overstretched. Therefore, focus of strengthening gateway clinics should have been directed at the other four clinics so that more patients and clients seek primary health services from these facilities. A further study should be done to find out why Zomba City Clinic, despite having second the largest workforce among the gateway clinics, has low outpatient utilization. It is evident from the study findings that the gateway clinics are not ready to fully take over all services offered by central hospital and therefore, it is recommended that Ministry of Health should not only develop four strategic documents to guide the whole process of decongesting central hospitals but should commit itself by allocating adequate financial resources in the Capital Investment Plan (CIP). In course of implementing decongestion of central hospital at operational level, the district health management and Central hospital teams should implement
  10. 10. 9 the decongestion process in phases not wholesale to allow adequate time for learning and capacity building. The District Health Management Team should conduct gateway clinic regular supervision to check quality of health services provided to community and availability of essential drugs at facility level. The District Health Management teams should deploy additional health workers with diverse skills to gateway clinics so that the facilities offer a wide range of outpatient services to satisfy the wants and interests of the clients. The District health management team should ensure that community feedback mechanisms are put in place to constantly get views of patients, clients and general public and regularly review the views to identify areas that require strengthening.
  11. 11. 10 CHAPTER 1: Introduction 1.1 Overview Chapter briefly presents background, problem statement, goals and objectives of the study. The chapter also discusses research questions and presents a road map of the research 1.2 Background Congestion of central hospitals is a major problem in developing countries in the world. Usually, the communities by-pass the health primary health facilities and go directly to central hospital without being referred (Cullinan, 2006). In Malawi, Public health services are offered at three levels. These are primary, secondary and tertiary health care levels of services (MOH, 2011) as illustrated in the figure 1 below: 3 2 1 Figure 1: Levels of health care services in Malawi (Source: MOH, 2011) According to WHO (2006) and Centre for Disease Control (2006), the primary function of tertiary referral hospitals is to provide complex clinical care to patients transferred from lower levels. However, the current Malawian practice is that central hospitals perform all three functions. The central hospitals provide primary health care services, which are supposed to be done at health centres and health posts. The central hospitals also offer secondary health care services, which are supposed to be taken care of by community or district hospitals. Tertiary – Central Hospitals Secondary -Community & District Hospitals Primary health care- Health posts/ Dispensaries/Health centres
  12. 12. 11 In addition, some communities do not fully use health centres, which are close to them, but instead they go directly to central hospitals for OPD and primary health care services. Consequently, the central hospitals are congested and sometimes they are blamed for using huge health budgets while still offering low quality tertiary health care services (Hensher, Price & Adomakoh, 2006). Ministry of Health in Malawi is implementing a number of health sector reforms and central hospital reform is one of them (MOH, 2011). Within the central hospital reforms there are number of reforms and these include out-sourcing of some services such as security, catering, cleaning; and decongestion. The study will focus on decongestion of central hospitals. The central hospitals are being decongested to ensure that central hospitals provide equitable access to tertiary quality health care services to all Malawians (MOH, 2011). The decongesting process has focused on removing general OPD and primary health care services from Central Hospitals to health centres (also known as Gateway clinics) around these central hospitals. Decongesting central hospitals is part of public sector reform and is in line with Malawi Decentralization Policy of 1998, which gives powers to District Councils to manage health centres, health posts, communicable diseases and provision of health education services to their district population. The main objective of decongesting central hospitals is to ensure that these hospitals focus on providing specialized and quality tertiary health care services to patients referred from lower levels of care (MOH, 2011).The proponents of decongesting central hospitals argue that specialists and doctors spend a lot of time in attending to patients with common minor conditions, which can easily be managed at health centre level. Consequently, the specialists do not have adequate time for patients that need their attention (Cullinan, 2006). There are four public central hospitals in Malawi. These are Queen Elizabeth, Zomba, Kamuzu and Mzuzu central hospitals. Zomba Central Hospital has been chosen, because it is close and convenient to the investigator and some processes have already started in decongesting this hospital.
  13. 13. 12 1.3 Problem statement Central hospitals are tertiary health care facilities and are supposed to provide specialized health care to complicated cases that have been referred from lower levels of health care. The challenge is that people go directly to central hospitals with minor common illnesses without being referred thereby causing congestion. Gateway clinics were introduced with the aim of decongesting the central hospitals. However, since this health sector reform was introduced, there has been no systematic study to understand how the gateway clinics are performing. Information on how these clinics are performing will provide strategic guidance on how to improve the system as well as how to approach future reforms. 1.4 Aim of the Study The research was aimed at providing comprehensive recommendations to Ministry of Health regarding key important factors that should be incorporated and improved in decongesting Zomba Central Hospital as well as how to approach future reforms. 1.5 Objectives of the study Objective 1: To find out reasons why patients and clients attend central hospital for outpatient and primary health care services Objective 2: To find out capacity of gateway clinics to accommodate additional services Objective 3: To investigate if the District Implementation Plans (DIP) for fiscal years 2011/2012 and 2012/2013 have adequate financial allocations to support renovation and refurbishments of Gate way clinics. Objective 4: To investigate whether the MOH has put in place strategic policy instruments to enable and guide decongestion of central hospitals. . Objective 5: To provide comprehensive recommendations to Ministry of Health on how to improve decongestion Zomba Central hospital.
  14. 14. 13 1.6 Research questions In order to have comprehensive overview on the preparedness of the gateway clinics, a set of research questions are formulated under each perspective of the balanced scorecard. The balanced scorecard is an approach that is used extensively in business and industry, government, and nonprofit organizations worldwide to align business activities to the vision and strategy of the organization, improve internal and external communications, and monitor organization performance against strategic goals (Kaplan and Norton, 1990) as seen figure 2 below. Figure 2: Balanced scorecard according to Kaplan/Norton with 4 future perspectives Finances: •How much funds are allocated in the District Implementation Plans for renovation of Gateway clinics? •How much funds are allocated in capital investment plan of MOH to support District health offices towards renovating Gateway clinics? Customers (patients and clients): •Why do patients go to the central hospital for OPD & primary health care services? •What are their views regarding the change? •How many OPD patients treated over one year period and proposed gate way clinics at both CHs and gateway clinics? Internal business processes: • Which services are offered at central hospital OPD and whether similar services will be offered at gateway clinics • Is there adequate infrastructure (equipment, rooms) to cater for these OPD and primary health services at gateway clinics? •Does the District Health Officer have the number and skill mix of staff to meet demand at these clinics? • Does MOH have any provision for additional staff to support DHOs to run gateway clinics? Vision and Strategy: improve quality of tertiary health services: decongesting Central Hospitals by removing OPD & primary health services to Gate way clinics Can gate way clinics decongest central hospitals in their current state? What changes are required for gateway clinics to successful decongest central hospitals? Learning and Innovation: •Does MOH have HR policy on staffing norm for gateway clinics regarding how many health workers and skill mix needed to run gateway clinics? •What is the time frame for the whole process or road map? Is it wholesale removal of primary health care services? •What is the magnitude of patients/clients at OPD that are not supposed come directly to central hospital?
  15. 15. 14 1.7 Road Map This section shows how the whole research is structured. Chapter one is introduction, chapter two is literature review, chapter three is methodology, Chapter four is research findings, chapter five is conclusions and recommendations and chapter six is personal reflection.
