Report No: 45867-SZ

General Assessment of the Mbabane Government Hospital, Swaziland

World Bank Human Development 1 Country Department 1

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Currency Equivalents

1 U.S. Dollar = 6 Emalangeni 1 Emalangeni = 0.17 U.S. Dollars

Fiscal Year

April 1 - March 30

ABREVIATIONS AND ACRONYMS

ALOS – Average Length of Stay BOT - Build, Operate, Transfer CEO - Chief Executive Officer CFO - Chief Financial Officer CT - Computerized Tomography CMS – Central Medical Stores GSH – Good Shepherd Hospital DHS - Demographic and Health Survey ENT – Ear, Nose and Throat ER – Emergency Room HE - Health Expenditures HIV/AIDS - Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HMIS - Health Management Information System HRH - Human Resources for Health ICU - Intensive Care Unit IFC – International Finance Corporation IT - Information Technology JICA - Japanese International Cooperation Agency MDGs – Millennium Development Goals MGH - Mbabane Government Hospital MOF - Ministry of Finance MOHSW - Ministry of Health and Social Welfare MPWT - Ministry of Public Works and Transport MTCPT - Mother to Infant Preventive Treatment MVAF – Motor Vehicle Accident Fund NERCHA - National Emergency Response Council on HIV/AIDS NGO - Nongovernment Organization OECD - Organization for Economic Cooperation and Development OOP - Out-of-Pocket (payments) OPD - Outpatient Department OR – Occupancy Rate OT - Operating Theater PHC – Primary Health Care

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PPP - Public/Private Partnership PS - Permanent Secretary QEII - Queen Elizabeth II Hospital RFM - Raleigh Fitkin Memorial Hospital SAM – Service Availability Mapping SE - Swaziland Emalangeni SMO – Senior Medical Officer SS - Social Security TB – Tuberculosis TPA – Third Party Administrator TWG – Technical Working Group VCT - Voluntary Counseling and Testing WCF – Workmen’s Compensation Fund WDI – World Development Indicators WHO – World Heath Organization

Vice President : Obiageli Ezekwesili Country Director : Ruth Kagia Sector Manager : Christopher Thomas

Task Team Leader : Oscar F. Picazo

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PREFACE

This report was prepared by a team led by Oscar Picazo, senior economist, AFTH1. Additional inputs were provided by Sheila Dutta, senior health specialist, AFTH1; Eric de Roodenbeke, former senior health specialist, AFTH2; and Barry Kistnasamy, consultant funded under a South African Trust Fund. Cristina Romero did the final copy-editing and formatting. The team benefited from guidance provided by Christopher Walker, lead health specialist, HNP cluster leader, AFTH1). The report was prepared under the leadership of Ritva Reinikka and Ruth Kagia, former and current country director for Country Department 1, and Dzingai Mutumbuka and Christopher J. Thomas, former and current sector manager for AFTH1.

The report was peer reviewed by Eva Jarawan, sector manager, AFTH2; Catherine O’Farrell, senior investment officer, Advisory Services Department of the World Bank Group’s IFC; and Dr. Sagie Pillay, chief executive officer of the Johannesburg Academic Hospital.

The team wishes to thank colleagues from the International Finance Corporation (IFC), especially Tanya Scobie and Desnei Leaf-Camp, for agreeing to make the subsequent briefing on public private partnerships as an approach to upgrading the hospital and improving health sector outcomes.

The team also wishes to thank Mr. Dumisani Shongwe of the Planning Department of the Ministry of Health and Social Services (MOHSW) and Dr. E. Austen Ezeogu, senior medical officer of the Mbabane Government Hospital (MGH), for the technical and logistic support they provided throughout the course of this work. The team also acknowledges the support provided by the other officials and staff of the Ministry of Finance (MOF), MOHSW, the National Emergency Response Council on HIV and AIDS (NERCHA), the Mbabane Government Hospital (MGH), and other government and nongovernment health facilities visited by the team. However, the authors do not implicate any of them for any error or omission in this report.

The findings and opinions expressed in this report are solely those of the authors. They do not represent those of the Kingdom of Swaziland, the Government of Swaziland, or the management and staff of the MOF, MOHSW, and MGH. Nor do they represent those of the Board, management, and staff of the World Bank.

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TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION AND OVERVIEW.................................................................. 1

A. Objectives and Constraints of the Assessment.......................................................................................... 1

B. Key Technical Findings and Recommendations ....................................................................................... 3

C. Process of Change ..................................................................................................................................... 4

CHAPTER 2: CONTEXT OF THE PLANNED HOSPITAL UPGRADING...................................... 6

CHAPTER 3: THE PHYSICAL STATE AND FUNCTIONALITY OF THE HOSPITAL................ 15

A. Physical State of the Hospital ................................................................................................................. 15

B. Functionality of the Hospital................................................................................................................... 17

CHAPTER 4: SCOPE AND SCALE OF HOSPITAL SERVICES ............................................... 19

A. Hospital Services .................................................................................................................................... 19

B. Case-Mix and Demand for Services........................................................................................................ 24

C. Human Resource Capacity .................................................................................................................... 26

D. Hospital Support Systems ....................................................................................................................... 28

CHAPTER 5: HOSPITAL PLANNING AND POLICY FRAMEWORK ....................................... 30

A. Planning and Policy Environment........................................................................................................... 30

B. Public/Private Partnership ....................................................................................................................... 33

CHAPTER 6: HOSPITAL INSTITUTIONAL AND INCENTIVE STRUCTURES......................... 35

A. Constraints of Institutional and Management Structure.......................................................................... 35

B. Options for Institutional Improvement.................................................................................................... 37

CHAPTER 7: OVERALL HOSPITAL PERFORMANCE, BOTTLENECKS, AND SERVICE

DEFICITS............................................................................................................................ 40

A. Hospital Performance.............................................................................................................................. 40

B. Key Bottlenecks and Service Deficits ..................................................................................................... 43

CHAPTER 8: OPTIONS FOR HOSPITAL UPGRADING AND FINANCING ITS CAPITAL

REQUIREMENTS................................................................................................................. 45

A. Options for Hospital Upgrading.............................................................................................................. 45

B. Options for Hospital Capital Investments ............................................................................................... 46

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CHAPTER 9: OPTIONS FOR FINANCING HOSPITAL RECURRENT COSTS.......................... 50

A. Trends in MGH and Hospital Allocations............................................................................................... 50

B. User Fees................................................................................................................................................. 52

C. Financing Schemes for Medical Referrals Abroad.................................................................................. 54

D. Other Potential Sources of Hospital Revenues ....................................................................................... 57

CHAPTER 10: RECOMMENDATIONS AND WAY FORWARD .............................................. 58

A. Short-Term Actions for Immediate Improvement................................................................................... 58

B. Medium-Term Actions for Sustainable Improvement............................................................................. 59

C. Assessment of the Features of the Proposed Referral Hospital ............................................................... 61

LIST OF PERSONS INTERVIEWED...................................................................................... 67

REFERENCES..................................................................................................................... 69

ANNEXES

ANNEX 1: SELECTED HEALTH EXPENDITURE FIGURES IN SOUTHERN AFRICAN COUNTRIES, 1999 AND 2003 .......................................................................................................... 63

ANNEX 2: GUIDE TO THE BUDGET HEADS AND RESPONSIBILITY CENTERS OF MOHSW BUDGET AND EXPENDITURE DATA AS USED IN THIS STUDY ............................................ 64

ANNEX 3: RECURRENT BUDGET AND EXPENDITURES OF THE MBABANE GOVERNMENT HOSPITALS AND ICU, ..................................................................................................................... 65

ANNEX 4: MAP OF SWAZILAND............................................................................................................ 66

TABLES

TABLE 1. ADMISSIONS, NORMAL DELIVERIES, DEATHS, AND HOSPITAL MORTALITY RATES OF HOSPITALS AND HEALTH CENTERS WITH BEDS IN SWAZILAND, 2001 AND 2002....................................................................................................................................................... 7

TABLE 2. RECURRENT EXPENDITURES OF MOHSW BY MAJOR BUDGET HEADS AND RESPONSIBILITY CENTERS, FY2003/04, FY2004/05, AND FY2005/06..................................... 10

TABLE 3. RECURRENT BUDGET AND EXPENDITURES AND VARIANCE OF MOHSW BY MAJOR BUDGET HEAD AND RESPONSIBILITY CENTERS, FY2005/06 ................................. 11

TABLE 4. EXPENDITURES OF GOVERNMENT HOSPITALS AND MEDICAL REFERRALS IN SWAZILAND, BY CATEGORY AND HOSPITAL, FY03/04, FY04/05, AND FY05/06 ............... 12

TABLE 5: SELECTED MGH PERFORMANCE INDICATORS, 1998–2004 .......................................... 20

TABLE 6: INPATIENT ACTIVITIES OF HEATH FACILITIES IN SWAZILAND, 2002..................... 21

TABLE 7. OUTPATIENT ATTENDANCES AND ADMISSIONS AT MBABANE GOVERNMENT HOSPITAL, 2005................................................................................................................................ 23

TABLE 8. CAUSES OF DEATH AT MBABANE GOVERNMENT HOSPITAL, 2005 ......................... 24

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TABLE 9. NUMBER OF DOCTORS AND NURSES, NUMBER OF BEDS, NUMBER OF PATIENTS, AND HEALTH WORKER:PATIENT RATIOS, BY WARD AT MBABANE GOVERNMENT HOSPITAL, 2005................................................................................................................................ 26

TABLE 10. RECURRENT BUDGET AND EXPENDITURES OF THE MBABANE GOVERNMENT HOSPITAL AND THE INTENSIVE CARE UNIT, BY MAJOR COST ITEMS: FY2003/04, FY2004/05, AND FY2005/06 ............................................................................................................. 52

TABLE 11. RECURRENT BUDGET AND EXPENDITURES OF MOHSW, BY MAJOR COST ITEMS: FY2004/05, AND FY2005/06 ............................................................................................... 52

TABLE 12. FEE STRUCTURE FOR GOVERNMENT HOSPITALS, EFFECTIVE JANUARY 1, 1998............................................................................................................................................................. 53

TABLE 13. ADVANTAGES AND DISADVANTAGES OF DIFFERENT FEATURES OF THE PROPOSED CENTRAL REFERRAL HOSPITAL............................................................................ 61

FIGURES

FIGURE 1: TRENDS IN PUBLIC AND PRIVATE SECTOR HEALTH FINANCING, 1998-2003.......... 9

FIGURE 2: MGH INPATIENT ADMISSIONS AND OUTPATIENT VISITS, 1998–2004 ..................... 20

FIGURE 3. TRENDS IN EXPENDITURES ON GOVERNMENT HOSPITALS.................................... 51

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CHAPTER 1: INTRODUCTION AND OVERVIEW

This report contains the findings of a World Bank team that conducted the general

assessment of the Mbabane Government Hospital (MGH) in order to assist the government make a decision on whether the hospital should be upgraded to a tertiary referral facility. The team visited Swaziland from June 5 to 16, 2006. A subsequent mission in May 2007 consisting of staff from the World Bank and the IFC also provided a briefing to various stakeholders on the possibility of using a public private partnership (PPP) approach in the upgrading of the MGH.

A. OBJECTIVES AND CONSTRAINTS OF THE ASSESSMENT

Objectives of the assessment. Over the two-week period, the mission: (a) Conducted ocular inspections of the MGH and interviews with hospital managers and department heads. (b) Visited other government and nongovernmental organizations (NGO) hospitals including the Raleigh Fitkin Memorial (RFM) Hospital in Manzini; the Mankayane Government Hospital; the Piggs Peak Government Hospital; and the Good Shepherd Hospital (GSH) in Siteki, Lubombo Region. (c) Reviewed policy documents, plans for hospital construction and refurbishment, and related health sector studies. (d) Conducted interviews with key stakeholders outside the MGH including the MOF, MOHSW, NERCHA, NGOs, professional associations, and donor partners.

The initial scope of work focused on assessing the state of the physical infrastructure and services being provided by the MGH, and the feasibility of upgrading these so that the hospital becomes the premiere tertiary referral hospital in the country. However, in the course of doing its work, the mission realized that much "upstream" work needs to be done in terms of understanding the background and context of the planned hospital upgrading, and of clarifying the overall macro and health policy environment and institutional structure of the hospital before "downstream" decisions could be made on the location, size, specific design and other aspects of hospital operations. Thus, the revised scope of work involves the following tasks:

• To understand the context of the planned hospital upgrading to tertiary referral status, and the key challenges facing the health sector in Swaziland.

• To undertake a general assessment of the physical state and functionality of the hospital; its current performance; its case-mix and its ability to meet the demand for its services; and key bottlenecks, service gaps and deficits1.

1 Given the short time frame, the World Bank mission was only able to undertake a general assessment of the prevailing conditions in the hospital. A full technical assessment is needed to inform the future specifications needed for the hospital.

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• To analyze the overall hospital planning and policy framework, and the constraints in the hospital’s management and operating environment.

• To analyze the appropriate scope and scale of MGH’s services in the context of its envisioned role as a tertiary referral hospital; the lower-cost alternatives to existing clinical, non-clinical, and social programs; and the role it should play vis-à-vis lower level facilities.

• To analyze the appropriateness of the hospital's existing institutional and incentive structures, including its governance and management, decision rights, claims on and use of budgetary and internally-generated funds and in-kind resources, and human resource use and incentives.

• To identify options that the government can consider in the financing of the hospital's capital investments and recurrent cost requirements, and the sustainability of these new hospital investments. In this regard, the close link between the financing of medical referrals abroad and the underfinancing of capital and recurrent costs at MGH need to be carefully analyzed.

Constraints of the assessment. The Bank's non-involvement in Swaziland's health sector over the past many years made the mission's work daunting. This is the team's first visit to Swaziland; it thus lacks familiarity with the sector and has no institutional memory on how certain government decisions were made. There is also a severe lack of up-to-date relevant data and where administrative data are recorded, they are often fragmented and not aggregated or summarized for easy analysis. Many relevant programs (e.g., user fees, referral financing, contracting of nonclinical services) have not been evaluated, and the feasibility of alternative service delivery models (e.g., dual practice, hospital autonomy) have not been studied or at least explored. Documentation on policy guidelines, rules and regulations, and plans could not all be located in the short time that the mission was in Swaziland. In general, there has not been much analytical work on the health sector done in the country, precluding the formulation of more robust, evidence-based conclusions. Given the short time-frame, much of the information gathered by the mission came from interviews with supply-side stakeholders (health providers, managers, and officials). As there were no interviews made with patients, households, or communities, the demand-side views were under-represented in this assessment.

Organization of the report. The early six chapters of the report (2 to 7) analyze the situation at the hospital and based on this analysis, the later chapters (8 and 9) explore options on how this situation can be improved. Chapter 2 provides the context of the planned upgrading of the hospital. Chapter 3 describes the physical state and functionality of the hospital. Chapter 4 presents the scope and scale of hospital services. Chapters 5 and 6 analyze the hospital planning and policy environment and its institutional and incentive structures. Chapter 7 assesses the overall hospital performance, its key bottlenecks, and service gaps and deficits. Chapter 8 explores various options for the physical upgrading of the hospital and the sourcing of capital investments while Chapter 9 explores options for financing the hospital's recurrent costs requirements. Chapter 10 discusses the way forward.

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B. KEY TECHNICAL FINDINGS AND RECOMMENDATIONS

1. Immediate/short-term actions. The urgent problems of MGH need to be addressed. MGH is severely underfunded and the situation of patients is extreme, and this must be corrected. This report calls for a "rescue fund" consisting of:

• An institutional improvement fund of Swaziland Emalangeni (SE) 10-15 million to purchase critical drugs and consumables, which could be implemented following the Intensive Care Unit (ICU) trading account.

• An operational improvement budget of SE 10-15 million to purchase critical medical equipment and undertake urgent repairs.

• A physical improvement budget of SE 5 million to improve toilets and ablution areas.

Medium-term actions for MOHSW. The technical options and proposals in this report are comprehensive, and they are in the nature of a hospital sector reform program covering:

• Reviewing the overall financing of the health sector in Swaziland, and specifically the hospital sub-sector, so that it receives government funding commensurate to the increasing needs for health services of the Swazi population, especially with raging HIV/AIDS epidemic.

• Formulation of specific plan for Mbabane Government Hospital, within the overall Swaziland development plan that includes appropriate standards, location, and sustainable investment parameters. The opening of the national laboratory and blood bank should fit in this plan or be reconsidered in order to limit excessive commitments on human and financial resources.

• Improvement of MGH budget and extra-budgetary resource generation, within the context of overall sector financing. Actions related to resource generation cannot be divorced from the institutional restructuring of MGH through hospital autonomy (or some semblance of it), and the adoption of public/private partnerships and regulation, including dual practice. Hence, an overall policy for evolving MGH into an autonomous body, or at least a public trust, should be formulated.

• Nursing and medical training to meet specialist hospital requirements. Given that Swaziland has no medical school, or specialist training institutions for the highest level of nursing, it is critical that the government should begin working with the professional councils now so that arrangements could be made soonest with training institutions abroad. Concomitant with this training, MGH and other hospitals need to develop an active management of their human resources so that they can be retained and better utilized.

Immediate and medium-term actions for the Government with respect to the two medical referral funds. Simultaneous to the MOHSW actions above, the Government should also focus on "low-lying fruits" that can yield positive impact, especially the needed

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changes with respect to the management and organization of the Phalala Fund and the Civil Servants Medical Referrals Scheme. At the request of the MOHSW, a separate report2 was prepared by the World Bank to assess these two schemes. They are currently incurring large expenditures (about SE 60 million annually) abroad, part of which could be used to fund the recurrent costs of MGH and other local providers over the medium-term, if services are improved. The key recommendations in this regard are:

• Immediate improvement in the management of the two funds including: adoption of clearer patient rationing criteria and better defined benefits; reduction in the number of providers and fee negotiation with these providers under a "preferred provider" arrangement or contract; introduction of claims utilization and review process in the two funds; strengthening the management information system to improve the claims review and payment process; and more aggressive claiming in relevant funds such as workmen’s compensation fund and motor vehicle accident fund.

• Conversion of the Civil Servants Medical Referral Scheme into a contributory social health insurance (SHI) fund with seed capital from government, and with regular contributions from employees (the civil servants) and the government as employer.

• Conversion of the Phalala Fund into an autonomous body reporting to the MOHSW. An Advisory Board should be created to assist in its governance and functions.

• In the medium term, Government should insure that both funds purchase health services for their members from the refurbished/new MGH, rather than refer across the border, to the extent that services at a renewed MGH would be medically appropriate and of acceptable quality.

C. PROCESS OF CHANGE

Technical Working Group. Because of the extent, depth, and complexity of these options and proposals, these need to be understood carefully and internalized by policymakers and program managers. A Technical Working Group (TWG) should be established as soon as possible to go through these options and proposals as an initial activity in the reform process. More importantly, any reform process ultimately obtains a political dimension as a few of the above proposals require new legislation. For this reason, it is important that the political leadership be involved in this process early, with guidance provided by technicians and specialists in the TWG.

Exploring the potential of public private partnership (PPP) approaches to provide greater access to higher quality services, improve health outcomes and Government’s value for money spent in the health sector. Specific PPP options should be explored in which capital investment is coupled with the requirement for improved clinical services and facility operations. This would include options for health facility and hospital refurbishment and/or construction, such as the Build-Finance-Operate-Transfer and other

2 World Bank, "Swaziland’s Funding of Medical Referrals Abroad: Assessment of the Two Schemes and Options for Improvement", draft dated June 15, 2007.

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long-term performance based service concessions. Any options should also consider the position and potential impact of improving specific facilities within the broader health sector and attempt to maximize public access higher quality services by, for example, bundling local and regional facilities together for across the board improvement. Appropriate examples may be learned from the Lesotho experience with the new national referral hospital PPP, in which a new public hospital, replacing the existing Queen Elizabeth II Hospital, and three public filter clinics will be built, financed and operated (including clinical services) for 18 years under a concession agreement with a PPP Partner.

