Im­prov­ing na­tional health de­liv­ery

The Sunday Mail (Zimbabwe) - - OPINION & ANALYSIS -

THE re­cent eco­nomic chal­lenges have not spared our health sec­tor. The strain has shown by way of medicines which have ei­ther been unavail­able, in short sup­ply, or un­af­ford­able. This ad­verse sit­u­a­tion has ob­tained in spite of Govern­ment ef­forts to keep stocks of vi­tal, essen­tial and nec­es­sary medicines in our clin­ics and hos­pi­tals at an av­er­age level of about 54 per­cent.

A sta­ble health en­vi­ron­ment is a peo­ple’s right and a key so­cial pil­lar of our Vi­sion 2030.

Vi­tal and essen­tial medicines are what sus­tain our na­tional pri­mary health­care sys­tem, which we run through clin­ics and dis­trict hos­pi­tals.

This level of health care and in­ter­ven­tion is our first line of de­fence when it comes to na­tional health. It should never fail and should be strength­ened al­ways.

Our Min­istry of Health and Child Care has iso­lated 19 drugs which must al­ways be in stock and avail­able in clin­ics and hos­pi­tals to un­der­pin our pri­mary health­care.

In ad­di­tion, Govern­ment en­sures ad­e­quate stocks for drugs for com­mu­ni­ca­ble dis­eases like HIV/Aids and tu­ber­cu­lo­sis, and for malaria.

To date, we have reg­is­tered re­mark­able suc­cess in con­tain­ing com­mu­ni­ca­ble dis­eases, even be­com­ing a global model on best prac­tices. Vi­tal medicines reach all our clin­ics and hos­pi­tals through dis­tri­bu­tion chan­nels of NatPharm, our cen­tral ware­house for phar­ma­ceu­ti­cals and re­lated prod­ucts.

NatPharm’s sup­ply-runs to com­mu­nity clin­ics, dis­trict and pro­vin­cial hos­pi­tals must al­ways be reg­u­lar and pre­dictable for an ef­fi­cient health de­liv­ery sys­tem.

Our part­ners have also weighed in to com­ple­ment Govern­ment ef­forts in de­liv­er­ing health ser­vices to our peo­ple. We thank them for their sup­port.

My Ad­min­is­tra­tion has en­sured that we are able to of­fer free health ser­vices in cer­tain crit­i­cal ar­eas, as well as tak­ing care of the vul­ner­a­ble. The same col­lab­o­ra­tive, com­mu­nity-based and fo­cused ap­proach has been demon­strated in con­tain­ing the re­cent out­break of cholera in some parts of our coun­try, prin­ci­pally in ur­ban ar­eas. De­vel­op­ment part­ners and cor­po­rates have played an out­stand­ing role. To­day the cholera threat is largely con­tained; but its harsh scars re­main on our Na­tion, and its painful lessons are there for all to see.

Never again should we be found want­ing in build­ing and main­tain­ing in­fra­struc­tures nec­es­sary for de­liv­er­ing safe ser­vices to our com­mu­ni­ties.

They de­serve bet­ter and should al­ways get the best from us.

The shame of so lit­er­ate a so­ci­ety suc­cumb­ing to such a me­dieval dis­ease should never be suf­fered again.

The on­go­ing medium and long-term mea­sures now un­der­way in var­i­ous towns and cities should for­ever end the shame.

We have made a de­ci­sion to make ba­sic health ser­vices avail­able and af­ford­able to all our com­mu­ni­ties. Yet this laud­able de­ci­sion to of­fer free health ser­vices has had a telling im­pact on na­tional drug sup­plies.

There is an up­surge in de­mand for ba­sic health ser­vices, all against our lim­ited re­sources. Our econ­omy, though on a def­i­nite re­bound, is not yet out of the woods.

The pres­sure on health ser­vices grows stronger as one scales up the lad­der of health­care, be­yond the pri­mary level.

Both at sec­ondary and cen­tral health­care lev­els, drugs gen­er­ally be­come rel­a­tively less avail­able and more costly.