  16. 16. 15 CHAPTER 2: Literature Review 2.1 Overview This chapter discusses various public sector reforms, health sector reforms, decentralization as part of public sector and health sector reforms and its link to decongestion of central hospitals. The chapter draws lessons learnt in implementing these reforms and contextualized in four thematic areas of balanced scorecard. With regard to balanced scorecard, major lessons are drawn on strategic direction, customer involvement, employment participation and human resource management position. The chapter also highlights lessons learnt on infrastructure development and resource allocation. The chapter ends with a conclusion. 2.2 Public sector reform Reform is used to describe many changes from minor adjustments to management arrangements to fundamental changes in ownership, governance and management arrangements. Genuine public sector reform can be defined as change in processes that either produces a measurable improvement in services or a noticeable change in the relationship between institutions of the state and the citizens (European Commission, 2009). Many developed countries have carried out New Public Management (NPM) types of public sector reform in the 1980s and 1990s (Hemant 2009) and developing countries like Malawi have also undertaken public sector reforms and continue to reform. Public sector reform is a deliberate action to improve the efficiency, effectiveness, professionalism, representativity and democratic character of a public service, with a view to promoting better delivery of public goods and services, with increased accountability. These reforms can include data gathering and analysis, organizational restructuring, improving human resource management and training, enhancing pay and benefits while assuring sustainability under overall fiscal constraints, and strengthening measures for public participation, transparency, combating corruption and creating conducive environment for private sector investment as a result of the reversal of socialist policies of 1960s and 1970s (OECD,1996;Hood, 2003; Hemant, 2009,& Victor, 2009). Motivations for reform mostly arise in response to social, economic and political problems. Governments are pressurized to reform by their constituents, civil society
  17. 17. 16 organizations and civil servants. Sometimes the reforms are driven by outsiders in case of donor aid dependent countries (EC, 2009). Globalization and changing of political systems have also contributed to public sector reforms in some countries (Hemant 2009 and EC, 2009). World Bank, International Monetary Fund and European Commission have been instrumental in supporting government reforms in most countries in Asia, Eastern Europe, Latin America and Africa (OECD, 1996, UNDP 1999, WBR 2001 and EC 2009).These organizations have supported governments to undertake various reforms ranging from structural adjustment including decentralization, public financial management, human resource management, anti- corruption, deregulation and privatization. IMF supports public financial management reforms including foreign monetary policies. On the other hand, World Bank and European Commission have supported implementation of public sector reforms on structural adjustment, anti-corruption and decentralization (EC 2009) whilst UNDP has put more focus on decentralization and governance (UNDP 1999). 2.3 Health Sector Reforms Health sector reforms are sustained processes of fundamental change in the policy and institutional arrangements in the health sector designed to improve functioning and performance of the sector (WHO, 1997). Literature shows countries have taken various health sector reforms either as part of public sector reforms or as individual health sectoral reforms. The health sector reforms include universal health coverage, cost control, centralization, multi- skilling quality improvement and decentralization. 2.3.1 Universal Coverage health reforms World Health Organization reports that the universal coverage reforms have been implemented with aim of reducing out-of pocket payment and increase prepayments for health services. Universal coverage as policy objective means that everyone has access to appropriate care when they need it and at affordable cost. Chinese public hospitals were lowly subsidized; consequently the citizens had to pay higher prices for health services out of pocket. The high prices denied majority of people from accessing the health services (WHO 2006). Public health sector is being reformed to reduce out of pocket payment. The emphasis of universal coverage is on prepaid and pooled contributions. According to WHO, nearly all developed countries provide guaranteed health coverage to their citizens except USA which
  18. 18. 17 introduced Obamacare recently. For instance, Germany Social code indicates that medical care should be provided solely according to an individual’s needs, whereas the financing of care is based solely on the individual’s ability to pay. The UK’s National Health Service provides comprehensive universal coverage with no financial access barriers. The federal government in Canada contributes to provincial plans only if care is provided to all citizens with minimal financial impediments. Out of pocket payments are below 23% of total health spending in most EU countries (WHO). According to the author’s experience, Malawi is implementing universal coverage of health services whereby government funds for provision of free health services in government health facilities to its citizens and sometimes enters into service level agreements with private health facilities if government health facilities are far away and the citizens can best be served by private health facility (MOH Final SWAp Report, 2010). Malawi has taken UK model of financing of public health services. However, WHO argues that universal and comprehensive insurance coverage is not sufficient to ensure equitable access to health services and points out that health authorities should pay attention to rational deployment of providers so that health services are readily available. 2.3.2 Cost control reforms World Health Organization reports that cost control reforms have been introduced after realizing that technology and ageing population were driving up health spending in developed countries. Most OECD countries have enacted cost control measures that regulate prices and volumes of health care and inputs (wages, prices and health–care production resources) into health care, caps on health care spending, either overall or by sector and shifts cost onto private sector through cost- sharing. Wage controls have been instituted in context of broader public sector pay restraint in countries such as Denmark, Finland and UK. Price and fees controls are in place between purchasers and providers in countries like Belgium, France and Germany. All OECD countries have put administrative prices for pharmaceutical drugs with exception of Germany, United States and Switzerland. Most EU countries have pre-marketing controls to determine whether a new technology is safe and cost-effective for a particular use. 2.3.3 Improving quality of health services These reforms focus at improving quality of health services. The implementation of quality improvement reforms are done with or without altering the basic structure or organization
  19. 19. 18 (Withanachchi, 2007). The approaches to quality improvement include establishing technical standards and clinical guidelines, strengthening of patients’ rights, quality assessment and accreditation and continuous improvement (Withanachchi 2007). World Health Organization notes the reforms on quality have focused on increasing accountability for quality provided to patients and clients. World Health Organization further reports that most developed countries have improved information systems and standards to enhance health system performance. For instance, Czech Republic established DRG-based system, a device for hospital management, and uses it to measure quality and output across hospitals. United Kingdom conducts mandatory public reporting on performance of health providers and patient safety and rewards high-performing providers with more funding. Professional associations monitor professional quality among doctors in the Netherlands. Countries and hospitals adopt different concepts and models to improve quality of health services. Castle Street Hospital for Women in Sri Lanka implemented total quality management (TQM) by using 5-S principles, a management tool used in car manufacturing industry in Japan. 5-S principle was discovered Hiroyuki Hirano in late 1980s. The approach was applied to hospital setting to improve quality of health services. The hospital identified items that were not necessary and disposed them off (sort), secondly they arranged the necessary items in good order to avoid time wastage of finding the items when need arises (Set order).cleaned the workplace to make workplace safe (sweep), then the hospital standardized by maintaining the first 3 S’s and the last S is Sustaining the good practices. Usually the model is used without additional resources in terms of equipment or human resources. The balanced scorecard approach (Kaplan and Norton, 1992) was used to assess the performance of the hospital in order to capture accomplishments on multiple objectives and multiple aspects. The success in implementing quality improvement reform using the model was attributed to, among other factors, good leadership of the hospital director and top management, continuous monitoring, improvement in communication between management and employees, and participation of employees in the quality cycles (Withanachchi, 2007). Sahlgrenska University Hospital implemented quality improvement in reducing waiting time at outpatient clinics without additional human resources (Eriksson 2010). Three major lessons are drawn from successful implementation of this initiative including adequate time is required in understanding and analyzing the situation to identify bottlenecks and methods to solve the
  20. 20. 19 challenges. Secondly, the reforms were introduced in phases. Eriksson reports that the initiative started with Rheumatology clinic in 2001, then Dermatology and Venereology clinics in 2004. The third factor was that all employees were involved by providing their opinions and participation in quality improvement cycles. 2.3.4 Multi-skilling of health manpower The multi-skilling of health care providers is the latest type of health sector reforms. Hurst (1997) and Adamovich (1996) argue that bulk of health care should be given by multi-skilled careers, not functional, compartmentalized and overspecialized professionals, who work to custom and practice, tend to underutilize their knowledge and skills. The rationale of multi- skilling calls for re-appraising and redesigning of work roles from traditional professional boundaries so that health workers provide a wide range of services to patients and clients (Martin and Healy (2009).
