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Implications of Decongesting Central Hospitals on Gate Clinics: Case study of Zomba Central Hospital in Malawi

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Zomba Central Hospital

GREVASIO MCHIGULUPATI CHAMATAMBE

100237367

A dissertation submitted in partial fulfillment to the requirements for the

Award of Master Degree in Strategic Management By

University of Derby

30th September, 2012

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Abbreviations ART Antiretroviral therapy

BP Blood Pressure

CIP Capital Investment Plan

CO Clinical Officer

DA Dermatology Assistant

DIP District Implementation Plan

DHO District Health Office(r)

DHMT District Health Management Team

DRG Diagnosis Related Group

DT Dental Therapist

EC European Commission

GTZ German Technical Co-operation

GIZ German International Co-operation

HIV Human immunodeficiency virus

HMIS Health Management Information System

HSSP Health Sector Strategic Plan

HTC HIV Testing and Counseling

IMF International Monetary Fund

LA Lumefantrine Artemther

LT Laboratory Technician

MA Medical Assistant

MCH Maternal and Child Health

MIM Malawi Institute of Management

MOH Ministry of Health

NPM New Public Management

OCO Ophthalmology Clinical Officer

OECD Organisation for Economic Co-operation and Development

OPD Outpatient Department

UK United Kingdom

UNDP United Nations Development Programme

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SWAp Sector Wide Approach

WBR World Bank Report

WHO World Health Organization

PMTCT Prevention of mother to child transmission

RDTs Rapid Diagnostic Tests

RN Registered Nurse

RTA Road Traffic Accident

TQM Total Quality Management

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Table of Contents Abbreviations ........................................................................................................................... 1 Figures ...................................................................................................................................... 5 Tables ....................................................................................................................................... 5 Acknowledgement ..................................................................................................................... 6 Executive Summary ................................................................................................................... 7 Chapter 1: Introduction 1.1 Overview ........................................................................................................................ 10 1.2 Background .................................................................................................................... 10 1.3 Problem statement ......................................................................................................... 12 1.4 Aim of the Study ............................................................................................................ 12 1.5 Research questions ....................................................................................................... 13 1.6 Road Map ...................................................................................................................... 14 Chapter 2: Literature Review 2.1 Overview ........................................................................................................................ 15 2.2 Public sector reform ....................................................................................................... 15 2.3 Health Sector Reforms ................................................................................................ 16

2.3.1 Universal Coverage health reforms ....................................................................................... 16 2.3.2 Cost control reforms ............................................................................................................ 17 2.3.3 Improving quality of health services .................................................................................. 17 2.3.4 Multi-skilling of health manpower ...................................................................................... 19 2.3.5 Centralization of hospitals .................................................................................................. 20 2.3.6 Decentralization.................................................................................................................... 20

2.3.6.1 Decongestion ................................................................................................................ 22

2.4 Critical lessons from the literature .................................................................................. 22 2.5 Way forward ................................................................................................................... 23 Chapter 3: Methodology 3.1 Overview ........................................................................................................................ 25 3.2 Introduction to research ................................................................................................. 25 3.3 Research Paradigm/Philosophy ..................................................................................... 26 3.4 Research Approach ................................................................................................................... 27

3.5 Research strategy .......................................................................................................... 27

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3.6 Research Purpose ......................................................................................................... 27 3.7 Research Design ........................................................................................................... 28 3.8 Research methods ......................................................................................................... 28 Chapter 4: Findings and Analysis 4.1 Overview ........................................................................................................................ 31 4.2 Limitations of the study .................................................................................................. 31 4.3 Strategic direction in decongesting central hospitals ..................................................... 31 4.4 Customer/community perspective .................................................................................. 33

4.4.1 Location ................................................................................................................................. 33 4.4.2 Health conditions that respondents presented at Zomba Central Hospital ................ 34 4.4.3 Factors that prompted respondents to seek OPD service from central hospital ....... 35 4.4.4 Rating of Zomba Central Hospital and Health centres .................................................. 37 4.4.5 Respondents’ approval of transferring (closing out) outpatient services for general

public to primary health care level. .................................................................................... 39 4.5 Business processes perspective .................................................................................... 40

4.5.1 Workload of outpatient department ................................................................................... 40 4.5.2 Stock out days of essential drugs...................................................................................... 42

4.5.3 Infrastructure ......................................................................................................................... 43 4.6 Financial allocation for renovating and refurbishing gateway clinics .............................. 43 Chapter 5: Conclusion and Recommendations 5.1 Overview ........................................................................................................................ 45 5.2 Conclusion ..................................................................................................................... 45 5.3 Recommendations ......................................................................................................... 47 Chapter 6: Personal Reflection 6.1 Overview ........................................................................................................................ 50 6.2 Major lessons learnt ....................................................................................................... 50 6.3 Challenges ..................................................................................................................... 51 6.4 Summary ....................................................................................................................... 52 Appendices

Appendix 1: Participant Briefing and consent and withdraw letters ........................................... 53 Appendix 2: Data collection tool 1: Individual questionnaire for OPD Clients .......................... 56 Appendix 3: Data collection Tool 2: Questionnaire for In-charges of Gateway clinics ......... 60 Appendix 4: Data collection tool 3a: Guiding questions for District Health Management Team ...... 65 Appendix 5: Data collection 3b: Guiding questions for Ministry of Health Planning) ............ 67

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References .............................................................................................................................. 68

Figures Figure 1: Levels of health care services in Malawi

Figure 2: Balanced scorecard

Figure 3: Onion research layers

Figure 4: Respondents’ health conditions Figure 5: Gateway clinics’ OPD Workload Figure 6: Clients at under-five OPD clinic

Figure 7: Adult OPD patients waiting to register

Tables Table1: shows reason for choice of data collection method/tool

Table 2: closest public health facility to respondents

Table 3: Reasons that persuade people seek OPD services at Zomba Central Hospital

Table 4: Rating of Zomba Central Hospital

Table 5: Health centre/gateway clinic rating

Table 6: Do you approve closing of outpatient department to general public.

Table 7: Status of Stock-out days of some selected essential drugs at Gateway

Table 8: Staffing levels of gateway clinics

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Acknowledgement I would like first of all to thank my wife and youngest son, Kondwani Chamatambe for their

encouragement and withstanding challenges encountered during the study; I therefore,

dedicate the study to them.

The author is indebted to Zomba Hospital Director, Dr. Martias Joshua, in development of the

study and for authorizing the study to be conducted at his institution.

The author acknowledges all participants in the study, the patients and clients at Zomba

Central Hospital Outpatient department, health centre in-charges, Mr. Medson Semba, Zomba

District Health Officer, and his DHMT members for support and responses given during the

study. Without their support and cooperation the study would not have been successful.

The author appreciates valuable input and guidance that was provided by Dr. Margaret

Sikwese, the independent study supervisor.

The author is also indebted to Dr. Dieter Koecher, former GIZ Health Coordinator, whose

organization provided scholarship for the study.

The author would like to thank Peter Makaula, Dr. Esther Ratsma, Mr. Macdonald Msadala,

Sekelani Phiri, Wiseman Chimwaza and Peter Dickson who provided moral and material

support during the study

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Executive Summary Central hospital is tertiary care health facility and supposed to provide highly specialized

services to patients that have been referred from lower levels of care. Unfortunately, most

central hospitals in the world including those in Malawi are providing services that are

supposed to be provided by primary and secondary levels of care in addition to providing

tertiary care services. Consequently, central hospitals are congested. Zomba Central Hospital

is one of the four central hospitals in Malawi. Zomba Central Hospital is a referral health

facility for six districts of Balaka, Machinga, Mangochi, Mulanje, Phalombe and Zomba in the

South Eastern Region of Malawi. The central hospital is congested with minor health

conditions which do not require specialist attention. There are a lot of self-referred clients and

patients who seek primary health care services in both under-five and adult outpatient

departments. People by-pass primary health care facilities and come directly to tertiary level

facility without being referred. Decongestion of central hospitals is a deliberate arrangement

intended to transfer out-outpatient services for general patients/clients to primary health care

level facilities. This cross-sectional study was conducted to find out how these primary health

care facilities were performing in decongesting Zomba Central Hospital. Both qualitative and

quantitative research methods were employed in the study. Individual questionnaires were

used to collect data from self-referred patients/clients at Zomba Central Outpatient department;

and health centre in charges. In-depth interviews were used to collect data from District Health

Management Team members and Ministry of Health.

The research findings were presented following four perspectives of balanced scorecard. The

balanced scorecard is a planning and management system, which is commonly used in both

private and public sectors to present a comprehensive overview of how an organization is

performing. The key findings were as follows:

With regard to strategic direction, study findings indicate that Ministry of Health did not have

three strategic documents (road map, human resource policy and minimum infrastructure

requirements for gateway clinics) in place to guide the decongestion process of central

hospitals. In addition, MOH did also not commit itself because the Capital Investment Plan for

2011 to 2016 did not contain financial allocation for renovating and extending gateway clinics.

Zomba Central Hospital and Zomba District Health Office were implementing the reform

process without policy guidance but rather implementation was based on gentleman

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agreement, good working relationship of the management teams of the two institutions.

Unfortunately, absence of a clear strategic direction affected readiness of the four perspectives

of balanced scorecard.

The study findings further show there were two major factors that forced people to seek

primary health services at central hospital. First, most respondents complained of persistent

stock-outs of drugs at health centres and that many people had inadequate knowledge

regarding the functions of central hospitals. Consequently, they regarded the central hospital

as any health facility.

With regard to business processes, the study revealed that the gateway clinics were not

providing wide range of health services except Matawale Health Centre. The other clinics did

not have capacity to offer some services due to shortage of human resource and equipment.

The study further shows that all gateway clinics experienced stock-out of all tracer drugs

except Tetanus Toxoid Vaccine, which was available throughout the year. Shortage of drugs

was a leading factor that persuades people to seek services at the central hospital.

Matawale Health Centre had the highest workload of outpatient attendance of 229% which

signified that the facility was already overstretched. Therefore, focus of strengthening gateway

clinics should have been directed at the other four clinics so that more patients and clients

seek primary health services from these facilities. A further study should be done to find out

why Zomba City Clinic, despite having second the largest workforce among the gateway

clinics, has low outpatient utilization.

It is evident from the study findings that the gateway clinics are not ready to fully take over all

services offered by central hospital and therefore, it is recommended that Ministry of Health

should not only develop four strategic documents to guide the whole process of decongesting

central hospitals but should commit itself by allocating adequate financial resources in the

Capital Investment Plan (CIP). In course of implementing decongestion of central hospital at

operational level, the district health management and Central hospital teams should implement

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the decongestion process in phases not wholesale to allow adequate time for learning and

capacity building.

The District Health Management Team should conduct gateway clinic regular supervision to

check quality of health services provided to community and availability of essential drugs at

facility level.

