by Julius Mugwagwa, recently in South Africa and Zimbabwe
Spending a week each in South Africa and Zimbabwe doing a pilot study for my new ESRC-funded project on ‘innovative spending in global health’ from the end of February to early March was indeed an eye and ear opener. For both me and the various people I met and talked to.
I met and had discussions with a wide range of people: officials in ministries and departments of health, universities, civil society organisations with activities in the health arena, retail pharmacists, private health practitioners and people going about their everyday lives in cities and rural areas. The issue of being creative and innovative in raising resources is a dominant one, not only in health, but in all facets of human endeavour. In fact there are all sorts of names and phrases in the local languages of South Africa and Zimbabwe to describe the innovative and entrepreneurial ‘wiring’ of those who are successful at accumulating resources.
There is an unwritten consensus that once the resources are there, spending them in an impactful way will not be a problem. It gave a bit of a jolt therefore when I asked the various people I spoke with whether they had stopped for a moment to think about innovative spending. The immediate reaction from those in organisations was that there was no innovative spending at all and that resources would simply flow through the channels that were set in institutional arrangements, budgets, strategic plans and other operational procedures.
On the question of who made the decisions on where to spend money, two responses were particularly striking. A retail pharmacist in South Africa was emphatic in saying they would not want to be at the decision-making table. All they wanted from there were decisions that would allow them to be effective at their part of the value chain. He highlighted that the tendency to want to bring everyone to the decision table ran contrary to all conventional wisdom and practice. For him, ‘even in the village where I grew up, you only need a small group of people to decide … the problem now is there has been an erosion of trust, so everyone wants to be there when decisions are made. But the reality is that whether you are there or not when decisions are made, benefiting from those decisions is a completely separate thing.’
A respondent from a church-funded and church-run hospital (a mission hospital) had a different reason for not wanting to be at the decision table: ‘We have a system that works, and we trust those few that are tasked with making the decisions. We are here to serve, and that mission binds people at all levels.’ A respondent from the ministry of health in Zimbabwe agreed, further highlighting that with mission hospitals, the dollar delivers so much more than in the public health care system. The respondent also concurred that not all people who came to the decision table were wanted there, while many others were wanted at the table but were not invited.
The 'innovative spending in global health’ study will be exploring these and many other issues further. Preliminary indications point to a modern-day take on Mother Theresa of Calcutta's famous quote: ‘We the willing, led by the unknowing ...’ Perhaps something like, ‘we the invited, sitting together with the wanted and unwanted, and acting on behalf of the uninvited and unavailable have decided, and that is final!’