  21. 21. 20 2.3.5 Centralization of hospitals The Norwegian Parliament transferred the ownership of all public hospitals from the county governments to the central state (Hage, 2006).The Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision- making processes. To facilitate changes seen as necessary, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives (Trond, 2009). The reform did not only transfer ownership from 19 counties to the central state. Two other elements in the reform were of equal importance. First, hospitals were set up as health enterprises or trusts and organized within five Regional Health Authorities (RHA). (Second, both the health enterprises and the RHAs were to be governed by boards comprising professional members. The Minister of Health, acting as their general assemblies appointed the board members at the RHA level (Trond, 2009). But the hospital reform did not deliver as far as the budgetary discipline in the sector is concerned; the deficits in the sector persisted also after the central state took over ownership. The restructuring of hospitals met resistance from employees, local politicians and trade unions such that some decisions which were made by RHA were reversed by parliament. In a fact the restructuring of the hospitals decreased access to certain services as some services were being transferred out to other counties. For instance, people have to travel long distances get some services such as maternity units. 2.3.6 Decentralization Many countries have implemented decentralization of health sector as part of public sector reforms under structural adjustment programmes (UNDP1999 & Muriisa 2008). Decentralization is the transfer of powers from central government to lower levels in a political- administrative and territorial hierarchy (Crook and Manor 1998, Agrawal and Ribot 1999).The power transfer can take two main forms. Administrative decentralization, also known as deconcentration, refers to a transfer to lower-level central government authorities, or to other local authorities who are upwardly accountable to the central government (Ribot 2002). Political, or democratic, decentralization refers to the transfer of authority to representative and
  22. 22. 21 downwardly accountable actors, such as elected local governments (Larson).The three types of administrative decentralization are devolution, delegation and deconcentration. Devolution is the transfer of governance responsibility for specified functions to sub-national levels, either publicly or privately owned, that are largely outside the direct control of the central government (Ferguson and Chandrasekharan). Delegation is the transfer of managerial responsibility for specified functions to other public organizations outside normal central government control, whether provincial or local government or parastatal agencies (Ferguson and Chandrasekharan). Deconcentration is defined in number of ways; Sayer defined deconcentration as the process by which the agents of central government control are relocated and geographically dispersed. Ribot (2002) in Larson defines deconcentration as a transfer to lower-level central government authorities, or to other local authorities who are upwardly accountable to the central government. Many countries have decentralized primary health services though details vary from country to country with different components assigned to government levels. Ghana implemented devolution in decentralizing its health services. Ghana’s Legislation decentralizes authority to quasi-private entities and gives individual hospitals responsibility for management of direct service decisions and operations (Govindaraj 1996, Atkinson 1999).Lesotho, Tanzania and Zambia followed deconcentration type of decentralization. Lesotho has separated management of hospitals from the primary health care facilities. Primary health care facilities are managed by district health office whilst District and tertiary hospitals are managed by hospital management teams. This reform was carried out to ensure that primary health care activities are given adequate attention in terms of planning and funding but the reforms did not specifically focus at decongestion of hospitals (Lesotho Decentralization Policy, 2003). The policy document of Lesotho also specifies staffing levels and skill mix for primary health care facilities. Legislations in Zambia and Tanzania mandate district health management system to devolve planning and clinic development and implementation responsibilities to districts and area specific, legally constituted Health management Boards, which are meant to play critical role in operating clinics (Kalumbe, 1997). However, Limbambala(2001) reports that Zambia made some achievement in decentralization and accountability when it implemented health sector reform from 1993 to 1998 but the reform failed to meet its objective of equitable
  23. 23. 22 accessible to health care. The major reason was poor handling of health reform by civil servants because politicians and planners did not reach consensus on type of reform and poor maintenance of infrastructure (Limbambala, 2001). 2.3.6.1 Decongestion Decongestion of central hospitals is both part of health sector reform and in the context of decentralization, it falls under deconcentration. Decongestion is an institutional arrangement which deals with removing of outpatient department and other primary health care services from central hospital to Gateway clinics (GTZ Mission Report, 2009). Gateway clinics in this study are referred to as government health centres that are close to the central hospitals and are earmarked to take over responsibility of managing primary health care activities from central hospitals. In context of decongestion, there is limited literature regarding closing general outpatient department for general patients and primary health care services. South Africa implemented decentralization of health services following primary health care approach in health service provision as per their Primary Health Care Blue paper of 1996 (Cullinan 2006). Although policy document points out patients using the public health system should only access higher levels of care once they have been assessed and referred upwards by health workers at a lower level, it was noted that people were still accessing primary health care services at high levels of care. The two major contributing factors were that primary health care facilities were not given adequate attention in terms of infrastructure development and frequent shortage of drugs and related supplies. In addition literature reveals that primary health facilities did not attract health workers because they did not have basic amenities such as electricity, water and proper communication. The facilities had inadequate rooms and equipment to provide all necessary services coupled with persistent stock-outs of drugs and other supplies (Cullinan 2006). On the other hand, the literature does not indicate that general outpatient departments in central hospitals were completely closed to general outpatients. 2.4 Critical lessons from the literature In summary, the literature demonstrates that reforms are unavoidable but require adequate preparation before embarking on them. Thorough understanding of the prevailing problems and environment in the process of initiating change are very vital for successful implementation of any reform (Europe Aid 2009, Eriksson 2010 and WDR 2008).It is important to identify major
  24. 24. 23 bottlenecks and methods that can be used to resolve these bottlenecks to meet desired changes. Good leadership has played vital role in initiating and implementation of reforms. The literature demonstrates leadership through development of vision, mission and strategic legislations and policies that define clearly on desired changes (Cullinan 2006,Hage 2006,Kalumbe 1997, UNDP 1999 and Withanachchi 2007).The desired changes should be agreed by all stakeholders including politicians (Kalumbe, 1997). The most successful reforms established steering committees or indeed recruited fulltime professionals to oversee daily operations of the reforms and report progress to the top management on regular basis (Eriksson 2010, Kalumbe 1997 and Withanachchi 2007 and). Since changes take time and sometimes people may resist change, several authors have pointed out the need to introduce changes in phases and provide adequate time frames to allow learning by doing and developing capacity before moving to the next levels (Eriksson 2010, Withanachchi 2007 and UNDP 1999). Some health sector reforms were successful because majority of employees were actively involved in reform processes and in some cases the employees provided their input before the reform processes start (Eriksson 2010, Maddock 2002, Porter 1997, Withanachchi 2007 and UNDP 1999). Since reforms are geared at improving service delivery to the customers, several authors have recommended that the customers’ opinions and views should be incorporated in designing changes (Karassavidou 2009 and UNDP 1999). In the context of decentralization, community participation is a prerequisite (UNDP 1999). Whilst some reforms can be implemented without major resource allocation, some reforms like decentralization of health services in South Africa and Lesotho required heavy resource allocation (Cullinan, 2006). Failure to provide adequate financial resources and good infrastructure negatively affected primary health centres (Cullinan 2006). Continuous monitoring and improved communication are seen as vital elements for successful implementation of reforms (Eriksson 2010, Karassavidou 2009 & Withanachchi 2007). 2.5 Way forward A number of factors will be explored in the study and therefore, the author recommend that the study should employ total quality management tool called balanced score card (Kaplan and Norton, 1992). The balanced scorecard framework can provide comprehensive overview of processes leading to decongesting central hospital and meet the study objectives.
  25. 25. 24 With regard to strategic direction, it is recommended that the study should investigate the leadership role of the central Ministry of Health in decongesting central hospitals in terms of policy direction and resource allocation for gateway clinics. It is recommended that the study finds out if the ministry has a road map that guides and tracks progress made on processes leading to decongesting the central hospitals in Malawi with specific timeframe as to when the whole process will be completed. In addition it is recommended that the study should find out whether the MOH has a unit with full time officers to manage hospital reforms including decongestion of central hospitals. Regarding customer perspective, it is also recommended that the study should find out factors that influence patients and clients to seek OPD services at central hospitals and seek their views and recommendations on the proposed changes. With regard to business processes, it is recommended that the study identify strengths and weaknesses of gateway clinics from in-charges and get some suggestions on how to improve the gateways clinics to accommodate increased workload of primary health care services from central hospital. In relation to financial perspective, some reforms failed because they were poorly funded. Therefore, it is recommended that the study investigates if the central Ministry of Health has earmarked funds for gateway clinics. The study should investigate this aspect as well from District Implementation Plan (DIP) for Zomba District Health Office if it contains itemized budget for construction or renovations of gateway clinics. In recognition of learning and innovation perspective, it is recommended that the study examines necessary skills required to deliver all primary health care services at gateway clinics and finds out if the DHO and Ministry of Health have health workers with these skills to run these clinics and Ministry’s position on skill mix requirements based on expected processes that should be taking place at gateway clinics.