The District Health Management teams should deploy additional health workers with diverse

skills to gateway clinics so that the facilities offer a wide range of outpatient services to satisfy

the wants and interests of the clients.

The District health management team should ensure that community feedback mechanisms

are put in place to constantly get views of patients, clients and general public and regularly

review the views to identify areas that require strengthening.

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CHAPTER 1: Introduction

1.1 Overview

Chapter briefly presents background, problem statement, goals and objectives of the study.

The chapter also discusses research questions and presents a road map of the research

1.2 Background

Congestion of central hospitals is a major problem in developing countries in the world.

Usually, the communities by-pass the health primary health facilities and go directly to central

hospital without being referred (Cullinan, 2006).

In Malawi, Public health services are offered at three levels. These are primary, secondary and

tertiary health care levels of services (MOH, 2011) as illustrated in the figure 1 below:

3 2 1 Figure 1: Levels of health care services in Malawi (Source: MOH, 2011) According to WHO (2006) and Centre for Disease Control (2006), the primary function of

tertiary referral hospitals is to provide complex clinical care to patients transferred from lower

levels. However, the current Malawian practice is that central hospitals perform all three

functions. The central hospitals provide primary health care services, which are supposed to

be done at health centres and health posts. The central hospitals also offer secondary health

care services, which are supposed to be taken care of by community or district hospitals.

Tertiary – Central

Hospitals

Secondary -Community & District Hospitals

Primary health care- Health posts/ Dispensaries/Health centres

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In addition, some communities do not fully use health centres, which are close to them, but

instead they go directly to central hospitals for OPD and primary health care services.

Consequently, the central hospitals are congested and sometimes they are blamed for using

huge health budgets while still offering low quality tertiary health care services (Hensher, Price

& Adomakoh, 2006).

Ministry of Health in Malawi is implementing a number of health sector reforms and central

hospital reform is one of them (MOH, 2011). Within the central hospital reforms there are

number of reforms and these include out-sourcing of some services such as security, catering,

cleaning; and decongestion. The study will focus on decongestion of central hospitals.

The central hospitals are being decongested to ensure that central hospitals provide equitable

access to tertiary quality health care services to all Malawians (MOH, 2011). The decongesting

process has focused on removing general OPD and primary health care services from Central

Hospitals to health centres (also known as Gateway clinics) around these central hospitals.

Decongesting central hospitals is part of public sector reform and is in line with Malawi

Decentralization Policy of 1998, which gives powers to District Councils to manage health

centres, health posts, communicable diseases and provision of health education services to

their district population.

The main objective of decongesting central hospitals is to ensure that these hospitals focus on

providing specialized and quality tertiary health care services to patients referred from lower

levels of care (MOH, 2011).The proponents of decongesting central hospitals argue that

specialists and doctors spend a lot of time in attending to patients with common minor

conditions, which can easily be managed at health centre level. Consequently, the specialists

do not have adequate time for patients that need their attention (Cullinan, 2006).

There are four public central hospitals in Malawi. These are Queen Elizabeth, Zomba, Kamuzu

and Mzuzu central hospitals. Zomba Central Hospital has been chosen, because it is close

and convenient to the investigator and some processes have already started in decongesting

this hospital.

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1.3 Problem statement Central hospitals are tertiary health care facilities and are supposed to provide specialized

health care to complicated cases that have been referred from lower levels of health care. The

challenge is that people go directly to central hospitals with minor common illnesses without

being referred thereby causing congestion. Gateway clinics were introduced with the aim of

decongesting the central hospitals. However, since this health sector reform was introduced,

there has been no systematic study to understand how the gateway clinics are performing.

Information on how these clinics are performing will provide strategic guidance on how to

improve the system as well as how to approach future reforms.

1.4 Aim of the Study The research was aimed at providing comprehensive recommendations to Ministry of Health

regarding key important factors that should be incorporated and improved in decongesting

Zomba Central Hospital as well as how to approach future reforms.

1.5 Objectives of the study

Objective 1: To find out reasons why patients and clients attend central hospital for outpatient

and primary health care services

Objective 2: To find out capacity of gateway clinics to accommodate additional services

Objective 3: To investigate if the District Implementation Plans (DIP) for fiscal years 2011/2012

and 2012/2013 have adequate financial allocations to support renovation and refurbishments

of Gate way clinics.

Objective 4: To investigate whether the MOH has put in place strategic policy instruments to

enable and guide decongestion of central hospitals.

.

Objective 5: To provide comprehensive recommendations to Ministry of Health on how to

improve decongestion Zomba Central hospital.

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1.6 Research questions In order to have comprehensive overview on the preparedness of the gateway clinics, a set of

research questions are formulated under each perspective of the balanced scorecard. The

balanced scorecard is an approach that is used extensively in business and industry,

government, and nonprofit organizations worldwide to align business activities to the vision

and strategy of the organization, improve internal and external communications, and monitor

organization performance against strategic goals (Kaplan and Norton, 1990) as seen figure 2

below.

Figure 2: Balanced scorecard according to Kaplan/Norton with 4 future perspectives

Finances: • How much funds are allocated in the District

Implementation Plans for renovation of Gateway clinics?

• How much funds are allocated in capital investment plan of MOH to support District health offices towards renovating Gateway clinics?

Customers (patients and clients): • Why do patients go to the central hospital for OPD & primary

health care services? • What are their views regarding the change? • How many OPD patients treated over one year period and

proposed gate way clinics at both CHs and gateway clinics?

Internal business processes: • Which services are offered at central

hospital OPD and whether similar services will be offered at gateway clinics

• Is there adequate infrastructure (equipment, rooms) to cater for these OPD and primary health services at gateway clinics?

• Does the District Health Officer have the number and skill mix of staff to meet demand at these clinics?

• Does MOH have any provision for additional staff to support DHOs to run gateway clinics?

Vision and Strategy: improve quality of tertiary health services: decongesting Central Hospitals by removing OPD & primary health services to Gate way clinics Can gate way clinics decongest central hospitals in their current state? What changes are required for gateway clinics to successful decongest central hospitals?

Learning and Innovation: • Does MOH have HR policy on staffing norm for gateway clinics regarding how many health workers

and skill mix needed to run gateway clinics? • What is the time frame for the whole process or road map? Is it wholesale removal of primary

health care services? • What is the magnitude of patients/clients at OPD that are not supposed come directly to central

hospital?

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1.7 Road Map This section shows how the whole research is structured. Chapter one is introduction, chapter

two is literature review, chapter three is methodology, Chapter four is research findings,

chapter five is conclusions and recommendations and chapter six is personal reflection.

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CHAPTER 2: Literature Review

2.1 Overview This chapter discusses various public sector reforms, health sector reforms, decentralization

as part of public sector and health sector reforms and its link to decongestion of central

hospitals. The chapter draws lessons learnt in implementing these reforms and contextualized

in four thematic areas of balanced scorecard. With regard to balanced scorecard, major

lessons are drawn on strategic direction, customer involvement, employment participation and

human resource management position. The chapter also highlights lessons learnt on

infrastructure development and resource allocation. The chapter ends with a conclusion.

2.2 Public sector reform

Reform is used to describe many changes from minor adjustments to management

arrangements to fundamental changes in ownership, governance and management

arrangements. Genuine public sector reform can be defined as change in processes that either

produces a measurable improvement in services or a noticeable change in the relationship

between institutions of the state and the citizens (European Commission, 2009). Many

developed countries have carried out New Public Management (NPM) types of public sector

reform in the 1980s and 1990s (Hemant 2009) and developing countries like Malawi have also

undertaken public sector reforms and continue to reform. Public sector reform is a deliberate

action to improve the efficiency, effectiveness, professionalism, representativity and

democratic character of a public service, with a view to promoting better delivery of public

goods and services, with increased accountability. These reforms can include data gathering

and analysis, organizational restructuring, improving human resource management and

training, enhancing pay and benefits while assuring sustainability under overall fiscal

constraints, and strengthening measures for public participation, transparency, combating

corruption and creating conducive environment for private sector investment as a result of the

reversal of socialist policies of 1960s and 1970s (OECD,1996;Hood, 2003; Hemant, 2009,&

Victor, 2009). Motivations for reform mostly arise in response to social, economic and political

problems. Governments are pressurized to reform by their constituents, civil society

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organizations and civil servants. Sometimes the reforms are driven by outsiders in case of

donor aid dependent countries (EC, 2009). Globalization and changing of political systems

have also contributed to public sector reforms in some countries (Hemant 2009 and EC, 2009).

World Bank, International Monetary Fund and European Commission have been instrumental

in supporting government reforms in most countries in Asia, Eastern Europe, Latin America

and Africa (OECD, 1996, UNDP 1999, WBR 2001 and EC 2009).These organizations have

supported governments to undertake various reforms ranging from structural adjustment

including decentralization, public financial management, human resource management, anti-

corruption, deregulation and privatization. IMF supports public financial management reforms

including foreign monetary policies. On the other hand, World Bank and European

Commission have supported implementation of public sector reforms on structural adjustment,

anti-corruption and decentralization (EC 2009) whilst UNDP has put more focus on

decentralization and governance (UNDP 1999).

2.3 Health Sector Reforms

Health sector reforms are sustained processes of fundamental change in the policy and

institutional arrangements in the health sector designed to improve functioning and

performance of the sector (WHO, 1997). Literature shows countries have taken various health

sector reforms either as part of public sector reforms or as individual health sectoral reforms.

The health sector reforms include universal health coverage, cost control, centralization, multi-

skilling quality improvement and decentralization.

2.3.1 Universal Coverage health reforms World Health Organization reports that the universal coverage reforms have been

implemented with aim of reducing out-of pocket payment and increase prepayments for health

services. Universal coverage as policy objective means that everyone has access to

appropriate care when they need it and at affordable cost. Chinese public hospitals were

lowly subsidized; consequently the citizens had to pay higher prices for health services out of

pocket. The high prices denied majority of people from accessing the health services (WHO

2006). Public health sector is being reformed to reduce out of pocket payment. The emphasis

of universal coverage is on prepaid and pooled contributions. According to WHO, nearly all

developed countries provide guaranteed health coverage to their citizens except USA which

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introduced Obamacare recently. For instance, Germany Social code indicates that medical

care should be provided solely according to an individual’s needs, whereas the financing of

care is based solely on the individual’s ability to pay. The UK’s National Health Service

provides comprehensive universal coverage with no financial access barriers. The federal

government in Canada contributes to provincial plans only if care is provided to all citizens with

minimal financial impediments. Out of pocket payments are below 23% of total health spending

in most EU countries (WHO). According to the author’s experience, Malawi is implementing

universal coverage of health services whereby government funds for provision of free health

services in government health facilities to its citizens and sometimes enters into service level

agreements with private health facilities if government health facilities are far away and the

citizens can best be served by private health facility (MOH Final SWAp Report, 2010). Malawi

has taken UK model of financing of public health services. However, WHO argues that

universal and comprehensive insurance coverage is not sufficient to ensure equitable access

to health services and points out that health authorities should pay attention to rational

deployment of providers so that health services are readily available.

