There are so many facets to health system reform that it would be difficult to cover them all in one instalment.
The word reform is often used with reference to the change or amendment to something that is defective in one way or another in order to make it better. The aim of reforming anything could be to make it more efficient. Restructuring, like reform, implies organising something differently, resulting in changes to the structure or practice.
Since reform, basically, implies change, those undertaking reforms should have the requisite change-management skills. They must, in particular, be prepared to manage a whole host of emotions among the stakeholders, which can be summed up under the phrase: “What’s in it for me?”
On August 13, 2020, local media was awash with reports of the round-the-country tour by the newly-appointed Health minister, Vice-President Constantino Chiwenga. According to the reports, the minister was not happy with, among other issues, those hospitals that were said to be demanding Covid-19 clearance certificates from people seeking medical services as well as those taking advantage of the Covid-19 pandemic to charge fees that were viewed as exorbitant. The minister announced that the government was soon to embark on a “restructuring and reforming” exercise of the health delivery system. He added that weaknesses had been identified in the current health system and “things will never be the same again . . .”.
The structural changes, he stated, were to be effected throughout the health system from the “village, district, provincial to referral hospitals.” Subsequent announcements by the minister were made, expressing the desire by government that citizens have “equitable access to health care services of sufficient quality”. The announcements were made in the backdrop of strikes by public health sector staff, inclusive of nurses, medical doctors and the allied health professionals. The specific objective of the reform of the Zimbabwe health care system has been reported as to develop a new structure of the Ministry of Health and Child Care, with three phases as outlined below:
l addition of a new top layer to the national health delivery system.
l the development of an organised strategic department in the ministry.
l (i) development and adoption of a sustainable funding model for the national health care system. (ii) develop conditions of service for the health staff to perform functions in the new structure. The VP Chiwenga has since announced that the first phase of the restructuring has been accomplished through the addition of “the fifth level or the quaternary hospital which is a high level research and development hospital.”
It is important to, on the outset, define what a health system is. The World Health Organisation (WHO) definition is that a health system is,“all the organisations, institutions, resources and people whose primary purpose is to improve health.” It is noteworthy that the efforts of individuals in a public or private work environment have the over-arching goal of improving the health status of individuals or communities. The actors in a health system, therefore, include the patients or clients, communities, the health regulatory entities, the service providers as well as the institutions responsible for health financing. It is anticipated, therefore, that a health system will equitably meet the expectations of individuals and communities regardless of their socio-political or economic status. Issues of equity have serious implications for the principle of justice and embedded in this principle is the aspect of fairness.
The reform of the health system normally refers to fundamental and purposeful change at all levels of the system. Such change, in essence, is holistic in nature and it is typified by the implementation of comprehensive or global structural changes, involving amendments to health policies and institutional arrangements. This is quite distinct from a situation where piecemeal changes are made in the structure. The ultimate aim of health system reform/restructuring is to enhance the performance of the health system. The health system must be fit for purpose, which is to improve the health of citizens or communities. As is the nature of systems, whatever happens to one part of the system will affect other parts of the same system, either positively or negatively. Sight should not be lost of the relationships and interconnections of the different parts that form the health system. Reformers of a health system, therefore, need to think of the possibility of unintended consequences, and not just the results that they aim for.
It is necessary to briefly describe the structure of the Zimbabwe health system, since although there maybe similarities, the structures tend to differ from country to country, even for countries in the same region. Without going into the finer details of the network of institutions, both public and private, in the system at each level, suffice to state that the structure has been, hitherto, besides the headquarters, been characterised by four levels, that is, the primary, secondary, tertiary and quaternary.
The primary, as the term suggests, is the basic level where institutions include the clinics/rural health centres, the secondary has district hospitals as the most distinct institutions, the tertiary has provincial hospitals and the quaternary level is where are found the central hospitals. Each lower level, ideally, refers patients to the next higher level, if necessary, for more specialised care.
The greater proportion of the health services are provided by the public health sector and these are complemented by the private health sector, that is, the private-for-profit, including private surgeries and hospitals and the private not-for-profit such as missions health facilities.
The literature reveals that the following list, though not exhaustive, constitutes some of the common reasons for governments to undertake health system reforms:
i) cost of providing health services exceedingly high to the extent of being unsustainable.
ii) radical political and economic changes, normally related to the arrival of a new political administration rather than the objective identification of dysfunctionalities of the existing system
