THE ongoing countrywide strike by doctors in government institutions confirms the endemic nature of industrial actions that have plagued the health sector over the years.
Work boycotts, stoppages, industrial actions or any form of protest at work in the health sector have a negative impact on people’s access to health-care and on the enjoyment of the constitutional right to the highest standard of health.
By Fortune Nyamande and Dewa Mavhinga
Section 76 of the Constitution of Zimbabwe explicitly provides for the right to health for all citizens and places the responsibility on government to ensure that it enacts policies, laws or other administrative measures that move the country towards its progressive realisation. But why is the country locked in a vicious cycle of endemic strikes by doctors, poor infrastructure, poor service delivery, and lack of equipment and resources within government medical institutions? The answer partly lies in the moribund Health Services Board (HSB), whose job it is, together with the Minister of Health and Child Care, David Parirenyatwa, to address the welfare and working conditions of medical personnel in government institutions.
The Health Services Board was established on June 1, 2005 through Statutory Instrument 88B of 2005 under the Health Services Act (Chapter 15:16 No. 28/2004). All health workers in the public sector were then moved from the Public Service Commission to the HSB.
The HSB was mandated with making appointments, grading, fixing conditions of service for health workers, investigating complaints made by health workers, supervising and monitoring hospital management boards and assisting in mobilising resources for the sector. The recurrence of industrial actions in the health sector points to an absolute failure in the HSB conceptual framework as well as the inability or unwillingness of Parirenyatwa and the HSB office bearers to properly and fully discharge their duties as set out in the Health Services Act.
The conceptualisation of the Health Services Board, which is failing in practice, was rooted in the belief that the health sector had peculiar challenges that needed the separation of the health workforce from the Public Service Commission, just as the Judicial Services Commission was set up to cater specifically for employees in the justice delivery system. Major weaknesses in the Health Services Act include that the Minister of Health and Child Care is empowered to appoint office bearers of the HSB; direct policy decisions; recognise or revoke representation of health worker associations; and appoint hospital management boards, among other responsibilities. The HSB therefore lacks independence as its office bearers are appointed, and beholden to the Minister of Health and Child Care.
This lack of autonomy of the HSB from the Ministry of Health and Child Care severely compromises the quality of decisions that the HSB makes and has a negative impact on the calibre of the health services bipartite negotiating panel as loyalty to the minister can be rewarded by appointment of health workers’ representatives with obscure constituencies and self motives.
The HSB bipartite negotiating panel have had some representatives of health workers who have been reappointed by the minister since 2008 and whose mandate from their respective associations is highly questionable.
The board does not have independent capacity to make decisions that have a bearing on the welfare of health workers. The Health Services Act stipulates that any decisions that have a bearing on increasing the resources required from the Consolidated Revenue Fund must be agreed upon with the Ministry of Finance. This requirement renders any negotiations between the HSB and health workers meaningless as they do not have any specific fiscal allocations from the Treasury that addresses health workers’ welfare. Any financial decision agreed in the health services bipartite negotiating panel will need to undergo a long, bureaucratic and less defined procedure of seeking Treasury agreement despite the presence of the director of budgets from the Ministry of Finance in the bipartite negotiating panel. What then is the essence of establishing a Health Services Board if it is not allocated specific votes from the national fiscus that deals with health workers salaries and allowances?
The HSB concept need to be urgently revised to make way for a more autonomous Health Services Commission that has a specific annual vote from the national budget. Unlike the current HSB with executive board members with packages and benefits, the new Health Services Commission must have non-executive board members who are appointed through an open, competitive process supervised by Parliament and involving the Minister of Health and Child Care in an advisory role. The minister must have no role in deciding which health workers’ associations are represented in the bipartite negotiating panel. This will ensure the appointment of genuine health workers leaders who offer constructive criticism and communicate the true level of motivation or despair in health workers.
The proposed Health Services Commission must have a clearly defined and fixed tenure, retirement age commensurate to the public service regulations and should adopt a results-based monitoring framework to guide new appointments or reappointments. The current situation under the HSB has seen recycling of board members who have been there since 2005 who are now well past retirement age with executive appointment benefits and packages. Executive board members in a large institution with an executive director and other senior managers is, in our view, a duplication of roles and waste of tax payers’ money. Parliament and the Executive have a huge task to equip and redirect the HSB towards its roles as stipulated in the Health Services Act or to discard the concept and consider a more appropriate model as proposed here.
The demands by the striking doctors made through the Zimbabwe Hospital Doctors Association (ZHDA), cannot be said to be unreasonable. In addition to welfare issues, the doctors have called upon for the Ministry of Health and Child Care to outline a clear plan towards restoration of normalcy in the conditions of service in the health sector and to “guarantee for the provision of essential medicines, emergency drugs and protective wear to maximise care of our loved patients.” Health workers, just like other essential services workers, deserve to get non-monetary incentives such as vehicles as is the case with the judiciary, the security sector, and traditional leaders. The brain drain in the medical field needs to be plugged by strengthening retention allowances. The Health Development Fund must be matched up by local resources such as the recently introduced mobile operators tax on health to retain health workers in district and provincial hospitals.
Parliament should urgently take steps to address the crisis in the health sector through the introduction of new laws to establish a competent, truly functional, and genuinely independent health services authority. Health is an essential service and any government should demonstrate its commitment to health through the way it treats its health workers. The problems in the health sector are known, together with viable solutions; what is missing is the right authority to urgently implement the solutions.
Dewa Mavhinga is Southern Africa director at Human Rights Watch, Twitter Handle @dewamavhinga He writes in his personal capacity.
Fortune Nyamande is spokesperson of the Zimbabwe Association of Doctors for Human Rights and is a public health and policy management fellow at Emory University. He also served as the past president of the Zimbabwe Hospital Doctors Association in 2014-2016. He can be contacted on firstname.lastname@example.org. He writes in his personal capacity.