2.3.2 Cost control reforms World Health Organization reports that cost control reforms have been introduced after

realizing that technology and ageing population were driving up health spending in developed

countries. Most OECD countries have enacted cost control measures that regulate prices and

volumes of health care and inputs (wages, prices and health–care production resources) into

health care, caps on health care spending, either overall or by sector and shifts cost onto

private sector through cost- sharing. Wage controls have been instituted in context of broader

public sector pay restraint in countries such as Denmark, Finland and UK. Price and fees

controls are in place between purchasers and providers in countries like Belgium, France and

Germany. All OECD countries have put administrative prices for pharmaceutical drugs with

exception of Germany, United States and Switzerland.

Most EU countries have pre-marketing controls to determine whether a new technology is safe

and cost-effective for a particular use.

2.3.3 Improving quality of health services These reforms focus at improving quality of health services. The implementation of quality

improvement reforms are done with or without altering the basic structure or organization

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(Withanachchi, 2007). The approaches to quality improvement include establishing technical

standards and clinical guidelines, strengthening of patients’ rights, quality assessment and

accreditation and continuous improvement (Withanachchi 2007). World Health Organization

notes the reforms on quality have focused on increasing accountability for quality provided to

patients and clients. World Health Organization further reports that most developed countries

have improved information systems and standards to enhance health system performance. For

instance, Czech Republic established DRG-based system, a device for hospital management,

and uses it to measure quality and output across hospitals. United Kingdom conducts

mandatory public reporting on performance of health providers and patient safety and rewards

high-performing providers with more funding. Professional associations monitor professional

quality among doctors in the Netherlands. Countries and hospitals adopt different concepts

and models to improve quality of health services. Castle Street Hospital for Women in Sri

Lanka implemented total quality management (TQM) by using 5-S principles, a management

tool used in car manufacturing industry in Japan. 5-S principle was discovered Hiroyuki Hirano

in late 1980s. The approach was applied to hospital setting to improve quality of health

services. The hospital identified items that were not necessary and disposed them off (sort),

secondly they arranged the necessary items in good order to avoid time wastage of finding the

items when need arises (Set order).cleaned the workplace to make workplace safe (sweep),

then the hospital standardized by maintaining the first 3 S’s and the last S is Sustaining the

good practices. Usually the model is used without additional resources in terms of equipment

or human resources.

The balanced scorecard approach (Kaplan and Norton, 1992) was used to assess the

performance of the hospital in order to capture accomplishments on multiple objectives and

multiple aspects. The success in implementing quality improvement reform using the model

was attributed to, among other factors, good leadership of the hospital director and top

management, continuous monitoring, improvement in communication between management

and employees, and participation of employees in the quality cycles (Withanachchi, 2007).

Sahlgrenska University Hospital implemented quality improvement in reducing waiting time at

outpatient clinics without additional human resources (Eriksson 2010). Three major lessons

are drawn from successful implementation of this initiative including adequate time is required

in understanding and analyzing the situation to identify bottlenecks and methods to solve the

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challenges. Secondly, the reforms were introduced in phases. Eriksson reports that the

initiative started with Rheumatology clinic in 2001, then Dermatology and Venereology clinics

in 2004. The third factor was that all employees were involved by providing their opinions and

participation in quality improvement cycles.

2.3.4 Multi-skilling of health manpower The multi-skilling of health care providers is the latest type of health sector reforms. Hurst

(1997) and Adamovich (1996) argue that bulk of health care should be given by multi-skilled

careers, not functional, compartmentalized and overspecialized professionals, who work to

custom and practice, tend to underutilize their knowledge and skills. The rationale of multi-

skilling calls for re-appraising and redesigning of work roles from traditional professional

boundaries so that health workers provide a wide range of services to patients and clients

(Martin and Healy (2009).

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2.3.5 Centralization of hospitals

The Norwegian Parliament transferred the ownership of all public hospitals from the county

governments to the central state (Hage, 2006).The Norwegian hospital reform of 2002 was an

attempt to make restructuring of hospitals easier by removing politicians from the decision-

making processes. To facilitate changes seen as necessary, the central state took over

ownership of the hospitals and stripped the county politicians of what had been their main

responsibility for decades. This meant that decisions regarding hospital structure and

organization were now being taken by professional administrators and not by politically elected

representatives (Trond, 2009). The reform did not only transfer ownership from 19 counties to

the central state. Two other elements in the reform were of equal importance. First, hospitals

were set up as health enterprises or trusts and organized within five Regional Health

Authorities (RHA). (Second, both the health enterprises and the RHAs were to be governed by

boards comprising professional members. The Minister of Health, acting as their general

assemblies appointed the board members at the RHA level (Trond, 2009). But the hospital

reform did not deliver as far as the budgetary discipline in the sector is concerned; the deficits

in the sector persisted also after the central state took over ownership. The restructuring of

hospitals met resistance from employees, local politicians and trade unions such that some

decisions which were made by RHA were reversed by parliament. In a fact the restructuring of

the hospitals decreased access to certain services as some services were being transferred

out to other counties. For instance, people have to travel long distances get some services

such as maternity units.

2.3.6 Decentralization Many countries have implemented decentralization of health sector as part of public sector

reforms under structural adjustment programmes (UNDP1999 & Muriisa 2008).

Decentralization is the transfer of powers from central government to lower levels in a political-

administrative and territorial hierarchy (Crook and Manor 1998, Agrawal and Ribot 1999).The

power transfer can take two main forms. Administrative decentralization, also known as

deconcentration, refers to a transfer to lower-level central government authorities, or to other

local authorities who are upwardly accountable to the central government (Ribot 2002).

Political, or democratic, decentralization refers to the transfer of authority to representative and

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downwardly accountable actors, such as elected local governments (Larson).The three types

of administrative decentralization are devolution, delegation and deconcentration.

Devolution is the transfer of governance responsibility for specified functions to sub-national

levels, either publicly or privately owned, that are largely outside the direct control of the

central government (Ferguson and Chandrasekharan).

Delegation is the transfer of managerial responsibility for specified functions to other public

organizations outside normal central government control, whether provincial or local

government or parastatal agencies (Ferguson and Chandrasekharan).

Deconcentration is defined in number of ways; Sayer defined deconcentration as the process

by which the agents of central government control are relocated and geographically dispersed.

Ribot (2002) in Larson defines deconcentration as a transfer to lower-level central government

authorities, or to other local authorities who are upwardly accountable to the central

government.

Many countries have decentralized primary health services though details vary from country to

country with different components assigned to government levels. Ghana implemented

devolution in decentralizing its health services. Ghana’s Legislation decentralizes authority to

quasi-private entities and gives individual hospitals responsibility for management of direct

service decisions and operations (Govindaraj 1996, Atkinson 1999).Lesotho, Tanzania and

Zambia followed deconcentration type of decentralization. Lesotho has separated

management of hospitals from the primary health care facilities. Primary health care facilities

are managed by district health office whilst District and tertiary hospitals are managed by

hospital management teams. This reform was carried out to ensure that primary health care

activities are given adequate attention in terms of planning and funding but the reforms did not

specifically focus at decongestion of hospitals (Lesotho Decentralization Policy, 2003). The

policy document of Lesotho also specifies staffing levels and skill mix for primary health care

facilities. Legislations in Zambia and Tanzania mandate district health management system to

devolve planning and clinic development and implementation responsibilities to districts and

area specific, legally constituted Health management Boards, which are meant to play critical

role in operating clinics (Kalumbe, 1997). However, Limbambala(2001) reports that Zambia

made some achievement in decentralization and accountability when it implemented health

sector reform from 1993 to 1998 but the reform failed to meet its objective of equitable

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accessible to health care. The major reason was poor handling of health reform by civil

servants because politicians and planners did not reach consensus on type of reform and poor

maintenance of infrastructure (Limbambala, 2001).

2.3.6.1 Decongestion Decongestion of central hospitals is both part of health sector reform and in the context of

decentralization, it falls under deconcentration. Decongestion is an institutional arrangement

which deals with removing of outpatient department and other primary health care services

from central hospital to Gateway clinics (GTZ Mission Report, 2009). Gateway clinics in this

study are referred to as government health centres that are close to the central hospitals and

are earmarked to take over responsibility of managing primary health care activities from

central hospitals. In context of decongestion, there is limited literature regarding closing general outpatient

department for general patients and primary health care services. South Africa implemented

decentralization of health services following primary health care approach in health service

provision as per their Primary Health Care Blue paper of 1996 (Cullinan 2006). Although

policy document points out patients using the public health system should only access higher

levels of care once they have been assessed and referred upwards by health workers at a

lower level, it was noted that people were still accessing primary health care services at high

levels of care. The two major contributing factors were that primary health care facilities were

not given adequate attention in terms of infrastructure development and frequent shortage of

drugs and related supplies. In addition literature reveals that primary health facilities did not

attract health workers because they did not have basic amenities such as electricity, water

and proper communication. The facilities had inadequate rooms and equipment to provide all

necessary services coupled with persistent stock-outs of drugs and other supplies (Cullinan

2006). On the other hand, the literature does not indicate that general outpatient departments

in central hospitals were completely closed to general outpatients.

2.4 Critical lessons from the literature In summary, the literature demonstrates that reforms are unavoidable but require adequate

preparation before embarking on them. Thorough understanding of the prevailing problems

and environment in the process of initiating change are very vital for successful implementation

of any reform (Europe Aid 2009, Eriksson 2010 and WDR 2008).It is important to identify major

23

bottlenecks and methods that can be used to resolve these bottlenecks to meet desired

changes.

Good leadership has played vital role in initiating and implementation of reforms. The literature

demonstrates leadership through development of vision, mission and strategic legislations and

policies that define clearly on desired changes (Cullinan 2006,Hage 2006,Kalumbe 1997,

UNDP 1999 and Withanachchi 2007).The desired changes should be agreed by all

stakeholders including politicians (Kalumbe, 1997). The most successful reforms established

steering committees or indeed recruited fulltime professionals to oversee daily operations of

the reforms and report progress to the top management on regular basis (Eriksson 2010,

Kalumbe 1997 and Withanachchi 2007 and). Since changes take time and sometimes people

may resist change, several authors have pointed out the need to introduce changes in phases

and provide adequate time frames to allow learning by doing and developing capacity before

moving to the next levels (Eriksson 2010, Withanachchi 2007 and UNDP 1999). Some health

sector reforms were successful because majority of employees were actively involved in

reform processes and in some cases the employees provided their input before the reform

processes start (Eriksson 2010, Maddock 2002, Porter 1997, Withanachchi 2007 and UNDP

1999). Since reforms are geared at improving service delivery to the customers, several

authors have recommended that the customers’ opinions and views should be incorporated in

designing changes (Karassavidou 2009 and UNDP 1999). In the context of decentralization,

community participation is a prerequisite (UNDP 1999). Whilst some reforms can be

implemented without major resource allocation, some reforms like decentralization of health

services in South Africa and Lesotho required heavy resource allocation (Cullinan, 2006).

