Despite millions being spent on health investment in Sub-Saharan Africa (SSA), health outcomes for HIV/AIDS, tuberculosis and malaria are still poor,⁽²⁾ indicating a weak relationship between public expenditure and health outcomes. Inadequate health service delivery is reflected by the poor results in the attainment of the Millenium Development Goals (MDGs). For instance, only 3 out of 46 countries in SSA are on track with meeting targets regarding the reduction of child mortality by two thirds between 2000-2015.⁽³⁾

Until recently, governments and donors have mainly focused on inputs such as ploughing finances into the development or improvement of certain services and related outputs stemming from such investments. However, governments are increasingly paying attention to issues related to governance as a possible means for service improvement.⁽⁴⁾ The World Bank defines governance as “the manner in which power is exercised in the management of a country's economic and social resources for development.”⁽⁵⁾ Poor governance has often been cited as one of the main reasons why Africa is still underdeveloped, despite her immense natural wealth and millions of aid dollars.⁽⁶⁾ Good governance is essential in order to improve the delivery of health services. This paper analyses governance gaps in healthcare systems and how they could be overcome, with a particular focus on the areas of budget and resource management, individual provider performance, health facility performance and corruption.

Budget and resource management

A budget leakage is the discrepancy between the authorised health budget and the amount of funds received by intended recipients such as frontline providers. Such leakages may occur at any point of the health system, namely, at national, provincial or district levels. Leakages can also occur in specific expenditure areas of a given public health budget.

Budget leakages hamper the provision of health services in many ways. For example, patients may be discouraged from utilising public health services due to additional expenses that they incur as a result of leakages. In 2000, 80% of non-wage health expenditures in Ghana never reached frontline providers.⁽⁷⁾ In another instance, an expenditure track carried out in 2004 showed that health centres in Chad received less than 1% of non-wage funds specifically set aside for them by the Ministry of Health. The poor suffered the most due to higher out-of-pocket expenses incurred while purchasing expensive medication. Studies subsequently recommended strategies that Chad would have to implement so as to improve budget management systems in that country. These included setting clear allocation rules about materials such as finances, non-medical hospital supplies and medications in a bid to reduce theft by administrators, encouraging better record-keeping of expenditure by health facilities, and providing the public with information on the transfer of health budget funds from the central government to local facilities.⁽⁸⁾

One component of budget leakages is payroll irregularities, which is associated with ghost workers. Instances of ghost workers occur when there is a discrepancy between the number of health workers on the payroll and those that are on-site, according to official employment records. This leads to great financial loss for the affected health ministries, a higher workload for health workers that are on-site, and non-functional health facilities as a result of absenteeism.⁽⁹⁾

Regular cleaning of payrolls and punishment of errant health workers have previously been used to curb cases of ghost workers. In South Sudan, the Eastern Equatoria State found that some health workers had left the system but were still receiving salaries. The Ministry of Health cleaned up the payroll and removed all the health workers that were not accounted for.⁽¹⁰⁾ Technology can also be used to successfully curb payroll irregularities. In 2001, Kenya’s Ministry of Health launched the Kenya Health Workforce Informatics System, which enables the detection of ghost workers through compulsory verification of all health workers by their supervisors across various health care sites. Health workers who have not been verified by supervisors cannot receive a salary.⁽¹¹⁾ In 2011, it was estimated that Malawi saved US$ 2 million a year from ghost workers in the public sector. This was attributed to policy change, which saw all civil servants ordered to open bank accounts, due to a decision by the Malawian Government to no longer pay salaries by cash.⁽¹²⁾

