Una belleza en el exilio

As the link between the MOHSW and the CHMT, the RHMT and the Regional Medical Officer (RMO) represent one of the most important elements of MOHSW’s new policy making and facilitative role. Its roles are to interpret and adapt national poli- cies to regional realities, provide support to the CHMT, and to evaluate CCHPs and progress reports before forwarding them to PMO-RALG/MOHSW.

Quote from an RMO

“I lost my hospital, I lost my authority, I have no funds. I am a senior medical officer, but I have nothing to do.”

Legal and Reporting Status

Document reviews, district case studies and key informant interviews at regional and central level indicate that there are persistent difficulties in the formal status RMO and the RHMT.

The RHMT is headed by the RMO, who is the adviser on health matters to the Regional Administrative Secretary (RAS). The RMO, who used to be the medical officer in charge of the regional hospital, legally still holds that responsibility, but in practice the Health Management Team, headed by a new MO in charge, is now taking decisions, although the latter is not mentioned in the legal documents.

Officially, only the RMO is recognised by PMO-RALG, although it is not a substantive post28 _{in civil service terms. Similarly, there is no act or legal tool that mandates the}

RMO and the RHMT. The regional level has not been the subject of any systematic review and has hardly benefited from the reforms. Despite having been on the JAHSR agenda several times during the evaluation period, these issues have still to be resolved.

Quote from MOHSW Staff Member

“With the reforms the regional level was simply forgotten!”

Funding the RHMT

Because the RHMT is not formally recognized by PMO-RALG, the Regional Secretariat (RS) funds the office costs of the RMO, but not the operational costs of RHMT activi- ties.

Two years ago, under local government reforms, five administrative clusters were created in each regional headquarters under the RAS. One of them is the social services cluster, of which health is a section or department with only one health expert, the RMO. This additional change means that the RMO is now responsible to an Assistant Administra- tive Secretary (AAS) heading the cluster and has lost his/her direct access to the RAS, further devaluating the RMO position.29

When the RMO was still directly under the MOHSW, the RHMT did not have a sepa- rate budget. Its operations were financed from the regional hospital budget. Since 2004 there is one operating cost budget line in the Medium Term Expenditure Framework (MTEF) for the social sector in the RAS office, but no specific amount allocated for health.

In order to enable the RHMTs to fulfil their duties, the MOHSW, while discussing the issue with PMO-RALG, temporarily earmarked a part of the central HBF for opera- tional costs of the RHMTs. These funds are to be transferred by the MOHSW to PMO- RALG, and from there to the RAS Office. However, in all six regions visited by the eval- uation the RMOs said that this money is not available to them, despite the fact that they make plans and budgets, which are approved. In some cases this is related to audit que- ries in relation to (mis)use of previously provided funds but in other cases there is no obvious reason. This means that the RHMTs have no funds for fuel and per diems to undertake visits to the districts, unless they are able to use vertical programme funds. Composition and Capacity of the RHMT

As with the CHMT, the composition of the RHMT remains very clinically oriented and does not reflect health reform initiatives such as the multi-sectoral approach, the develop- ment of the CHF, and the development of PPP. While the RHMT is supposed to sup- port and supervise the CHMTs, the latter have been more extensively trained. One RMO commented on the lack of effective capacity (including lack of funds) of the RHMT by saying “giving councils more responsibility is good, but if they are not performing well, there should be a hand to correct them. But we can only give advice, which can be accepted or not”.

The Search for A Solution on the Roles and Capacities of the RHMT

In June 2007 (during the main data collection mission of the evaluation) the Permanent Secretaries of the MOHSW and PMO-RALG agreed that a seven-member RHMT would be recognised in the RAS office as a separate cluster, giving the RMO his/her team back as well as a direct reporting link again to the RAS. This agreement could help to resolve the difficult financial state of the RHMTs.

During the evaluation three possible core functions at regional level were noted: 1. clinical supervision (more or less the classic function of the RHMT);

2. support to CHMT in planning, finance, HR, logistics, administration etc. (the renewed function of the RHMTs, which they have not been able to fully exercise, due to lack of funds and competence); and

3. health inspectorate (at present non-existing, but necessary for quality assurance).

29) Unless the RMO is the AAS, as is the case in Iringa Region. The AAS is one of the departmental heads, making the cluster head a primus inter pares position.

These functions need to be studied in parallel with the suggested tasks and composition of the CHMT and an assessment of how much support the CHMT is likely to need in the future. While teams from the regional hospitals can be contracted to clinically super- vise council hospitals, RHMTs in the RAS office could support the CHMTs and a sepa- rate (semi-autonomous) small health inspectorate team could be established at the regional level to inspect quality, safety and access to health care, as well as investigating complaints and safeguarding the rights of patients.