Failure to provide adequate financial resources and good infrastructure negatively affected

primary health centres (Cullinan 2006).

Continuous monitoring and improved communication are seen as vital elements for successful

implementation of reforms (Eriksson 2010, Karassavidou 2009 & Withanachchi 2007).

2.5 Way forward A number of factors will be explored in the study and therefore, the author recommend that the

study should employ total quality management tool called balanced score card (Kaplan and

Norton, 1992). The balanced scorecard framework can provide comprehensive overview of

processes leading to decongesting central hospital and meet the study objectives.

24

With regard to strategic direction, it is recommended that the study should investigate the

leadership role of the central Ministry of Health in decongesting central hospitals in terms of

policy direction and resource allocation for gateway clinics. It is recommended that the study

finds out if the ministry has a road map that guides and tracks progress made on processes

leading to decongesting the central hospitals in Malawi with specific timeframe as to when the

whole process will be completed.

In addition it is recommended that the study should find out whether the MOH has a unit with

full time officers to manage hospital reforms including decongestion of central hospitals.

Regarding customer perspective, it is also recommended that the study should find out factors

that influence patients and clients to seek OPD services at central hospitals and seek their

views and recommendations on the proposed changes.

With regard to business processes, it is recommended that the study identify strengths and

weaknesses of gateway clinics from in-charges and get some suggestions on how to improve

the gateways clinics to accommodate increased workload of primary health care services from

central hospital.

In relation to financial perspective, some reforms failed because they were poorly funded.

Therefore, it is recommended that the study investigates if the central Ministry of Health has

earmarked funds for gateway clinics. The study should investigate this aspect as well from

District Implementation Plan (DIP) for Zomba District Health Office if it contains itemized

budget for construction or renovations of gateway clinics.

In recognition of learning and innovation perspective, it is recommended that the study

examines necessary skills required to deliver all primary health care services at gateway

clinics and finds out if the DHO and Ministry of Health have health workers with these skills to

run these clinics and Ministry’s position on skill mix requirements based on expected

processes that should be taking place at gateway clinics.

25

CHAPTER 3: Methodology

3.1 Overview The chapter contains introduction to research, spells out research philosophy and approach.

The chapter also highlights research strategy and discusses details regarding on which

respondents each research method will be used. The research will use both qualitative and

quantitative research methods.

The research aims at providing a comprehensive direction to Ministry of Health on best way to

strengthen gateway clinics to successfully decongest Zomba Central Hospital and use the

lessons learnt in processes of decongesting other Central hospitals in Malawi. In order to

answer research problem, questions and research objectives the research will need to collect

data from four types of respondents who have interest in changes in management of general

outpatient department and primary health care services from central hospital to gateway

clinics.

A questionnaire will be administered to customers (clients, patients/guardians) to find out

reasons why they come to central hospital. The in-charges of gateway clinics will be

interviewed to find out why people by–pass gateway clinics and go directly to central hospitals

through a questionnaire as well; the in-charges will be interviewed as part of internal analysis

to find strengths and weaknesses of gateway clinics; the district health managers and directors

from central Ministry of Health will interviewed though in-depth interviews.

3.2 Introduction to research The research process for this study has been chosen from critical analysis of the research

onion with clear academic underpinning to satisfy the aims and objectives of the overall

research piece. The author has considered each layer of the onion separately to diagnose

relevance of each layer to come up with research philosophy, research approach, and

research strategy and data collection methods that are relevant to this research work.

26

Figure 3: Onion research layers (Saunders, 2003)

3.3 Research Paradigm/Philosophy Paradigm’ refers to the process of scientific practice based on people’s philosophies and

assumptions about the nature of knowledge (Kuhn 1962). In this context, it is about how

individuals believe research should be conducted. There are three philosophies positivism,

Interpretivism and realism.

Positivism is a view that believes that reality is external and objective, and knowledge is only

significant if it is based on observations of this external reality. It is the basis on which much

‘scientific’ enquiry has taken place. This viewpoint is usually referred to as the quantitative

approach (Bryman and Bell, 2007). Interpretivism is a view that believes that the world and reality are not objective and exterior to

the researcher, but are socially constructed and given meaning by people. Inevitably, several

different variants exist which are closely associated with this view (Bryman and Bell, 2007). This is usually referred to as the qualitative approach.

Realism shares some philosophical aspects with ‘positivism’, i.e. related to external objective

influences of the ‘macro’ aspects of society that could be considered as the ‘givens’. However,

‘realism’ acknowledges the importance of understanding people’s socially constructed

interpretations and meanings (some form of objective reality), while seeking to understand

27

broader social forces, structures or processes that influence and perhaps even constrain, the

nature of people’s views and behaviours (Bryman and Bell,2007 and Saunders,2007).

The author has adopted realism, a philosophy that shares both some aspects of positivism and

Interpretivism in order to meet aim and objectives of the study.

3.4 Research Approach According to Saunders (2003), deductive approach develops theory and hypothesis or and

design research to test hypothesis. Usually it uses quantitative data. On the other hand

inductive approach emphasizes of gaining an understanding of feelings that humans attach to

events. It deals with collection of qualitative data.

The study will employ both deductive and inductive approaches.

3.5 Research strategy Based on the onion by Saunders (2003), there are many research strategies in research that

include case study, survey, experiment and many more.

Case study is a research strategy which involves an empirical investigation of a particular

contemporary phenomenon within its real life context using multiple sources of evidence.

Survey is associated with deductive approach and allows collection of large amount of data in sizeable population in highly economic way through standardized questionnaire to allow comparison. Experiment is the classical form of research that owes much to the natural sciences. The

strategy could involve defining theoretical hypothesis, selection of samples of individuals from

known population and allocation of samples to different experiments.

The study is a cross-sectional case study as the data will be collected at one point in time. The

study will engage both quantitative and qualitative data collection methods.

3.6 Research Purpose To provide comprehensive direction to Ministry of Health on best way to strengthen gateway

clinics to successfully decongest Zomba Central hospital and further recommend use of

balanced scorecard framework to assess preparedness of gateway clinics for other central

hospitals in Malawi.

28

3.7 Research Design

The research will collect data through questionnaire and semi-structural interviews. The

research will use stratified random sampling method for patients and clients at outpatient

department. Self-referred patients and clients will be randomly selected whereby every 5th

patient or client will be enrolled in the study. It will also purposely select in-charges of five

gateway clinics, 2 DHMT members for Zomba District Health Office and Director of Planning

for Ministry of Health to be enrolled in the study.

3.8 Research methods Interviewer- administered questionnaire for patients and clients at outpatient department and

in-charges of gate way clinics. Key informants interviews with DHMT members and director at

central Ministry of Health. The data collection tools will be pre-tested on small group with

similar characteristics to ensure validity and reliability of data to be collected. Each method is

explained in table 1 below. Table1: shows reason for choice of data collection method/tool

Explanation of choice of Participants: Patients and clients will be interviewed to find out reasons why they get outpatient health

services at central hospital and find out if they are aware regarding the role or functions of

central hospitals in delivery of health services.

*Obj

ectiv

e Participant Data Collection Method

Reason for choice of method

Population Size

Sample Size

Sample Criteria

Data Collection Date

1 Patients and clients at

Zomba Central Hospital

Outpatient department

Individual

questionnaire

High volume,

frequencies

600 150 By clinic /

Random

June, 2012

2, 3. 4 & 5

DHO, Central hospital

and Planning

department of MOH-

Key informants

In-depth

interviews

Depth, low

volume

3 3 100%

sample

June, 2012

2 &6

gateway clinics in-charges

Questionnaire

High volume 5 5 100% sample

June, 2011

29

In-charges of Gateway clinics –key informants will be interviewed to assess the communication

strategies that are in place to inform people regarding role of central hospital and other levels

of health care. The in-charges will also be interviewed to find out services offered, workload

and stock-out days of tracer drugs. They are also being interviewed to get their perspective

regarding the change and their recommendations to the change.

District Health Officer and Hospital Administrator as key informants will be interviewed to

assess whether the District Health Office has allocated funds to renovate the gateway clinics

and whether funds are adequate to meet estimated bills of quantities in their district plan for

2011-2012 as well as 2012-2013. In addition, they are asked to find out if the District Health

Office has extra health workers to be deployed in gateway clinics.

Ministry of Health (Planning Department.)-key informant will be interviewed to assess if capital

investment plan has funds for renovation of gateway clinics and find out if the Ministry has a

road map or milestones to follow on hospital reform as strategy. Key informant will also be

interviewed to assess whether the Ministry has developed policy regarding staffing levels and

skill mix for gateway clinics in anticipation of increased workload. In addition, the study will

investigate if there is a unit to coordinate the central hospital reform with full time personnel.

3.9 Ethics of data collection The research proposal including data collection tools will be approved by Research Ethical

Committee of university of Derby before actual data collection exercise starts. In addition, all

participants in the research will be briefed about the research aims and that the information

they provide, will not be disclosed to any third party, except as part of dissertation findings, or

as part of supervisory or assessment processes of the University of Derby. In addition, the

participants will be informed that the data provided will be kept until 30th April, 2013 for scrutiny

by the University of Derby as part of the assessment process. The participants will be informed

that if they feel uncomfortable with any of the questions being asked, they may decline to

answer those specific questions. They may also withdraw from the study completely at any

time, and their answers will not be used. Each participant will sign an informed consent letter

as per attachments in appendix 1.

30

3.10 Data Entry and Analysis Excel will be used to analyze data. The software has been chosen because it is has functions

required in the study. In addition, the research will employ descriptive statistics to analyze the

data for easy interpretation.

31

Chapter 4: Findings and Analysis

4.1 Overview

The chapter presents limitations and challenges encountered during the study. The chapter

also discusses major findings of the study and they affect decongestion of the central hospital.

4.2 Limitations of the study Concerning the customers who were interviewed through individual questionnaire, more

women than men participated in study. This was due to fact that health workers were striking

and as a result of the strike, health services especially OPD was disturbed. This affected

patronage of patients to outpatient department. Even when services resumed fewer men than

women came for the OPD services and this affected gender representation of the study.

The readers should interpret the findings with caution on rating of central hospital and health

centres, since the patients were interviewed at Zomba Central Hospital, there may be a

courtesy bias. Future studies should consider interviewing patients at both central hospital and

gateway clinics to eliminate this bias.