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CHAPTER 2: CONTEXT OF THE PLANNED HOSPITAL UPGRADING

This chapter describes the context of the planned upgrading and refurbishment of the Mbabane Government Hospital. It highlights: (a) the paradox in the country’s middle-income status and its relatively developed health network with its poor health indicators; (b) the rising "quadruple burden of disease" occasioned by the massive HIV/AIDS epidemic and its requirements (preventive, promotive, treatment, chronic, and hospice care) and the parallel emergence of "lifestyle" and noncommunicable diseases; (c) the danger of falling government and donor resource commitments to the health sector in the midst of rising burden of disease, including the worsening human resource shortage; and (d) the inefficient, inequitable and unsustainable use of medical referral financing programs.

Swaziland is a compact country with a small population and a middle-income economic status. The country has approximately 1.1 million people living in one of the smallest states in Southern Africa (17, 364 sq. km). The country is divided into four regions (Hhohho, Manzini, Lubombo and Shiselweni), 55 tinkhundla and 360 chiefdoms. Population data show that 78 percent lives in rural areas; 54 percent is under 18 years of age; 3 percent is above 64 years of age; and 26 percent consists of women of childbearing age (15 to 49 years). Per capita GDP in 2005 was about US$2,280 (Atlas method), making it a Category III - out of five categories - IBRD country, in the same band as Brazil, China, and Thailand. As much as 69 percent of the population is poor, 48 percent ultra poor. Income inequality is severe, with the richest 20 percent owning 56.3 percent of income.

Because of its small size and a good road network, physical access to health facilities is relatively good. The health system comprises public, private (for profit and not-for-profit) and traditional sectors. The public health system is managed at national (central), regional and facility levels. It is a centralized system with decision-making inputs from the Ministries of Finance, Public Service and Information, Public Works and Transport, and Economic Planning. The Nursing, Medical and Dental Councils make up the health professional regulatory authorities. The Swaziland public health system has 187 outreach sites, 162 clinics, 12 health centers, 8 public health units, and 7 hospitals. It is estimated that 80 percent of the population lives within a radius of 8 km. of a health facility. In addition, there are 73 mission health facilities, 53 private clinics, and 22 industry-supported health centers and clinics. There are 184 doctors; 3,070 registered nurses; 275 nurse assistants; 46 pharmacists; 4,000 rural health motivators; and other allied health professionals. These translate to 1:5,953 doctor-population ratio and 1:356 nurse-population ratio (1:1,522 and 1:243 respectively in South Africa).

The hospital system is not very consistent and is evolving. Although the country and population is small (in size), a complex hospital system has evolved. From an ownership point of view, hospitals are either public or private (not-for-profit or for-profit), although two major nonprofit hospitals - Good Shepherd and Raleigh Fitkin - have traditionally

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received subventions from government. From a functional point of view, it is possible to classify the hospitals in four categories: (a) the MGH which is supposed to be the national referral hospital; (b) general hospitals – Raleigh Fitkin, Piggs Peak, Hlatikulu, Mankayane, Good Shepherd; (c) specialized hospitals – Tuberculosis, Psychiatric/Mental; (d) local hospitals – Dvokolwako, Matsanjeni, Shitobela, Nhlangano. The core hospital system is made of categories (a) and (b) hospitals. The role of (c) and (d) “hospitals” in support of the national health policy is not clear and has been recently evolving. Relations with other hospitals and health facilities are not formalized in a policy document. The private for-profit sector is not monitored, thus its activity is unknown. Table 1 shows selected hospital activity data for hospitals where information is available.

Despite its middle-income status and good service delivery network, Swaziland’s health, nutrition, and population indicators are poor and are more in line with much-poorer countries in sub-Saharan Africa. For instance, Swaziland's crude death rate (18.6 per 1,000 people) is worse than Africa as a whole (17.8 per 1,000 people); its life expectancy of 35 years is far lower than Africa as a whole (46 years); its maternal mortality ratio of 370 per 100,000 live births, though respectable by African standards, is worse than the average for lower middle income countries (149 per 100,000); and its infant mortality rate of 105 per 1,000 live births is far higher than the average for lower middle income countries (119 per 1,000). The World Development Indicators (WDI) database shows a drastic increase in infant mortality rate from 78 per 1,000 live births in 1990 to 105 in 2003. Similarly, WDI shows the under-five mortality rate to have increased from 110 per 1,000 live births in 1990 to 153 in 2003. The national infant mortality rate is estimated to have increased from 94.4 per 1,000 live births in 1990 to 97.3 in 2000. Given the above declines in key health and population indicators, Swaziland will be unable to meet its health Millennium Development Goals (MDGs) by 2015.

Table 1. Admissions, Normal Deliveries, Deaths, and Hospital Mortality Rates of Hospitals and Health Centers with Beds in Swaziland, 2001 and 2002

Admissions Normal

Deliveries Deaths Hospital

Mortality Rates Facilities

2001 2002 2001 2002 2001 2002 2001 2002 Dvokolwako HC

959 936 211 219 48 36 5.0 3.8

Emkhuzweni RHC

2,075 1,336 848 434 198 175 9.5 13.1

Mbabane GH

10,305 11,305 2,900 3,429 1,152 860 10.8 7.6

Mbabane PHC

1,020 19 499 0 24 7 2.4 36.8

Piggs Peak Hospital

4,343 3,919 1,301 1,453 344 271 7.9 6.9

The Clinic 1,795 2,047 105 83 16 22 0.9 1.1 Hhohho Region

Subtotal

20,891 19,562 5,864 5,618 1,782 1,371 8.5 7.0

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Good Shepherd Hospital

5,073 4,732 1,559 1,494 169 142 3.3 3.0

Mhlume Clinic

650 897 76 90 9 26 1.4 2.9

Ngomane Clinic

639 382 53 42 1 7 0.2 1.8

Simunye Health Center

1,398 971 278 142 20 24 1.4 2.5

Sithobela RHC

1,138 689 161 49 71 47 6.2 6.8

Ubombo Ranches HC

1,954 1,262 204 113 53 44 2.7 3.5

Lubombo Region

subtotal

10,852 8,933 2,331 1,930 323 290 3.0 3.2

Imphilo Clinic

2 1,176 0 37 0 8 0.0 0.7

Mankayane Clinic

2,282 2,498 589 737 282 350 12.4 14.0

RFM Hospital

9,996 9,446 4,821 3,629 783 789 7.8 8.4

Manzini Region

subtotal

12,280 13,120 5,410 4,403 1,065 1,147 8.7 8.7

Hlatikulu Hospital

7,389 5,052 1,936 2,004 543 350 7.3 6.9

Matsanjeni Clinic

2,211 1,936 240 365 112 131 5.1 6.8

Nhlangano HC

1,724 1,800 457 550 75 60 4.4 3.3

Shiselweni Region

subtotal

11,324 8,788 2,633 2,919 730 541 6.4 6.2

Grand Total 55,347 50,403 16,238 14,870 3,900 3,349 7.0 6.6 Source: MOHSW Reports, various years.

The HIV and AIDS epidemic is maturing while diseases of lifestyle and aging are emerging, raising the challenge of the "quadruple burden" of disease. Swaziland eclipsed Botswana as the country hardest-hit with HIV and AIDS in 2003, when the national adult prevalence rate rose to 38.8 percent, based on sentinel surveillance data from antenatal clinics. By 2005, the prevalence rate has climbed further to 42.6 percent. More recent and more accurate Demographic and Health Survey indicates a seroprevalence rate of 26 percent in 2006/07. The incidence of tuberculosis (TB) has rapidly increased in parallel with the maturing HIV/AIDS epidemic: TB incidence per 100,000 people has multiplied by about five times from 266.8 in 1990 to 1,082.9 in 2003. According to the MOHSW, the

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prevalence of HIV among adults with TB (“dual infection” status) is approximately 80 percent. What this implies is an increasing burden of chronic diseases crowding hospital beds. Life expectancy at birth is expected to drop from 54.4 years in 1990 to as low as 29.7 years by 2010, primarily due to the unprecedented impact of HIV/AIDS. Indeed, demand for hospice care is staggering. On top of these public-health problems, ailments associated with lifestyle and aging (diabetes, cardiovascular diseases, violence, accidents, and trauma) have emerged and are showing up significantly in bed occupancy and use of the medical referral financing schemes.

No recent health expenditure data that include spending by government, donors, private sector, and households are available. However, based on data collected by the World Health Organization (WHO) (2006) for the period 1998 to 2003, one could infer that donor health financing has been declining, and government health spending has been adjusted to make up for the decline in donor aid (Figure 1). The proportion of the private sector health spending has not varied over the period, except for 1998 when it was a bit larger.

Figure 1: Trends in Public and Private Sector Health Financing, 1998-2003

The hospital sector accounts for a large chunk of the MOHSW budget, but MGH itself takes a modest share of resources that is probably not commensurate with its role as a referral facility. This is probably a combination of historical budgeting plus the frequent referral of patients to South Africa. Table 2 shows the recurrent expenditures of MOHSW for three fiscal years by major cost centers and programs. The hospital sector covers nine government hospitals3, the special medical care unit, and the intensive care unit within MGH, and they collectively account for the lion's share of expenditures, up to 51.3 percent in FY05/064. This share has been increasing over the past three fiscal years. However,

3 See Table 4 for the listing. 4 This share of hospital expenditures to total government recurrent health expenditures has not changed since the 1980s. Barnum and Kutzin (1993) report that Swaziland spent 52 percent of its government health expenditures on hospitals in 1983-84, much lower than the 69 percent proportion in 1976-77. (See Table 2-2, page 20.)The Swazi health system’s orientation towards hospitals remains entrenched to this day.

0%

20%

40%

60%

80%

100%

1998 1999 2000 2001 2002 2003

Private HE by third party

OOP HE as % of private HE

Donor HE as % of total HE

Govt without donor HE

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MGH plus the associated ICU within it, only accounted for 18 to 20 percent of MOHSW’s expenditures, less than what one could expect from a central referral hospital in a typical East and Southern African country, which could consume up to 30 percent of total government health expenditures, although in keeping with West Africa where a central hospital usually takes up 10-20 percent of the MOH budget. In terms of growth of expenditures, the hospital sector also tended to expand faster than other programs (48.6 percent from FY03/04 to FY05/06), although public health programs exceeded this growth (50.5 percent over the similar period). MGH +ICU’s expenditures, however, grew more modestly (41.0 percent) than the hospital sector as a whole.

Table 2. Recurrent Expenditures5 of MOHSW by Major Budget Heads and Responsibility Centers, FY2003/04, FY2004/05, and FY2005/06

(In SE Million)

Items Budget Heads or

Responsibility Centers

FY03/04 FY04/05 FY05/06 % Growth FY03/04 - FY05/06

(%) Minister’s & PS’s offices

10, 11 37.9 35.1 34.8 (8.2)

CMS & central lab 21 7.9 10.4 8.3 5.1 Public health programs & health centers

32 39.8 58.3 59.9 50.5

Hospitals6 4101 to 4110 + 4117

148.1 179.3 220.3 48.6

Of which, MGH + ICU

4104 + 4117 55.8 70.7 78.7 41.0

Other regional clinics & noncommunicable disease control

4111 to 4116; 4118 to 4120

58.0 66.3 76.0 31.0

Social welfare 51 11.2 11.0 29.9 167.07

Grand Total - 302.9 360.4 429.2 41.7 Note: Data from this and succeeding tables exclude expenditures under the Phalala Fund and Civil Servants Medical Referral Financing Scheme, since these are outside MOHSW. Source: This and subsequent tables rely on budget and expenditure computer printouts produced by Joseph M. Khumalo, accounts Department, MOHSW, on June 7, 2006. See Annex for the explanation of the budget heads and responsibility centers.

The hospital sector is also prone to overshooting its allocated budget, far more than other MOHSW programs. Table 3 shows the variances in the allocated budgets and

5 These exclude capital expenditures. They also exclude expenditures under the two medical referral financing schemes (Phalala and Civil Servants). 6 This includes all named hospitals under Head 41, i.e., Responsibility Centers 4101 to 4110 (10 facilities in all) plus Responsibility Center 4117, the Intensive Care Unit at MGH. 7 The large growth was due to the establishment of the Mbabane Children’s Medical Clinic for abandoned infants, orphans and vulnerable children, including those from HIV/AIDS.

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expenditures of MOHSW’s cost centers and programs. In FY2005/06, the hospital sector collectively overspent SE 33.9 million, far more than the overspending registered by public health programs and other regional clinics/noncommunicable diseases control program. The rest of the cost centers stayed within their budgets.

Table 3. Recurrent Budget and Expenditures and Variance of MOHSW by Major Budget Head and Responsibility Centers, FY2005/06

(SE Million)

Items Budget Heads or Responsibility

Centers

Budget Expenditures Variance

Minister’s & PS’s offices 10, 11 46.0 34.8 11.2 CMS & central lab 21 8.1 8.3 0.2 Public health programs & health centers

32 43.8 59.9 (16.1)

Hospitals8 4101 to 4110 + 4117

186.4 220.3 (33.9)

Of which, MGH + ICU 4104 + 4117 56.6 78.7 (22.1) Other regional clinics & noncommunicable disease control

4111 to 4116; 4118 to 4120

54.5 76.0 (21.5)

Social welfare 51 36.2 29.9 6.2 Grand Total - 375.0 429.2 (54.2) Source: This study.

Among government hospitals, MGH’s gross expenditure growth over the past three fiscal years was a bit slower than for all hospitals combined, but it tends to incur substantial overspending. Among the 11 hospitals and hospital programs shown in Table 4, four had growth higher than overall hospital sector growth of 48.5 percent. These are the Psychiatric Hospital, Mankayane Hospital (a newly refurbished and expanded facility), Sithobela Hospital, and the "Special Medical Care Unit" (a small but fast-growing program). MGH’s expenditure growth over the period was 46.7 percent. However, MGH’s overspending tends to overshadow the rest. While all hospitals (except the TB Hospital) have significant variances in their budget allocations and actual expenditures, MGH accounted for a hefty 63.9 percent of the total hospital overspending for FY05/06. So there seems to be a deliberate effort to rein in MGH expenditures, but that effort is not succeeding simply because of the immense financial requirements of the hospital.

8 This includes all named hospitals under Head 41, i.e., Responsibility Centers 4101 to 4110 (10 facilities in all) plus Responsibility Center 4117, the Intensive Care Unit at MGH.

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Table 4. Expenditures of Government Hospitals and Medical Referrals in Swaziland, by Category9 and Hospital, FY03/04, FY04/05, and FY05/06

(SE Million)

Hospital Name FY03/04 FY04/05 FY05/06 % Growth FY03/04 - FY 05/06

Variance Between Budget & Expend.

In FY05/06Mbabane Government Hospital

47.9 61.2 70.3 46.7 (23.9)

ICU 7.9 9.5 8.4 6.3 (1.8) MGH+ICU

Subtotal55.8 70.7 78.7 41.0 -

Mankayane Hospital

9.4 13.5 15.7 67.0 (2.1)

Pigg’s Peak Hospital

12.0 14.6 16.5 37.5 (4.0)

Hlatikulu Hospital 20.1 24.9 26.9 33.8 (6.1) Public General

Hospitals Subtotal41.5 53.0 59.1 42.4 -

Mental Hospital 33.2 36.6 60.010 80.7 (6.3) TB Hospital 1.4 1.5 2.0 42.9 0.8 Special Medical Care Unit

1.4 1.9 2.5 78.6 (1.0)

Special HospitalsSubtotal

36.0 40.0 64.5 79.2 -

Nhlangano Hospital 5.5 5.6 6.5 18.2 (1.2) Sithobela Hospital 3.6 4.4 5.5 52.8 (2.3) Dvokolwako Hospital

5.7 5.6 5.9 3.5 (2.1)

Local HospitalsSubtotal

14.8 15.6 17.9 20.9 -

All Hospitals 148.1 179.3 220.3 48.5 (37.4) Phalala Fund n.a. n.a. 32.8 n.a. Civil Servants Medical Referral Scheme

n.a. n.a. 14.4 n.a. -

Referral Funds Subtotal

n.a. n.a. 47.2 n.a. -

n.a. n.a. 267.5 n.a. - Source: This study.

9 These categories are not official. They are merely employed here for analytical and illustrative purposes. 10 No suitable explanation could be provided for this large increase in expenditures.

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The government has favored specialized hospitals in terms of funding. Over the past three fiscal years, all hospitals have benefited from increased resources in nominal terms (Table 4). However, the growth of expenditures rate has been very significant for the specialized hospitals (79.2 percent), compared to MGH (41.0 percent), public general hospitals (42.4 percent), and local hospitals (20.9 percent). Local hospitals have had little attention. The increasing funding support for specialized hospitals need to be examined further, as it is not clear what their role is in expanding overall access to hospitalization or in supporting the health care delivery system. In terms of shares, MGH represents the biggest part of the budget from these four hospital categories. (The two private hospitals are not included in these figures although they represent an important part of the service delivery11). Over the last three years, MGH has benefited from about one-third (35.7 percent in FY05/06) of hospital public resources. A little more than a quarter (26.8 percent in FY05/06) was spent for the three other public general hospitals, while the specialized hospitals had about 29.3 percent and local hospitals, 8.1 percent.

Government-funded medical referrals abroad are increasingly becoming unaffordable, inequitable, and inefficient. On an annualized basis, both the Phalala Fund and the Civil Servants’ Medical Referrals Financing Scheme12 will spend approximately SE 60 million on referrals to South Africa this fiscal year, almost equal MGH’s entire budget in FY04/05 (i.e., SE 61.2 million). In the previous fiscal year, these funds spent SE 47.2 million. The schemes benefit a very small number of Swazis (about 1,500 patients this fiscal year, and 1,220 patients the previous fiscal year) who incur large per-patient costs (SE 41,000 in the case of Phalala and SE 31,000 in the case of the civil servants’ scheme), raising serious issues of equity and cost-ineffective use of public resources. For both schemes, no active purchasing ‘is done to get discounted fees from doctors and hospitals since rates are obtained at the point of need. The gatekeeping and paying functions are bifurcated, hence patients are not tracked and utilization review does not occur. Management problems occur especially at the payment stage; misrouted claims and "reminder" bills have led to unnecessary, additional or superfluous payments. No summary statistics are regularly produced from the utilization, claims and payment records, precluding management review and analysis of program performance. The massive size of these schemes raises concerns about how they are being implemented, and the need to explore alternative ways of operating them. These issues are examined in greater detail in a separate assessment report (World Bank, 2007).

The planning and resource allocation for hospitals should include the direct expenditures on government hospitals, subventions to mission hospitals, as well as the funds spent on medical referrals abroad. So far, this has not happened, because of the separation of fiscal responsibilities with respect to these programs, the lack of data, and absence of coordination among those responsible for allocating resources. As Table 4 shows, the addition of medical referrals financing to hospital resources dramatically changes the picture of overall hospital financing in Swaziland. Referrals financing in FY05/06 (SE 47.2 million) accounts for 17.6 percent of total hospital financing, excluding subventions to mission hospitals. The increase of referrals financing to an estimated SE 60

11 The private hospitals receive direct subventions from the Treasury, which are outside the budget of the MOHSW. Ideally, these subventions should be included in the analysis of hospital financing, but lack of data during the June 2006 mission precluded such an analysis. 12 These two medical referral financing schemes are explained in greater detail in Chapter 9.

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million in FY06/07 means that it is eating into the available resource envelop for hospitals, although technically the "envelops" are separately allocated.

