Need for Hospital Reform and Draft Road Map

Malawi German Health Programme

04/2010

Outline

1. Current situation: demand, supply, results

2. Challenges and possible solutions

• Improved decision making in CH

• Reorganisation of CH

• Additional Funding

3. Roadmap2

3

1. Increasing demand

50000

60000

70000

80000

90000

100000

2002 2004 2006

Admissions

100000150000200000250000300000350000400000450000

2002 2004 2006

OPD Attendance +165% + 56%

QECH 2002-2007

Increasing budgets

4

Better results?!

5

 

total admissions

adm./daytotal patient

daysavg. length

of stayin-patients per day

deathin-patient

mortality (%)

Jan-07 268 8,6 1039 3,87 33,5 85 31,7

Feb-07 273 9,7 1179 4,31 42,1 68 24,9

Mar-07 310 10,0 970 3,12 31,2 61 19,6

Apr-07 249 8,3 1221 4,90 40,7 64 25,7

May-07 260 8,3 977 3,74 31,5 60 23,0

Jun-07 246 8,2 721 2,93 24,0 66 26,8

Jul-07 251 8,1 1019 4,05 32,8 65 25,9

Aug-07 300 9,6 1078 3,59 34,7 71 23,6

Sep-07 336 11,2 1075 3,19 35,8 67 19,9

Oct-07 315 10,1 1201 3,81 38,7 60 19,0

Total 2808 9,2 10480 3,73 34,3 667 23,7

Medical Dptm KCH in 2007 Each and every day > 2 patients die in one single ward …

6

2. challenges

Lack of Human Resources

Low Motivation

Quality of Care

Limits to Decision Making

Overcrowding/ High Workload

Underfunding

7

solutions

Lack of Human Resources

Low Motivation

Quality of Care

Limits to Decision Making

Overcrowding/ High Workload

Underfunding

Increased Decision Power

8

solutions

Lack of Human Resources

Low Motivation

Quality of Care

Limits to Decision Making

Overcrowding/ High Workload

Underfunding

Increased Decision PowerReorganisation

9

solutions

Lack of Human Resources

Low Motivation

Quality of Care

Limits to Decision Making

Overcrowding/ High Workload

Underfunding

Increased Decision Power

Additional Sources

Reorganisation

I. Strengthening adequate Decision Making within Hospital Management

11

e.g. Financial Management…

0

500

1000

1500

2000

2500

3000

3500

4000

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Admission Paediatric Ward QECH Fiscal Year 2007-2008

12

e.g. Financial Management…

020406080

100120140160180

Jul

AugSep O

ctNov

Dec Jan

Feb Mar Apr

Jun

Expenditure Budget

13

e.g. Financial Management…

0

500

1000

1500

2000

2500

3000

3500

4000

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Admission Paediatric Ward QECH Fiscal Year 2007-2008

020406080

100120140160180

Expenditure Budget

Financing inputs

Financing outputs

ResultBased

Financing

II. Reorganisation of Central Hospitals

15

Functions of the Central Hospitals in Malawi

• Tertiary care

• Training

• Research

• But also: Secondary care (district hospital)

• And even: PHC (OPD)

III

II

I

16

e.g. efficient use of resources

Diagnosis Number Percentage Cumulative percentage

1 Malaria 14,758 15.6 15.6

2 Pneumonia 11,514 12.1 27.7

3 Other non-communicable diseases 9,097 9.6 37.3

4 Other surgical conditions 6,065 6.4 43.7

5 Diarrhoea (non bloody) 5,430 5.7 49.4

6 Gynaecological disorders 4,360 4.6 54.0

7 HIV/AIDS 4,311 4.5 58.5

8 Pneumonia < 5 years 4,272 4.5 63.0

9 Anaemia 3,641 3.8 66.8

10 Tuberculosis 3,375 3.6 70.4

Top 10 diseases for admissions, QECH, July 2007 – June 2008 (Total = 94,747)

Majority of patients = primary and secondary care

OPD becomes nested health

center

Administrative separation within Wards (embedded District Hospital)

III. Cost Recovery andAlternative Sources of

Financing

18Use of Government health services by socio-economic group (L. Mangham 2006)

Incidence of illness

Gvt. Hospital Utilisation

Gvt. Health Centre Utilisation

Quintile

1 (poor20%) 20% 23 % 14 % 18.2 %

2 20% 26 % 17.8% 22.7%

3 20% 29 % 20.9% 18 %

4 20% 31 % 22.3% 26.1%

5 (rich 20%) 20% 29 % 24.9% 15 %

Residence

Urban 11.3% 7.1% 16.3% 6.8%

Rural 88.7% 92.9% 83.7% 93.3%

e.g. Equity

•Cost recovery in private wards

•Private insurance

•National Health Insurance ?!

19

Lack of Human Resources

Low Motivation

Quality of Care

Limits to Decision Making

Overcrowding/ High Workload

Underfunding

Increased Decision Power

Additional Sources

Reorganisation

IV. Road Map

1. Allocating responsibilities

2. Specifying the content of the reform measures

3. Identification of governing structure and board composition

4. Drafting legislation

5. Determining personnel policies and transition arrangements

6. Developing systems, procedures and plans

7. Communication to staff and the public

8. Preparation of service plans

9. Developing service level agreements and performance management systems

10.Selecting and training key managers and board members20

2. Content of the reform

21

Financial management

HR management

Service development

planning

Limited autonomy

Permission to reallocate funds within the yearly budget

staff remain civil servants but hospital can e.g. select or reject staff

plans have to be approved by MoH

Full autonomy

The hospital has complete control over its finances and can decide how to develop and spend its budget

Hospitals decide on recruitment and staff policies; they set their own staffing levels and salary scales

discretion to develop services and raise fees as long as these meet the service agreements with MoH

Approach

22

Thanks a lot !