Job purchasing

Job purchasing refers to payments made by job-seekers in exchange for employment in the public sector, a practice that often bypasses appointing on merit. Purchasing of health posts is quite common in Africa; the share of public officials who reported job purchasing over a decade ago ranged from 9% in Benin, 20% in Uganda, 25% in Ghana and up to 50% in Zambia.⁽¹³⁾ In these countries, health work positions were ‘bought’ from health facility committees or board members. This could lead to the employment of unqualified staff, thereby affecting the quality of health services.⁽¹⁴⁾ An improvement of appointment procedures could substantially reduce incidents of job purchasing. For example, health workers who wish not to be transferred remote areas may be willing to pay informal fees in an attempt to be assigned to more attractive areas, or even be transferred from such locations, for those already posted there. This could be curbed through the employment of health workers who already have ties with a given area by virtue of being originally from the area. Alternatively, the state could provide incentives such as attractive career development opportunities and hardship allowances to health workers posted in such areas. In their recent article, Maliselo and Magawa argue for more effective implementation of this option in the case of rural Zambia, where incentives on offer have not proven sufficient to attract or retain medical doctors.⁽¹⁵⁾ Further lessons could be drawn from Kenya, where the employment of health workers follows a well-documented process involving the Ministries of Health, Finance, and State for Public Service and the Public Service Commission.⁽¹⁶⁾ It is not difficult to imagine how such an approach would prevent questionable employment techniques in the public service.

Health worker absenteeism

Absenteeism is defined as the chronic, unexcused absence from work, which adversely affects health worker productivity and undermines health service quality.⁽¹⁷⁾ Absenteeism is symptomatic of governance failure, as health workers assume little or no accountability to the healthcare facilities that employ them, or to patients.⁽¹⁸⁾

Uganda is currently experiencing a health worker crisis, with absenteeism complicating the situation. In 2011, a study found that Ugandan health workers may be absent from their posts as much as 35% of the time, with doctors and nurses being quite likely to be absent. The few remaining health workers are, thus, overworked. There have been cases where non-medical personnel such as askaris (guards) and porters treat patients.⁽¹⁹⁾ In light of this, it is estimated that Uganda loses about 26 billion Ugandan shillings (US$ 9,794,820) annually due to health worker absenteeism alone.⁽²⁰⁾ To counter this, the Ugandan Government, through the Ministry of Health, has instructed hospital directors and district officials to sack doctors and other health workers who spend three months away from duty without approval. Through the support of its development partners, the Ugandan Government has also publicised the policies that govern workers’ absences. In addition, the Government has pledged its support for the training of human resource leaders and managers. This would ideally develop health managers’ management skills, including putting into place systems that would help quantify the rate of absenteeism, as well as identify reasons behind rampant absenteeism.⁽²¹⁾

Absenteeism can also be reduced by improving the work climate so as to boost morale and job satisfaction among health workers. In Kenya, a study done in Machakos District found that in 2008 the health worker absenteeism rate, averaging 25% at the time, cost each health facility US$ 51,000 per month. Interventions such as creating staff lounges with free tea, refurbishing facilities, cleaning yards, and offering continuing education opportunities considerably motivated health workers, as shown by improvements in attendance and performance.⁽²²⁾ In Mali, community health associations were at the forefront of efforts to curb health worker absenteeism. These initiatives included the construction of clinic staff housing, provision of potable water and transport for commuting health workers. Higher morale, as a result of these could, in turn, enhance the quality of health services provided.⁽²³⁾ Health professional councils such as doctors’ and nurses’ associations can also play a role in reducing absenteeism by helping put into place enabling working environments, instilling professionalism among their members and respect for their respective occupations, and penalising those who do not perform accordingly. For example, by civil service associations in Rwanda and Zambia have led to the successful implementation of sanctions against some health workers. In Rwanda, errant health workers are sanctioned at two levels, namely, at the relevant health facility and by the Civil Service Commission. In Zambia, 12% of all attrition among health workers in 2009 was due to dismissal, thus pointing towards Zambian health authorities’ stance towards errant workers.⁽²⁴⁾

Health facility funding

Health facilities are an important aspect of health service delivery and they tend to take up a large portion of health care budgets. Most SSA countries tend to rely on global or line-item budgets based on historical allocations when providing funds to health facilities. These budgets are lump-sum allocations to hospitals and do not offer incentives for a given health facility to increase efficiency and equity. Line-item budgets restrict hospital spending and limits managers’ abilities to allocate funds where needed, contributing to inefficiency.⁽²⁵⁾ The rigidity of budgets, leading to ineffective and inefficient health service delivery, is indicative of poor governance.