The health system suffers from shortage of human resources for health (HRH) and severe capacity constraints. Due to declining government allocation to health in the midst of increasing disease burden, shortage in health workers has ensued since the early 2000, especially of nurses. Poor pay and incentives and poor working conditions, as well as stressful workloads, were frequently cited as precipitating factors for the worker shortage. (The government did increase significantly the salaries of nurses in FY2003/04, from about SE 2,700 to SE 4,000 per month for a general nurse, and from SE 3,500 to SE 7,800 per month for double-qualified nurse, somehow abating the human resource crisis.) Still, the "pull factors" of better potential remuneration and working conditions in such countries as South Africa and the United Kingdom remains tempting. In recent years, it has been estimated that the attrition rate for health staff in Swaziland has reached 11 percent per year. Thus, according to WHO, while there were 187 medical doctors in 2001, by 2003 the number had declined to 160, of whom only 58 were in the government service. As to nurses, a total of 3,070 are registered in the country, but more than half of them are in the private sector. The shortage of health workers is exerting adverse impact on service expansion and quality of care. Lack of capacity in health personnel is hindering the scaling up of major health interventions, including ARV treatment, tuberculosis, and malaria. In many cases, nurses are being moved from existing functions, such as maternal and child health (which are underfunded programs to begin with), to voluntary counseling and testing (VCT) services (which have bilateral donors and Global Fund sponsors). Thus, indirectly preventive and promotive health services are being neglected in favor of palliative care and treatment.

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CHAPTER 3: THE PHYSICAL STATE AND FUNCTIONALITY OF THE HOSPITAL

The hospital in its current state cannot respond to country’s health needs in providing

decent quality care with dignity for the patients and their families. Nevertheless, a full technical and functional assessment is needed before deciding whether the hospital should be refurbished and extended or fully rebuilt on-site or elsewhere. However, to be fully useful such an assessment should be made in relation with a Hospital Development Plan based on service priorities and description of the level of service delivery. A complete assessment would require multidisciplinary technical capacities (architect, civil engineer, biomedical engineer, hospital planner, and hygiene specialist). Such a task may take 2-3 person-months consultancy work. [It should be noted that a technical and functional assessment alone is insufficient for decision taking purposes. Government must assess the options for new approaches to the management and delivery of all services at the hospital, including facilities management, operations and maintenance, specialist support and clinical services, as recommended earlier in this report. Refurbishment and/or replacement facilities that have been undertaken without a parallel changes in management have almost inevitably led to the continuation of the same service delivery problems in new surroundings]

In 2004, a company contracted by the MOH studied the refurbishment and extension of the hospital. Although the pictures documenting the consultants’ report accurately depict the poor condition of the hospital, a more systematic and comprehensive technical analysis would have been expected before any proposal for the future of MGH. Such an analysis should not mix basic maintenance issues (replacing electrical attire, the curtains or painting the walls) with all the structural issues that are critical for undertaking a construction program. The extensions showed in the representations are not documented by a functional description or an analysis of potential utilization. There is no program sustaining the architectural options and no economic analysis to determine optimal surfaces and to estimate the recurrent costs. Any future project should be fully documented before decision making.

A. PHYSICAL STATE OF THE HOSPITAL

Hospital utilities (electricity, water, heating, and communications) suffer from major shortcomings.

A project to upgrade the hospital would need to rely on a totally new electrical installation because the current one is not secured (both for the people and the equipment). It has no flexibility, and the power distribution is inadequate to meet the needs of modern medical equipment. Except for the ICU, no unit has a decent electrical supply. The electrical installation needs to be assessed in term of quality, security, power, continuity, stability and flexibility of the distribution.

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The low-intensity communications distribution system is old and limited to telephones monitored by a 20-year-old switch board. Because of the absence of individual patient rooms in the wards, there is no call system and although the hospital is large and staff is mobile, there is no portable internal phone or pager. The portable radios for staff on-call benefit a limited number of persons. An upgraded hospital would need these devices, especially in the context of a shortage of skilled staff. The current telephone installation could not support any IT application. There is no Intranet or local Ethernet networks.

The water distribution system is in poor condition; in many places the washing basins are out of service and water leakages are frequent. The distribution is limited and a redistribution of the wards or an improvement of inpatient services would need major works for redesigning the pipe distribution in between levels. Water pressure seems to be a problem, especially in the kitchen and the laundry.

The water borne sewerage system seems inadequate and the drainage system would need to be assessed when the hospital faces heavy rainfalls. In many areas, the gutters are damaged. The grey marks on the walls as well as the areas covered with moss at the bottom of walls indicate the importance of damp and humidity affecting the buildings. There is no specific provision for the treatment of laboratory waters containing toxic chemicals.

The thermo distribution is very poor. The steam production out of coal is highly polluting in an urban area and has a poor performance. The cooling system is absent, damaged or not fully adequate. Although a central cooling and heating system might be too expensive and difficult to maintain, it would be necessary to implement local systems in critical areas [ICU, operating theater (OT), Imaging Department, outpatient cabinets and Lab]. During the winter, heating would also be necessary, it is currently lacking or provided by individual heathers hanged in the wards, most of them out of service.

There is a medical gas distribution system that has been added to the existing buildings. It provides vacuum and oxygen to all the wards but with a limited number of connections. A refurbishing of the hospital would need to reconsider this installation in relation to alternative cost-saving technologies in relation to effective use (oxygen concentrator and electrical vacuum when needed) in relation to clinical specialty.

The hospital buildings are a patchwork of constructions that have been added over the years, the roofs and attires are in poor condition, and fire protection is ineffective.

The quality of the building varies. Most of the added one level small buildings are of poor quality. Most of the structure of the two main buildings looks good but it would be necessary to have a technical evaluation of their quality and an investigation of the nature of the wall crakes. The roof structure needs also a specific assessment. It is also important to have a description of the location of pillars and building constrains before taking options for refurbishing.

The roofs are in poor condition and there is a need for replacement of a large section of them. In the wards where false ceilings have been implemented they are often in poor condition. A remodeling of the distribution of the wards would lead to a full reconstruction of the false ceiling and implementation of them in places where they don’t exist (the high ceiling is not energy saving). This would need to be executed with respect to the climate to

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improve insulation to help cooling down the wards when it is hot and reduce heat waste when it is cold.

The building attires are in poor condition; most of the window frames, the floor tiles and ceilings are damaged. There are no built-in shading devices to reduce solar impact on the external walls, and windows do not open to favor natural air cooling and ventilation (an hygiene issue).

Fire protection is ineffective. There is no static security (poor construction material, no secured sections of buildings with fire resistant doors), and poor active security (smoke detectors, fire hose, and fire extinguishers are insufficient or out of order). There are no systematic emergency exits, and no provision to evacuate patients with limited autonomy. If a building catches fire, it is most likely that the consequences would be severe, including human casualties. Refurbishing would lead to significant measures to reduce risks.

B. FUNCTIONALITY OF THE HOSPITAL

Many medical and other pieces of equipment are out-of-service; power and water systems needed to support such equipment are unreliable.

(a) There is no inventory to permit a review of the condition of the equipment ward by ward. In the various wards that have been visited the equipment was often out of service either because they were very old or utilization and a lack of maintenance had lead to premature damage. Except for a Computerized Tomography (CT) scan which is not operated currently, there are a very limited number of equipment that could be reutilized in an upgraded hospital.

(b) The power and water distribution is important to secure the equipment and to ensure a lasting utilization. The utilization of equipment is also linked to effective skill and a decent setting (i.e., there are endoscopes and ultra sound equipment which are not currently used at full potential). There is no adequate relation between equipment, installation and available skills.

Although the location of the hospital is good (it being in the center of town), it is on a hilly slope and estate capacity to expand is very limited.

(c) The hospital is well located in the town and access is fairly easy. There was a well designed flow of patients and staff that was suppressed when the former main entrance was closed for the construction of the national laboratory. Now there are two separate access areas, one leading to the Maternity and the other to the Casualty departments. The entrances/exits are not directly on a passing road. If the traffic were to increase significantly in the coming years, it would be necessary to secure the access with an adequate transit scheme. Nevertheless, it being on a hilly slope (like many building in Mbabane) leads to additional costs when building complex and important buildings. If the project that was drawn in 2004 was to be executed the hospital would be over 8 different levels while most of the wards are currently distributed on two levels.

(d) The hospital has little free estate capacity; extension would need to be done mostly by having high rise buildings. Compact buildings have less flexibility than separate

18

buildings, and there is a need to master all the horizontal and vertical flows in a well thought out organization. The vehicle traffic and parking will be a problem if car ownership increases in the coming years. Currently the parking capacity is of about 75 cars and extension would request to find a solution for the cars on the premises of the hospital or in the close neighborhood.

The distribution of services and wards is helter-skelter and do not permit an optimal physical flow of patients.

(e) The closing of the former entrance of the hospital has aggravated the difficulties to manage the various flows of patients. Orientation within this hospital is very difficult because there are no clear routes leading the various categories of users to various services.

(f) The absence of specific routes limits internal circulation and the multiple accesses to the wards leads to overcrowding within the hospital.

(g) The services have been added overtime without a master plan to optimize the functional relations between the services. The obstetric ward is far away from the pediatric ward and cannot take advantage of the Operating Theaters which are distant and are in the upper level. The laboratories and X-ray facilities are not close to the Casualty department and Outpatients department. The Rehabilitation department is far from Orthopedics department. Currently the ward distribution is a maze where medical and surgical activities are together while outpatient activities are scattered. Upgrading the hospital should lead to a full redistribution of the wards to make consistent departments and to minimize distances between wards and support facilities with common activities.

Inpatient hosting conditions are no longer suitable.

(h) The inpatient wards are not suitable for caring for the patients in relation to their medical needs and with dignity. The excess occupation of medical wards and the under optimal distribution of beds are limiting any attempt to improve quality of care. The standard of the recently build Mankayane hospital should be considered as a minimal requirement for MGH future (rooms for 6 to 8 patients at maximum) [even fewer with the prevalence of TB]. The size of the wards should be corresponding to the adequate patient nurse ratio. Depending on the intensity of care, the wards should be between 20 to 35 beds, except for the ICU or specialized services. With 6 to 8 beds to a room it is easier to optimize capacity utilization between specialties.

(i) Access to water supply (for cleaning, caring and catering) is very limited and toilets are not sufficient for patients, visitors, and staff.

(c) There are no places for families to stay out of the ward. To insure better hygiene, care and privacy, families should be excluded at certain hours and for those coming from out of the city it would be important to have some space for them to wait. The families’ facilities are also important for hygiene purpose, as it is better to separate the utilization of lavatories.

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CHAPTER 4: SCOPE AND SCALE OF HOSPITAL SERVICES

2. This chapter describes the services provided by MGH (Section A), discusses the hospital case mix and the demand for its services (Section B), and assesses the human resource capacity (Section C) as well as the support systems (Section D).

A. HOSPITAL SERVICES

3. MGH currently provides the following departmentalized services:

• Inpatient Departments - Medical, Pediatric, Orthopedic, Surgical, Obstetrics and Gynecology, Ophthalmology, Psychiatry, Urology, Dental, Ear, Nose and Throat, Radiology, Pharmaceutical, Laboratory, Audiology and Speech Therapy, Occupational Therapy and ICU.

• General Outpatients & Special Clinics - Casualty, Pediatric, Dermatology, Medical, Sexually Transmitted Diseases, Gynecology, Tuberculosis, Psychiatric, Dental, Orthopedic, Non-Communicable Diseases Clinic (e.g. Hypertension & Diabetes), Dental, Surgery, ENT (Ear, Nose, Throat) Clinic, Voluntary Counseling and Testing Clinic, Breast Cancer, Eye Clinic

• Clinical Support Services - X-Ray, Pharmacy, Laboratory, Occupational Therapy, Physiotherapy, Orthopedic Workshop, Mortuary, Catering, Laundry, Biomedical Engineering, Ambulance Services, Administration

Basic MGH statistics. MGH is a 450-50113-bed multi-specialty hospital and has about 30 percent of the total hospital beds in Swaziland (total of 1,619 beds). Table 5 and Figure 2 show selected MGH performance indicators for the period 1998 to 2004. The average length of stay (ALOS) has gone down while the death rates have gone up over the period 1998 to 2004. Outpatient visits have remained fairly stable albeit with a significant dip in the period 2001 to 2003. The inpatient admissions have gone up significantly and may reflect the mature HIV/AIDS burden of disease with concomitant higher death rates. The bed occupancy rates are a cause for concern and may not be a true reflection of current practice as many wards may be closed owing to staff shortages. (The hospital was overcrowded during the team’s study visit)

13 There is no common official reckoning of the number of beds in the hospital. The World Bank Team reckons that 501 is probably the capacity, but 450 is the "functional" number of beds.

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Table 5: Selected MGH Performance Indicators, 1998–2004

Years ALOS14 (days)

Occupancy (%)

Death Rate (%)

Inpatient Admissions

Outpatient Attendances

1998 9 73 9 13,238 113,284 1999 8 72 10 13,913 116,016 2000 8 73 12 15,086 119,232 2001 8 65 12 13,070 105,463 2002 7 63 13 14,018 104,113 2003 7 59 13 14,165 97,848 2004 6 63 10 18,110 111,253

Source: Annual reports of MGH, 1998-2004

Figure 2: MGH Inpatient Admissions and Outpatient Visits, 1998–2004

MGH is leading the hospital network but this results more of the downgrading of the hospital system than of the improvement of MGH performance. At the moment MGH is the largest hospital of the country and the one which has the best capacity to provide referral care. This situation has not been as such in the recent past when the two faith-based hospitals had also effective specialized services. Although MGH provides some specialized care, the situation of specialized care delivery has deteriorated over the past years in the country because of the absence of a policy combining investments in medical equipment and mobilization and scaling up of high level technical and specialist skills (especially amongst the medical and nursing staff). It is very important to note that the outpatient activity is increasing and is important for recruiting referral patients but is also asign of the weakness of a primary health care (PHC) delivery system in Mbabane.

MGH is important in terms of beds, inpatient admissions, and outpatient attendances, but these factors need to be understood in the context of the overall Swazi health system.Although MGH accounts for 30 percent of beds of the country, it has only 20 percent of

14 Average length of stay

0

20000

40000

60000

80000

100000

120000

140000

1998 1999 2000 2001 2002 2003 2004

In PatientAdmissions

OutpatientAttendances

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the inpatients (Table 6). The significant inpatient activity from health centers which have no declared beds may be one of the explanations. The other is linked to the longer average length of stay in MGH. This may be because the patients need longer care because they have a higher injury and disease burden and more extensive service need. Alternatively the back referral system to a local hospital may not be efficient. The latest MGH data may change the picture if the other facilities have not increased in similar proportion to their activities. The specialized hospitals (TB Hospital, Mental Hospital, and the special medical care unit) have no recorded in-patient activities and no recorded out-patient activities. Their ratio of expenditures/activity is therefore the worst in the country.

Table 6: Inpatient Activities of Heath Facilities in Swaziland, 2002

Hospitals Beds Inpatients Bed-days ALOS Occupancy Rate (%)

MGH 501 11,305 81,009 7.17 44 Public General Hospitals - Mankayane, Piggs Peak, Hlatikulu 420 11,469 65,076 5.67 42 Private General Hospitals - Raleigh Fitkin Memorial, Good Shepherd 472 14,178 74,672 5.27 43

Public & Private GH 892 25,647 139,748 5.45 43 Local Hospitals - Nhlangano, Sithobela, Dvokolwako 97 3,425 10,171 2.97 29 Total Others - Emkhuzweni, Mbabane PHC, The Clinic, Mhlume, Ngamane, Simunye, Umbobo, Imphilo, and Matsanjeni. 129 10,026 16,567 3.27 35

National Total 1,619 50,403 247,495 4.91 42 Source: Health Statistics Report, 2001-2002. MOHSW.

The lack of data on outpatient activities does not allow the measurement of the hospital contribution to service provision. This is unfortunate because hospitals play a significant role, especially for specialized care. If MGH is included in the regional outpatient data it accounts for about 10% of the national outpatient activity. Having gross outpatient activities does not provide worthy information for activity analysis because the work load and skill required are not the same for a prenatal care visit and an ophthalmologist visit. It is also important to measure the volume of activity of the pharmacy, laboratories and imaging departments which are mostly in the hospitals. For the outpatient activity, private practice usually plays an important role so there is a need to have data on it. These remarks call for major efforts in measuring activities in the various facilities with enough details to be able to have the evidence which allow allocation of resources based on outputs rather than on inputs. Without these figures it is impossible to consider reallocating resources to favor efficiency and better distribution of care.

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Further data on case mix, especially in relation to the burden of HIV/AIDS may explain the longer length of stay in MGH. The role of the other general hospitals (both public and private) is obvious but the role of the local hospitals is not clear. These “hospitals” have less beds and activities than the other health facilities. The activity cannot make a difference in their role, thus this hospital labeling would need to be better sustained by policy and relevant measures to increase the scope and volume of activities. (A typical classification is district, regional, specialist and referral hospitals differentiated by staff, equipment, support facilities and infrastructure depending on the level of care). The bed occupancy rates are low all over the country and may reflect closed or non-commissioned wards. The specific data from MGH indicates that the national data may underestimate the actual occupancy rate because of the poor recording. With the latest data of 2005, about 18,000 inpatients were recorded. With an ALOS of 7 days, then the OR would be between 70 percent and 77 percent depending on actual bed availability - 450 or 501. With the target 85 percent occupancy rate (OR) and a 7 days ALOS the hospital could care for 22,000 inpatients if all 501 beds are operational. However, actual activity will be limited by the physical constrains related to bed distribution in the wards, e.g., the ward for ophthalmology is oversized and the beds cannot be easily utilized unless a major reorganization of the hospital is undertaken to create a multi-disciplinary acute ward for surgery.

Case mix differentiation by acute, sub-acute, or chronic care as well as by injury or disease state is important as the staff, equipment and infrastructure support will vary depending on the diagnostic and treatment interventions. Many patients with the burden of disease due to HIV/AIDS are being managed in acute care wards that may increase cross-infection as well as prevent the use of skilled staff for other activities. There is a system in place for more accurate follow up of the hospital activity but the chance of success is weak because there is no incentive system for producing accurate activity data.

MGH renders a range of high level curative services and has specialist support in Surgery, Obstetrics and Gynecology, Pediatrics, Intensive Care and Urology. Internal Medicine is an important discipline and does not have specialist cover. The hospital had 25 doctors, 4 matrons, 28 nursing sisters, 144 staff nurses, 50 assistant nurses and other support staff in 2005. It has certain unique services that are not found elsewhere in Swaziland (ICU, Dialysis15) and also serves as a clearing facility for referrals to South Africa. It is overwhelmed by the quadruple burden of disease, and competing priorities for preventive, promotive and curative care as well as palliative and chronic care. Approximately 111,000 patients were seen in the outpatient department (OPD) in 2005 reflecting an attendance of 305 patients per day (see Table 7). The burden of disease in the outpatients’ department appears to be mainly environmentally and HIV related (upper respiratory tract, eye, skin, and gastro-intestinal infections and diseases). Some 18,110 patients were admitted as inpatients in 2005 (an average of 50 patients per day being admitted). The mature HIV/AIDS epidemic has its consequences on inpatient load as 50 percent of the bed occupancy is due to HIV/AIDS-related illness16 and 54 percent of deaths being HIV/AIDS and TB-related (Table 8). At the same time, 15 percent of deaths

15 In fact, treatments are undertaken in the ICU; these were previously taken in specific ward which is currently closed. 16 A more rigorous analysis of the difference in the average length of stay between HIV+ patients and non-HIV patients should be conducted to understand the impact of HIV on the turnover of beds in the hospital.

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are due to the chronic disease burden of hypertension, diabetes mellitus and cardiac disease. HIV/AIDS tends to crowd out other conditions and physical, material, and financial resources that can cover a range of disease conditions become insufficient. This affects staff morale and lowers the quality of patient care.