  26. 26. 25 CHAPTER 3: Methodology 3.1 Overview The chapter contains introduction to research, spells out research philosophy and approach. The chapter also highlights research strategy and discusses details regarding on which respondents each research method will be used. The research will use both qualitative and quantitative research methods. The research aims at providing a comprehensive direction to Ministry of Health on best way to strengthen gateway clinics to successfully decongest Zomba Central Hospital and use the lessons learnt in processes of decongesting other Central hospitals in Malawi. In order to answer research problem, questions and research objectives the research will need to collect data from four types of respondents who have interest in changes in management of general outpatient department and primary health care services from central hospital to gateway clinics. A questionnaire will be administered to customers (clients, patients/guardians) to find out reasons why they come to central hospital. The in-charges of gateway clinics will be interviewed to find out why people by–pass gateway clinics and go directly to central hospitals through a questionnaire as well; the in-charges will be interviewed as part of internal analysis to find strengths and weaknesses of gateway clinics; the district health managers and directors from central Ministry of Health will interviewed though in-depth interviews. 3.2 Introduction to research The research process for this study has been chosen from critical analysis of the research onion with clear academic underpinning to satisfy the aims and objectives of the overall research piece. The author has considered each layer of the onion separately to diagnose relevance of each layer to come up with research philosophy, research approach, and research strategy and data collection methods that are relevant to this research work.
  27. 27. 26 Figure 3: Onion research layers (Saunders, 2003) 3.3 Research Paradigm/Philosophy Paradigm’ refers to the process of scientific practice based on people’s philosophies and assumptions about the nature of knowledge (Kuhn 1962). In this context, it is about how individuals believe research should be conducted. There are three philosophies positivism, Interpretivism and realism. Positivism is a view that believes that reality is external and objective, and knowledge is only significant if it is based on observations of this external reality. It is the basis on which much ‘scientific’ enquiry has taken place. This viewpoint is usually referred to as the quantitative approach (Bryman and Bell, 2007). Interpretivism is a view that believes that the world and reality are not objective and exterior to the researcher, but are socially constructed and given meaning by people. Inevitably, several different variants exist which are closely associated with this view (Bryman and Bell, 2007). This is usually referred to as the qualitative approach. Realism shares some philosophical aspects with ‘positivism’, i.e. related to external objective influences of the ‘macro’ aspects of society that could be considered as the ‘givens’. However, ‘realism’ acknowledges the importance of understanding people’s socially constructed interpretations and meanings (some form of objective reality), while seeking to understand
  28. 28. 27 broader social forces, structures or processes that influence and perhaps even constrain, the nature of people’s views and behaviours (Bryman and Bell,2007 and Saunders,2007). The author has adopted realism, a philosophy that shares both some aspects of positivism and Interpretivism in order to meet aim and objectives of the study. 3.4 Research Approach According to Saunders (2003), deductive approach develops theory and hypothesis or and design research to test hypothesis. Usually it uses quantitative data. On the other hand inductive approach emphasizes of gaining an understanding of feelings that humans attach to events. It deals with collection of qualitative data. The study will employ both deductive and inductive approaches. 3.5 Research strategy Based on the onion by Saunders (2003), there are many research strategies in research that include case study, survey, experiment and many more. Case study is a research strategy which involves an empirical investigation of a particular contemporary phenomenon within its real life context using multiple sources of evidence. Survey is associated with deductive approach and allows collection of large amount of data in sizeable population in highly economic way through standardized questionnaire to allow comparison. Experiment is the classical form of research that owes much to the natural sciences. The strategy could involve defining theoretical hypothesis, selection of samples of individuals from known population and allocation of samples to different experiments. The study is a cross-sectional case study as the data will be collected at one point in time. The study will engage both quantitative and qualitative data collection methods. 3.6 Research Purpose To provide comprehensive direction to Ministry of Health on best way to strengthen gateway clinics to successfully decongest Zomba Central hospital and further recommend use of balanced scorecard framework to assess preparedness of gateway clinics for other central hospitals in Malawi.
  29. 29. 28 3.7 Research Design The research will collect data through questionnaire and semi-structural interviews. The research will use stratified random sampling method for patients and clients at outpatient department. Self-referred patients and clients will be randomly selected whereby every 5th patient or client will be enrolled in the study. It will also purposely select in-charges of five gateway clinics, 2 DHMT members for Zomba District Health Office and Director of Planning for Ministry of Health to be enrolled in the study. 3.8 Research methods Interviewer- administered questionnaire for patients and clients at outpatient department and in-charges of gate way clinics. Key informants interviews with DHMT members and director at central Ministry of Health. The data collection tools will be pre-tested on small group with similar characteristics to ensure validity and reliability of data to be collected. Each method is explained in table 1 below. Table1: shows reason for choice of data collection method/tool Explanation of choice of Participants: Patients and clients will be interviewed to find out reasons why they get outpatient health services at central hospital and find out if they are aware regarding the role or functions of central hospitals in delivery of health services. *Objective Participant Data Collection Method Reason for choice of method Populatio n Size Sample Size Sample Criteria Data Collection Date 1 Patients and clients at Zomba Central Hospital Outpatient department Individual questionnaire High volume, frequencies 600 150 By clinic / Random June, 2012 2, 3. 4 & 5 DHO, Central hospital and Planning department of MOH- Key informants In-depth interviews Depth, low volume 3 3 100% sample June, 2012 2 &6 gateway clinics in- charges Questionnair e High volume 5 5 100% sample June, 2011
  30. 30. 29 In-charges of Gateway clinics –key informants will be interviewed to assess the communication strategies that are in place to inform people regarding role of central hospital and other levels of health care. The in-charges will also be interviewed to find out services offered, workload and stock-out days of tracer drugs. They are also being interviewed to get their perspective regarding the change and their recommendations to the change. District Health Officer and Hospital Administrator as key informants will be interviewed to assess whether the District Health Office has allocated funds to renovate the gateway clinics and whether funds are adequate to meet estimated bills of quantities in their district plan for 2011-2012 as well as 2012-2013. In addition, they are asked to find out if the District Health Office has extra health workers to be deployed in gateway clinics. Ministry of Health (Planning Department.)-key informant will be interviewed to assess if capital investment plan has funds for renovation of gateway clinics and find out if the Ministry has a road map or milestones to follow on hospital reform as strategy. Key informant will also be interviewed to assess whether the Ministry has developed policy regarding staffing levels and skill mix for gateway clinics in anticipation of increased workload. In addition, the study will investigate if there is a unit to coordinate the central hospital reform with full time personnel. 3.9 Ethics of data collection The research proposal including data collection tools will be approved by Research Ethical Committee of university of Derby before actual data collection exercise starts. In addition, all participants in the research will be briefed about the research aims and that the information they provide, will not be disclosed to any third party, except as part of dissertation findings, or as part of supervisory or assessment processes of the University of Derby. In addition, the participants will be informed that the data provided will be kept until 30th April, 2013 for scrutiny by the University of Derby as part of the assessment process. The participants will be informed that if they feel uncomfortable with any of the questions being asked, they may decline to answer those specific questions. They may also withdraw from the study completely at any time, and their answers will not be used. Each participant will sign an informed consent letter as per attachments in appendix 1.
  31. 31. 30 3.10 Data Entry and Analysis Excel will be used to analyze data. The software has been chosen because it is has functions required in the study. In addition, the research will employ descriptive statistics to analyze the data for easy interpretation.