Equally, donor sup­port be­gins to de­cline more and more. Donors have tended to con­fine their sup­port to pri­mary health care level. Every­thing else is left to Govern­ment.

This is es­pe­cially so in re­spect of non-com­mu­ni­ca­ble dis­eases (NCDs). Yet NCDs are in­creas­ingly be­com­ing a big­ger men­ace to our peo­ple, pos­si­bly be­cause of chang­ing life­styles.

NCDs re­quire ex­pen­sive medicines for care and treat­ment. We used to man­u­fac­ture more than 80 per­cent of our drugs. Our phar­ma­ceu­ti­cal in­dus­try used to be very strong and com­pet­i­tive, even well-reck­oned within the re­gion and be­yond.

I am talk­ing of hey­days of phar­ma­ceu­ti­cal man­u­fac­tur­ers and en­ter­prises like CAPS, Dat­labs, Phar­manova, Varichem and many such drug man­u­fac­tur­ers.

We have since lost that ca­pac­ity and have be­come a net im­porter of essen­tial drugs. This we must re­verse.

For that rea­son, our health­care sys­tem is now ex­posed to ex­ter­nal shocks and to the ups and downs of our econ­omy.

We need for­eign cur­rency to im­port medicines. For­eign ex­change earn­ings are a func­tion of our abil­ity to ex­port. Therein lies the chal­lenge. At no time has this tur­bu­lent link be­tween the state of the econ­omy and the avail­abil­ity of drugs and other phar­ma­ceu­ti­cal prod­ucts in the coun­try been so di­rect and im­pact­ful as in the past weeks dur­ing which our econ­omy has reg­is­tered sharp shocks and chal­lenges.

Although we are slowly creep­ing out of this eco­nomic trough, the neg­a­tive im­pact this bad patch has had on the health­care sec­tor is still be­ing felt. The drugs sup­ply sit­u­a­tion in the coun­try had de­te­ri­o­rated, with many key drugs ei­ther unavail­able, un­af­ford­able or in short sup­ply.

In the ma­jor­ity of cases, th­ese drugs which are mostly im­ported, were now be­ing sold in hard cur­ren­cies, thus adding an ad­di­tional bur­den on the sick. This is un­ac­cept­able.

There are things we have to do to check, ar­rest and re­verse th­ese ad­verse de­vel­op­ments, and to stop their re­cur­rence.

Prin­ci­pally, for­eign ex­change re­leases to the health sec­tor must be upped ini­tially, and then main­tained at lev­els which avert stock-outs. Our dis­burse­ment de­ci­sions must rest on an un­der­stand­ing that health is a hu­man need which thus can­not be post­poned with­out en­dan­ger­ing hu­man life.

Key facts and fig­ures im­me­di­ately stand out. Over the years, our im­porters of essen­tial drugs have ac­cu­mu­lated a debt of about US$27 mil­lion. To­day th­ese im­porters’ cred­it­wor­thi­ness in the eyes of their for­eign sup­pli­ers is very low. The debt has ac­cu­mu­lated largely be­cause of scarce for­eign cur­rency for for­eign pay­ments.

We thus need a dou­ble thrust on this front, namely deal­ing with the legacy debt in the in­dus­try, while meet­ing cur­rent drug needs and stock­ing for the fu­ture.

The fig­ures be­fore me show that re­cent dis­burse­ments by the Re­serve Bank of Zim­babwe have largely been swal­lowed by the legacy debt, with very lit­tle go­ing to­wards fresh orders of phar­ma­ceu­ti­cal prod­ucts with which to meet cur­rent de­mand, let alone for re­stock­ing. In the im­me­di­ate and in­terim, we must use our na­tional drug store fa­cil­ity, NatPharm, which is the least en­cum­bered, as our ve­hi­cle for plac­ing fresh orders for medicines, while we tackle the legacy debt.