Facing different types of care level at MGH requires a strong organizational and managerial capacity that is currently lacking at the hospital. MGH functions at three levels of the health system simultaneously, making management really daunting. There are high outpatient attendances due to conditions that can be managed at a primary care level. While there is a Public Health Clinic across the road, most patients seek care at MGH as their first contact with the health system. Thus, MGH also provides primary care services. There is no functional referral system or a clear organization within MGH to manage a first line role. The limited number of government health centers and clinics in Mbabane area forces MGH to automatically dispense first line care, even as it attempts to provide some in-bound referral services and to out-source referral services that it cannot provide to South Africa. On the other hand, there are many inpatients needing palliative or supportive care prior to discharge and these patients can be managed in a ‘step-down’ facility and require a lower level of health professional/clinical skill-mix. Such an option would have a strong impact on bed turnover in the more specialized acute services although there are issues to deal with relating to stigmatization of patients and the psychological burden for the health workers posted in specialized palliative units. Communication with the other regional hospitals, other health facilities and to the private sector as well as the out-referral hospitals in South Africa is vital to the sustained functioning of the referral system. MGH needs to notify the other facilities about its range and scope of services as well as what support it can give to or need from the regional hospitals through back referral of patients. Thus, in a low-population area like Swaziland, it is probably more effective to have the same facility taking over different levels of care, but this requires an organizational scheme that can manage these multiple roles.

Table 7. Outpatient Attendances and Admissions at Mbabane Government Hospital, 2005

Outpatient Attendances Admissions

Disease Condition Total Disease Condition Total Upper respiratory tract infection

31,523 Retroviral diseases 1,114

Eye disorders 13,526 Diarrhoeal diseases 1,035 Skin disorders 9,740 Tuberculosis 869 Diarrhoeal diseases 9,330 Pneumonia 631 Genital disorders 9,001 Abortions 554 Digestive disorders 6,985 Trauma cases 504 Accidents/trauma 6,185 Cancers 421 Musculoskeletal disorders 4,995 Oropharyngeal candidiasis 389 Hypertension 4,784 Hypertension 346 Lower respiratory tract infection

4,686 Skin diseases 340

Other diagnoses 3,958 Anemia 329

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Diabetes mellitus 3,400 Chronic renal failure 326 Respiratory tract infection 326 Bronchopneumonia 278 Meningitis 252 Assault cases 242 Diabetes Mellitus 236 Encephalopathy 211 Retained products of conception

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Heart diseases 155 Others 2,887 Others 9,360 Total 111,000 Total 18,110 Source: MGH, 2006

Table 8. Causes of Death at Mbabane Government Hospital, 2005

Disease Condition Total Pneumonia 205 Diarrhoeal diseases 194 Tuberculosis 173 Retroviral diseases 143 Meningitis 120 Anemia 114 Encephalopathy 87 Bronchopneumonia 74 Cancers 69 Cerebrovascular accidents 45 Heart diseases 43 Respiratory tract infections 42 Oropharyngeal candidiasis 39 Diabetes mellitus 37 Hypertension 37 Renal failure 28 Malnutrition 26 Hepatitis 26 Assault cases 23 Skin diseases 23 Source: MGH, 2006

B. CASE-MIX AND DEMAND FOR SERVICES

For the hospital to meet its current case-mix, increasing the number of beds is certainly not the suggested first response. Although some services are currently overcrowded (medical wards), others are underutilized (ophthalmic ward, private ward and isolation ward). The current overall occupancy rate is stable at around 70 percent, but is lower than the optimal rate of 85 percent. A reduction and redistribution of beds should allow better utilization of the limited resources of the skilled health professionals. But to

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be feasible this reduction should rely on the growth of the capacities (technical and physical) of health centers and clinics (public and private). There is also an issue on choosing how to articulate the palliative care with the home-based care strategy and to position the hospital in a way that allows it greater efficiency with its limited resources.

The HIV related epidemic is the key factor of the hospital case-mix. Although the high rate of prevalence is recognized in the country, the hospital is not yet organized to fully face the consequence of this epidemic. The coding of the patients does not relate the health status to the HIV status and there is not a real follow up of the patients through the different services they need to face the burden of opportunistic diseases that confront HIV infected persons. The hospital is still working under a paradigm of tropical disease orientation or short individual acute episodes, while most of its patients are in a chronic-disease pattern with several hospitalizations. If home - based care can be developed, the remaining patients needing supportive and palliative care can be hosted in the wards if the beds are in good-sized separate rooms of 6 beds maximum. If home-based care is problematic because of the shortage of staff to follow up patients, or of the patient’s poor housing conditions, then the volume of patients requesting palliative care may lead to the hospital to consider specific wards for them. In this case to limit the risk of stigmatization and to limit the psychological burden on health workers, it would be better if these wards were reserved to all type of palliative care for adults and children (AIDS, cancer, severe malnutrition) but at the same time ensure that cross infection does not occur. The dimension of palliative care in MGH is related to the specific role of its VCT center and the prospect of the development of VCT centers in the country. Introducing palliative care should not isolate the patient from the family; thus, the hospital’s palliative care program should be designed for patients from the MGH’s own catchment area.

The development of traffic injuries, interpersonal violence and personal lifestyle leads to a growing demand for more specialized care in surgery and medicine. Both of these new types of medical demands should also lead to a more patient-oriented approach instead of a disease specific response. Most of trauma surgery needs rehabilitation; diabetic patients need dietary advice along with medical and laboratory follow up. All these patients will come to the hospital for repeated consultation over a long period of time. Once their chronic condition is stabilized they should be referred to their local health facility for follow up and may require referral to MGH for specific interventions at certain times.

Due to the persistent high fertility rate, the mother and child services represent a large part of the hospital’s activity (one third of admissions). Technically a part of the obstetric deliveries could be made in a health center having capacity to transfer in good condition obstetrical emergencies and acute neonatal and pediatric problems. However options have to be taken in the context of the HIV/AIDS epidemic and the best possible organization to ensure mother to infant preventive treatment (the MTCPT program with nevirapine). Distances and transportation has to be taken into account as it may be more effective to centralize deliveries with a well performed MTCPT program rather than to manage health centers with lack of human resources and lower staff qualifications.

Some specific specialist disciplines are missing at MGH.There is no medical practitioner specialized in internal medicine (and more specific sub-disciplines like cardiology, endocrinology, gastroenterology, pulmonology, ENT, ophthalmology,

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dermatology and rheumatology, and there are no formal relations with the private sector for a combined response by the private and public sectors to the underserved medical needs in both the sectors. When there is a specialist, it is often not sufficient for medical, surgical and obstetrical emergencies. For these activities in relation to an effective emergency department it would be expected that MGH provides such services around the clock.

There has been no analysis of patient residence and the catchment population for MGH. It is impossible to estimate, by diagnosis and treatment intervention, the catchment area of MGH. It is likely that most out-patients (except for the VCT center) are coming from Mbabane or the closest towns or villages in that region. On the other hand, patients may bypass other hospitals and health centers because of a perception that better care is available at MGH. The referral pattern has been fluctuating in relation to available equipment and specialists at MGH given the shortages of staff and the non availability of equipment. In a country the size of Swaziland it is easy to have an updated chart (quarterly or bi-annual… but best would be to have it online) of available services (public and private) to guide health staff working in any health facility to refer patients where it is most appropriate.

There are some inappropriate services being rendered. The orphanage for mentally challenged children should be managed by the Welfare Directorate outside MGH. The children are at risk of getting hospital-acquired infections and the hospital environment is not conducive to their socialization. There are overextended mandates in the form of provision of wheelchairs, crutches, splints and underutilized workshops owing to lack of consumables.

C. HUMAN RESOURCE CAPACITY

High vacancies exist for medical doctors and, to a lesser extent, for nurses. Table 9 shows that 4 out 7 established posts for specialists are vacant (57 percent), while 15 out of 31 for general practitioner posts are vacant (48 percent). The table also shows few vacancy rates for registered nurses (8 percent) but a more significant one for nursing assistants (18 percent).

Table 9. Number of Doctors and Nurses, Number of Beds, Number of Patients, and Health Worker:Patient Ratios, by Ward at Mbabane Government Hospital, 2005

Wards Total

Doctors Total

Nurses No. of Beds

Surplus Floor Beds

Patient Admissions

Patient Per

Doctor

Patient Per

Nurse Maternity 017 54 93 0 4,888 - 91 Surgical, Male

3 17 36 0 593 198 35

Surgical, Female

6 15 34 0 504 84 34

Medical, 2 21 44 44 1,544 772 74

17 Note that the 2 Gynecology doctors also cover Maternity wards.

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Male Medical, Female

0 25 n.a. 0 1,920 - 77

Gynecology 2 16 26 418 1,407 704 88 Pediatrics 019 24 54 0 1,950 - 81 Orthopedics 3 17 30 0 371 124 22Isolation 0 10 5 0 75 - 8 Psychiatry 0 4 n.a. 0 0 - - Eye 120 13 n.a. 0 131 131 10 Audiology 0 3 n.a. 0 2,009 - 670 Operating Theater

621 34 n.a. 0 1,199 200 35

Total 23 253 n.a. 48 16,591 n.a. n.a. Source: MGH, 2006

The health workforce does not reflect adequate planning and deployment. This may be due to the underlying staff shortages, skills mix or increased disease burden of HIV/AIDS especially in the medical specialties. The high workload of the nurses and doctors in some wards will lead to problems with quality of care and low morale. Of note is the low ratio in the isolation unit that may need different management considerations for greater efficiency of staff deployment.

MGH and the regional hospitals need highly skilled specialists, nurses and other support personnel. Training of a cadre of specialists has to begin now as the lag time for agraduate is approximately 4 to 5 years post graduation as a doctor depending on the specialty. The country cannot rely only on the volatile international market of specialists

to organize its service delivery22. Negotiations have to be held with medical schools in the region to assist with capacity building. With this scheme MGH and some other regional hospitals would have a key role to play as satellite teaching hospitals. The Faculty of Health Sciences at the University of Swaziland should train the advanced nursing cadres for the specialties (ICU, theatre, anesthetics, ophthalmology, orthopedics, neonatology, etc) and where needed, in partnership with nursing colleges in the Southern African region. Further interaction with the Nazarene College of Nursing in Manzini and the Nursing College at Good Shepherd Hospital is needed to meet the training and in-service needs at MGH. Policy changes in South Africa with respect to the provision of internship training opportunities over 2 years for newly qualified doctors have to be factored into the restructured MGH. This will entail having supervisory staff, adequate accommodation, and ability to conduct various care and treatment interventions in the general specialties. Research and research networks must be fostered with local, regional,

18 Cubicles 19 Although this table reports no doctor, the World Bank team did meet a doctor in charge of Pediatrics. 20 This table reports an Eye doctor, but the position is actually vacant. This item may refer to a visiting Eye doctor. 21 While there are surgeons, it is not clear whether there are operating theater doctors. The surgical interventions are for inpatient surgery wards. There may be double counting between OT and surgery wards. 22 No data were provided on the nationality of doctors practicing at MGH. However, based solely on the meetings made by the World Bank team, the MGH doctors were preponderantly foreigners.

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and international partners that will deepen the support to MGH as well as strengthen its human resource capacity, recruitment and retention strategies. Clinical support personnel in the clinical technology, radiology, laboratory and pharmacy disciplines as well as the ancillary rehabilitative disciplines also need to be recruited to ensure the high level support care for patients in MGH.

To improve the human resource situation at the hospital, management needs to focus on the following:

Immediately recruit and train specialist medical, nursing and clinical support personnel for the currently vacant posts in the hospital.

Design and implement a management and organizational development program for the MGH personnel that builds collegiality and team work, enhances morale and skills, as well as creates a sense of belonging.

Prioritize occupational health and safety especially on HIV/AIDS and TB. According to the Swaziland Nurses Association, a 2004 survey at MGH showed that in an average month, about 20 nurses experienced needle stick injuries. Furthermore, only 10 percent of nurses nationwide have been trained on the universal precautions of HIV/AIDS. Infection control is another area of concern and needs a policy, plan and implementation to prevent any patient or staff cross-infection.

Ensure complementarities with other donor funded program to prevent ‘brain drain’ to those activities. There is a need for policy to second or rotate staff to such activities to enable capacity building and a sense of being part of one system. Rotations could be done with Global Fund projects and the Baylor Center of Excellence, although it is not currently being practiced.

Develop partnerships with the private (for profit) sectors to ensure adequate coverage by medical, nursing and other personnel in under resourced specialties. In some instances, MGH has staff that can cover the private sector and in other areas, the private sector should support MGH.

D. HOSPITAL SUPPORT SYSTEMS

The hospital management information system leaves much to be desired. A minimum data set of health information and hospital information data should be collected to aid with decision-making at various levels of the health and hospital system. But only very recently (November 2005) was a computer introduced for the Health Management Information System (HMIS), and even then, data entry only began in February 2006, and as of to-date, it is able to capture admissions only. The software being used (MS DOS-based) is very old. The system uses ICD (International Classification of Diseases) 9, while much of the world is now using ICD 10. There is much laxity in the recording of diagnosis, and some patients are discharged without the final diagnosis. (Some patients are being discharged without a formal admission process.) Indeed, some unqualified staff could be writing the diagnosis. A patient can be coded with as many as 3 diagnoses, which is problematic as there can be no definitive summary of final diagnosis. Loss of records could happen, and the physical storage of records is not conducive to good record

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keeping. The combined effect of this is the general lack of a culture of data for decision-making. In stores operation, the process is completely manual, and there is yet no plan for computerization. Nevertheless the basic organization is there making the ground for potential significant improvement of medical data management. The information system on management is almost inexistent. Each administrative function may keep track of information but it is not organized for management purpose. There are almost no computers to support the administrative activities and no data base. Implementing an information system would need to start from the ground.

The health technology policy and plan is non-existent. By and large, it has been driven by donors probably in reaction to a wish-list from the hospital. The initial capital investment has been excellent but the follow-up, maintenance and support for the use of the technology has been lacking. This has negative implications for the quality of service delivery (both diagnostic and interventive) and may increase the number of patients referred to South Africa owing to service delivery failure (having the skilled personnel but no equipment; having the equipment but no personnel; having the equipment and personnel but not consumables). There is no Information Technology (IT) policy and plan and there are few computers and peripherals in the hospital that function on an ad-hoc unconnected basis.

Telemedicine is underdeveloped. Telemedicine could be done with donor support especially in the fields of laboratory and radiology, and with specialist support from South Africa and elsewhere. Successful models are in operation for Ophthalmology (Edendale Hospital in Pietermaritzburg, South Africa) and a Clinical HIV/AIDS training program by distance education in Durban, South Africa. The technology and professional support is available but will be dependent on infrastructure in Swaziland (IT, broadband communications).

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CHAPTER 5: HOSPITAL PLANNING AND POLICY FRAMEWORK

The Mbabane Government Hospital is the apex of the health facility network, but it is burdened with multiple objectives for which it has severely inadequate resources. The MGH is supposed to be the center of the health network. It is the largest health facility (450 operating beds that could be expanded to 501) in the country, serving multiple roles as (a) a national referral hospital - it has certain unique services that are not found elsewhere in Swaziland, e.g., ICU, Dialysis; (b) a clearing facility for referrals to South Africa; (c) a regional hospital for the Hhohho region and Mbabane city23; and (d) a source of primary care for many patients in its immediate catchment area. (There is a Public Health clinic across the road, but patients continue to use MGH as their first contact with the health system.) The hospital provides preventive, promotive, curative and rehabilitative services through designated departments. A national reference laboratory is also being built alongside the hospital. In addition to these health-service roles, it has multiple social functions, including a facility for abandoned children and providing support and income-generating activities for people with disabilities. Despite these multiple societal expectations, the hospital has not received adequate financial support. The share of MGH to total MOHSW budget actually declined from 13.9 percent in 2003/04 to 12.4 percent in 2005/06, although its share of actual expenditures increased from 15.8 percent to 16.3 percent. The hospital has been overspending over the past three fiscal years.

A. PLANNING AND POLICY ENVIRONMENT

Hospitals in Swaziland exist in a very weak policy and planning environment. It is difficult to assess the rationale of upgrading the MGH into a tertiary referral facility due to non-existent or severely out-of-date legislative framework and policies. These frameworks for hospitals are of vital importance given the large resource implications of hospital investments and the deployment of sophisticated equipment and staff. No current health legislation exists, and most governance, policy, administrative, and institutional arrangements are from a 1983 framework, which invoked the principles of primary health care focusing principally on the control and prevention of tropical and infectious diseases in poor countries (with little inputs on hospital care). The Nurses and Midwives Act was passed way back in 1965, and a draft bill to update it is still pending review at the MOHSW. The era of HIV and AIDS and re-emergent diseases co-existing with an increasing burden of non-communicable diseases, the changing role of government in the health sector, technological advances and new ways of delivering health services (e.g., private health care and partnerships, home-based care; hospice care; and chronic/palliative care in hospitals), and the changing roles of professionals in this new

23 In hospital planning, there is no place for duplication of a national and a regional hospital in the same area, although it is normal that one hospital mixes both functions. A national referral hospital is just a step ahead on specialties, but rely on a regional-type of medical activity.

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environment certainly require new health legislation. A draft National Health and Social Welfare Policy is under deliberation and seeks to introduce such new health legislation.

No national health facilities plan or framework exists to guide future capital investments in the sector. Due to the non-existent health facilities development framework, hospital investments have been heavily politicized, with health managers and specialists often being sidelined about the location and size of major hospitals, as exemplified in the cases of (a) the planned Lubombo Regional Hospital within minutes of an existing mission hospital - Good Shepherd - which receives government subvention, and which is popularly perceived to be providing good quality care; (b) the soon-to-be completed TB Hospital in Manzini which is also within minutes of an existing mission hospital - RFM - which will soon be taken over by government; (c) the special medical care unit with unclear role in the health system; and (d) the huge and modern National Reference Laboratory under construction, which has been grafted onto the old wings of the MGH, and in the process limiting the possibility of needed expansion of the existing hospital. Until such national health facilities investment plan is formulated, Swaziland could expect more politically-motivated construction and refurbishment, and external donors offering capital projects on an ad hoc and un-coordinated basis.

A national health facilities plan covering the needs of the health system should be put in place and donors invited to contribute to that plan. Should the decision be taken to refurbish or replace any Government facilities by any means (including PPPs), a capital works plan and program for MGH as well as the upgrading or provision of new regional hospitals should be developed alongside the human resource, health technology, drug supply, laboratory, and referral and support facilities plan. Such plans may explore the various forms of PPPs that may be feasible for implementation of certain elements of the plan. Donor assistance for specific capital investments should be based on this national plan. Sustainability of the capital investments must be built into the donor support and include operating funds for adequate maintenance and replacement plans. Any plan must also directly address the need for experienced management and clinical service improvements.

No hospital planning parameters exist, and no written national standards have been formulated for the layout and construction of hospitals. Hospital managers found it difficult to answer basic information on the size of their catchment population. According to the staff of the Ministry of Public Works and Transport (MPWT), although typical drawings exist for hospitals of various levels, there are no written standards or manuals. At the individual institutional level, no long-term plan exists that should guide the physical expansion of the specific hospital. At MGH, donors’ investments from the Italians, Japanese International Cooperation Agency (JICA), the Chinese, the U.S. Defense Department, etc. have led to ad hoc growth of wings, wards, and services through the years. The growth of the capital plant (at MGH and Piggs Peak) is uneven, and so does the maintenance of these assets, as most donors tend to maintain only their donations of wings, buildings, or health technology. The supporting infrastructure of sanitation, water, electricity and telecommunications is not factored in and can overwhelm the existing facility.

In general, the government has been preoccupied with construction of buildings with little attention devoted to maintenance and recurrent cost requirements. Capital

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investments are needed but the recurrent/operational budgets are an important consideration. There is no maintenance schedule in hospitals, with concomitant infrastructure and technology failure. According to MPWT staff, ideally 30 percent of the annual capital budget should be for construction and 70 percent for maintenance, but the ratio is reversed in almost every year. Comprehensive maintenance (including preventive maintenance) is not feasible because of the very limited budget, and the burgeoning capital base. Indeed, the maintenance budget is going down in all sectors. "Property or estate planning and management" is an alien concept in service ministries.