The manner in which health facilities are funded offers a potentially powerful incentive for providers to improve quality and efficiency of health service delivery. Pay-for-performance has been gaining recognition in the recent years as governments and donors seek to ensure that health facilities receive funds tied to their performance. Some studies have shown that performance incentives targeted at facilities can improve performance by increasing demand and access to health services, thereby strengthening health systems and aiding progress towards the attainment of health-related MDGs.⁽²⁶⁾

Monitoring health administrators’ ability to manage human resources and exercise authority over expenditure seems to improve the performance of health facilities. In Uganda, 68 health facilities entered into contracts with non-governmental organisations (NGOs), in which they would receive funding if certain targets on immunisation, family planning and deliveries by skilled birth attendants were met. Most facilities did meet the set targets.⁽²⁷⁾ Similarly, in Haiti, three health facilities that were contracted by NGOs could earn up to 10% of their historical budget if they met set targets on immunisation, vaccinations, prenatal visits and family planning. Results showed that not only did the facilities meet all those targets, but accountability and management systems, such as increased spending and flexibility, also improved. In turn, the NGOs received more funding. The pilot was a success and was scaled up nationally to 25 facilities.⁽²⁸⁾

Corruption

Informal paymentsin the health sector include fees paid by patients towards individuals, mostly for services that are meant to be free.These payments may include, among others, fees for medication, avoiding the queue, or as an insurance to receive better care from health workers in future. These practices can broadly be classified as corrupt. Corruption is another manifestation of poor governance. In Africa, corruption is widespread in almost all development sectors, including health, so much that it has been accepted as an ‘African problem’.⁽²⁹⁾ Corruption in the health sector can mean the difference between life and death, and has been cited as a causal factor for high maternal mortality rates of women during pregnancy in African countries. This occurs when such women are unable to pay the bribes required by health workers in exchange for services.⁽³⁰⁾

In the public health system, corruption negatively affects the availability of resources, lowers the quality of services offered, denies populations equal access to healthcare, and increases the cost of services provided. For example, corruption is widespread at different levels of the Mozambican public health system, starting from the reception area when booking appointments with doctors, for laboratory services, and even in mortuaries.⁽³¹⁾ In many cases, patients who cannot afford to pay bribes are turned away. To deal with this issue, a central unit was established by the Mozambican Ministry of Health, where patients could report corrupt activities, bad treatment by staff and long periods of waiting in queues. The unit is tasked with establishing committees comprising civil society, local and religious leaders, and patients in the public health system to address the aforementioned issues. The initiative seems to have borne fruit, with a report released over the past year showing that incidents of bribery had decreased substantially.⁽³²⁾

The pharmaceutical sector represents 20-30% of global health expenditure, rendering it susceptible to corruption. Corruption in the African pharmaceutical sector is well documented, going so far as to form a sub-plot in the Oscar-winning 2005 film, The Constant Gardener.⁽³³⁾ Corruption in the pharmaceutical sector affects the economy and patients in several ways. Examples range from negative drug effects or death resulting from counterfeits, lack of access to essential medicines, or non-payment of taxes to governments, therefore lessening revenue. In 2002, several West African countries did not receive sufficient antiretroviral treatment because corrupt officials had sold the ARV supplies to pharmaceutical markets in Europe. As a result, patients in West Africa could not access much-needed life-saving medication.⁽³⁴⁾ Nigeria has one of the most corrupt pharmaceutical systems in the world. In 2001, it was estimated that 68% of pharmaceutical products in that country were counterfeits. Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) was subsequently tasked with strengthening medication testing procedures and enforcing regulations starting from the manufacturing stage, registration and distribution of medication. A follow-up study in 2004 found that NAFDAC had largely succeeded by reducing the amount of counterfeit drugs in the country by up to 80%. NAFDAC achieved this through mass public awareness campaigns and strict regulation of the pharmaceutical sector.⁽³⁵⁾ The World Health Organization launched the Good Governance for Medicines (GGM) Programme in year 2004, which helps countries curb pharmaceutical corruption by emphasising transparent, accountable administrative procedures and the promotion of ethical practices in this sector.⁽³⁶⁾

Concluding remarks

The value of good governance cannot be emphasised enough when it comes to guiding effective and efficient use of investments in the health sector. It is important for governments and donors to not only focus on the input and outputs, but ensure that these resources are used effectively to ensure maximum impact on health outcomes.