Where for­eign drug sup­pli­ers have lo­cal agents who may be in­ca­pac­i­tated to im­port for rea­sons al­ready cited, some ar­range­ments may have to be reached with NatPharm so we move speed­ily to plug the im­port gap.

In other cases, drugs may have to be im­ported through Govern­ment-to-Govern­ment ar­range­ments, with the re­spon­si­ble min­istry, sup­ported by the min­istries of Fi­nance and Eco­nomic De­vel­op­ment, For­eign Af­fairs and In­ter­na­tional Trade, and Trans­port and In­fras­truc­tural De­vel­op­ment, mov­ing with speed to se­cure ar­range­ments, and to move drugs to sta­bilise the sit­u­a­tion in the short­est pos­si­ble time.

NatPharm re­quires about US$60 mil­lion to sta­bilise the drug sup­ply sit­u­a­tion in the coun­try. This will be made avail­able while we mo­bilise funds to re­tire the legacy debt so as to re­open re­la­tions with for­eign sup­pli­ers.

This week we will host the Vice-Pres­i­dent of In­dia. In­dia is a key drug sup­plier to us.

Govern­ment hopes to take full ad­van­tage of this fra­ter­nal visit to ex­plore pos­si­bil­i­ties on phar­ma­ceu­ti­cal sup­plies on the back of govern­ment-to-govern­ment ar­range­ments.

Like­wise, we will en­gage other gov­ern­ments with sup­ply ca­pac­ity at good value for money. Our scope of en­gage­ment with friendly gov­ern­ments will go be­yond drug im­ports. We will ex­plore ways to re­boot our ca­pac­ity for the lo­cal pro­duc­tion of essen­tial drugs as be­fore. Phar­ma­ceu­ti­cal drug man­u­fac­tur­ers led by CAPS have to be res­ur­rected. This means re­tool­ing them and twin­ning them with good eq­uity part­ners.

I am happy that dis­cus­sions be­tween CAPS and a prospec­tive part­ner are at a very ad­vanced stage. Be­fore long we will cel­e­brate a re­tooled and op­er­a­tional CAPS which should re­cover its past glory as a key drugs sup­plier in the re­gion and on the con­ti­nent.

Sim­i­lar com­pa­nies like Varichem, Phar­manova, Dat­labs, as well as NatPharm’s pro­posed man­u­fac­tur­ing sub­sidiary, NatMed, must, like­wise, be sup­ported.

There is a huge mar­ket for drug man­u­fac­tures on the con­ti­nent where only a cou­ple of na­tions have man­u­fac­tur­ing ca­pac­ity.

Many Zim­bab­weans are turn­ing to for­eign coun­tries for spe­cialised health­care. This is very ex­pen­sive for our Na­tion. Zim­babwe’s health­care is not com­pet­i­tive, rel­a­tive to sim­i­lar ser­vices in other coun­tries, devel­op­ing or de­vel­oped. But the story goes fur­ther than af­ford­abil­ity.

It is also about sparse skills in the coun­try, and about poorly-equipped health fa­cil­i­ties.

Yet what we end up spend­ing on for­eign care more than dou­bles what we need to build th­ese spe­cial­ist skills, and to equip and stock our spe­cialised hos­pi­tals for more ad­vanced in­ter­ven­tions. A few ex­am­ples il­lus­trate my point: ◆ We only have three heart sur­geons in the whole coun­try;

◆ We have seven neuro-sur­geons, mostly based in Harare;

◆ We have one di­a­betol­o­gist, even though an es­ti­mated three mil­lion Zim­bab­weans suf­fer from di­a­betes; ◆ We can’t do vi­tal or­gan trans­plants; and ◆ We don’t even have a na­tional or­gans reg­is­ter. The story goes on and on. Yet we have a very healthy base of gen­eral prac­ti­tion­ers, sur­geons and physi­cians who, with a small frac­tion of what we spend on med­i­cal tourism, we could eas­ily turn into spe­cial­ist physi­cians. The time has now come for us to do just that.