There is no clear policy on the financing of secondary and tertiary referral services, and who/what illness conditions should receive full or partial government subsidies for treatment, whether domestically or abroad. Swaziland has no overall social protection policy. The "medically indigent" is not defined in the policy; the blanket application of no or low fees for all probably results in free-loading. The limited coverage of health insurance means that the government would need to heavily subsidize hospital care for many Swazis in the years to come, unless existing medical referral schemes are converted into contributory social health insurance programs. At present, the Phalala scheme provides 100 percent subsidy to a very limited segment of society, while the civil servants’ referral scheme continues to be funded out of the budget, without a defined contribution from civil servants. Moreover, for both these schemes, there is no official cap on expenditures, so the financing of referrals abroad (secondary and tertiary care) is effectively open-ended.

Hospital construction is often undertaken with little regard for training and staffing needs, especially for specialist doctors and nurses. Professional and specialized personnel take many years of education and training (15 years for a medical specialist) to gain competency. This long lead time, plus the fact that almost all specialist doctors practicing in the public sector in Swaziland are expatriates, calls for a long-term human capital investment plan. Interface and links with the Ministry of Education and training institutions (the university and affiliated nursing colleges) are weak. The regional hospitals and the envisaged high level referral hospital (the new MGH) will need highly skilled specialists, nurses, and other support personnel. Training of a cadre of specialists has to begin now as the lag time for a medical graduate is approximately 4 to 5 years depending on the specialty. Specialist nurses would need an addition 12-18 months’ training. Negotiations have to be held with medical schools in the region to assist with capacity building. The Faculty of Health Sciences (if it has the capacity) should train the advanced nursing cadres for the specialties (ICU, theatre, anesthetics, ophthalmology, orthopedics, neonatology, etc.). The Swazi management institute should also be encouraged to establish a program of training health staff on managerial functions.

MGH has no human resource policy or plan. Most Human Resource Management and Organizational Development structures are from the 1980s. Personnel issues are dealt with at the MOHSW level with multiple other ministerial inputs and approvals. The ‘brain drain’ of nurses and the lack of medical and clinical support staff have implications for service delivery. (Almost 12 percent of nursing posts and 33 percent of medical posts are vacant in the public sector. Moreover, the increasing volume of patients suggests the need to review the provider/patient ratios to ensure that the established posts are enough

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to cover the needs). Most doctors are expatriates. Most wards function with lower-level skilled nursing personnel.

B. PUBLIC/PRIVATE PARTNERSHIP

There is little legal or policy framework on public private partnerships (PPP). In general, the government has not been in active engagement with the private sector. Most support services are rendered in-house with little contracting out of non-clinical services (except technology maintenance). There is no policy on public/private relationships except for: (a) a management contract for catering services at MGH; (b) contracting out security services; and (c) secondment of management staff from government to the RFM Hospital [Chief Executive Officer (CEO) and Chief Financial Officer (CFO)], but even this is in the manner of a financial "government rescue operation" rather than actively promoting synergies between the two sectors. [The first wave of contracting out of hospital services mainly dealt with the non-clinical or hotel services (portering, catering, gardening and grounds maintenance, minor building maintenance and security); the second wave considered clinical support services such as laboratory, radiography, health technology; and the third wave may need a policy shift wherein the government/MOHSW is the custodian or steward of health policy and provides the framework for the financing and delivery of health services, but contracts out with various parties to deliver the actual services]. The financial framework can be in the form of block grants or subsidies; this is already being done through a rather passive basis through the annual provision of a subvention or "implicit contract" to the RFM and the Good Shepherd Hospitals, but this could be in a more active form through a written and monitored health service contract which specifies output deliverables, as was recently introduced in Malawi. The PPP guidelines, which are still to be developed, should also define how the government can invest in nonprofit (mission) sector health facilities, and specify how expensive but under-utilized equipment in government facilities, such as the CT-scan, can be offered for use to private practitioners at an appropriate fee, so that these procedures are not out-sourced abroad, with the consequent loss of foreign exchange.

There is no policy or administrative guideline defining the dual practice of physicians. Indeed, there appears to be government distrust of the private sector with a strict policy preventing health civil servants from working in the private sector and vice versa. In a dynamic labor market that is increasingly influenced by global forces, it would be suitable to adopt flexible employment arrangements to make better use of scarce skilled staff in the country and to allow professionals extra income from their knowledge, instead of them embarking on enterprises for which they are not prepared for. Dual practice would "match" the existing equipment with the existing professional; a severe and common problem in both government and mission facilities where a professional may be available but not the complementary equipment; or where the equipment may be available but not the skilled professional. Short of this "matching" of both inputs - which are available albeit not in the same facility - would be both wasted and under-utilized. This "matching" would result in a functional service, which would limit the referrals to South Africa and provide financial incentives for local investments, both human and capital. In addition, the "matching" would allow health professionals to keep up their skill levels while allowing both the public and private patients access to care. MGH has some centers of repute (laboratory, ICU, and to a lesser extent,

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radiography24) and some specialists who are the only skilled persons in Swaziland (Urology). Other fields, such as Occupational Therapy and Radiography, are also quite advanced relative to what exists elsewhere in Swaziland.

Dual practice should be operationalized by allowing extramural practice for MGH doctors, or intramural practice in MGH for private specialists (since MGH makes referrals to them anyhow). This potentially fruitful arrangement (which exists in one form or another in almost all countries) is being hindered by the absence of relevant policy. In contrast, in South Africa, public doctors can use as much as 20% of their time in private practice; in Mozambique, private clinics exist in tertiary hospitals; and in many developing countries, government doctors openly practice privately, and private practitioners provide services in public facilities on a sessional basis. Fears have been expressed in Swaziland that dual practice would result in theft of government property, but this argument flies in the face of the fact that even without dual practice, medical equipment are disappearing out of MGH and other facilities (i.e., theft appears to be a problem unrelated to dual practice, and may have to do with poor security and management. The major need to outsource security in MGH was to reduce dramatically the theft of equipment and consumables). Doctors need to be monitored closely under a dual practice regime to ensure that no parties unduly benefit or suffer from this arrangement. In addition, the policy should clearly define the revenue sharing model (between government and the practitioner or facility) for the use of MGH facilities. A differentiated tariff structure can be put in place. This revenue-generating model can build on the success of the private (full-paying) wing currently in existence.

24 The radiography equipment and scope of service at MGH is similar to one of basic regional hospital in sub-Saharan Africa. A CT-scan exists but is not operating. Echography is very limited, and there are no dynamic imaging or exams with contrast products. There is no intervention radiology which requires a practitioner. For these reasons, although radiography at MGH is above what exists in the rest of the health facilities in Swaziland, it is not yet at that stage where it could be considered a center of repute.

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CHAPTER 6: HOSPITAL INSTITUTIONAL AND INCENTIVE STRUCTURES

Section A of this chapter discusses the current institutional and management structure. It highlights the institutional constraints faced by hospital management in their attempts to improve services. Based on the analysis of these institutional constraints, Section B provides options for improving the institutional and incentive environment.

A. CONSTRAINTS OF INSTITUTIONAL AND MANAGEMENT STRUCTURE

MGH is operated as a classic budgetary unit within the hierarchical (vertical) administrative structure of the government. While this may be suitable for lower-level health facilities, global experience shows that it is inappropriate for a complex organization such as a tertiary hospital that requires independence and flexibility to use a range of sophisticated inputs to achieve its multiple objectives. While MOHSW is the hospital’s parent ministry, other ministries are heavily involved in the various inputs of the hospital (the Treasury for financial matters, Public Service Commission for employees, Public Works and Transport for maintenance, the Central Medical Stores for drugs). Hospital management feels that the multiple reporting is not enhancing the service delivery needs of the hospital and adds to the bureaucratic burden. Hospital staff are not differentiated from other ministries within the civil service (one size fits all in the Public Service framework). The hospital sector is a complex environment with differentiated professional and support staff working with multiple inputs (specialized work environments, drugs, technology and skills) and having multiple outcomes. A rigid civil service that does not allow for this differentiation and complexity of work does so at its peril.

Hospital management (especially the clinical manager) appears not to be involved in the decision-making process at MOHSW involving the hospital. Hospital managers are not consulted about their day-to-day needs. Heads of clinical professionals, allied health professionals, and those from the support departments feel marginalized by the budget process after repeated requests and promises are not fulfilled. The budget and expenditure process is not perceived to be transparent. It does not take account of the real needs of the hospital and is based on simple incremental budgeting. In general, the hospital is "managing up rather than down". There is too much focus on fiduciary control rather than service performance to clients/patients. There is too much recording for and reporting to higher-level authorities, but very little actual monitoring by these authorities.

MGH’s lack of decision-making power leads to poor governance and management environment. The management team of MGH has evolved from the past medical model (of medical superintendent + matron + medical secretary – which is still in operation in the regional hospitals) to the current management model (of hospital manager + hospital administrator + senior medical officer). This change, which was initiated in 1985, is supposed to improve MGH management performance by separating the jobs of the

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hospital manager (who is supposed to look at the strategic directions of the hospital) and the hospital administrator (who is supposed to look at the day-to-day operational aspects) and the senior medical officer who is suppose to promote effective clinical governance and management. Despite this change, however, the MGH management team continues to be hobbled by the highly centralized procedures of MOHSW to which the hospital reports. In fact, due to the lack of MGH autonomy, the functions of the hospital manager and administrator appear to have largely blended and there doesn’t seem to be much justification for strategic planning within the hospital when most of the key decisions are made by the parent organization (MOHSW). MGH hospital management sees this "rigid", overly hierarchical reporting structure as focused on the control of inputs ("micromanagement"), rather than the monitoring of performance. Indeed, because it does not have any autonomy, MGH management lacks control and decision-making power over key functions, resulting in the sorry state of the hospital. In contrast, the Good Shepherd Hospital (which continued with the medical model of management led by the Medical Superintendent and is an autonomous entity) is generally regarded as a better-run facility. Thus, what seems to matter more is the degree of institutional autonomy, rather than the composition of the management team!

MGH’s existing institutional structure is not appropriate for a tertiary referral facility; maintaining such a structure leads to under-performance. While it is tempting to blame the hospital’s sorry state to the lack of adequate financing, additional financing will yield little positive result in the long term unless the institutional structure of MGH is reformed towards giving it more autonomy. The mission found many institutional shortcomings of MGH arising from its current lack of managerial and financial autonomy:

Lack of control over the budget. As a hierarchically-managed unit without autonomy, MGH receives line-item budgets from MOHSW. For each and every use of these budget lines, MGH has to ask approval from MOHSW. There is no flexibility to transfer resources from a line item to another.

Inability to decide on the level of fees and to retain them and the consequent lack of institutional and staff incentives to generate non-budgetary revenues. All revenues have to be turned over by MGH to the General Consolidated Fund of the Treasury. In any case, revenue collections are currently a very small proportion of recurrent costs. Only about SL 3.6 million in fees are collected, compared to about SL 46 million budget (or 7.8% cost recovery).

Lack of control over the maintenance of physical plant, equipment, and vehicle fleet.The Ministry of Public Works and Transport is responsible for most of the maintenance, and this budget is separate from that of the hospital. The hospital’s mandate in maintenance only covers minor activities, such as painting, carpentry, and plumbing. Although MGH hosts the national bio-medical team, medical equipment management is limited but supported by some contracts with private companies. It does not seem that hosting the national team provides a shortcut for immediate response. The vehicle fleet is also under MPWT. In both cases of maintenance and fleet management, response from MPWT can be delayed. The limit for expenses on repair of breakdowns is extremely low (SL 5,000), and beyond this approval has to be sought from the Treasury. This means that equipment down-time can be long. The problem is exacerbated by the lack of

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standardization of donated equipment, some of which are very old and maintenance contracts.

Inability to choose the best and most reliable supplier of drugs. Unlike the autonomous Good Shepherd Hospital which has been given by government significant leeway to purchase drugs outside of Central Medical Stores (CMS), MGH is required to source its drugs solely from CMS, and thus suffers all the attendant inefficiencies that this entails, i.e., unreliable drug supply and stock outs. In each given month, about 30% of the drugs are out of stock at the pharmacy. If no funds are forthcoming from the Treasury, requests are made on an “I owe you” basis to CMS, leading to unsustainability of drug supplies.

Inability to quickly hire or fire professional and technical staff. Except for the orderlies who are hired by the hospital itself, all professional and technical staff are civil service employees, which makes it extremely difficult to change staffing patterns in response to emerging or changing disease priorities or availability of domestic or external funding. The organogram is vintage 1980s, way before the AIDS epidemic and other emergent diseases. Although posts have been added through the years, the number of professional staff is short of the real needs based on actual workload. Underperforming or superfluous staff are almost impossible to remove. Creating a new post involves considerable lead time (4-6 months for an established post; at least 1 year for a new post, if the budget is available), since for a new post, at least four ministries are involved (Public Service, Finance, Economic Planning, and Health). There is no workload analysis or prospective studies to determine the volume and categories of staff required to run an effective MGH. Without such a study it is impossible to highlight the gaps and excesses.

Inability to use more flexible labor arrangements in response to shortage of skilled workers, and difficulty of managing appropriate staff skill mix. Typical of other hospitals without autonomy and with "inherited" staff plans, MGH exhibits overstaffing of low-skill jobs and understaffing of high-skill jobs. It would be suitable for the hospital to have a better balance of high-skill and low-skill jobs.

Inability to gain the full benefits of contracting out. The catering contract involves hospital staff. Although the contract has reduced food thefts, it still has to generate efficiency savings in the use of staff. The contracting period (annual) is not appropriate to engage a contractor in financing equipments to enhance quality and productivity.

Inability to dismiss staff involved in hospital thefts, or who are unproductive. MGH has been plagued by theft of medical equipment and medicines that are frequently reported in the press; some involving hospital staff. While there may be strong documented case against a specific staff, the long and costly administrative process towards dismissal inhibits efforts to go in this direction. Neither can MGH management dismiss staff outright for being unproductive.

B. OPTIONS FOR INSTITUTIONAL IMPROVEMENT

The government can consider various options for improving flexibility in the financing, management, and use of inputs and thereby improve hospital performance.

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Health Service Commission. Following a Constitutional provision, the government is considering establishing a Health Service Commission to take MOHSW health workers out of the Public Service. This would allow the new Commission to upgrade staff salaries and improve benefits. No further details are available on how the Commission would actually function (a consultant was slated to work on this in June 2006). However, it is perceived by most to be a far superior option than the status quo, i.e., health workers as civil servants. In the case of MGH, however, the Commission-route may improve the benefits of staff but it will not allow hospital management flexibility in the use of other inputs since MGH will remain as an attached administrative unit under the MOHSW. Except for a small relief in better-salaried hospital workers, all the other administrative constraints listed above will persist.

Decentralization of responsibility, but without devolving fiscal authority, to hospital management.

Granting of autonomy to the hospital. Giving greater independence to the hospital to manage its operations requires that its parent ministry deal with it on an arm’s length relationship. As detailed in the next sections, the mission thinks this is the best option for MGH.

For the new MGH to function properly, it is critical that the "best practice" elements of hospital autonomy be introduced. These consist of the following:

Establishment of an independent governing body, the Hospital Board. The Board should consist of well-respected stakeholders of the hospital, and should include representations from the central government, health professionals, patients/clients, etc. This is intended to depoliticize decision-making. MOHSW will have to oversee Board decisions to ensure they are in line with national policies and priorities.

Provision of a global budget. The granting of autonomy should be accompanied by moving from line-item budgeting to a global budget so that savings in one service area can be shifted to another. Under line-budgeting, this is not possible to do since any savings in one line item reverts back to the Treasury; hence there is very little incentive for managers to be efficient. (Why save if you cannot use your savings?) The global budget provides such an incentive. Rules on budgeting and transferring line-items should be in place to grant good governance and transparency.

Formulation, implementation, and monitoring of a results-based contract. In exchange for the granting of autonomy, the Hospital Board and hospital management should be made accountable for results. These performance requirements should be specified in advance, and the framework of achieving them recorded in the Contract. The process of formulating the Contract is intended to clarify and focus the objectives of the hospital and to lay out the formal, agreed-upon criteria and indicators of results.

Use of contracting or outsourcing. As much as feasible, all payments of the hospital should be performance-related so that efficiency savings can be generated. The hospital must be allowed to source inputs (including drugs) and services from the best and most reliable provider or supplier, rather than be forced to rely on traditional sources. Exposing

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hospitals to a modicum of market discipline has been shown to improve their performance.

While providing autonomy to the hospital has many benefits, it also poses certain risks. These risks may include the following:

Choice of governance and management structure. Ideally, there should be external and internal governance structures that provide transparency and accountability while rewarding employees and managers for results. The composition, functions, and responsibilities of the hospital management, therefore, are critical elements. While flexibility is needed to allow management to dispense its functions (e.g., hiring and firing of staff, making necessary purchases), it must at the same time adhere to set rules of fiduciary accountability. While it must "manage inwards" to make staff as productive as possible, it must also "manage outwards" to keep its clients satisfied. Achieving balance in these often competing aims requires an appropriate institutional structure that is conducive to the Swazi environment.

Fiscal pressures. Hospital reforms carried out in an environment of fiscal difficulties tend to be less successful. Autonomy itself does not solve the hospital performance problems if the hospital continues to be under-resourced due to overall financial squeeze. In addition, if the hospital succeeds in dramatically improving its services due to autonomy, its client base may increase, requiring increasing direct government subsidy, unless additional resources can be tapped elsewhere (through user fees, insurance reimbursements, other internal revenues, or donor support).

Failure to undertake complementary reforms in contracting. If the contracting process is flawed (lack of competition and rigged tendering, for instance), the hospital may not get the best "value for money" for any of the transactions it enters (contracts for catering, laundry, security, maintenance, and even clinical services).

Inability to protect poor hospital clients and other social functions deemed critical.This is the greatest fear that most of the mission’s interviewees expressed. The hospital caters largely for the underprivileged, and the hospital’s search for more revenues under an autonomous management regime may make it raise fees in excess of what most clients can afford. This potential problem can be addressed explicitly under the Performance Contract, which specifies the level of fees to be charged.

Failure to regulate the new entity, and to monitor its performance. As the MOHSW evolves from being directly involved in MGH management to being its steward, it needs to have new institutional skills related to regulation and monitoring hospital performance.

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CHAPTER 7: OVERALL HOSPITAL PERFORMANCE, BOTTLENECKS, AND SERVICE DEFICITS

This chapter pulls together the various findings of the previous chapters and provides

an overall assessment of hospital performance. Section A assesses such performance in terms of social aspects (equity and responsiveness), technical aspects (quality of care and scope of services), economic aspects (efficiency and productivity), and managerial aspects (organization, decision-making process, and accountability). Finally, Section B discusses the hospital’s key bottlenecks, service gaps and deficits.

A. HOSPITAL PERFORMANCE

The absence of a clear, written definition of MGH’s role, as well as poor availability of data, precludes proper assessment of how well or poorly MGH is performing.Hospital performance should be assessed in relation to MGH’s role in the national health policy (which includes service delivery, referral, training, research, supervision, or other functions). Because of the absence of a clear definition of MGH’s role, the focus of this assessment rested on the hospital’s primary role: delivering health care. It would be important to consider at least two other major roles in a more detailed analysis of hospital performance: its training and research role, and its referral and supervision role. The limited availability of data both from the hospital and the health sector leads to general consideration on hospital performance.

To become an effective referral hospital, MGH performance would have to be significantly improved. If the physical environment and the lack of equipment accounts for the current limited performance, the major causes of this result have to be found in mobilizing the human resources as well as in the institutional arrangements. Physical investments (buildings and equipment) can improve performance but in a limited manner and with little perspective of sustainability if the institutional and organizational issues are not addressed prior any major investment.