  32. 32. 31 Chapter 4: Findings and Analysis 4.1 Overview The chapter presents limitations and challenges encountered during the study. The chapter also discusses major findings of the study and they affect decongestion of the central hospital. 4.2 Limitations of the study Concerning the customers who were interviewed through individual questionnaire, more women than men participated in study. This was due to fact that health workers were striking and as a result of the strike, health services especially OPD was disturbed. This affected patronage of patients to outpatient department. Even when services resumed fewer men than women came for the OPD services and this affected gender representation of the study. The readers should interpret the findings with caution on rating of central hospital and health centres, since the patients were interviewed at Zomba Central Hospital, there may be a courtesy bias. Future studies should consider interviewing patients at both central hospital and gateway clinics to eliminate this bias. 4.3 Strategic direction in decongesting central hospitals The study has found that although, Ministry of Health expressed need to have central hospital reform (MOH, HSSP, 2011), it had not played its leadership role in developing policy instruments to guide decongestion of central hospitals and allocating resources to undertake the reforms (UNDP,1999 and Karassavidou ,Glaveli & Papadopoulos, 2009). The study shows that four strategic policy documents were not in place: road map, minimum infrastructure requirements (rooms and equipment) for gateway clinics, human resources policy detailing cadres and skill mix. The capital investment plan for 2011-2016 did not contain funds for gateway clinics. Capital Investment Plan contains priority projects for Ministry of Health for a specified period with funding estimates. The road map on decongestion of central hospitals was supposed to highlight different prioritized processes that were supposed to take place and time frame within which the whole
  33. 33. 32 process of decongesting central hospitals is expected to finish. This finding is in sharp contrast to assertions of Drucker (2000) who emphasizes that accountability of results can be assured if resources are allocated against attainment of defined targets, priorities and deadlines. The author agrees with Drucker in emphasizing the fact that government projects should have timespan during which the project activities could be accomplished. The study further indicates that Ministry of Health did not make any decision on whether all primary health activities would be transferred to gateway clinics at once or in phases. Stakeholders should clearly decide whether all general outpatient services would be transferred to gateway clinics at once or in phases. The reforms in Zambia failed because technical experts and politicians did not agree on type of the reform (Kalumbe, 1997). However, UNDP (1999), Withanachchi (2004), Withanachchi (2007), Zineldin (2008) point out that reform should be taken in phases to allow time for observation and capacity building. Regarding human resource, the study further reveals that there was no new human resource policy that reflects minimum number of health workers and skill mix for gateway clinics in recognition of additional functions and increased demand of services. MOH said that staffing of health centres of 2 clinician, 2 nurses and 1 environmental health officer applied to gateway clinics as well. This finding is in contrast to Lesotho health sector reform policy which highlighted skill mix that should be available at each level of service delivery. The author felt that Ministry of Health would have critically examined outpatient services, essential health package elements and community expectations and made decision on the staffing levels and skill mix required for gateway clinics. Ministry of Health could bench mark Matawale Health Centre as a model of gateway clinics to decongest central hospital. The study further found that Ministry of Health had not shown any commitment in allocating financial resources for renovating gateway clinics. The capital investment plan for the Ministry of Health did not contain financial allocation to support construction or renovation of gateway clinics in Zomba. Extension and construction of additional rooms and procurement of medical equipment for gateway clinics could not be financed fully through the monthly funding that the district health office receives. Zomba District Health Office received funds which were meant for operations including maintenance not development (Malawi Decentralization policy, 1998).
  34. 34. 33 The study further found that there was no independent unit established with full time person employed to coordinate day to day activities but instead Deputy Director of SWAp had been chosen to oversee the processes. The author felt that Deputy SWAp Director was full time job and very demanding too. UNDP (1999),Withanachchi (2004), Department of Public Expenditure and Reform of Ireland (2011) point out the need to establish unit with full time experienced person to coordinate day to day reform activities and report to management on regular basis. 4.4 Customer/community perspective 4.4.1 Location The study findings reveal that majority (100%) of the people in the sampled population who seek general OPD services at the Zomba Central Hospital were from within Zomba District. 55 %( n= 83) of the respondents were from within Zomba City and 45% (n=67) of respondents were coming from Zomba Rural. The study further indicates that 42% (n= 63) of respondents were coming from within 1-5 KM, 36 %( n= 54) were coming within 6-8Km and 29% (n=43) respondents were 9 Km or more away from the central hospital. With regard closest health facilities to the respondents, the study reveals that that most of the respondents (76%) reported to come from around health facilities that were targeted as gateway clinics of Sadzi, Zomba City Clinic, Matawale, Namadidi, and Zilindo. Refer to Table 2 below which shows the closest public health facility to respondents. Table 2: closest public health facility to respondents (Source: Author’s study) Health Facility Number of respondents Percent Sadzi 54 36.0 Zomba City Clinic 19 12.7 Matawale 17 11.3 Namadidi 12 8.0 Thondwe 9 6.0 Zilindo 5 3.3 Naisi 3 2.0 Chingale 3 2.0 Police 3 2.0 Cobbe Barracks 2 1.3 Lambulira 2 1.3
  35. 35. 34 This finding demonstrates the fact the task force on decongestion of Zomba Central Hospital probably made right selection of these facilities as gateway clinics. However, the study further shows that 21% of the respondents were coming from other facilities (such as Thondwe, Lambulira, Nasawa, Chingale and Naisi) outside gateway clinics. This means that whilst the major focus was to strengthen the gateway clinics, the author felt that these other facilities should have been strengthened as well if decongestion of Zomba Central Hospital was to be achieved. 4.4.2 Health conditions that respondents presented at Zomba Central Hospital The respondents were asked what health condition or issue brought them to hospital. The respondents had option of answering or not. 141 respondents answered the question giving a response rate of 94%.The study reveals that there were five major reasons of OPD consultation in both under-five and adult Outpatient department. These conditions represent 66% of all OPD consultations in sampled population. Cough accounted for 30 %( n=43) of the respondents, 15 %( n=21) of respondents came for immunization and growth monitoring, 13% of the respondents were treated for malaria, 10% of the respondents consulted the OPD for BP check-up and collecting BP drugs. Upper respiratory tract infections constituted 7% of the respondents. Seven percent of the respondents had diarrhoea. The study further found that that 2% and 1% of the respondents came to OPD for dental and antenatal clinic services respectively. Refer to figure 4 below. Nasawa 2 1.3 Gwelero 2 1.3 Domasi 1 0.7 Machinjiri 1 0.7 None(Central hospital) 7 4.7 Not known 8 5.3
  36. 36. 35 Figure 4: Respondents’ health conditions (Source: Author’s study) Cough was the highest cause of OPD consultation at Zomba Central Hospital, which relates to the period of winter when the study was conducted. However, an annual outpatient attendance shows that leading cause of OPD consultation was malaria (Zomba Central Hospital HMIS Annual Report, 2011 and MOH HMIS Annual Report, 2011). On the other hand, all these conditions reported by respondents were within 13 elements of essential health care package and could be managed at primary health care level (MOH HSSP 2011-2016). This confirms the views of proponents of decongestion who argue that the central hospitals are congested with conditions which could easily be managed at lower levels of care (Cullinan, 2006). 4.4.3 Factors that prompted respondents to seek OPD service from central hospital The study investigated to find out factors that persuaded the respondents to seek general outpatient services at Zomba Central Hospital. The study has found that there were five major reasons that influenced people (respondents) to seek OPD service at the hospital as per table 3 below. Table 3: Reasons that persuade people to seek OPD services at Zomba Central (Source: Author’s study) Reason Frequency Percent Frequent shortage of drugs in health centres 60 40% Regard central hospital as any health facility 43 29% collection of BP drugs 14 9% Negative attitude of staff in health centres 11 7% Central hospital is very accessible 10 7% unavailability of health workers at health centres 5 3%