4.3 Strategic direction in decongesting central hospitals The study has found that although, Ministry of Health expressed need to have central hospital

reform (MOH, HSSP, 2011), it had not played its leadership role in developing policy

instruments to guide decongestion of central hospitals and allocating resources to undertake

the reforms (UNDP,1999 and Karassavidou ,Glaveli & Papadopoulos, 2009). The study shows

that four strategic policy documents were not in place: road map, minimum infrastructure

requirements (rooms and equipment) for gateway clinics, human resources policy detailing

cadres and skill mix. The capital investment plan for 2011-2016 did not contain funds for

gateway clinics. Capital Investment Plan contains priority projects for Ministry of Health for a

specified period with funding estimates.

The road map on decongestion of central hospitals was supposed to highlight different

prioritized processes that were supposed to take place and time frame within which the whole

32

process of decongesting central hospitals is expected to finish. This finding is in sharp contrast

to assertions of Drucker (2000) who emphasizes that accountability of results can be assured if

resources are allocated against attainment of defined targets, priorities and deadlines. The

author agrees with Drucker in emphasizing the fact that government projects should have

timespan during which the project activities could be accomplished.

The study further indicates that Ministry of Health did not make any decision on whether all

primary health activities would be transferred to gateway clinics at once or in phases.

Stakeholders should clearly decide whether all general outpatient services would be

transferred to gateway clinics at once or in phases. The reforms in Zambia failed because

technical experts and politicians did not agree on type of the reform (Kalumbe, 1997).

However, UNDP (1999), Withanachchi (2004), Withanachchi (2007), Zineldin (2008) point out

that reform should be taken in phases to allow time for observation and capacity building.

Regarding human resource, the study further reveals that there was no new human resource

policy that reflects minimum number of health workers and skill mix for gateway clinics in

recognition of additional functions and increased demand of services. MOH said that staffing of

health centres of 2 clinician, 2 nurses and 1 environmental health officer applied to gateway

clinics as well. This finding is in contrast to Lesotho health sector reform policy which

highlighted skill mix that should be available at each level of service delivery. The author felt

that Ministry of Health would have critically examined outpatient services, essential health

package elements and community expectations and made decision on the staffing levels and

skill mix required for gateway clinics. Ministry of Health could bench mark Matawale Health

Centre as a model of gateway clinics to decongest central hospital.

The study further found that Ministry of Health had not shown any commitment in allocating

financial resources for renovating gateway clinics. The capital investment plan for the Ministry

of Health did not contain financial allocation to support construction or renovation of gateway

clinics in Zomba. Extension and construction of additional rooms and procurement of medical

equipment for gateway clinics could not be financed fully through the monthly funding that the

district health office receives. Zomba District Health Office received funds which were meant

for operations including maintenance not development (Malawi Decentralization policy, 1998).

33

The study further found that there was no independent unit established with full time person

employed to coordinate day to day activities but instead Deputy Director of SWAp had been

chosen to oversee the processes. The author felt that Deputy SWAp Director was full time job

and very demanding too. UNDP (1999),Withanachchi (2004), Department of Public

Expenditure and Reform of Ireland (2011) point out the need to establish unit with full time

experienced person to coordinate day to day reform activities and report to management on

regular basis.

4.4 Customer/community perspective

4.4.1 Location The study findings reveal that majority (100%) of the people in the sampled population who

seek general OPD services at the Zomba Central Hospital were from within Zomba District. 55

%( n= 83) of the respondents were from within Zomba City and 45% (n=67) of respondents

were coming from Zomba Rural. The study further indicates that 42% (n= 63) of respondents

were coming from within 1-5 KM, 36 %( n= 54) were coming within 6-8Km and 29% (n=43)

respondents were 9 Km or more away from the central hospital.

With regard closest health facilities to the respondents, the study reveals that that most of the

respondents (76%) reported to come from around health facilities that were targeted as

gateway clinics of Sadzi, Zomba City Clinic, Matawale, Namadidi, and Zilindo. Refer to Table 2

below which shows the closest public health facility to respondents.

Table 2: closest public health facility to respondents (Source: Author’s study)

Health Facility Number of respondents Percent

Sadzi 54 36.0 Zomba City Clinic 19 12.7 Matawale 17 11.3 Namadidi 12 8.0 Thondwe 9 6.0 Zilindo 5 3.3 Naisi 3 2.0 Chingale 3 2.0 Police 3 2.0 Cobbe Barracks 2 1.3 Lambulira 2 1.3

34

This finding demonstrates the fact the task force on decongestion of Zomba Central Hospital

probably made right selection of these facilities as gateway clinics. However, the study further

shows that 21% of the respondents were coming from other facilities (such as Thondwe,

Lambulira, Nasawa, Chingale and Naisi) outside gateway clinics. This means that whilst the

major focus was to strengthen the gateway clinics, the author felt that these other facilities

should have been strengthened as well if decongestion of Zomba Central Hospital was to be

achieved.

4.4.2 Health conditions that respondents presented at Zomba Central Hospital The respondents were asked what health condition or issue brought them to hospital. The

respondents had option of answering or not. 141 respondents answered the question giving a

response rate of 94%.The study reveals that there were five major reasons of OPD

consultation in both under-five and adult Outpatient department. These conditions represent

66% of all OPD consultations in sampled population. Cough accounted for 30 %( n=43) of the

respondents, 15 %( n=21) of respondents came for immunization and growth monitoring, 13%

of the respondents were treated for malaria, 10% of the respondents consulted the OPD for BP

check-up and collecting BP drugs. Upper respiratory tract infections constituted 7% of the

respondents. Seven percent of the respondents had diarrhoea. The study further found that

that 2% and 1% of the respondents came to OPD for dental and antenatal clinic services

respectively. Refer to figure 4 below.

Nasawa 2 1.3 Gwelero 2 1.3 Domasi 1 0.7 Machinjiri 1 0.7 None(Central hospital) 7 4.7 Not known 8 5.3

35

Figure 4: Respondents’ health conditions (Source: Author’s study)

Cough was the highest cause of OPD consultation at Zomba Central Hospital, which relates to

the period of winter when the study was conducted. However, an annual outpatient

attendance shows that leading cause of OPD consultation was malaria (Zomba Central

Hospital HMIS Annual Report, 2011 and MOH HMIS Annual Report, 2011). On the other hand,

all these conditions reported by respondents were within 13 elements of essential health care

package and could be managed at primary health care level (MOH HSSP 2011-2016). This

confirms the views of proponents of decongestion who argue that the central hospitals are

congested with conditions which could easily be managed at lower levels of care (Cullinan,

2006).

4.4.3 Factors that prompted respondents to seek OPD service from central hospital The study investigated to find out factors that persuaded the respondents to seek general

outpatient services at Zomba Central Hospital. The study has found that there were five major

reasons that influenced people (respondents) to seek OPD service at the hospital as per table

3 below. Table 3: Reasons that persuade people to seek OPD services at Zomba Central (Source: Author’s study)

Reason Frequency Percent Frequent shortage of drugs in health centres 60 40% Regard central hospital as any health facility 43 29% collection of BP drugs 14 9% Negative attitude of staff in health centres 11 7%

Central hospital is very accessible 10 7% unavailability of health workers at health centres 5 3%

36

40% of the respondents reported that health centres were experiencing frequent shortage of

drugs. During the study, the author observed that some clients/patients at Matawale Health

Centre were told that the facility had run out of drugs for their conditions and instead they were

instructed to buy from private shops. This finding suggests that the shortage of drugs at health

centre level could be a genuine concern. However, the study did not find out how many

patients at health centre did not receive drugs for their ailments.

Sometimes people seek outpatient services at central hospital because they do not know

distinctions among different levels of health care delivery and what conditions should be

treated at each level of care. To this effect, the study shows that 29% of the respondents came

to the central hospital because they regarded central hospital as any health facility. This finding

demonstrates knowledge gap and is being attributed to fact that both District Health Office and

all five gateway clinics did not plan community advocacy and sensitization meetings regarding

functions on three levels of health care and health conditions that could be treated at each

level of health care.

The study also reveals that some of respondents (9%) came to central hospital for BP check-

up and collection of BP drugs. Hypertension and diabetes were included as part of new

Essential Health Care Package (MOH-HSSP, 2011-2016), but major challenge was that

Ministry of Health had not yet changed drug policy at the time of study so that

hypertensive(BP) drugs were available at primary health care level.

The study indicates that seven percent of the respondents alleged they seek health services at

central hospital because health workers at health Centres had negative attitude towards

clients. Negative attitude of health workers is a long standing issue which could have been

minimized if the health facility advisory committees (health centre or hospital) were active. The

health facility advisory committees are supposed to receive, discuss and resolve community

concerns. Unfortunately, these committees are not meeting as stipulated or only focus at

witnessing delivery of drugs at health facility (MOH-Zonal Annual Report (2011).

Looking for high quality services at Central hospital 4 3% health centre opens late and closes early 2 1% Total respondents 149 100%

37

Some respondents (3%) reported that central hospital is very accessible. The author observes

that the accessibility is attributed to fact that Zomba Central Hospital is along the main road

between Zomba City and Blantyre City and there is good availability of public transport such as

Mini-buses and taxis to and from the hospital. As the gateway clinics are being strengthened,

the issue of accessibility should be worked out as well by collaborating with other stakeholders

who could provide these amenities.

Three percent of the respondents came to the hospital for quality health services. The quality

of health services is a cross-cutting issue. Health authorities should strike a balance to ensure

that health services do not only meet technical quality but should incorporate quality factors

from the customers’ view point (Withanachchi, 2007).

4.4.4 Rating of Zomba Central Hospital and Health centres With regard to rating of Zomba Central hospital and health centres, 145 respondents rated the

hospital giving a response rate of 96% whilst 120 participants rated health centres yielding a

response rate of 80%. The discrepancy was probably due to fact that some respondents

regarded central hospital as their closest health facility and therefore, they could not rate

health centres.

The respondents rated the both the Central hospital and public health centres on scale of 5 to

1. The numbers have following meanings; 5 means excellent, 4 means very good and 3

neutral, 2 means very bad and 1 means worst.

The total weighted scores were interpreted as follows; Green means excellent services with

total weighted scores within a range of 100-80%. Decision making, no action is required but

should be encouraged to maintain the services. Yellow has total weighted scores within the

range of 79-60% and means very good services but needs fine tuning of remaining issues.