The assessment of MGH’s social performance pertaining to equity and responsiveness shows the following:

(j) The current tariffs (user fees) are far below the actual cost of services. The high utilization of the OPD and the occupation rate of available inpatient service indicate that for most of the population the hospital seems accessible. However, the fee system does not allow any differences according to families’ incomes or to the burden of diseases. The redistribution pattern is horizontal because the fee structure is more favorable for patients with major diseases than for patients with minor health concerns (flat-fee per day or per prescription). There seem to be an exemption procedure to allow patient access when they cannot pay the fee. As the hospital has strictly no incentive to maximize recovering the fees, it is expected that no pressure is put on those who cannot pay. During the visit it was impossible to assess if there was any form of under the table payment for faster service or specific privileges.

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(k) The current organization does not engender any effort to improve responsiveness.Patient satisfaction is not measured and the staff has no incentives to improve responsiveness to patient needs. The governance model of the hospital is not related to community or patient representatives and this is another limitation to responsiveness.

The assessment of MGH’s technical performance pertaining to quality of care and scope of services shows the following:

(l) The physical environment and the limited staff are major constraints to quality of care improvement. The support staff provides a good cleaning service which could be improved with the introduction of hygiene, health and safety and infection control protocols and adequate supervision. Medical records exist as well as procedures to record activities; both of these provide necessary conditions for implementing quality assurance programs. A systematic review of hospital deaths and hospital stays longer than the average length of stay, per pathology, could provide the ground for improving quality of care. An important effort could be made in a better management and cleaning of the various stock rooms as support staff is sufficient for this task.

(m) In a hospital where there is a large proportion of low-immunity patients, hygiene is critical. If the overall aspect of the hospital looks fairly clean in the context of a decayed physical environment, it is not obvious that the patient benefits from all the preventive hygiene measures in the wards, in the operating theaters (e.g., quality of sterilization) and for all the invasive procedures. There is a separation of the waste: household waste is picked up by city waste service (the stock of waste in the hospital is unsecured), and medical waste goes to an outside premise (on the top of the hill). To implement hygiene, the whole distribution of the utility rooms and circuits of clean and soiled material would need to be reviewed to limit cross infection risk. With the importance of HIV, this matter should be considered seriously.

(n) The scope of service is below what would be expected in a referral hospital for a middle-income country of about one million inhabitants. All the current equipment is not utilized because of a lack of medical skills. When medical skill exists (as in urology, gynecology-obstetrics, and pediatrics, the equipment is lacking, sometimes even for low-cost effective devices. The consequence of this situation is inconsistency in the medical response to patient needs. Some fairly sophisticated services are present like dialysis (although this service is currently within ICU) while basic interventions like cataract surgery are no longer provided. Over the years, the scope of service has fluctuated, making it difficult for patients to rely on the hospital. There is no master plan describing the rationale for implementing specialties in relation to the national health priorities and the current supply of care. In the past 20 years, the scope of service has been reduced in a vicious circle of shortage of skilled doctors and insufficient up-to-date operating equipment (it is a chicken-and-egg situation: the question is not which one must come first but how both are going to be maintained to sustain high level interventions and activities).

The assessment of MGH’s economic performance pertaining to efficiency and productivity shows the following:

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(o) The absence of an organized emergency department and the important flow of unmanaged out-patients do not make MGH a very efficient hospital. The large inpatient wards where all types of pathologies are all together are not a sign of efficient clinical management. But to go beyond these considerations it would be necessary to analyze the hospital case mix and outcomes to measure if the medical response in MGH is adequate. To better support MGH’s referral function it might be necessary to start by the extension and upgrade of PHC in the various clinics of the country. In Mbabane, the lack of an effective health center and no formalization of relations with the private sector are factors affecting the efficiency of the hospital. Finally the little capacity for decision making is currently the major factor limiting improvement in efficiency because both the absence of incentives and the rigid institutional environment do not favor behavior to seek solutions to better utilize the hospitals assets. If MGH was to focus its activity on more specialized care the consequence would be a decrease of volume of activities. So not to face in the future the usual criticism on the low cost effectiveness of the hospital it is important to monitor case-mix and associated work load. Otherwise some will say that changing MGH to a high level referral hospital has made it less cost-effective: there may be a cost increase while activity has decreased (of course it is not the same type of activity, but it has to be supported by evidence)

(p) Considering the limited number of staff and the current activity of the hospital, labor productivity can be considered as fairly good in the country (under the assumption that quality of care is adequate; patients complain that nurse are there but not enough) Nevertheless the working schedules do not optimize the use of human resources, leading to overtime (which is not always paid triggering strong workers’ protests). It would be possible to restructure the staff planning to decrease overtime While there are long period of double team presence (a 12 hours schedule can be relevant in some specialties while a 8-10-8 schedule can limit overlapping to 2 hours a day). The health workers’ productivity has also to be assessed in relation with the outcomes related to quality of care and with patient satisfaction. The capital productivity is poor because of the poor physical and technical environment described previously. It is limited by the absence of incentives to optimize the utilization of capital. Unoccupied and overcrowded wards coexist.

The assessment of MGHs managerial performance pertaining to organization, decision-making process, and accountability shows the following:

(q) The organization is fully administrative, based mostly on reporting but not on monitoring progress or performance. This administrative organization is not supported by computerized system which would ease the monitoring and could lead to a decision-making process based on data rather than on the replication of routines or on assumptions.

(r) The current outsourcing of the kitchen is a good example of limited organizational performance. The current contracts do not take any of the advantages of out-sourcing on human resource management, maintenance and capital investment. Annual contracts trigger high transaction costs and offer little possibility for maximizing a surplus to share.

(s) There is a management committee, but it is totally overwhelmed by the day-to-day issues while there is no strategic thinking or planning. The institutional environment

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is the major cause of this situation: risk-taking is not rewarded and getting results is not recognized.

(t) Accountability is purely limited in the respect of rules. In an environment where the legal framework is weak and bureaucracy important, most of the accountability will be related to smooth day-to-day management in respect with the rules. In such a system, individuals try to find a protective "umbrella" to avoid responsibilities and certainly not look for innovative ways to better serve the people or better use the scarce resources.

B. KEY BOTTLENECKS AND SERVICE DEFICITS

A hospital is a system where a missing element downplays the overall performance.To improve hospital performance it is necessary to address at the same time several major bottlenecks. The core triangle of issues is related to: (a) organizational / institutional arrangements to favor incentive and good governance, (b) availability of skilled and dedicated human resources, and (c) physical (buildings and equipment) and technical (utilities and consumables) environment. The MGH has deficits in all these areas. It seems that over the past years, the overall performance has decreased due to the combination of deficit in each of these three areas.

The organizational and institutional shortfalls rely on (a) the legal environment and (b) the individual capacities in (c) a socio-cultural context. At present the legal environment is very centralized and decision making process is scattered in between numerous lines of powers both within the MOH and between MOH and the rest of the government. Within the hospital, although there is a manager, decision- making is limited because of small possible influence on resource allocation. The budget is of a few item lines (staff, transport, drugs, services, and consumables) to be spent under the authority of MOHSW which is in charge of purchasing goods (drugs and hotel commodities like consumables) and services (contracts). The staff, representing 80 percent of the current expenditures, is paid directly at central level. There is no incentive to develop activities because all recovered resources go to the Treasury. For human resource management, the hospital has little responsibilities except for rotation between the units and managing annual leave. The head of departments have barely any responsibilities in managing their inputs and there is no shared managerial governance with transparency on available inputs and decision making process. For all the key hospital players there is a deficit in management capacity, because they have received no training to fulfill such tasks. The socio-cultural context does not favor challenging established processes. The expatriate doctors as the heads of departments have also a limited influence due to their status. If with their contract they had a clear mission, it would be easier for them to be more active in the decision making process. Currently they may be afraid of losing their job if they interfere too much in the hospital management, especially when it comes to human resource related matters.

There is an obvious lack of skilled medical human resources; most of the specialists are expatriates under contracts. Over the years there is a turn over without a clear staffing policy to sustain and develop certain specialties and favor the tutoring of local Swazi doctors. There cannot be a project to develop MGH as a referral hospital without a long term human resource plan both to hire senior specialists on the international market and to train abroad enough local people to be able to take over in the coming years. The

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medical specialist market is global and the national retention strategy has to include an incentive package and a minimum 10 years contract to retain the nationals who have benefited from a scholarship abroad.

There is an obvious shortage of professional nurses. However, additional shortcomings are related to little incentive and sanction in relation to the work performed. The importance of dedicated and trained nurses for the specific activities of each service is also very important to sustain a specialized activity. More responsibilities for Heads of Departments and nursing sisters to report on staff performance linked with an incentive system could make a difference in the daily quality of care to the patients and would add to the willingness to learn and apply new skills.

Technical deficits in key areas are hampering hospital operations. It is not useful to develop all the numerous physical limitation faced by the services as fully detailed in the 2005 annual report. Nevertheless it seems important to stress that a referral hospital relies on the effectiveness of its technical wards. Although the laboratory has been upgraded with funds mostly coming from the HIV/AIDS programs, there are still some gaps: the pathology service is not effective, and blood availability is a recurrent problem. The Imaging Department provides only basic radiography; most specialized examinations as well as ultra sound imaging are not available (the CT scanner is not operating currently). The pharmacy reports an average 30% of out of stock from its essential drugs list. It would be rational to invest in critical equipment when there is a specialist who could develop activities with just the procurement of this equipment. If this can save some transfers of patients abroad, it should be expected to make this a priority. The lack of managerial capacity does not lead to document the need for these investments (a review of Phalala referral cases could provide the necessary information).

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CHAPTER 8: OPTIONS FOR HOSPITAL UPGRADING AND FINANCING ITS CAPITAL REQUIREMENTS

This chapter explores options for upgrading the MGH and for financing the capital

investments of such upgrading.

A. OPTIONS FOR HOSPITAL UPGRADING25

A restructured MGH can function as a central referral hospital concomitant with the upgrading or reconstruction of the regional hospitals except for Mankayane26. The options for MGH are to split the hospital into 3 arms:

• aprimary/ambulatory care facility with regional level hospital beds27. The primary care facility will act as a ‘gateway’ centre and prevent direct admission of patients to MGH’s specialist units except where a patient has been referred from another health facility. It must be staffed by generalist doctors supporting well trained nurse practitioners. The inpatient beds will be used by patients not needing specialist care and be managed by the generalist doctors and appropriately skilled nurses.

• a central referral hospital with multi-specialty inpatient wards and specialty outpatient clinics. The referral hospital should have the 8 general specialties (medicine, pediatrics, obstetrics and gynecology, surgery, orthopedic surgery, anesthetics, radiology, pathology) and various sub specialties and would depend on a formal epidemiological assessment of the health and disease profile of Swaziland [review the Demographic and Health Survey (DHS) study], the referral system and appropriate and adequate human, technological and financial resources. A well organized and resourced ICU / high care unit with emergency outpatient facilities should be part of the hospital. Patients can only access this hospital through referral from the primary care facility or from another health facility or as an emergency patient.

• a ‘step-down’ facility for palliative/supportive care for terminally ill patients (including those HIV infected patients needing supportive care) as well as patients treated in the referral hospital in the acute stages but needing lower level care prior to discharge or back referral to another health facility. This part of the hospital may not be differentiated by name to prevent stigma but be supported by a different skills mix of personnel. Of note is a short stay facility for patient’s

25 As the title of this section clearly states, these are options - not rigid recommendations - that the Government can consider. Even within the World Bank team that made this assessment, there were vigorous discussions and disagreements. What is laid out here is the "majority view" of the team. 26 Mankayane is well constructed but lacks the maintenance support and human resources. 27 On the other hand, it is not reasonable to separate a regional hospital from a national hospital in such a small country like Swaziland.

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families who come from areas outside of Mbabane and provide supportive care and support to the patient.

This report suggest a feasibility study of the development of a ‘greenfield’ site with easy geographic access versus on site reconstruction. An alternative option is the development of the current facility as a primary care facility with general inpatient beds functioning as a district hospital in Mbabane with the referral hospital being built on a ’greenfield’ site. The site may be equidistant between the major towns of Manzini and Mbabane. This may become a more expensive proposal given the lack of economies of scale and the shared support and managerial services on one site. Restructuring the hospital on site has to take in consideration the role of MGH for current service delivery. The hospital cannot be closed and restructuring by phases is longer, more expensive and very uncomfortable for patients and staff, especially in a compact hospital like MGH. The current building plans of the laboratory and the blood-bank have to be taken into consideration while studying the alternative plans for the development of MGH on a ‘greenfield’ site or on the current site. In many instances it is easier and more economical to construct a new facility at a new site given its intended specialist function and stature and the age and current physical state of the existing hospital. Adequate transport routes (air and road) must be taken into consideration for access and referrals of patients.

The regional hospitals need upgrading (except for Mankayane) and some general specialties (surgical, medical/pediatric, obstetric/gynecology) with strong family medicine support in the absence of the general specialties. Virtually all the regional hospitals require reconstruction and rehabilitation. (Clarity is needed about the planned hospital facility in the Lubombo region and the completed hospital in Manzini and their relationships to the GSH and RFM respectively). Perceived quality of care issues and a formally organized referral system are important considerations to prevent bypassing of the regional hospital to get to the new MGH.

MGH has some centers of repute (laboratory, ICU) and some specialists who are the only skilled persons in Swaziland (urologist, occupational therapist). A revenue sharing model and updated pricing model (between government and the resource person or facility) to use MGH facilities and the specialized skills should be considered. In addition, the health professionals can keep up their skill levels while allowing both the public and private patients access to care. This revenue generating model can build on the success of the private (full paying) wing currently in existence.

B. OPTIONS FOR HOSPITAL CAPITAL INVESTMENTS

The Government can consider various options for financing the capital investments for MGH. However, each option has inherent risks that must be weighed against the benefits. The traditional approach has been the separation of funding with service delivery. Typically, the Government or donor(s) provide the funding, and either the Ministry of Works or private contractor (through a tender) undertakes the construction. Years of World Bank experience through such mechanism has shown it is cost-ineffective, since private firms involved only in the design and construction of the facility have the incentive of “over-designing” or "over-sizing" the facility. This moral hazard problem manifests itself in the fact that the larger the hospital, the larger is the contractor's potential profits. There are also the usual problems of commissioning and

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staffing, once the construction is completed (e.g., the Mankayane Hospital, which the mission visited, remains to this day underutilized due to equipment breakdown (although recently provided) and a lack of staff accommodation.) Would-be contractors also tend to under-estimate construction costs just to get their foot in the door, leaving the funder at a loss for coming up with the additional resources when the construction is already underway. Finally, since the contractor is not at risk for operating the facility it built, it has no incentive for worrying about the recurrent cost implications of the new facility28 and there is no guarantee of improved service and health outcomes as performance standards and monitoring are not included. Thus, there is an inherent "moral hazard" problem of the traditional approach. Furthermore, there is a lot of room for possible corruption which leads to overestimation of actual cost and an important waste of public resources.

Paying contractors on a turn-key basis is superior to the traditional approach. Many projects have been financed in the nineties in the middle income countries under this scheme with often a strong support from Organization for Economic Cooperation and Development (OECD) countries to promote their national companies which benefit from the bids. The moral risk was considered as important as for the traditional approach. Corruption is always a major risk in the process of granting the contract and the provider has a certain interest to gain the bid but not to build and equip a cost effective hospital. In fact two opposite situations have resulted from turn-key approaches. In countries where there was a demand for technology the turn-key project have provided too sophisticated hospitals while local capacity and funding could not sustain it. In countries were budget concern was up front, the turn-key project has provided low quality building and equipment which never operated as it was suppose to. In these projects the consequences of investments on recurrent costs have been neglected. As in the traditional approach when national capacities are weak, turn key projects have strong moral hazard because providers are not accountable for operating the hospital.

In lieu of the above approaches, the government could use a novel contracting mechanism of Public Private Partnership, including the possibility of a long-term concession. One possibility is the use of a BOT scheme which combines both the building (B) of the facility and its operation (O), and its eventual transfer (T) to the government. Based on increasing evidence (Taylor and Blair, n.d.), significant efficiencies can be gained by Build-Operate-Transfer schemes to construct the new hospital andto deliver health services. BOT solves the "moral hazard" problem by making the contractor bear the risk for the construction as well as the operation of the facility. For instance, if the contractor overbuilds a facility, it will not be as profitable as when it is built of the right size. Achieving cost-savings through the BOT approach hinges on the participation of the private sector in long-term contracts for the design,

28 This statement is true in a situation where hospitals have no autonomy and government has weak capacity to monitor construction and equipping, which is the current situation in Swaziland. However, in countries where hospitals have autonomy and technical capacity to oversee construction and equipping, this traditional approach of funding and construction is quite effective and probably more appropriate than BOT/commissioning, as described below. For instance, in France which has adopted a BOT approach in competition with the traditional approach, it is considered that the BOT market won’t be more than 10 percent of the total construction market.

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financing, building, and operation of hospital facilities, which may be as long as 15 years (Taylor and O’Farrell, 2005).

The efficiency gains (“value for money”) from PPPs (including BOT) are clear, and the evidence base is increasing. Reviewing global case studies, Menheere and Pollalis (1996) concluded: “The greatest advantage…for the government is the subcontracting of the majority of the risks to the private sector, with the latter willing to finance and assume risks in the development of a public facility. At the end of the concession period, the government will inherit a well-operated project without investing public funds and with little risks. A consequence of not investing its own money is that the project can take place even if the government’s budget is limited. The finance is obtained by private organizations and the execution of the project is independent of the financial planning of the government. Furthermore, because the design, development, and construction are all the responsibilities of a single party, the concessionaire, the facility should be more effective and efficient.”

A more recent review of the key drivers of “value-for- money” from BOT schemes includes the following (IFS, 2003):

Risk transfer. The transfer to the private sector of those risks that it is better-able to manage, which includes most risks associated with the design, construction, operation, technological change, and finance.

Output-based specification. The requirement that services are specified in terms of payment for a specified output, on which performance can be measured, has been linked to quality and timing of delivery. This contrasts with the conventional approach to public procurement that is based on pre-determined funding of inputs.

Long-term nature of contracts. The time profile of contracts provides scope to recover costs of the initial investment, develop alternative approaches to service delivery, and focus on costing over the whole life of the project.

Competition. Value-for-money is easier to demonstrate where there is effective price-led competition.

The PPP success relies on capacity to fund the operation and to manage the transfer.A Government adopting a PPP approach has to put on the table the funding for the operation either through the access to insurance system or subsidies (paid on fee for service) guaranteed over the years. If there is no clear perspective of the annual potential resources no private company will engage in a money losing business. So PPP can lead to more efficient spending but requires enough resources. If the hospital sector is under-funded PPP will not be possible. For the transfer, the government must secure the conditions because otherwise the company will limit maintenance to reduce its operating cost. In this case when the hospital will be transferred major investments might be needed.

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The equity effects of PPP schemes, however, continue to be intractable. Very few studies have examined the effect on poor communities of the conversion (including contracting) of public hospitals. Studies in the U.S. show contrasting results. Bovberg, et al (2004) analyzed closures and conversions of public hospitals in five U.S. cities and concluded that the converted hospitals are struggling to maintain funding for indigent care, and that a safety net program funded outside of what the converted hospitals generate internally, is necessary. However, Legnini, et al. (1999) found that, in the five hospitals they studied, access to care for low-income patients have been preserved after conversion. If the PPP structure and contracting mechanism is not carefully constructed, it is possible that the contractor will “cherry-pick” health services and maintain only those it deems to generate a surplus, and get rid of those that do not, although these might be the very services that the poor need most. Although these are American experiences, they point to the same policy issues that hospital conversion in Swaziland would engender. To address these potential problems, the role of the Government as an active purchaser of health services must be strengthened by defining the key health services that it wants delivered to its citizens, setting goals, and monitoring outcomes. As a policymaker, the Government needs to define appropriate user fee levels and co-payments, as well as the needed waivers and exemptions for the poor, and how these can be funded out of the Treasury’s contribution, or through cross-subsidy mechanisms from private patients, if appropriate.