  37. 37. 36 40% of the respondents reported that health centres were experiencing frequent shortage of drugs. During the study, the author observed that some clients/patients at Matawale Health Centre were told that the facility had run out of drugs for their conditions and instead they were instructed to buy from private shops. This finding suggests that the shortage of drugs at health centre level could be a genuine concern. However, the study did not find out how many patients at health centre did not receive drugs for their ailments. Sometimes people seek outpatient services at central hospital because they do not know distinctions among different levels of health care delivery and what conditions should be treated at each level of care. To this effect, the study shows that 29% of the respondents came to the central hospital because they regarded central hospital as any health facility. This finding demonstrates knowledge gap and is being attributed to fact that both District Health Office and all five gateway clinics did not plan community advocacy and sensitization meetings regarding functions on three levels of health care and health conditions that could be treated at each level of health care. The study also reveals that some of respondents (9%) came to central hospital for BP check- up and collection of BP drugs. Hypertension and diabetes were included as part of new Essential Health Care Package (MOH-HSSP, 2011-2016), but major challenge was that Ministry of Health had not yet changed drug policy at the time of study so that hypertensive(BP) drugs were available at primary health care level. The study indicates that seven percent of the respondents alleged they seek health services at central hospital because health workers at health Centres had negative attitude towards clients. Negative attitude of health workers is a long standing issue which could have been minimized if the health facility advisory committees (health centre or hospital) were active. The health facility advisory committees are supposed to receive, discuss and resolve community concerns. Unfortunately, these committees are not meeting as stipulated or only focus at witnessing delivery of drugs at health facility (MOH-Zonal Annual Report (2011). Looking for high quality services at Central hospital 4 3% health centre opens late and closes early 2 1% Total respondents 149 100%
  38. 38. 37 Some respondents (3%) reported that central hospital is very accessible. The author observes that the accessibility is attributed to fact that Zomba Central Hospital is along the main road between Zomba City and Blantyre City and there is good availability of public transport such as Mini-buses and taxis to and from the hospital. As the gateway clinics are being strengthened, the issue of accessibility should be worked out as well by collaborating with other stakeholders who could provide these amenities. Three percent of the respondents came to the hospital for quality health services. The quality of health services is a cross-cutting issue. Health authorities should strike a balance to ensure that health services do not only meet technical quality but should incorporate quality factors from the customers’ view point (Withanachchi, 2007). 4.4.4 Rating of Zomba Central Hospital and Health centres With regard to rating of Zomba Central hospital and health centres, 145 respondents rated the hospital giving a response rate of 96% whilst 120 participants rated health centres yielding a response rate of 80%. The discrepancy was probably due to fact that some respondents regarded central hospital as their closest health facility and therefore, they could not rate health centres. The respondents rated the both the Central hospital and public health centres on scale of 5 to 1. The numbers have following meanings; 5 means excellent, 4 means very good and 3 neutral, 2 means very bad and 1 means worst. The total weighted scores were interpreted as follows; Green means excellent services with total weighted scores within a range of 100-80%. Decision making, no action is required but should be encouraged to maintain the services. Yellow has total weighted scores within the range of 79-60% and means very good services but needs fine tuning of remaining issues. Red means urgent action and is represented by total weighted scores of less than 60% as per tables 4 and 5 below Table 4: Rating of Zomba Central Hospital (Source: Author’s study) Responde nts Total responses weighting average total weighted scores Expected total weighted scores Total 145 663 725 excellent 97 5 485
  39. 39. 38 very good 39 4 156 neutral 6 3 18 very bad 1 2 2 worst 2 1 2 Table 5: Health centre/gateway clinic rating (Source: Author’s study) Interpretations of total weighted scores Central Hospital Health centres/gateway clinics 725-580 Excellent service-maintain 600-480 579-435 very good -needs fine tuning of remaining issues 479-360 <434 Good but major improvement are needed urgently<360 The study found that the respondents rated Zomba Central Hospital as an excellent service provider because it had 663 total weighted scores which fall within the green band which represents 100-80% of the total weighted scores The health centres/gateway clinics were rated as very good because they had 414 total weighted scores which fall within the range of 79 -60% of total weighted scores. Therefore, the respondents perceived Zomba central Hospital as a better service provider as compared to the health centres. The author attributes the high rating of Zomba Central Hospital to constant availability of drugs and offering wide range of services (Zonal HSSP Review Meeting, 2012). In order to improve image of health centres, the decongestion should focus at ensuring drug availability and introducing wide range of services including changing drug policy to ensure that all drugs for essential health care package are available at primary health care level (gateway clinics) as well as rural health centres. Respondents Weighting average Total weighted scores Expected Total weighted scores Totals 120 414 600 excellent 14 5 70 very good 48 4 192 neutral 38 3 114 very bad 18 2 36 worst 2 1 2
  40. 40. 39 4.4.5 Respondents’ approval of transferring (closing out) outpatient services for general public to primary health care level. The respondents were asked if they would approve the closing of outpatient department to general public so that the central hospital focuses its effort on tertiary care. The questions had a total 144 responses giving a response rate of 96%. The responses were weighted as follows= very strongly approve=5, strongly approve=4, not sure 3, strongly disapprove=2 and very strongly disapprove=1. The total expected scores from all respondents assuming they very strongly approved would have been 720 scores refer to table 6 below. Table 6: Do you approve closing of outpatient department to general public Responses frequency Weighting average Total weighted scores Total expected weighted scores Very strongly approve 21 5 105 720 Strongly approve 16 4 64 not sure 8 3 24 strongly not approve 42 2 84 Very strongly not approve 57 1 57 Total 144 334 Interpretation of the total scores 720-541 Accept Close of general outpatient department 540-401 work out on few outstanding issues before implementing the decision <400 do not close, do thorough ground work before implementation of the decision Based on the total weighted scores, the respondents in the study had disapproved the closing of general out patient department as total scores fall within red band of less than 400 scores. Instead, thorough ground work should be done on gateway clinics before considering closure of the department to general public.
  41. 41. 40 4.5 Business processes perspective With regard to business processes, the gateway clinics have various challenges namely; Outpatient workload, supply chain of drugs, availability of services and infrastructure. 4.5.1 Workload of outpatient department According to MOH SWAp 2004-2010 and MOH HSSP, 2011-2016, outpatient attendance does not only indicate availability and accessibility of public health services to the general public but also shows workload of the health facilities. If the outpatient attendance reaches 100% and above against catchment area population over 12 months period, it means the services are accessible and manageable. The study has found that Matawale, Zomba city Clinic and Zilindo were operational for entire period under review whilst Namadidi and Sadzi have been operational for half of the period. The study further shows that workload varied across the gateway clinics. Matawale health Centre had the highest workload (259%) of OPD consultations, followed by Zilindo (113%), and 56% for Zomba City Clinic. Zomba City Clinic was less accessible and there is need to find out why the facility OPD services were not readily accessible and utilized. If Zomba City Clinic was fully utilized, it could easily take up pressure from Matawale Health Centre. Namadidi and Sadzi had 21% and 46% of OPD consultations respectively. Although Namadidi and Sadzi functioned for half of the year, these facilities were supposed to have been utilized by 50% of population by end of fiscal year. Namadidi underperformed during the six months period as compared to Sadzi which achieved 46% of OPD utilization. Refer graph below that shows workload of each facility. Figure 5: Gateway clinics OPD Workload (Source: HMIS Reports 2011/2012)
  42. 42. 41 Although, Matawale OPD utilization is the highest, it signifies that the facility was overstretched and this development may negatively affect quality of health services being offered and refer pictures below Figure 6: Clients at under-five OPD clinic Figure 7: Adult OPD patients waiting to register Both pictures were taken at 11:45 am but the facility had still a lot clients waiting for OPD services. Matawale Health Centre was already congested and it should not have been targeted facility for decongesting central hospital but rather much focus should have been given the other facilities such as Sadzi, Zomba City Clinic, Namadidi and Zilindo. Some respondents had attributed poor outpatient attendances in some gateway clinics to non-adherence scheduled opening and closing hours. The attendance could also be attributed to fact that there were only few health workers who did not leave close to some facilities like Namadidi and Zilindo. During the study, the author did not only witness a facility opening late but found that one facility was closed for the whole day because the only health worker was sick.