Red means urgent action and is represented by total weighted scores of less than 60% as per

tables 4 and 5 below Table 4: Rating of Zomba Central Hospital (Source: Author’s study)

Respondents

Total responses

weighting average

total weighted scores

Expected total weighted scores

Total 145 663 725

excellent 97 5 485

38

very good 39 4 156 neutral 6 3 18 very bad 1 2 2 worst 2 1 2

Table 5: Health centre/gateway clinic rating (Source: Author’s study)

Interpretations of total weighted scores

Central Hospital Health centres/gateway clinics

725-580 Excellent service-maintain 600-480 579-435 very good -needs fine tuning of remaining issues 479-360 <434 Good but major improvement are needed urgently<360 The study found that the respondents rated Zomba Central Hospital as an excellent service

provider because it had 663 total weighted scores which fall within the green band which

represents 100-80% of the total weighted scores The health centres/gateway clinics were

rated as very good because they had 414 total weighted scores which fall within the range of

79 -60% of total weighted scores. Therefore, the respondents perceived Zomba central Hospital as a better service provider as

compared to the health centres. The author attributes the high rating of Zomba Central

Hospital to constant availability of drugs and offering wide range of services (Zonal HSSP

Review Meeting, 2012). In order to improve image of health centres, the decongestion should

focus at ensuring drug availability and introducing wide range of services including changing

drug policy to ensure that all drugs for essential health care package are available at primary

health care level (gateway clinics) as well as rural health centres.

Respondents Weighting average

Total weighted

scores

Expected Total weighted scores

Totals 120 414 600 excellent 14 5 70 very good 48 4 192 neutral 38 3 114 very bad 18 2 36 worst 2 1 2

39

4.4.5 Respondents’ approval of transferring (closing out) outpatient services for general public to primary health care level. The respondents were asked if they would approve the closing of outpatient department to

general public so that the central hospital focuses its effort on tertiary care. The questions had

a total 144 responses giving a response rate of 96%. The responses were weighted as

follows= very strongly approve=5, strongly approve=4, not sure 3, strongly disapprove=2 and

very strongly disapprove=1. The total expected scores from all respondents assuming they

very strongly approved would have been 720 scores refer to table 6 below. Table 6: Do you approve closing of outpatient department to general public Responses frequency Weighting

average Total

weighted scores

Total expected weighted

scores Very strongly approve 21 5 105 720 Strongly approve 16 4 64 not sure 8 3 24 strongly not approve 42 2 84 Very strongly not approve 57 1 57 Total 144 334 Interpretation of the total scores

720-541 Accept Close of general outpatient department 540-401 work out on few outstanding issues before implementing the decision <400 do not close, do thorough ground work before implementation of the decision

Based on the total weighted scores, the respondents in the study had disapproved the closing

of general out patient department as total scores fall within red band of less than 400 scores.

Instead, thorough ground work should be done on gateway clinics before considering closure

of the department to general public.

40

4.5 Business processes perspective

With regard to business processes, the gateway clinics have various challenges namely;

Outpatient workload, supply chain of drugs, availability of services and infrastructure.

4.5.1 Workload of outpatient department According to MOH SWAp 2004-2010 and MOH HSSP, 2011-2016, outpatient attendance does

not only indicate availability and accessibility of public health services to the general public but

also shows workload of the health facilities. If the outpatient attendance reaches 100% and

above against catchment area population over 12 months period, it means the services are

accessible and manageable. The study has found that Matawale, Zomba city Clinic and Zilindo

were operational for entire period under review whilst Namadidi and Sadzi have been

operational for half of the period. The study further shows that workload varied across the

gateway clinics. Matawale health Centre had the highest workload (259%) of OPD

consultations, followed by Zilindo (113%), and 56% for Zomba City Clinic. Zomba City Clinic

was less accessible and there is need to find out why the facility OPD services were not readily

accessible and utilized. If Zomba City Clinic was fully utilized, it could easily take up pressure

from Matawale Health Centre. Namadidi and Sadzi had 21% and 46% of OPD consultations

respectively. Although Namadidi and Sadzi functioned for half of the year, these facilities were

supposed to have been utilized by 50% of population by end of fiscal year. Namadidi

underperformed during the six months period as compared to Sadzi which achieved 46% of

OPD utilization. Refer graph below that shows workload of each facility.

Figure 5: Gateway clinics OPD Workload (Source: HMIS Reports 2011/2012)

41

Although, Matawale OPD utilization is the highest, it signifies that the facility was overstretched

and this development may negatively affect quality of health services being offered and refer

pictures below

Figure 6: Clients at under-five OPD clinic Figure 7: Adult OPD patients waiting to register

Both pictures were taken at 11:45 am but the facility had still a lot clients waiting for OPD services.

Matawale Health Centre was already congested and it should not have been targeted facility

for decongesting central hospital but rather much focus should have been given the other

facilities such as Sadzi, Zomba City Clinic, Namadidi and Zilindo. Some respondents had

attributed poor outpatient attendances in some gateway clinics to non-adherence scheduled

opening and closing hours. The attendance could also be attributed to fact that there were only

few health workers who did not leave close to some facilities like Namadidi and Zilindo. During

the study, the author did not only witness a facility opening late but found that one facility was

closed for the whole day because the only health worker was sick.

42

4.4.2 Stock out days of essential drugs Table 7: Status of Stock-out days of some selected essential drugs at Gateway clinics July, 2011 to June 2012

As per table above, the study investigated on the availability of drugs by monitoring stock out-days of

eleven essential drugs commonly used for managing the most common conditions at health Centre level.

According SWAP matrix 2004-2010, essential drugs are supposed to available for 365 days. The study

has found that all five health facilities had experienced stock outs in all drugs except for Tetanus Toxoid

vaccine (TTV). Zomba City Clinic and Sadzi had stock outs of seven drugs, Matawale had stock outs of

six drugs and Namadidi had stock outs of five drugs. Zilindo experienced less stock outs .All facilities

had stock out of malaria rapid test kits. The average stock out days ranged from 3.6 days to 83.2 days for

gentamicin and ferrous sulphate respectively.

Health facility

/drugs

Oral

rehydrati

on Salts

TT

vaccine Contrimoxa

zole HIV Test

Kits Ferrous

sulphate Gentamic

in Metronid

azole Benzylpe

nicilin Diezepam

injectable LA(any

combinati

on)

RDTs for

malaria

Matawale 56 0 81 7 200 0 133 0 0 0 76

Zilindo 0 0 156 0 0 0 161 0 0 84

Zomba City

Clinic

150 0 0 84 69 18 80 43 0 0 48

Sadzi 31 0 31 52 87 0 20 0 196 0 81

Namadidi 0 0 90 60 0 0 0 30 60 60

Average stock

out days

47.4 0

71.6 28.6 83.2 3.6 78.8 8.6 45.2 12 69.8

43

The stock out of essential drugs confirmed the concerns raised by respondents who

complained of frequent shortage of drugs at health centre level. Unless supply chain of drugs

was properly managed, communities would continue to patronize central hospitals with minor

ailments that should have been managed at gateway clinics.

4.5.3 Infrastructure

The study findings show that all five health facilities except Matawale health Centre have

infrastructure challenges in terms of rooms, and medical equipment to provide a wide range of

health services refer to figure 8 of Matawale Health Centre.

Figure 8: Matawale Health Centre

Although renovations were done in some facilities, the building structures could not

accommodate additional services. In addition, the study shows that Zilindo and Namadidi do

not have staff houses; the staff members were coming from distant places to work at these

facilities. The study has also found that only Matawale and Zomba city Clinic had all three

basic amenities such as water, electricity and communication. These amenities are very crucial

in providing quality health care services.

4.6 Financial allocation for renovating and refurbishing gateway clinics With regard to financial allocation, the study has found that financing of the renovations is

adhoc because both District Implementation Plans for 2011/12 and 2012/13 for Zomba District

Health Office did not have specific allocation of funds to finance renovations and refurbishment

of gateway clinics. Renovations had been undertaken at gateway clinics with funds that were

initially earmarked for other activities. The study further noted that general records keeping and

44

sharing of information regarding estimated cost of renovations was a challenge among

management members. It was also difficult to establish how much funds Zomba District Health

Office had used for renovating and refurbishing these facilities.

4.7. Learning and Innovation perspective Table 8: Staffing levels of gateway clinics(source: Author’s Study) health Facility/ staffing

CO MA NT CN RN AEHO/EHO

DT OCO DA LT Totals

Matawale 3 1 8 2 5 2 4 1 0 3 29

Zilindo 0 1 1 0 0 0 0 0 0 0 2

Zomba City Clinic

2 0 3 1 0 0 0 1 1 0 8

Sadzi 0 0 2 0 1 0 0 1 0 0 4 Namadidi 0 0 1 0 0 0 0 0 0 0 1 Totals 5 2 15 3 6 2 4 3 1 3 44

The table above demonstrates that out of the five health facilities only Matawale Health Centre

had the highest number of health workers with various skill-mix requirements befitting a health

facility to be gateway clinic. At the same time, the table shows that Namadidi had the least

number of health workers and limited skill mix. According to the author observation, availability

of multiple skills necessitated Matawale Health Centre to offer wider range of health services

than the other facilities which had limited skill mix availability. Whilst the table may show that

there was poor deployment of staff for some cadres, some of the facilities lacked equipment

and rooms to fully utilize the skills in these health workers. For instance, Sadzi Health Centre

had an ophthalmology clinical officer but did not practice because there was no room and

equipment to eye related services. Matawale health centre was the only facility that was

offering maternity services hence it had more nurse technicians and registered nurses than

any other gateway clinic.

45

CHAPTER 5: Conclusion and Recommendations

5.1 Overview This chapter discusses key challenges that affect performance of gateway clinics as observed

from the findings chapter. The chapter then takes critical analysis of how these challenges can

be solved. The chapter makes recommendations of what management at both National and

district levels should do to decongest central hospital.

5.2 Conclusion In summary, in reference to four perspectives of balance scorecard, the study findings have

shown that there was little progress made in strengthening gateways to decongest Zomba

Central hospital. With regard to strategic direction, the Ministry of Health did not have strategic

policies documents in place to guide the whole decongestion reform. For instance, there was

no road map, each central hospital and respective DHO were expected to develop their own

road map for the reform process. There was no timeframe regarding when the whole process

was expected to finish completely. Whilst it is important that there could be road map for

decongesting each central hospital at operational level, it is very crucial that these individual

central road maps are informed by national road map.

Ministry of Health did not develop a new policy on staff establishment for gateway clinics and

the ministry assumed that staffing norm for health centre should apply to gateway clinics as

well. However, examining the pressure and expectations of the people who participated in the

study, all gateway clinics were supposed to be staffed with various cadres like Matawale

Health Centre that acted like community hospital. Presence of various cadres is not only

important at to provide a wide range of services but as it assists to decongest central hospitals

as they would meet interests and meet aspirations of the people.