The socio-political effects of these schemes also need to be carefully assessed. Amajor cause of concern is job losses following reorganization by the private contractor (Prokosch and Dolan, 2001). To address this issue, it could be agreed that existing MGH health workers move over to the new hospital operator under conditions no worse than their existing pay and benefit conditions29. The new operator should also be required to provide a training program for health professionals, which should be the hallmark of the PPP. Excessive foreign involvement and the weak local participation in contracting and negotiation can also derail the process. There is no easy solution to this problem, but there is a clear need for both MOHSW and the Treasury to strengthen their technical capacity to negotiate, with technical assistance that can be provided by donors. Finally, BOT is new in the country, and although it is being discussed in other African countries, there is no precedent in the health sector except in South Africa, where it is becoming the standard practice. Towards this end, it would be necessary to glean experiences and lessons in other sectors/countries, and use these to inform the PPP process in the country.

29 To be sure, a simple transfer of staff to the private operator will not change the situation of low staff productivity and motivation. The operator should have the flexibility in human resource management (hire, discipline, and fire staff) to achieve the best results for the hospital.

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CHAPTER 9: OPTIONS FOR FINANCING HOSPITAL RECURRENT COSTS

This chapter explores various options to improve recurrent-cost financing for the

upgraded hospital. It analyzes trends in the government budget of MGH. It also looks at extra-budgetary resources including user fees; the potential savings from plowing back monies spent on referrals abroad; and maximizing reimbursements from private medical schemes, the workmen’s compensation fund, and motor vehicle insurance (road accident fund). Data scarcity and time limitations precluded a more comprehensive assessment of each of these potential revenues as well as other sources, e.g., hospital canteens and parking lots, training fees, research programs, technical affiliations, and donations. It is expected that a more careful financial assessment should be undertaken as part of the preparatory work for upgrading.

A. TRENDS IN MGH AND HOSPITAL ALLOCATIONS

Analysis of the budget and expenditure trends of MGH30 shows the following trends and patterns.

(a) The increasing focus on special hospitals has crowded out the spending on MGH, but most especially local hospitals. All hospital types received nominal increases in their allocations over the past few years, but as Figure 3 shows, the government has given preference to special hospitals (TB Hospital, which is newly constructed and soon to open, and Mental Hospital). As a result, the share of MGH to total hospital sector expenditures declined from 37.7 percent in FY03/04 to 35.7 percent in FY05/06. Regional hospitals such as the one in Mankayane was also newly refurbished and expanded, and a new hospital site has been cleared in the Lubombo Region, within minutes to the Good Shepherd Hospital. If these investments in special and regional hospitals continue apace, the resources that should go to MGH will be squeezed even further over the medium term.

30 By MGH, this section refers to the total of MGH line item (budget code 4104) and the ICU line item (budget code 4117).

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Figure 3. Trends in Expenditures on Government Hospitals (SE Million), by Category, FY03/04, FY04/05, FY05/06

55.841.5 36

14.8

70.7

5340

15.6

78.7

59.1 64.5

17.9

0

20

40

60

80

100

MGH+ICU Public GH Special Hosp Local Hosp

FY03/04 FY04/05 FY05/06

(b) MGH shows large variances between its budget allocation and expenditures from year to year, although this is a problem that also bedevils the entire MOHSW. Variances are particularly large for personnel and associated human-resource costs (see Table 10). Indeed, it seems the entire Ministry does not have a good handle on this issue. These overspendings were certainly caused, to a large extent, by the recent staff salary increases.

(c) The MGH input mix reflects a pattern of heavy use of personnel and drugs and medical supplies characteristic of tertiary facilities. MGH typically uses two-thirds (65-66 percent) of its expenditures on personnel costs and 19-22 percent on drugs and other medical supplies (see Table 11). In contrast, MOHSW as a whole uses less than half (43-46 percent) of its expenditures on personnel costs and about 13-18 percent on drugs; MOHSW does use a far larger proportion of its expenditures on other recurrent costs (39-44 percent). Care must be exercised in drawing conclusions from these figures, however, since certain other recurrent costs of MGH are incurred by other Ministries, e.g., repairs and vehicle maintenance are the responsibility of the Ministry of Public Works and Transport.

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Table 10. Recurrent Budget and Expenditures of the Mbabane Government Hospital and the Intensive Care Unit, by Major Cost Items: FY2003/04, FY2004/05,

and FY2005/06 (In SE Million)

FY2003/04 FY2004/05 FY2005/06 Cost

Items Budget Exp Variance Budget Exp Variance Budget Exp Variance Personnel costs, allowances, and SS costs

26.5 36.5 (10.0) 24.6 47.3 (22.7) 39.4 52.3 (12.9)

Drugs and other medical supplies

8.3 12.1 (3.8) 8.3 15.0 (6.7) 8.3 14.8 (6.5)

Other recurrent costs

9.0 7.2 1.8 8.9 8.5 0.4 8.9 11.5 (2.6)

Total recurrent costs

43.8 55.8 (12.0) 41.8 70.7 (28.9) 56.5 78.7 (22.2)

Totals are rounded figures. See details in the Annex. Source: This study.

Table 11. Recurrent Budget and Expenditures of MOHSW, by Major Cost Items:

FY2004/05, and FY2005/06 (In SE Million)

FY2003/04 FY2004/05 FY2005/06 Cost

Items Budget Exp Variance Budget Exp Variance Budget Exp Variance Personnel costs, allowances, and SS costs

98.6 131.1 (32.5) 147.3 165.2 (17.9) 151.2 185.5 (34.4)

Drugs and other medical supplies

53.3 53.1 0.2 39.7 51.0 (11.3) 45.9 57.0 (11.1)

Other recurrent costs

101.8 118.7 (16.9) 125.9 144.2 (18.3) 177.9 186.7 (8.7)

Total recurrent costs

253.7 302.9 (49.2) 312.9 360.4 (47.5) 375.0 429.2 (54.2)

Total are rounded figures. Source: This study.

B. USER FEES

Sliding scale user fee schedule should be implemented as soon as practicable. At present, user fees are uniform across all patients (except private patients, who are charged

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abit more). The current fee levels became effective on January 1, 1998, nearly a decade ago, and have not been adjusted to take account of inflation (see Table 12). Once the hospital improves its services and attracts a variety of clients including those with ability to pay, it must consider a sliding scale user fee schedule and charge those with ability to pay (those with insurance coverage, for instance) as near to the full cost as possible, even as it continues to charge much lower fees to the poor. Fees for high-tech diagnostic and imaging services need to be revised. Fee-paying patients under the proposed intramural practice of doctors must be charged appropriately so that they do not unduly receive government subsidy. In the case of the autonomous Kenyatta National Hospital in Nairobi, for instance, fees for expensive CT scans are artificially kept low, even as most of the patients using it belong to the middle- and upper-classes, resulting in perverse subsidy going to the rich. In the case of Malawi and Zimbabwe, the uniformly low fees subsidize patients with medical aid scheme coverage, thus benefiting the private medical schemes rather than the hospitals, which could very well use the foregone income. The Swazi user-fee policy stipulates that "market rate" will be charged to medical aid patients, but it is not clear how this is implemented, since no separate schedule has been developed for such patients. In any case, medical aid patients do not usually go to MGH, since "private practice" is not allowed in the hospital except for the use of the private wing.

Table 12. Fee Structure for Government Hospitals, Effective January 1, 199831

Services SE US$ Equivalent32 General Outpatients, consultation and medication

10 1.67

General Inpatients, accommodation per day (first 10 days)

6 1.00

Private Inpatients, accommodation per day (first 10 days)

60 10.00

Lab (per test) 3 0.50 X-ray (per film) 5 0.83 Ultrasound/ECG 20 3.33 Operations, General (minor - major) 15-25 2.50-4.17 Operations, Private (minor - major) 25-50 4.17-8.33 Mortuary (per day) 3 0.50 International vaccinations 30 5.00 Source: MOH

The Ministry of Finance should allow for fees to be retained at the facility where they are generated. Contrary to established best practice in most developing countries, in Swaziland, any fee revenues generated by government health facilities go to the MOF’s Consolidated Funds. No evaluation has ever been done on the revenue impact of the fee program. The recent experience of Mankayane hospital indicates that adding a small fee to the regular fee can provide a positive incentive because this money is retained locally

31 The fee schedule covers hospitals, health centers, and clinics, but only relevant hospital fees are reported in the above table. 32 At mid-2006 exchange rate of SE6=US$1.

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and allows urgent small expenditures which can smooth the hospital’s day to day operation.

The government should also consider differential fees for different levels of care, to reduce facility bypass. The current fee policy has uniform rates for all hospitals. A new, upgraded MGH acting as a referral facility should have fees higher than the other health facilities, except for primary-care services that it provides to the catchment area where these services are not available. The most effective model is to be able to have an internal self referral scheme with a gate keeping mechanism through OPD and ER. Specialist consultation when not related to emergency can be organized with appointments and adequate fees. A fee waiver system can complement this organization to allow access for poor patients needing specialist care.

C. FINANCING SCHEMES FOR MEDICAL REFERRALS ABROAD

Swaziland spends a considerable amount of resources for medical referrals to South Africa. Based on the World Bank (2007) assessment of the Phalala and Civil Servants' medical referral schemes (see below), these two funds will spend about SE 60.0 million on referrals to South Africa this fiscal year. In the previous fiscal year, the two funds spent SE 47.2 million. While no accurate estimate can be made of the number of cases that can be treated locally, it is clear that a significant number of them should not have been referred in the first place. These include: (a) terminal cases that have very little chance of getting better; (b) disease conditions that should have been averted if there were better prevention programs, e.g., cervical cancer, some cardiac cases that should have been dealt with earlier as chronic cases; (c) general specialties which represent 3 of the top 5 referred cases, including orthopedics, ophthalmology, and Eye, Nose, and Throat cases; and (d) "politically connected" cases that could be screened out if there were clearer criteria for, and a stronger system of, referrals. Thus, a significant proportion of the expenditures incurred in the two referral schemes could be plowed back to the country if "nondeserving" cases as explained above were not referred, and if some of the remaining referred cases can be treated locally, either at the "upgraded" MGH or at private facilities in Swaziland.

Civil Servants Medical Referrals Scheme. This scheme has been in operation since 1995. The beneficiaries include civil servants of Swazi nationality who are pensionable (i.e., excludes casual or temporary employees, contractors, and foreigners) and their dependents (spouse and children not above 21 years, or if the latter are still in school, not above 25 years). Under this scheme, beneficiaries can be referred outside Swaziland "if there is no available medical care in the country". The fund also provides US$120 per night per patient (maximum of 2 nights) for subsistence and transport allowance while in transit to the referral facility. The fund is administered by the Accountant General's Office, which is under the MOF. The scheme was funded initially by SE 10 million (about US$1.7 million), but rose to SE 14.4 million last fiscal year. In 2006, 2 percent of the total 7 percent annual salary increment of civil servants was channeled to the fund.

Requests for referrals to South Africa are sent to the Referral Board consisting of the Senior Medical Officer (SMO) of the Mbabane Government Hospital (head) and other MGH specialists. The Board assesses the validity of the referral request, and if it is found valid, the head or an assigned member of the Board contacts a relevant doctor (and

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hospital) in South Africa. The South African doctor/hospital sends a price quotation and, using this information, the SMO writes a letter of request to the Accountant General, who guarantees that the money is available to pay for this specific request. With this letter of guarantee, the patient is dispatched to South Africa for treatment. At the end of treatment, the doctor/hospital sends the bill to the MOF/Accountant General for payment. The referring doctor is not involved at all in this payment process. The government pays in full the billed amount.

Phalala Fund. The Phalala Fund shoulders the cost of referrals abroad of non-civil servants. In principle, this scheme is supposed to cover the medically indigent; in practice, it covers almost any Swazi national. Indeed, because of the lack of clarity in the scheme’s eligibility criteria, it is prone to abuse by influential members of society. In the opinion of many stakeholders, the scheme is poorly targeted and poorly managed. As one respondent noted, "Phalala is for people who know other people" (i.e., with connections). The scheme is funded through a "suspense account" of the MOF. In the last fiscal year, it spent SE 32.8 million.

In terms of procedures, the Phalala scheme is implemented very much like the civil servants’ scheme. However, in the Phalala scheme, only about 3/4 of the requests get final approval. Second medical opinions are often sought to ascertain the validity of the Phalala request for referral. Of the total number of patients referred under the Phalala scheme for the first five months of 2006, 37 percent was neurosurgery, 31 percent oncology, 15 percent ophthalmology, 11 percent orthopedic, and 10 percent cardiovascular cases.

The World Bank (2007) assessment of these two schemes revealed these major weaknesses:

Only a very tiny segment of the population (less than 1 percent) benefit from the large subsidy. This fiscal year, it is estimated that these two schemes will benefit about 1,500 patients; last fiscal year, they benefited 1,200 patients. The equity impact of the schemes, therefore, is highly adverse. The lack of cost-effectiveness guidelines and clear rationing criteria (in terms of age, severity, and disease prognosis) also implies that the fund could be used for cases that are of dubious social value. The same amount of money being spent on the two referral schemes now could gain a far higher level of welfare (measured in terms of disability adjusted life years for the total population) if they are used to support improvements in local health facilities which cater to a wider number of Swazis.

Fees and other prices are not negotiated beforehand and are completely supplier-determined. Fees are requested at the point of need, when the government is at its weakest negotiating position (especially for non-elective surgeries when the patient faces a real risk of dying if s/he is not dealt with immediately). The schemes are thus a "blank check" for South African doctors and hospitals: whatever amount that they ask is paid for by the Government. The number and regularity in the flow of patients should provide these schemes with a stronger negotiating position vis-à-vis providers of services, but this is not taken advantage of by the government as monopsony buyer of services.

The bifurcation of responsibilities between MGH referring doctors and MOF scheme administrators engenders supplier-induced cost inflation. The local referring doctors are

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involved only in the medical assessment and are not involved in fee negotiation or payment, which are the purview of the MOF/Accountant General. This process causes problems: (a) No patient tracking ever takes place, providing incentives to the admitting doctor or hospital to unnecessarily prolong the confinement of the patient. (b) No utilization review is ever undertaken, providing incentives to the admitting doctor or hospital to add superfluous tests or medications. Finally, bed confinement can be unnecessarily prolonged due to the unavailability of transport to bring home the treated patient.

The payment process suffers from management problems. The payor could mistakenly pay a bill twice or thrice due to multiple "reminder" billings. Misrouted bills of patients from other countries could also occur. Lack of computerization engenders these problems.

The schemes are financially nontransparent. Both the civil servants’ and the Phalala referral financing schemes do not produce any periodic or annual summary tables of their operations, much less an audited financial statement. At a minimum, the mission recommends that the following information be generated: Number of patients served, final diagnosis of illness, initial amount guaranteed by the MOF, final amount paid for by the MOF, attending doctor and hospital used by the patients. Summary statistics also need to be analyzed, e.g., volume of patients per doctor or hospital, cost per doctor or hospital.

Potential savings on referrals can be generated if the MGH is upgraded. An example from Lesotho could shed light on the magnitude of likely savings. Lesotho is currently replacing its tertiary facility, the Queen Elizabeth II Hospital (QEII), in part as an effort to save significant medical and airfare/other transport costs (and foreign exchange). QEII data from April 1, 2000 to March 30, 2001 show that 1,048 patients were referred to hospitals in neighboring Bloemfontein, mostly involving late-stage cancer (most of which would not have been referred if they were diagnosed earlier), cardiovascular, musculoskeletal, and kidney and thyroid cases (Bicknell, et al., 2002). This number of referred patients is admittedly low, and well below the critical volume needed to support astand-alone tertiary care service. However, what is not known are the other referrals that occur outside the purview of QEII Hospital, i.e., self-referred private patients who go directly to South African hospitals. While the actual number and cost of referrals are not known, it is estimated that at least Rand 10 to 12 million per year is being spent on referrals, of which Rand 4.5 to 5.0 million could be saved if services are upgraded at QEII Hospital. (In 2000/01, MOHSW actually paid Rand 4.14 million in claims, but this excludes remaining unpaid claims during the year, which is rolled over the next year). Based on the available data, Lesotho saved about 37.5 percent to 50.0 percent of the annual cost of medical referrals.

The government should consider the following options to improve both schemes.These options are not necessarily mutually exclusive.

• The rules of the Phalala scheme should be revised to allow payments to the new MGH hospital for services that patients can use instead of being referred to South Africa.

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• Conversion of the civil servants’ referral scheme into a full-blown mandatory and contributory medical aid scheme. This should permit for more professional management of the scheme, including use of health insurance principles and practices in patient gate-keeping, utilization review and case management, claims processing, management information system, reserve requirements, etc.

• Active and periodic fee negotiations before actual referrals are made.

• Limiting the number of accredited providers to those willing to provide services at a negotiated fee (through "preferred provider" arrangements) to reduce medical inflation.

• Contracting out the billing and claims review to a professional Third Party Administrator (TPA).

• Harmonizing the roles of the Referral Board (as gatekeepers) and MOF/Accountant General (as payor) of the scheme so that patient tracking and utilization review could occur.

• Computerization of the financial and information system.

• Organization of the ten-year administrative and utilization data so that an evaluation of the two referral schemes could be made.

D. OTHER POTENTIAL SOURCES OF HOSPITAL REVENUES

MGH should obtain reimbursements from private medical aid schemes. Extramural medical practice should be allowed at MGH so that it can receive insurance reimbursements from private medical aid schemes. The mission’s interview with Swazi Med Scheme indicates that it is not using MGH because private doctors are not allowed to use its equipment and facilities. Allowing extramural medical practice under an agreed-upon tariff revenue program between the hospital and private doctors would provide MGH with an additional revenue stream. Most of these private patients are currently being referred to South Africa, even if the required medical equipment and procedures are at MGH. Thus, existing MGH hospital assets are not being tapped for their full revenue potential.

MGH should maximize reimbursements from MVAF and WCF. MGH should pursue more active claiming of benefits by occupational or vehicular-accident patients from the Workmen’s Compensation Fund (WCF) and the Motor Vehicle Accident Fund (MVAF), respectively. These funds are underutilized, and they could be significant source of revenues for the hospital if it develops its traumatology department in relation with a more effective ER and ambulance system.

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CHAPTER 10: RECOMMENDATIONS AND WAY FORWARD

Improving the role of MGH will require mobilization of important resources. It must

be clear that potential savings both on existing schemes to finance care abroad will not be sufficient to finance the improvement of MGH. It must also be clear that the existing pattern for resource management does not favor optimal utilization. Therefore, injecting more resources makes it a priority to review the whole resource mobilization and allocation system. Considering the available resources, it will be important to make choices to favor the most effective expenditures. But tradeoffs should not all be made within the health sector which is currently seriously under funded. The burden of disease the country is facing should call for a more massive effort to finance health care to preserve the existing human capital. With a burden of disease from HIV of more than 50 percent of hospitals’ activities, it is expected that part of the funds under NERCHA would contribute to the improvement of hospitals’ service delivery. These resources should be additional to the ones supported by the MOH budget. A substitution of resources would send a very negative message on MOH engagement to improve the national health care delivery system.

Serious improvements will need a combination of organizational changes and resource mobilization both for MGH and the other health facilities. But before these actions impact on the actual performance of the hospital, it will take some years. It is then important to complement a medium-term plan by a series of emergency measures to provide an immediate effect, building confidence in the future both for the population and the staff. The government should be aware that providing these emergency measures without engaging in the suggested longer-term reform and capacity-building process will not be sustainable and might have negative effect as it will raise the hopes from the population and the staff.