  43. 43. 42 4.4.2 Stock out days of essential drugs Table 7: Status of Stock-out days of some selected essential drugs at Gateway clinics July, 2011 to June 2012 As per table above, the study investigated on the availability of drugs by monitoring stock out-days of eleven essential drugs commonly used for managing the most common conditions at health Centre level. According SWAP matrix 2004-2010, essential drugs are supposed to available for 365 days. The study has found that all five health facilities had experienced stock outs in all drugs except for Tetanus Toxoid vaccine (TTV). Zomba City Clinic and Sadzi had stock outs of seven drugs, Matawale had stock outs of six drugs and Namadidi had stock outs of five drugs. Zilindo experienced less stock outs .All facilities had stock out of malaria rapid test kits. The average stock out days ranged from 3.6 days to 83.2 days for gentamicin and ferrous sulphate respectively. Health facility /drugs Oral rehydrati on Salts TT vaccine Contrimoxa zole HIV Test Kits Ferrous sulphate Gentamic in Metronid azole Benzylpe nicilin Diezepam injectable LA(any combinati on) RDTs for malaria Matawale 56 0 81 7 200 0 133 0 0 0 76 Zilindo 0 0 156 0 0 0 161 0 0 84 Zomba City Clinic 150 0 0 84 69 18 80 43 0 0 48 Sadzi 31 0 31 52 87 0 20 0 196 0 81 Namadidi 0 0 90 60 0 0 0 30 60 60 Average stock out days 47.4 0 71.6 28.6 83.2 3.6 78.8 8.6 45.2 12 69.8
  44. 44. 43 The stock out of essential drugs confirmed the concerns raised by respondents who complained of frequent shortage of drugs at health centre level. Unless supply chain of drugs was properly managed, communities would continue to patronize central hospitals with minor ailments that should have been managed at gateway clinics. 4.5.3 Infrastructure The study findings show that all five health facilities except Matawale health Centre have infrastructure challenges in terms of rooms, and medical equipment to provide a wide range of health services refer to figure 8 of Matawale Health Centre. Figure 8: Matawale Health Centre Although renovations were done in some facilities, the building structures could not accommodate additional services. In addition, the study shows that Zilindo and Namadidi do not have staff houses; the staff members were coming from distant places to work at these facilities. The study has also found that only Matawale and Zomba city Clinic had all three basic amenities such as water, electricity and communication. These amenities are very crucial in providing quality health care services. 4.6 Financial allocation for renovating and refurbishing gateway clinics With regard to financial allocation, the study has found that financing of the renovations is adhoc because both District Implementation Plans for 2011/12 and 2012/13 for Zomba District Health Office did not have specific allocation of funds to finance renovations and refurbishment of gateway clinics. Renovations had been undertaken at gateway clinics with funds that were initially earmarked for other activities. The study further noted that general records keeping and
  45. 45. 44 sharing of information regarding estimated cost of renovations was a challenge among management members. It was also difficult to establish how much funds Zomba District Health Office had used for renovating and refurbishing these facilities. 4.7. Learning and Innovation perspective Table 8: Staffing levels of gateway clinics(source: Author’s Study) health Facility/ staffing CO MA NT CN RN AEHO/ EHO DT OCO DA LT Tota ls Matawale 3 1 8 2 5 2 4 1 0 3 29 Zilindo 0 1 1 0 0 0 0 0 0 0 2 Zomba City Clinic 2 0 3 1 0 0 0 1 1 0 8 Sadzi 0 0 2 0 1 0 0 1 0 0 4 Namadidi 0 0 1 0 0 0 0 0 0 0 1 Totals 5 2 15 3 6 2 4 3 1 3 44 The table above demonstrates that out of the five health facilities only Matawale Health Centre had the highest number of health workers with various skill-mix requirements befitting a health facility to be gateway clinic. At the same time, the table shows that Namadidi had the least number of health workers and limited skill mix. According to the author observation, availability of multiple skills necessitated Matawale Health Centre to offer wider range of health services than the other facilities which had limited skill mix availability. Whilst the table may show that there was poor deployment of staff for some cadres, some of the facilities lacked equipment and rooms to fully utilize the skills in these health workers. For instance, Sadzi Health Centre had an ophthalmology clinical officer but did not practice because there was no room and equipment to eye related services. Matawale health centre was the only facility that was offering maternity services hence it had more nurse technicians and registered nurses than any other gateway clinic.
  46. 46. 45 CHAPTER 5: Conclusion and Recommendations 5.1 Overview This chapter discusses key challenges that affect performance of gateway clinics as observed from the findings chapter. The chapter then takes critical analysis of how these challenges can be solved. The chapter makes recommendations of what management at both National and district levels should do to decongest central hospital. 5.2 Conclusion In summary, in reference to four perspectives of balance scorecard, the study findings have shown that there was little progress made in strengthening gateways to decongest Zomba Central hospital. With regard to strategic direction, the Ministry of Health did not have strategic policies documents in place to guide the whole decongestion reform. For instance, there was no road map, each central hospital and respective DHO were expected to develop their own road map for the reform process. There was no timeframe regarding when the whole process was expected to finish completely. Whilst it is important that there could be road map for decongesting each central hospital at operational level, it is very crucial that these individual central road maps are informed by national road map. Ministry of Health did not develop a new policy on staff establishment for gateway clinics and the ministry assumed that staffing norm for health centre should apply to gateway clinics as well. However, examining the pressure and expectations of the people who participated in the study, all gateway clinics were supposed to be staffed with various cadres like Matawale Health Centre that acted like community hospital. Presence of various cadres is not only important at to provide a wide range of services but as it assists to decongest central hospitals as they would meet interests and meet aspirations of the people. There were no minimum infrastructure requirements in terms of buildings and equipment that were supposed to available at gateway clinics. The capital investment plan did not indicate funds earmarked for extension or renovation of gateway clinics. The extension and renovation works could not be undertaken with operational budget provided to District Health Offices. The reform processes to decongest Zomba Central Hospital were not based on principles but rather on the willingness and good working relationship between the Zomba Central Hospital Management Team and Zomba Health Management Team. The author feels that the reform
  47. 47. 46 processes may cease or stop depending on change of management at district health office or Zomba Central Hospital as they are not based on policy guidelines. The findings of the study suggest that gateway clinics were not ready to take over whole primary health care activities from Zomba Central Hospital. The facilities are facing numerous challenges ranging from inadequate infrastructure, human resource, adhoc funding, inadequate community involvement and awareness and supply chain. One out the five health facilities regarded as gateway clinics had minimum infrastructure that enables it accommodate a number of services than the other facilities. It was that same facility that has health workers with varied skill mix which enabled it to offer a wide of health services. This was the only facility that offered the following services: dental, maternity, laboratory and full PMTCT package to pregnant women who test HIV positive. There were no plans to involve community leadership and general public who are key stakeholder to the decongestion of central hospital. Both District Health Office and five health facilities did not have written plans on community involvement and awareness although the reform will affect the communities. All five facilities experienced stock out of essential drugs during the period under review. The frequent shortage of drugs is forcing people to seek services at central hospital among other factors. The study findings revealed that the following factors forced people to seek out patient services at Zomba Central hospital: frequent drug shortage, inadequate awareness among community members on functions of central hospital and regard it as any facility, some services were not available gateway clinics, negative attitude of staff including opening late and closing early of gateway clinics, poor accessibility of some health facilities. Consequently, the respondents rated central hospital as the facility that offered superior health services as compared to the health centres (including gateway clinics). The community did not approve closure of general outpatient department of central hospital unless the challenges highlighted above were resolved.