There were no minimum infrastructure requirements in terms of buildings and equipment that

were supposed to available at gateway clinics. The capital investment plan did not indicate

funds earmarked for extension or renovation of gateway clinics. The extension and renovation

works could not be undertaken with operational budget provided to District Health Offices. The

reform processes to decongest Zomba Central Hospital were not based on principles but

rather on the willingness and good working relationship between the Zomba Central Hospital

Management Team and Zomba Health Management Team. The author feels that the reform

46

processes may cease or stop depending on change of management at district health office or

Zomba Central Hospital as they are not based on policy guidelines. The findings of the study

suggest that gateway clinics were not ready to take over whole primary health care activities

from Zomba Central Hospital. The facilities are facing numerous challenges ranging from

inadequate infrastructure, human resource, adhoc funding, inadequate community involvement

and awareness and supply chain. One out the five health facilities regarded as gateway clinics

had minimum infrastructure that enables it accommodate a number of services than the other

facilities. It was that same facility that has health workers with varied skill mix which enabled it

to offer a wide of health services. This was the only facility that offered the following services:

dental, maternity, laboratory and full PMTCT package to pregnant women who test HIV

positive. There were no plans to involve community leadership and general public who are key

stakeholder to the decongestion of central hospital. Both District Health Office and five health

facilities did not have written plans on community involvement and awareness although the

reform will affect the communities. All five facilities experienced stock out of essential drugs

during the period under review. The frequent shortage of drugs is forcing people to seek

services at central hospital among other factors.

The study findings revealed that the following factors forced people to seek out patient

services at Zomba Central hospital: frequent drug shortage, inadequate awareness among

community members on functions of central hospital and regard it as any facility, some

services were not available gateway clinics, negative attitude of staff including opening late

and closing early of gateway clinics, poor accessibility of some health facilities. Consequently,

the respondents rated central hospital as the facility that offered superior health services as

compared to the health centres (including gateway clinics). The community did not approve

closure of general outpatient department of central hospital unless the challenges highlighted

above were resolved.

47

5.3 Recommendations

In order to successfully decongest central hospitals, there is need to strengthen the gateway clinics. The recommendations have categorized into two as follows:

National level-Ministry of Health should:

1.0 Develop key strategic documents to guide the decongestion of central hospitals and

strengthening of gateway clinics in all four perspective areas of balanced scorecard as

follows:

Develop road map on decongestion of central hospitals that defines OPD

services to be transferred out and also details how, where and when different

processes will be accomplished.

Develop minimum infrastructure and equipment requirements for gateway clinics

in recognition to additional functions and increased workload. Institutional staff

houses should be incorporated into this policy document.

Develop human resource policy for gateway clinics that is in tandem with current

demands and anticipated services to be added. The policy should focus at skill

mix required to offer all EHP interventions. This may necessitate deployment of

other cadres of professional health workers at gateway clinics such as medical

doctors, clinical officers, laboratory technicians, dental therapists etc. 2.0 Make commitment by allocating substantial financial resources for extension,

renovations and refurbishment of gateway clinics in her Capital Investment Plan and

make sure that the resources are available at District level to support related works.

3.0 Since reforms take time and some facilities do not have capacity to deliver all services,

it is recommended that primary health care services should be transferred in phases to

allow time for learning and capacity building.

48

4.0 Revise drug policy to introduce some hypertensive and diabetes drugs at primary health

care level since these elements have been included in the list of essential health care

package.

5.0 MOH should allocate adequate budget for drugs and procure them timely to prevent

frequent stock outs at health facility level.

6.0 Re-deploy all health workers who manage general outpatient and primary health care

services at central hospitals to district health offices.

District level 7.0 The financing of the renovations and extension of gateway clinics is adhoc, it is

recommended that District Health Management Teams should plan for renovations and

extension of gateway clinics in the District Implementation Plan and ensure that the

renovations are done in relation to expected services to be offered as may be outlined

in the minimum infrastructure requirements for gateways.

8.0 District Health Management Teams should conduct regular supervisions to gateway

clinics and other health facilities to monitoring delivery of health services and flash out

any shortcomings that may be identified. This supervision will among other things

monitor stock levels of drugs.

9.0 As part of community involvement, DHMT should develop strategies to engage

community leadership and raise awareness on the decongestion of central hospitals

stressing on what conditions are expected to be managed at each of the three levels of

care. The health facility advisory committees should be given necessary knowledge and

skills to effectively link the catchment population and respective health facility

10.0 In order to improve the image of health centres, the DHMTs should establish feedback

mechanism to get views/concerns such as suggestion boxes or conduct exit interviews

on regular intervals to identify areas that require strengthening.

49

11.0 Fix and ensure Namadidi Sadzi and Zilindo gateway clinics have all three amenities of

water, electricity and communication.

12.0 Re-deploy additional health workers to Namadidi Dispensary and ensure that the facility

opens and closes according government stipulated times.

50

Chapter 6: Personal Reflection

6.1 Overview The chapter discusses major lessons learnt from the study and challenges experienced from

the author’s perspective.

6.2 Major lessons learnt I have learnt that literature review is a major pillar in business research. Through literature

review I have had in-depth understanding of all forms of public sector reforms. I have learnt

various approaches of introducing reforms and how to make health reforms successful. Among

other issues I have learnt that Central government should have clear position of any reform by

developing necessary policies, allocation of resources to fast track reforms and that reforms

should have time frame within which they will be completed. In addition, I have learnt reforms

should be implemented in phases. I feel this knowledge is very vital to me personally because I

can work as consultant in the hospital reform and indeed on any reform based on the concepts

that I have learnt through this study. Since I have acquired adequate knowledge and expertise

in the study, I intend to share the knowledge with Director of Zomba Central hospital and

Ministry of Health through report and meetings so that they learn the approach used and

recommendations derived from the study.

The study was important because I have had an opportunity to use new knowledge I have

gained during the entire course of strategic Management. In this regard, I have had a chance

to test some new approaches such as balanced score card. I have realized that although the

balanced score card was designed to be used for private sector; it could be used in public

sector provided you are very clear regarding how you want to use it. In this study, all five

components of the balanced score card were assessed. However, I have learnt that

performances of perspectives of balanced scorecard are dependent on clear goals and

strategy. In the study, Ministry of Health lacked policy guidelines, which would have shown its

position, and those policy guidelines would have an influence on what should happen in each

of the four perspectives.

51

I have learnt that a good research topic is a product of wide consultations with various

stakeholders and supervisors on one hand but also wide reading of what other authors have

written on the topic. In my study I had consulted funders like German Health Programme who

were supporting Ministry of Health with Hospital Reform but also provided scholarship to the

author. I had also consulted Director of Central Hospital and Zomba District Health Officer who

were implementing hospital reform.

I have learnt that in order to have buy-in from a good number of people, the study should

address some gaps/challenges that organization is facing in its operations. Zomba Central

Hospital and Zomba District Health Office supported the study because they wanted to learn

from the study grey areas that require improvement in decongesting their central hospital.

Although implementation of central hospital reform started without consulting the communities,

I have also learnt that customers, the patients and clients are equally important and clever

because they could analyze skills available at health facility and make rational decision as to

where they should seek primary health services. If they have noted that the primary health

care level facility does not provide a particular service, they do not wait for referral if they know

that they could get those services at another health facility including central hospital. Most

gateway clinics did not have wide range of skills and services, consequently people opted to

seek these services at Zomba Central hospital. The health sector reforms should involve

communities who are the users of the services so that they share their point of view. In this

study the communities have given reasons that force them to seek services at central

hospitals. Unless these challenges communities face at gateway clinics are resolved, they will

continue to seek services at central hospitals.

I have learnt that multi-skilled health workers, adequate buildings (rooms) and equipment plus

good supply of essential are key instrumental factors that can enable a primary health care

facility (gateway clinic) offer wide range of health services .

6.3 Challenges In course of the study, I have experienced some challenges.

52

The study requires good time management to meet office obligations and study requirements. I

had just changed jobs. The current job requires a lot of my time and it was really challenging to

get adequate time for the study, new job and family. Therefore, time management was very

critical in order to fulfill office, academic and family obligations. I have learnt that time is one

the scarce resources I need to manage very well in my undertakings.

Initially, Malawi German Health Programme offered to provide financial support to carry out

this independent study but the decision changed after change of programme leadership. This

meant that I had to source extra personal financial resources to conduct the independent

study.

Lastly, data collection exercise was disturbed because health workers were striking. As a

result of the strike, health services especially OPD was disturbed. The communities could not

access the services for some days and therefore it was difficult to get respondents. The gender

representation of the study was affected because fewer men than women came for OPD

services during the strike period.

6.5 Summary It was worthwhile to conduct independent study because it has deepened and widened my

understanding of the public sector reform. The study has not only enabled me to apply new

concepts that I learnt during the course but it has also given confidence in how best to conduct

business research. The current knowledge acquired through this will be shared with interested

parties and individuals through reports, presentations and publications.

53

Appendices

Appendix 1: Participant Briefing and consent and withdraw letters

Dear Participant, MSc Strategic Management – Participant Briefing and Consent Letter I am Grevasio Mchigulupati Chamatambe and I am collecting data from you which will be used in my dissertation for Ministry of Health, as part of my MSc Strategic Management at the University of Derby, in collaboration with the Malawi Institute of Management (MIM). The aim of the dissertation research is to assess level of preparedness of gate way clinics and provide recommendations to successfully decongest Outpatient department at Zomba Central Hospital, and the information you will be asked to provide will be used to help to provide insights to achieve this objective. The data you provide will only be used for the dissertation, and will not be disclosed to any third party, except as part of the dissertation findings, or as part of the supervisory or assessment processes of the University of Derby. The data you provide will be kept until 30th April 2013, so that it is available for scrutiny by the University of Derby as part of the assessment process. If you feel uncomfortable with any of the questions being asked, you may decline to answer specific questions. You may also withdraw from the study completely, and your answers will not be used. And, if you later decide that you wish to withdraw from the study, please write to me at (Grevasio Mchigulupati Chamatambe, Zonal Health Office, Box 216, Zomba Malawi Email address: grevasiochamatambe@yahoo.co.uk) no later than 1st August 2012 and I will be able to remove your response from my analysis and findings, and destroy your response. I have read and understood the contents of this consent and briefing form, and freely and voluntarily agree to participate in this research. I am happy to be identified as a participant in the research by my position at work (e.g. as a member of the executive committee).

54

Signed Please print your name Date

55

Dear Participant, MSc Strategic Management – Participant Debriefing and Withdrawal Letter Thank you for agreeing to participate in my research, your help was much appreciated and I can confirm the following:

• The information I collected from you will be used in my dissertation for (Ministry of Health), as part of my MSc Strategic Management at the University of Derby, in collaboration with the Malawi Institute of Management (MIM).

• The aim of the dissertation research is to assess level of preparedness of gate way

clinics and provide recommendations to successfully decongest Outpatient department at Zomba, and the data you provided will be used to help to provide insights to achieve this objective.

