Ningún conjunto de premisas no-morales (naturales/metafísicas) puede implicar una conclusión moral

This section examines the progress in reforms at the only national referral hospital included in the scope of the district case studies, the Bugando Medical Centre (BMC).35

34) Appreciation Remarks by the Minster of Health and Social Welfare (Hon. Professor David Mwakyusa) at the Ceremony of Receiving Ambulance Vehicles from US Ambassador (30th _{Jan 2006).}

35) The information on BMC is based on an interview with the Chair of the Hospital Board and the Director.

The BMC has 910 beds and is a referral hospital for 13 million people in the regions of Mwanza, Mara, Kagera, Shinyanga, Tabora and Kigoma. The occupancy rate has slightly increased over the years and now stands at 76%, reflecting increased efficiency. BMC is also a teaching hospital for the Bugando University College of Health Sciences. Funding the BMC

As owner of BMC, the Tanzania Episcopal Conference of Catholic Bishops is responsi- ble for capital investment and rehabilitation of infrastructure. In principle, the GoT pays ongoing running costs. According to the Director, the real operating costs of BMC are TSH 6 billion per annum, but their budget is TSH 2 billion. Cost-sharing revenues have increased more than ten-fold over the period and now stand at TSH 1,200 million per year, while the contribution of the MOHSW to operating costs is TSH 800 million. BMC has an allocation with MSD, but report receiving only 20% of their allocation. Apart from the regular cost-sharing revenues and revenues from patients with insur- ance, the BMC has actively searched for alternative sources of income, such as dona- tions, a twinning agreement with a German hospital and recently with a hospital in New York, bypass fees and a private and VIP ward. They are also trying to enter into contracts with private companies and raising revenue by marketing laundry and kitchen services.

Governance and Management

BMC functions as a partnership between the MOHSW, the Catholic Church, the Touch Foundation and other partners. The Bishop In-charge of the Department of Health of the Tanzanian Episcopal Conference acts as Chair of the governing Board with repre- sentatives from the Catholic Church and the GoT as members.

The Board meets four times a year and discusses plans, budgets, expenditures, audits, progress reports and political issues. The Board also approves employment of specialists and other higher cadre. An Executive Committee of eight people manages the BMC on a day-to-day basis. There is also a Management Committee, comprising of all heads of departments (25). With this management structure the BMC complies fully with the intended hospital reforms.

Access and Quality

The BMC has three social welfare committees, who decide on granting exemptions for the poor and vulnerable. Nurses assess the financial situation of eligible patients, who can either be fully exempted or be allowed to only pay part of the regular fees. Patients have the possibility to appeal, when they don’t agree with the decision of the welfare commit- tee. The costs of granting exemptions have to be recouped from other sources, as the gov- ernment does not compensate for them. The annual value of granted exemptions in BMC is around TSH 400 million.

As referral hospitals are the highest level of care in the country, peer review is the mecha- nism used for quality control. There are no regular meetings between the four referral hospitals and the national Chief Medical Officer (CMO), but in 2003 a peer review was organised between three referral hospitals. These are supposed to happen every year, but due to lack of funding this has not happened since. BMC therefore organised its own peer review by the referral hospital of Nairobi.

BMC has a number of policies to promote quality of care: zero tolerance to corruption and theft, patients can get all treatment they need in the hospital, nursing attendants

cannot attend patients, patients never sleep on the floor or two in a bed, and relatives are not allowed to stay overnight in the ward.

While general conclusions on the four referral hospitals cannot be drawn from the above, it does appear that the BMC has been creative and successful in making ends meet, achieving good quality of care, addressing patients’ rights and improving efficiency, pos- sibly because of their relative autonomy to introduce reforms. They were able to give up- to-date financial information, not present in most public hospitals visited. Their experi- ence could provide valuable lessons for other state and non-state hospitals.

It seems clear that hospital reform has not progressed at the same pace as other aspects of health sector reform. Some informants attribute the continuing problems in governance and management of regional hospitals to the lack of a management culture in the hospi- tal sector and a continued preference for management by medical doctors with little or no training in management. The practice of having hospitals run largely by medical staff also reduces the number of higher trained staff available for clinical practice.

At the same time, it should be acknowledged that the reform plans were very ambitious. Such far-reaching reforms would be difficult to implement in a short time frame in any country. It might be more effective to set more explicit priorities within the reform plans for the health sector and to implement specific reforms sequentially.

6.4 Detailed Recommendations

1. Already agreed hospital reforms should be given a higher priority in HSSP3. (1, 2 and 3)

2. Policy and practices regarding bypass fees should be reassessed in light of their impact on referrals and, if permitted (to generate extra income), should be established at a high enough level to discourage bypassing, except in cases of emergency. (2)

3. The drug allocations for regional and referral hospitals should be reviewed. (2) 4. Patients should be consulted regularly on their perceptions of quality of and access

to regional and referral hospitals, and hospitals should be required to respond with planned improvements. (2)

5. The (financial) incentive structure for MOHSW staff should be adjusted to make it more attractive for Medical Officers to do clinical work in regional and referral hospitals than to work in the administration (including the MOHSW itself). (2) 6. MOHSW should institute a policy of encouraging the employment of professional

managers to run hospitals, not necessarily medical doctors, in order to foster better management and retain doctors in clinical practice. (3)

7. The exchange and sharing of information between regional hospitals in each zone and between referral hospitals in the country should be increased through such mechanisms as staff exchange visits, annual regional meetings, and use of web- based tools such as e-mail and web-portals. (2)

Conclusions: Central Support Systems

1. Infrastructure: Despite construction and rehabilitation activities, there are still