  48. 48. 47 5.3 Recommendations In order to successfully decongest central hospitals, there is need to strengthen the gateway clinics. The recommendations have categorized into two as follows: National level-Ministry of Health should: 1.0 Develop key strategic documents to guide the decongestion of central hospitals and strengthening of gateway clinics in all four perspective areas of balanced scorecard as follows:  Develop road map on decongestion of central hospitals that defines OPD services to be transferred out and also details how, where and when different processes will be accomplished.  Develop minimum infrastructure and equipment requirements for gateway clinics in recognition to additional functions and increased workload. Institutional staff houses should be incorporated into this policy document.  Develop human resource policy for gateway clinics that is in tandem with current demands and anticipated services to be added. The policy should focus at skill mix required to offer all EHP interventions. This may necessitate deployment of other cadres of professional health workers at gateway clinics such as medical doctors, clinical officers, laboratory technicians, dental therapists etc. 2.0 Make commitment by allocating substantial financial resources for extension, renovations and refurbishment of gateway clinics in her Capital Investment Plan and make sure that the resources are available at District level to support related works. 3.0 Since reforms take time and some facilities do not have capacity to deliver all services, it is recommended that primary health care services should be transferred in phases to allow time for learning and capacity building.
  49. 49. 48 4.0 Revise drug policy to introduce some hypertensive and diabetes drugs at primary health care level since these elements have been included in the list of essential health care package. 5.0 MOH should allocate adequate budget for drugs and procure them timely to prevent frequent stock outs at health facility level. 6.0 Re-deploy all health workers who manage general outpatient and primary health care services at central hospitals to district health offices. District level 7.0 The financing of the renovations and extension of gateway clinics is adhoc, it is recommended that District Health Management Teams should plan for renovations and extension of gateway clinics in the District Implementation Plan and ensure that the renovations are done in relation to expected services to be offered as may be outlined in the minimum infrastructure requirements for gateways. 8.0 District Health Management Teams should conduct regular supervisions to gateway clinics and other health facilities to monitoring delivery of health services and flash out any shortcomings that may be identified. This supervision will among other things monitor stock levels of drugs. 9.0 As part of community involvement, DHMT should develop strategies to engage community leadership and raise awareness on the decongestion of central hospitals stressing on what conditions are expected to be managed at each of the three levels of care. The health facility advisory committees should be given necessary knowledge and skills to effectively link the catchment population and respective health facility 10.0 In order to improve the image of health centres, the DHMTs should establish feedback mechanism to get views/concerns such as suggestion boxes or conduct exit interviews on regular intervals to identify areas that require strengthening.
  50. 50. 49 11.0 Fix and ensure Namadidi Sadzi and Zilindo gateway clinics have all three amenities of water, electricity and communication. 12.0 Re-deploy additional health workers to Namadidi Dispensary and ensure that the facility opens and closes according government stipulated times.
  51. 51. 50 Chapter 6: Personal Reflection 6.1 Overview The chapter discusses major lessons learnt from the study and challenges experienced from the author’s perspective. 6.2 Major lessons learnt I have learnt that literature review is a major pillar in business research. Through literature review I have had in-depth understanding of all forms of public sector reforms. I have learnt various approaches of introducing reforms and how to make health reforms successful. Among other issues I have learnt that Central government should have clear position of any reform by developing necessary policies, allocation of resources to fast track reforms and that reforms should have time frame within which they will be completed. In addition, I have learnt reforms should be implemented in phases. I feel this knowledge is very vital to me personally because I can work as consultant in the hospital reform and indeed on any reform based on the concepts that I have learnt through this study. Since I have acquired adequate knowledge and expertise in the study, I intend to share the knowledge with Director of Zomba Central hospital and Ministry of Health through report and meetings so that they learn the approach used and recommendations derived from the study. The study was important because I have had an opportunity to use new knowledge I have gained during the entire course of strategic Management. In this regard, I have had a chance to test some new approaches such as balanced score card. I have realized that although the balanced score card was designed to be used for private sector; it could be used in public sector provided you are very clear regarding how you want to use it. In this study, all five components of the balanced score card were assessed. However, I have learnt that performances of perspectives of balanced scorecard are dependent on clear goals and strategy. In the study, Ministry of Health lacked policy guidelines, which would have shown its position, and those policy guidelines would have an influence on what should happen in each of the four perspectives.
  52. 52. 51 I have learnt that a good research topic is a product of wide consultations with various stakeholders and supervisors on one hand but also wide reading of what other authors have written on the topic. In my study I had consulted funders like German Health Programme who were supporting Ministry of Health with Hospital Reform but also provided scholarship to the author. I had also consulted Director of Central Hospital and Zomba District Health Officer who were implementing hospital reform. I have learnt that in order to have buy-in from a good number of people, the study should address some gaps/challenges that organization is facing in its operations. Zomba Central Hospital and Zomba District Health Office supported the study because they wanted to learn from the study grey areas that require improvement in decongesting their central hospital. Although implementation of central hospital reform started without consulting the communities, I have also learnt that customers, the patients and clients are equally important and clever because they could analyze skills available at health facility and make rational decision as to where they should seek primary health services. If they have noted that the primary health care level facility does not provide a particular service, they do not wait for referral if they know that they could get those services at another health facility including central hospital. Most gateway clinics did not have wide range of skills and services, consequently people opted to seek these services at Zomba Central hospital. The health sector reforms should involve communities who are the users of the services so that they share their point of view. In this study the communities have given reasons that force them to seek services at central hospitals. Unless these challenges communities face at gateway clinics are resolved, they will continue to seek services at central hospitals. I have learnt that multi-skilled health workers, adequate buildings (rooms) and equipment plus good supply of essential are key instrumental factors that can enable a primary health care facility (gateway clinic) offer wide range of health services . 6.3 Challenges In course of the study, I have experienced some challenges.
  53. 53. 52 The study requires good time management to meet office obligations and study requirements. I had just changed jobs. The current job requires a lot of my time and it was really challenging to get adequate time for the study, new job and family. Therefore, time management was very critical in order to fulfill office, academic and family obligations. I have learnt that time is one the scarce resources I need to manage very well in my undertakings. Initially, Malawi German Health Programme offered to provide financial support to carry out this independent study but the decision changed after change of programme leadership. This meant that I had to source extra personal financial resources to conduct the independent study. Lastly, data collection exercise was disturbed because health workers were striking. As a result of the strike, health services especially OPD was disturbed. The communities could not access the services for some days and therefore it was difficult to get respondents. The gender representation of the study was affected because fewer men than women came for OPD services during the strike period. 6.5 Summary It was worthwhile to conduct independent study because it has deepened and widened my understanding of the public sector reform. The study has not only enabled me to apply new concepts that I learnt during the course but it has also given confidence in how best to conduct business research. The current knowledge acquired through this will be shared with interested parties and individuals through reports, presentations and publications.
  54. 54. 53 Appendices Appendix 1: Participant Briefing and consent and withdraw letters Dear Participant, MSc Strategic Management – Participant Briefing and Consent Letter I am Grevasio Mchigulupati Chamatambe and I am collecting data from you which will be used in my dissertation for Ministry of Health, as part of my MSc Strategic Management at the University of Derby, in collaboration with the Malawi Institute of Management (MIM). The aim of the dissertation research is to assess level of preparedness of gate way clinics and provide recommendations to successfully decongest Outpatient department at Zomba Central Hospital, and the information you will be asked to provide will be used to help to provide insights to achieve this objective. The data you provide will only be used for the dissertation, and will not be disclosed to any third party, except as part of the dissertation findings, or as part of the supervisory or assessment processes of the University of Derby. The data you provide will be kept until 30th April 2013, so that it is available for scrutiny by the University of Derby as part of the assessment process. If you feel uncomfortable with any of the questions being asked, you may decline to answer specific questions. You may also withdraw from the study completely, and your answers will not be used. And, if you later decide that you wish to withdraw from the study, please write to me at (Grevasio Mchigulupati Chamatambe, Zonal Health Office, Box 216, Zomba Malawi Email address: grevasiochamatambe@yahoo.co.uk) no later than 1st August 2012 and I will be able to remove your response from my analysis and findings, and destroy your response. I have read and understood the contents of this consent and briefing form, and freely and voluntarily agree to participate in this research. I am happy to be identified as a participant in the research by my position at work (e.g. as a member of the executive committee).
  55. 55. 54 Signed Please print your name Date

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