• The information you provided will only be used for the dissertation, and will not be

disclosed to any third party, except as part of the dissertation findings, or as part of the supervisory or assessment processes of the University of Derby.

• The data you provided will be kept until 30th April 201), so that it is available for

scrutiny by the University of Derby as part of the assessment process.

• If you later decide that you wish to withdraw from the study, please write to me at (Grevasio Mchigulupati Chamatambe, Zonal Health Office, Box 216, Zomba Malawi Email address: grevasiochamatambe@yahoo.co.uk) no later than 1st August 2012 and I will be able to remove your response from my analysis and findings, and destroy your response.

Please do not hesitate to contact me if you have any queries relating to this study. The contact at MIM is the MSc Strategic Management programme co-ordinator, Hendrina Msosa. Hendrina can be reached by telephone: 01711547 or email: msosah@mim.co.mw Kind Regards GREVASIO M.CHAMATAMBE

56

Appendix 2: Data collection tool 1: Individual questionnaire with Clients at Outpatient and MCH (maternal and Child Health) departments at Zomba Central Hospital Preamble: include explanation of study to the research participants Welcome the interviewee-greet participant and offer place to sit, introduce yourself

Explain the purpose of the interview

Inform the interviewee that the information shall be confidential

Get consent for the interview: Read consent letter and let the participant sign

Read participant’s withdraw letter, sign and give it to the participant

Date of interview: Interviewee No……………………….. Name of Investigator People: Who are the people seek OPD and primary health care services at Zomba Central Hospital

1. Gender: Male

Female

2. Education background a. None b. Primary c. Secondary d. Tertiary e. Others (specify)

Where are they coming from? Place/location 3. Name of your village/area

4. Is your village/location

a. within Zomba City b. Within Zomba District but outside city c. Other district (specify)

5. What is the distance from this Zomba Central Hospital to your home (approximate in

KM? a. Within 1-5 KM

b. 6-8 KM

57

c. 9 KM and above

Health problems affecting the people who visit General OPD 6. What health problem/issue(s) has brought you here today? Check diagnosis on the

health profile? a. Malaria

b. Upper respiratory infections

c. Cough

d. Diarrhoea

e. RTA

f. others(specify)

7. Have you received service for your condition or issue? a. Yes b. No

8. Which other government health facility apart from the Zomba Central Hospital is close to you?

a. Zomba City Clinic

b. Sadzi

c. Matawale

d. Zilindo

e. Namadidi

f. Others (specify)

g. None

9. What is the distance to this health facility from your home? (Approximate in KM) a. Within 1-5km

b. 6-8 KM

c. 9 KM and above

Reasons for seeking health services at General Outpatient department and other primary health care departments

10. Why have you preferred to come to Zomba central Hospital rather than other

government health facilities around?

a. unavailability of health workers

b. Frequent shortage of drugs in health centres

58

c. Regard central hospital as any other health facility

d. Negative attitude of staff at health centres

e. Easy to find transport /very accessible

f. Others(specify)

11. How do you rate the quality of health services offered at Zomba Central Hospital?

Excellent

Very good

Good/bad Very bad worst

12 How would rate the quality of health services offered at gateway clinic close to you

Clients’/patients’ Knowledge/awareness on core functions of central hospital 13 Do you know what type of Health services/conditions Central Hospitals are supposed to

be offering?

a. yes

b. No

14 If yes, mention some of conditions

a. Referred cases from district and other hospitals

b. Complicated cases that require specialist attention

c. People involved in road accidents

d. Others (specify)___________________________________

15 Mention services which are offered to you or your relatives at Zomba Central Hospital

which you cannot get from other health facilities? List.

59

16 Would you approve an idea of closing of General Outpatient department and other

departments offering primary health care services at Zomba Central Hospital? Please

tick appropriate option that fits your rating.

Very strongly

approve

Strongly

Approve

Approve/not

approve

Strongly not

approve

Very

strongly

not

approve

17 If Zomba Central Hospital closes the OPD and primary health services for general

patients or clients, where else will you go for these services?

a. Matawale

b. Sadzi

c. Zomba City Clinic

d. Zilindo

e. Namadidi

f. Others (specify) __________________________________

18 What improvements should be done on this Gateway clinic so that it properly takes up

primary health care services including the general outpatient services from Zomba

Central hospital?

______________________________________________________________________

______________________________________________________________________

_____________________________________________

Thank the interviewee for all his or her responses and precious time spent on the

questionnaire.

Note: a) Only self-referred patients, clients or their guardians will be eligible for the study.

60

Appendix 3: Data collection Tool 2: Questionnaire for In-charges of Gateway clinics Date of interview: Name of health facility

a) Matawale Health Centre

b) Zilindo

c) Sadzi

d) Zomba City Clinic

e) Namadidi

Catchment area population ( ) Interviewee No……………………….. Name of Investigator Welcome the interviewee-greet participant and offer place to sit, introduce yourself Explain the purpose of the interview Inform the interviewee that the information will be kept as confidential Get consent for the interview: Read consent letter and let the participant sign Read participant’s withdraw letter, sign and give it to the participant 1.0 Availability of selected drugs and other supplies used for running Outpatient

department and other primary health care services for last eight months July, 2011 to June, 2012.

Examine stock out days of these supplies

Commodity No of days Oral Rehydration salts TT Vaccine Contrimoxazole

Rapid test kits for HIV

TB drugs

Ferrous sulphate

Gentamicin

61

Metronidazole

Ampicillin

Benzyl penicillin

Diazepam injectable

LA (of any combination)

RTDs for malaria

2.0 Workload of the OPD How many people attended OPD for both under five year old and over five year old patients for

gateway clinics for July, 2010 to June, 2011?

a) <5 OPD attendance

b) >5 OPD attendance

3.0 Current staffing levels at time of study Number of health workers working at Gate way clinics

Cadre Number a) Clinical officers

b) Medical assistants

c) Nurse technicians

d) Psychiatric nurses

e) Community nurses

f) Registered nurses

g) Environmental Health Officers

h) Dental technician

i) Eye technician

j) Skin Technician

k) Laboratory technicians

4.0 Is the gateway clinic meeting minimum staff norm of Ministry of Health (two nurses, one medical assistant, and one environmental health officer)

a) Yes

62

b) No 5.0 Programmes to educate the communities

a) Existence of programme for educating the public on roles of central hospital and other

levels of health care at the health facility (July, 2011 to March, 2012 or beyond)

b) Number of sessions on the topic

c) No of Planned community sensitization meetings in the catchment area

d) No of community sensitization meetings actually done in the same period

6.0 Services offered by Gate way Clinic a) OPD

b) Family Planning

c) Antenatal

d) Maternity

e) Postnatal

f) Immunization

g) Growth monitoring

h) HTC

i) PMCTC

j) ART

k) Health education

l) Nutrition

m) Malaria testing

n) TB testing

7.0 Availability of rooms to offer different primary health care services (minimum room availability for gate way Clinics)

a) OPD waiting area

b) OPD consultation room

c) Injection room/

d) Dressing room

e) Holding room

f) FP

63

g) ANC

h) Delivery room

i) Postnatal room

j) HTC

k) PMTCT

l) ART

m) Laboratory

n) Immunization room

o) Growth monitoring Area

p) Dental room

q) Eye room

r) Skin room

s) Oral rehydration therapy corner(room)

t) Drug dispensing room

u) Drug store

8.0 Check availability of the following amenities in the gate way clinics

a) piped water inside facility

b) Electricity(Solar or ESCOM)

c) Communication(Radio/Ground line)

9.0 What should be improved for your health facility to accommodate increased demand of health services if Zomba Central Hospital is finally closed for general out patients? Increase number of staff Need supply from medical store Availability of other services No accommodation for staff

64

Thank the interviewee for all his or her responses and precious time spent on the

questionnaire.

65

Appendix 4: Data collection tool 3a: Guiding questions for In-depth interview with members of District Health Management Team Funding of the gateway clinics

1. Does the annual District Implementation Plan for 2011/2012 for Zomba District Health

Office have an allocation of funds for renovating the Gateway Clinics, if not where do

they get funds for the renovations being made? Verify in the DIP

No specifically allocated for renovation but getting funds from maintenance

2. According to your estimates for renovations and related works to make gateway clinics

ready, how much funds do you require to use on these gateway clinics? See the

quotations from District PAM unit.

At the time the survey, documentation regarding costing and expenditure was not

available as the Administrator who could give detailed information was on holiday and

accounts had no segregated information on maintenance payments

3. What is the gap in financing for the project?

4. How else do you intend to raise all funds for the exercise apart from District ORT

funding?

Human resource for Gateway clinics

5. Taking up Central Hospital OPD and other primary health services is a big task.

What are current staffing levels and gap or how many health workers are needed for

each gateway clinic?

Cadre Required available Gap

Nurse midwife

technician/ENMs

Registered nurse

and midwife

Medical assistants

66

Clinical officer

Dental

assistants/therapists

Laboratory assistant

Ophthalmologic

clinical officer/nurse

EHO/AEHO

HSAs

Is Zomba Central Hospital in agreement to planning to release some staff working in the

primary health care section to DHO? Yes or No, if yes check written documentation

Availability of space to accommodate additional or increased interventions

6. Do your facilities have space to accommodate the additional primary services from

Central Hospital- adequate rooms for diagnostic laboratory, HTC, FP, ANC, Postal natal

care, PMTCT, OPD, ART, eye, skin, dental?

7. Do you have a time frame when you as district health office will completely take over

general OPD and primary health services from Zomba Central Hospital? Verify

documentation.no

Education of the communities on roles of different levels of health care 8. Do you have planned sensitization of communities to minimize political tension (District

Commissioner, Zomba City Council Chief executive, Members of Parliament, Traditional

Authorities and communities around Zomba Central hospital) neutral sensitization-three

levels of care-mass media

Thank the interviewee for all his or her responses and precious time spent on the interview.

67

Appendix 5: Data collection 3b: Guiding questions for In-depth interview with Planning Department of Ministry of Health (Director of Planning)

The interview will focus on financial and human resource planning to prepare gateway clinics

ready to take up all primary health care services from central Hospitals. It will also focus on the

time frame for the exercise.

1. Does the capital investment plan have funds allocated to facilitate renovation of gate

way clinics and how much? E.g. for Zomba Gate way clinics –collect a copy of the plan

if possible

2. Does the Ministry of Health have timeframe when the whole process of decongesting

central hospitals should be completed-OPD transferred- verify the project plan if

available or road map

3. Planned staff skill mix at gateway clinics or they are treated just like other health

centres? Required staffing levels-proposed staffing levels policy. Check policy

documents if available

4. Who is following up progress taking place towards central hospital reform in various

central hospitals? Monitoring system in place

Thank the interviewee for all his or her responses and precise time spent on the interview.

68

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