As I write, the Min­istry of Higher and Ter­tiary Ed­u­ca­tion, Sci­ence and Tech­nol­ogy De­vel­op­ment has com­pleted a na­tional skills au­dit. Ex­cept this is in very broad, generic terms. I now want each sec­tor, the health sec­tor es­pe­cially, to de­rive and de­velop from this broad au­dit, sec­tor-spe­cific skills au­dits which should help with our over­all na­tional skills de­vel­op­ment plan­ning.

Gone are the days where we just re­ceive any schol­ar­ships on of­fer from friendly coun­tries.

We must now spell out ar­eas of skills need which are reck­oned in terms of our de­vel­op­ment vi­sion and pri­or­i­ties, and the num­bers we aim for, so we seek schol­ar­ships that build na­tional ca­pac­i­ties in ar­eas of great­est need.

The health sec­tor must blaze a new trail in this re­gard.

Much more, the skills strategy must be en­com­pass­ing. By def­i­ni­tion, med­i­cal work is col­lab­o­ra­tive. What this means is that which­ever key skill we tar­get must de­velop along­side sup­port­ive skills in re­lated dis­ci­plines.

Hard on the heels of this must be a pro­gramme of equip­ping our fa­cil­i­ties with mod­ern med­i­cal gad­gets which those skills re­quire to func­tion.

The old De­part­ment of Na­tional Schol­ar­ships which we are re­struc­tur­ing will be a key ve­hi­cle for this broad na­tional skills strategy. Our pro­vin­cial and cen­tral hos­pi­tals are need­lessly clogged by cases which in fact should be dealt with at lower lev­els.

Our in­abil­ity to en­sure that in­sti­tu­tions at pri­mary level are ad­e­quately staffed and pro­vided with core com­pe­ten­cies has cre­ated this im­pos­si­ble sit­u­a­tion where pro­vin­cial and cen­tral hos­pi­tals are no longer re­fer­rals for com­pli­cated cases re­quir­ing spe­cialised in­ter­ven­tions only.

Poor work­ing fa­cil­i­ties and con­di­tions are to blame for this col­lapse in the na­tional re­fer­ral sys­tem which should serve us well.

Add to this the ab­sence of trauma fa­cil­i­ties along our high­ways where traf­fic ac­ci­dents are fre­quent. Il­lus­tra­tively, any se­ri­ous traf­fic ac­ci­dent cases along the Harare-Chirundu High­way will have to be rushed back to Chin­hoyi and Harare!

This is quite typ­i­cal on all our high­ways. We have lost many lives as a re­sult.

We now need to re­visit our whole in­sti­tu­tional health­care chain, both by way of spa­tial dis­tri­bu­tion and the de­ploy­ment of key com­pe­ten­cies across th­ese in­sti­tu­tions.

There is a lot more which is needed in the health sec­tor than I have been able to cover in this ar­ti­cle. I have not, for in­stance, dealt with the key area to do with na­tional health in­surance.

This vi­tal link in the health de­liv­ery chain has all but col­lapsed. Yet it en­sures our cit­i­zens are as­sured of care, both dur­ing their ac­tive lives and later on in life.

Health in­surance is a key area for col­lab­o­ra­tive in­vest­ment ac­tion by both the pub­lic and pri­vate sec­tor. It re­quires ma­jor re-map­ping. What I have done in this in­stal­ment is merely broach key points for a con­ver­sa­tion which can­not wait any longer if our Vi­sion 2030, by which we aspire to be an up­per mid­dle in­come econ­omy, is to be re­alised.

Be­yond pres­sure points of the day, we need a broad vi­sion that gets us to the end-state we de­sire. We have many ex­pe­ri­enced prac­ti­tion­ers in the health sec­tor. Our med­i­cal schools are churn­ing out hun­dreds of bright ju­nior doc­tors. So, too, are our in­sti­tu­tions for train­ing nurses, and al­lied skills.

All we need is to har­ness this brain power for far-reach­ing pol­icy de­ci­sions and ac­tions.

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