A. SHORT-TERM ACTIONS FOR IMMEDIATE IMPROVEMENT

Institutional improvements. The ICU has a trading account (separate budget line) and if the assessment of this experience is positive, a similar trading account should be opened for the hospital which could receive an annual budget of SE 30 to SE 40 million (not including personnel costs) to cover its operational expenses. A guideline for the utilization of the funds would be provided to the hospital which should continue to purchase drugs at the Central Medical Store (except when a stock-out occurs, in which case drugs should be bought from the private market). A governance board should be implemented to favor transparency and information on decision-making and utilization of these resources. An audit of the utilization of funds should also be included in the guideline. This should be possible within public accounting and purchasing rules. Such a measure would allow the hospital to better respond to its priorities with a limited administrative burden. It would improve local responsibilities and commitment. Results would rely on hospital management team and not any more on the MOHSW decisions. This would shorten time for hospital decision making. With this measure, steps should also be taken to favor hospital initiatives to find additional resources to fund its activities.

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The hospital should be allowed to develop revenue-generating activities as long as they provide a net positive margin (e.g., renting the conference room, selling medical services to the private sector). The utilization of these additional resources should be specified by the MOH (e.g., for urgent repairs, or purchase of small equipment). These institutional improvements could be implemented for the next fiscal year to demonstrate government’s willingness to improve the situation at MGH. When implemented, it should be mentioned that these measures constitute a transition before the government moves to hospital autonomy.

Operational improvements. To guide the most urgent operational improvement two considerations should be taken: the current skills-mix and the analysis of the medical transfers to South Africa. The alignment of existing medical skills with equipment and vice versa could contribute significantly to improve the effectiveness of MGH. Most of the heads of department have submitted lists of priority equipments that could enhance their medical practice and quality of care. The planning department of the MOH just needs to organize a few meetings with the hospital management team and the heads of department to better prioritize this list in relation to recurrent costs and outcomes for the patients. Within a two-year plan for a SE 15 to 20 million, most of the needed equipment could be bought and implemented. The budget and procurement process for consumables needed for the new equipment will have to be implemented when purchasing of equipment is done.

Technical and physical improvements. The medical equipment should be secured in a safe technical environment. The utilities (e.g., electricity) will have to be reviewed to avoid instigating any premature breakdown. It might also be necessary to refurbish some rooms to allow an efficient utilization of some of this equipment. For the patients, a minimal investment plan could be proposed by the MGH to improve inpatient hospital stay. A limited budget of less than SE 5 million for the two coming years could contribute to this, mostly in repairing the toilets and ablution areas and in insuring a little more privacy for the patients. The hospital management team should be responsible for preparing an action plan and following up its implementation. The resources could be made available on the trading account to reduce delays and transaction costs.

B. MEDIUM-TERM ACTIONS FOR SUSTAINABLE IMPROVEMENT

The development of MGH will be relevant and sustainable only if it is fully related to a national health development plan and to a hospital development plan. For this reason sustainable improvement cannot be considered in a short-term horizon. Starting in July, a full assessment of the supply of health care service will be undertaken (service availability mapping - SAM project) and the DHS study is currently undergoing. These two studies are critical to launch a health service planning process. This section will not cover institutional issues related to human resources, civil works and resource mobilization and allocation but will only outline the planning process leading to the upgrading of MGH.

Determine the scope of services and in-patient capacity of the hospitals of the country. The SAM project will allow prioritizing the efforts to provide district hospital level of care in each of the regional hospital and in some of the most remote health centers. A hospital referral system relies on a solid first line of hospitals which should be

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accessible for almost all the population. This first line hospital care would provide the most cost effective care in medicine, pediatrics, gynecology-obstetrics and surgery. Based on the DHS study, the activities (patient admissions, occupation ratio and average length of stay per specialty) of the hospitals (including the private sector), and the trend of evolution of HIV related morbidity on estimates of bed needs can be made and a list of essential hospital services to be delivered. Compared to the current situation, it will possible to present the gaps for each hospital and the priorities in filling these gaps.

Finalize a hospital program for each hospital. There is a need to undertake a full physical and technical assessment for each hospital to measure the gaps between the current physical condition of operation and what is needed to respond to its priority mission. The country has to adopt standards setting its minimal requirement in term of service organization and inpatient lodging conditions. The Mankayane Hospital could serve as a reference to set these standards. This planning exercise relies on specialized hospital planners which are not available in Swaziland. Architects and civil work engineers do not have the capacity to write on their own a hospital program. But once the program for each hospital is written they will have to make a feasibility study to draw a hospital master plan. These feasibility studies should only be done once the government has engaged on priorities. To develop a hospital development plan there are two options. Either there is an upgrading process all over the country following priorities related to service delivering, or there is a plan to upgrade each hospital one after the other. If enough resources can be mobilized it will be more effective and rapid to upgrade each hospital in a 5 year plan covering all the country. If the resources are not sufficient then a 10 year plan with an upgrading process all over the country will be more suitable. In both cases it is recommended to have a hospital master plan for each hospital.

Articulate the development of MGH with the hospital development plan. The MGH should follow the same process than the other hospitals but it should also include a list of services to be able to respond to regional hospital referral needs and to minimize transfer abroad. Considering the specific cost of transferring abroad and the very poor condition of this hospital, there is a need for a master plan, which should be done only once the other hospitals have finalized their program and once the plan for the health delivery system in Mbabane region has been completed33. This master plan should rely on a program that is currently missing and on feasibility studies. The economical analysis of the various options will determine the next steps for the development of MGH. The current extension of the hospital is not a cost- effective choice. Surfaces are extremely over-sized, there is no functional analysis, and this construction might limit rational decision making on the future location of the hospital. If the option is to refurbish the hospital on-site, then the master plan should consider reutilization of a large portion of the building under construction, most probably to host technical services. The upgrading of MGH will require major investments because it will be necessary to restructure the hospital organization. Refurbishing the existing building is a "short-view" option because the potential reduction in investment cost will be paid in higher operating costs while the inpatient services will still not be appropriate to respond to the referral needs.

33 Who would consider adequate to start a building by designing its roof??? A referral system is similar, once foundations are laid than if is possible to build the top floor.

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C. ASSESSMENT OF THE FEATURES OF THE PROPOSED REFERRAL HOSPITAL

The table below summarizes the possible general features of the proposed central referral hospital and the advantages and disadvantages of each feature.

Table 13. Advantages and Disadvantages of Different Features of the Proposed Central Referral Hospital

Possible Features of the

Proposed Central Referral Hospital

Advantages Disadvantages

Policy and legislative changes to provide greater autonomy and decision- making, including the project’s possible definition as a Public Private Partnership

Legal framework protects management. MOH manages by results and holds the CEO/manager of MGH accountable. PPP contract provides managerial and operational accountability.

Will be outside some of the civil service frameworks. Will need skilled management team at MOH and MGH to manage the process.

Function as a stand-alone high level specialist referral hospital

Ideal opportunity to break with the past and create a new MGH. Patients can only access MGH by referral except for emergency care.

Financial viability may be questionable. Loss of economies of scale and shared services and infrastructure. Need well developed referral system.

Function as a high level referral hospital together with a primary care, regional and a step-down facility

All facilities provided on one site but operating as different cost units under unified management. Can share support services and infrastructure.

Needs skilled management, good management systems, and a well developed referral system. May revert to status quo. Will need differentiated skill-mix of personnel in the different facilities.

Current site Easy access to patients. Close to MOH and other government departments.

No facility to decant patients to during construction of new buildings / renovations. Utilities (electricity, sanitation and water, telecoms) may not be satisfactory. May prove to be a costlier option.

'Greenfield' site Easier to program and plan on a new site. Will become symbolic of a quality health system.

Need to assess access of patients taking into account equity (geographic and indigent). Transfer of staff may become an issue if outside Mbabane.

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Financing model – public/ private partnership

Government need not put up entire capital immediately. Current trend in the region with positive examples May stimulate revenue generation and improve service delivery. Will provide a contractual mechanism for accountability, insure maintenance and enhance project sustainability.

Need transaction advisors and contract management capability. Procurement systems need to be intact. Long term contracts required to enable private investors to get their return on investment. MOH and MOF must ring fence the project’s annual payments within the budget, to insure that Government’s contractual obligations are met, which in turn provide support for recurrent expenditures.

Financing model by MOH/ Ministry of Public Works and Transport

Centrally managed and controlled.

May divert scarce management resources given the magnitude and complexity of the project. Private contractors may over design or over build the hospital, since their profits depend on the size of the contract and are not at risk for the operation of the facility. Not linked to performance targets or services improvements.

Source: This study.

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ANNEX 1: Selected Health Expenditure Figures in Southern African Countries, 1999 and 2003

Indicators Year SwazilandBotswana Lesotho Namibia South

Africa 1999 6.4 5.2 5.4 7.0 8.7 Total HE as % of

GDP 2003 5.8 5.6 5.2 6.4 8.4 1999 59.0 54.3 80.9 73.3 41.1 Gov’t HE as % of

total HE 2003 57.3 58.2 79.7 70.0 38.6 1999 41.0 45.7 19.1 26.7 58.9 Private HE as %

of total HE 2003 42.7 41.9 20.3 30.0 61.4 1999 11.8 6.7 9.1 13.1 10.7 Gov’t HE as % of

total gov’t expend. 2003 10.9 7.5 9.5 12.4 10.2 1999 0.0 n.a. 0.0 1.2 3.5 SS exp. on health

as % of gov’t HE 2003 0.0 n.a. 0.0 1.9 4.6 1999 18.6 22.7 n.a. 74.7 77.4 Private health

plans as % of private HE

2003 19.6 21.8 n.a. 76.0 77.7

1999 40.9 30.3 20.0 21.3 17.1 OOP exp. as % of private HE 2003 42.4 28.8 18.2 19.2 17.1

1999 10.3 2.2 3.6 2.4 0.1 Donor HE as % of total HE 2003 5.5 2.9 8.2 5.3 0.5

1999 87.0 138.0 28.0 127.0 257.0 US$ per capita total HE 2003 107.0 232.0 31.0 145.0 295.0 Key: HE = health expenditures; SS = social security; OOP = out-of-pocket spending. Source: World Health Report 2006.

Source: Data gleaned from www.who.int/whosis/country/indicators.cfm

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ANNEX 2: Guide to the Budget Heads and Responsibility Centers of MOHSW Budget and Expenditure Data as Used in This Study

Budget &

Expenditure Items

Budget Codes

Specific Budget Heads or Responsibility Centers Included in This Study

Minister’s and PS’s offices

10,11 Minister’s Office (1001); Principal Secretary’s Office (1102); Institute of Health Sciences (1103); Research & Planning Unit (1104); and Nat’l Adv. Com. on Substance Abuse (1105).

CMS & central lab

21 Central Medical Stores (2101) and Central Laboratory (2102).

Public health programs & health centers

32 Health units and health centers in Mankayane (3201), Mbabane (3202), Hlatikulu (3203), King Sobhuza II (3204), Siteki (3205), Pigg’s Peak (3206), and Manzini (3212). Primary Health Care (3207); 3208, Nutrition Councils (3208); National Oral Health Services (3209); Tuberculosis Center (3210); and Bilharzia Control Unit (3211). Health inspectorates in Manzini (3213), Hhohho (3214), Shiselweni (3215), and Lubombo (3216). Biomedical Engineering (3217); AIDS Program Unit (3218); Unidentified Program (3219); Health Education Unit (3221); and Special Health Care (3222). Regional clinics in Manzini (3223), Hhohho South (3224), Hhohho North (3225), Shiselweni (3226), and Lubombo (3227).

Hospitals 4101 to 4110 4117

Hospitals including Mental (4101), Mankayane (4102), TB (4103), MGH (4104), Nhlangano (4105), Pigg’s Peak (4106), Hlatikulu (4107), Sithobela (4108), and Dvokolwako (4109). Special Medical Care Unit (4110) and Intensive Care Unit at MGH (4117).

Of which, MGH+ICU

4104 4117

MGH (4104) and Intensive Care Unit (4117).

Other regional clinics & noncommun-icable disease control

4111 to 4116 4118 to 4120

Regional clinics in Manzini (4111), Hhohho/ Mbabane sub-district (4112), Hhohho/Pigg’s Peak sub-district (4113), Shiselweni (4114), Lubombo (4115), and Matsanjeni (4116). Noncommunicable Disease Control Program (4118). Emkhuzweni Health Center (4119) and Maguga Clinic (4120).

Social welfare

51 Social Welfare (5101) and Mbabane Children’s Clinic (5102).

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ANNEX 3: Recurrent Budget and Expenditures of the Mbabane Government Hospitals and ICU,

by Major Cost Items: FY2003/04, FY2004/05, and FY2005/06 (In ’000,000 )

FY2003/04 FY2004/05 FY2005/06 Cost Items Budget Exp Variance Budget Exp Variance Budget Exp Variance

MGH Personnel costs, allowances, and SS costs

24.3 33.4 (9.0) 22.6 43.4 (20.8) 35.6 51.1 (15.6)

Drugs and other medical supplies

5.8 9.8 (4.2) 5.8 12.7 (6.9) 5.8 12.9 (7.2)

Other recurrent costs

5.2 4.7 (0.5) 5.2 5.2 Negl. 5.1 6.2 (1.1)

Total, MGH

35.3 47.9 (12.7) 33.6 61.2 (27.6) 46.4 70.3 (23.9)

ICU Personnel costs, allowances, and SS costs

2.2 3.1 (0.9) 2.0 3.9 (1.9) 3.8 1.2 2.6

Drugs and other medical supplies

2.5 2.3 0.2 2.5 2.3 0.2 2.5 1.9 0.6

Other recurrent costs

3.8 2.5 1.3 3.7 3.3 0.4 3.8 5.3 (1.5

Total, ICU

8.5 7.9 0.6 8.2 9.5 (1.2) 10.1 8.4 1.8

MGH + ICU Personnel costs, allowances, and SS costs

26.5 36.5 (10.0) 24.6 47.3 (22.7) 39.4 52.3 (12.9)

Drugs and other medical supplies

8.3 12.1 (3.8) 8.3 15.0 (6.7) 8.3 14.8 (6.5)

Other recurrent costs

9.0 7.2 1.8 8.9 8.5 (0.4) 8.9 11.5 (2.6)

Total, MGH+ICU

43.8 55.8 (12.0) 41.8 70.7 (28.9) 56.5 78.7 (22.2)

Source: Summary table constructed from computer printouts produced by Joseph M. Khumalo, Accounts Department, MOHSW, June 7, 2006. Totals are rounded off figures.

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Annex 4: Map of Swaziland

67

LIST OF PERSONS INTERVIEWED

Dr. Kayode O. Akingba, Head of Department, Paediatrics, Mbabane Government

Hospital Ms. Catarina Andrade, Health Economist, NERCHA; seconded to MOHSW Dr. K.A. Badejo, Head of Department, Obstetrics and Gynaecology, Mbabane

Government Hospital Ms. Busi Bhembe, Executive Director, Baylor College of Medicine - Bristol Myers

Squibb Children’s Clinical Centre of Excellence - Swaziland Ms. Ncamsile Buthelezi, Architect, Ministry of Public Works and Transport Mr. Charles Dlamini, Head of Accounts, Mbabane Government Hospital Ms. Hlobsile Dlamini, Management Services Division, Ministry of Public Service and

Information Ms Kabelo Dlamini, Occupational Therapist, Mbabane Government Hospital Mr. Leonard Dlamini, Hospital Administrator, Raleigh Fitkin Memorial Hospital Mr. M.P. Dlamini, former Nursing Registrar, Swaziland Nursing Council Ms. Nellie Dlamini, Director, Management Services Division, Ministry of Public Service

and Information Ms. Nomathemba Dlamini, Principal Secretary, MOHSW Ms. Nombulelo Dlamini, Assistant Statistician, MOHSW Ms. Phallokati Dlamini, Laundry Department, Mbabane Government Hospital Mr. Sigelela Dlamini, Acting Principal Secretary, MOHSW Mr. Sipho Dlamini, Catering Manager, Royswa Food Services Ms. Thokozile Dlamini, Matron III, Mbabane Government Hospital Ms. Thulile Dlamini, Inservice Education Coordinator, Mbabane Government Hospital Dr. Adam Groeneveld, Head of Department, Urology, Mbabane Government Hospital Ms. Musa Fakudze, Principal Secretary, Ministry of Finance Dr. E. Austen Ezeogu, Senior Medical Officer, Mbabane Government Hospital Ms. Thembisile Khumalo, Registrar, Swaziland Nursing Council Mr. Titus M. J. Khumalo, Assistant Director, Management Services Division, Ministry of

Public Services and Information Mr. Abson Kunene, Senior Health Administrator, MOHSW Ms. Senani Mabaso, Ophthalmic Nurse, Eye Clinic, Good Shepherd Hospital Dr. Cusphina Mabuza, Director of Health Services, MOHSW Dr. Sanele N. Mabuza, Head of Department, Ophthalmology, Mbabane Government

Hospital Ms Thulie Magagula, Head of Department, Pharmacy, Mbabane Government Hospital Dr Vusi S. Magagula, Head of Department, Dental Services, Mbabane Government

Hospital Mr. Jabulani Malindzisa, Inspector of Works, Biomedical Department, Mbabane

Government Hospital Ms. T. A. Maseko, Hospital Manager, Mbabane Government Hospital Dr. N. J. Matekere, Head of Department, Intensive Care Unit, Mbabane General Hospital Dr. L. D. Mathunjwa, Chairperson, Swaziland Medical Association Dr. Murmly Mathunjwa, Faculty of Health Sciences, University of Swaziland Mr. Dumisani Mavuso, Quantity Surveyor, Ministry of Public Works and Transport Dr. Mazibuko, VCT Center, Mbabane Government Hospital

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Ms. Gladys T. Mbambo, Matron I, Mbabane Government Hospital Ms. Glory S. Mbisi, Nursing Registrar, MOHSW Ms. Futhi H. Mdluli, CEO, Raleigh Fitkin Memorial Hospital Mr. Masitsela Mhlanga, President, Swaziland Nurses Association Ms. Emmah Nomsa Mlangeni, Matron I, Mankayane Government Hospital Ms. Thabsile g. Mlangeni, Principal finance Officer, MOF Dr. Mlawanda, VCT Center, Mbabane Government Hospital Mr. Jamieson M. Mlipho, Senior Human Resource Officer, Ministry of Public Service

and Information Ms. Dorica Mndzebele, Medical Technologist, National Reference Laboratory Ms. Beauty Mnisi, VCT Center, Mbabane Government Hospital M. Munta Mntungwa, Undersecretary, MOHSW Ms. Phindile Motsa, Health Management Information System, Mbabane Government

Hospital Mr. Patrick N. Muir, Director, Human Resource Training Department, Ministry of Public

Services and Information Mr. Robert Ngcobo, Orthopedic Technician, Mbabane Government Hospital Mr. Ezekiel Nxumalo, Stores Officer, Mbabane Government Hospital Ms. Maris P. Nxumalo, Deputy chief Nursing Officer, MOHSW Dr. D. Okello, Country Representative, WHO Dr. Okonda, Pathologist, National Reference Laboratory Dr. Patrick P. Okuth, VCT Center, Mbabane Government Hospital Dr. Aby Philip, Medical Superintendent, Good Shepherd Hospital Ms Thobile Seyama, Acting Head of Department, Radiography, Mbabane Government

Hospital Ms. Tsabedze Shadrack, SAPO, Ministry of Economic Planning and Development Mr. Dumisani Shongwe, Health Planning Officer, MOHSW Ms. Bethy Simdare, NPH Matron, MOHSW Mr. Peter Similane, Manager, Swazi Medical Scheme Dr. Nonhlanhla A. Sukati, Senior Lecturer, Faculty of Health Sciences, University of

Swaziland Mr. Jabulani P. Tibana, Maintenance Engineer/Manager, Ministry of Public Works and

Transport Ms. Zwane Thembie, Acting PPO, Ministry of Economic Planning and Development Ms. Happy R. Tsabedze, Hospital Administrator, Mbabane Government Hospital Mr. Richard Walwema, Lab Supervisor, Mbabane Government Hospital Dr. Derek Von Wissel, Director, NERCHA

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