By Julius Mugwagwa
A field trip to Zimbabwe and South Africa in July for meetings and discussions with stakeholders as part of the innovative spending in health project was as expected thought-provoking in more ways than one. Discussions with various people in the continuum from ordinary people and families in rural communities to leading academics and surgeons revealed that indeed there are many innovative practices being employed for the sake of delivering health to people. As would be expected, the practices have positive and negative effects alike on the individuals, institutions and the broader health care system.
One health seeking trend that has taken root in the two countries over the years is the preference by people to use private doctors and clinics, as opposed to public clinics and hospitals. There are a number of reasons motivating this, ranging from lived experiences and perceptions of lack of delivery on the part of these frontline health delivery facilities to changing human preferences as people become more ‘affluent’ and therefore cannot afford to be ‘seen’ queuing for hours on end at a government clinic. Some people also feel that one major deterrent is the attitude of the staff (especially nurses) at these facilities. User fees paid at these clinics are still very low, and health staff are all too aware that the patient is not the ‘boss’ in this case, hence the staff can get away with ‘big brother’ or ‘big sister’ attitudes. Factor in the ideational and financial influence of the people in the diaspora, especially for Zimbabwe … ‘mum, you can’t wait in the queue for that long with your painful legs, only to get simple painkillers … we are sending money for you to the go to the private doctor … don’t worry about the cost, we will pay, your health is more important’ … then, yes, you have more people against the primary health facilities than for the facilities.
Tracing the journey that brought things to where they are now reveals a lot of complex realities. Many years of little, if any, improvement in the primary healthcare facilities due to economic challenges and pressure on these facilities from increasing populations and mounting health challenges have meant that these facilities are indeed failing to deliver. This has necessitated entry into the space of different other players to cater for the needs, and while this happens, for the service users and providers alike, the focus on cost often remains overshadowed and as one health policy manager noted … ‘we are usually alerted to these cases of high hospital fees, not by the patients, but their relatives or other stakeholders not directly using the service at the time in question. Those in need of a treatment, where they have room to choose, usually go for the option where service is guaranteed. Cost becomes a secondary issue when one is choosing between being well and being unwell, and those making business out of health know this’.
This issue raises a number of pertinent points with respect to health delivery, from institutional capacity, health delivery models, patient and broader stakeholder awareness and health-seeking behaviours to the role of policy; further broadening (and complicating!!) the horizons of inquiry for the question ‘what should money be spent on to make health innovations more effective in developing countries?’