Written by Janet Mugo ⁽¹⁾

NOTES:

(1) Contact Janet Mugo through Consultancy Africa Intelligence's Public Health Unit ( public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) Lewis, M. and Petterson G., ‘Governance on health care delivery’, The World Bank, October 2009, http://elibrary.worldbank.org.
(3) Gauthier, B., ‘Service delivery in education and health in Africa’, The World Bank, 2011, http://zonecours.hec.ca.
(4) Gauthier, B., ‘Some elements of guidance for the design and implementation of PETS/QSDS’, The World Bank, May 2010, http://tap.resultsfordevelopment.org . 
(5) ‘What is governance?’, The World Bank, http://web.worldbank.org.
(6) Kanyam, D., ‘Bad governance: The bane of Africa’s underdevelopment’, Modern Ghana, October 2009, http://www.modernghana.com.
(7) ‘Public Expenditure Tracking Surveys (PETS) and Quantitative Service Delivery Survey (QSDS) Guidebook’, The World Bank, 2012, http://pets.prognoz.com.
(8) Wane, W., ‘Public health in Chad: Connecting spending and results’, The World Bank, August 2008, http://siteresources.worldbank.org.
(9) ‘Addressing ghost workers in Kenya’s healthcare systems’, The Global Integrity Innovation Fund, http://innovation.globalintegrity.org. 
(10) Nakimangole, P., ‘Health ministry to remove ghost workers from payroll’, Gurtong, September 2012, http://www.gurtong.net.
(11) ‘Kenya health workforce informatics system’, United Nations Population Fund, 2001, http://www.unfpa.org.
(12) ‘Malawi saves $2m from ghost workers’, News24, May 2011, http://www.news24.com. 
(13) Azfar, O., Kähkönen, S. and Meagher, P., ‘Conditions for effective decentralized governance: A synthesis of research findings’, IRIS Publication, 2001, http://www.iris.umd.edu.
(14) Ibid.
(15) Maliselo, T. and Magawa, R., ‘Retaining doctors in rural Zambia: A policy issue’, Consultancy Africa Intelligence, 2013,  http://www.consultancyafrica.com.
(16) ‘Kenya health assessment 2010’, USAID, 2010, http://www.cmamforum.org.
(17) ‘The World Health Report 2006: Working together for health’, World Health Organization, 2006, www.who.int.
(18) Ibid.
(19) Nalugo, M., ‘Porters, askaris treat patients in hospitals’, The Monitor, August 2012, http://www.monitor.co.ug. 
(20) Businge, C., ‘Health report unearths 200 ghost workers’, New Vision Online, November 2010, http://www.newvision.co.ug. 
(21) ‘When no one is there: Uganda’s absent health workers’, IntraHealth International, December 2011, http://www.intrahealth.org.
(22) ‘Voices from the capacity project: What about the health workers? Improving the work climate at rural facilities in Kenya’, IntraHealth International, http://www.intrahealth.org.
(23) Deussom, R., et al., ‘Holding health workers accountable: Governance approaches to reducing absenteeism’, IntraHealth International, 2012, http://www.intrahealth.org.
(24) Vujicic, M., et al., ‘Working in health: Financing and managing the public sector health workforce’, The World Bank, June 2009, http://www.who.int.
(25) Ibid.
(26) ‘Performance-based incentives’, Health systems 20/20, http://www.healthsystems2020.org.
(27) Lundberg, M., ‘Client satisfaction and the perceived quality of primary health care in Uganda’ in ‘Are you being served? new tools for measuring service delivery’, World Bank Publications, 2008, http://books.google.co.ke.
(28) Eichler, R., et al., ‘Performance-based incentives for health: Six years of results from supply-side programs in Haiti’, Centre for Global Development, 2007, http://www.cgdev.org. 
(29) Cockcroft, L., ‘Corruption: A global problem or an African cancer?’, African Arguments, September 2012, http://africanarguments.org.
(30) Ibid.
(31) ‘Mozambique: Corruption undermining health service’, IRIN, 28 November 2012, http://www.irinnews.org.
(32) Ibid.
(33) Britton, A., ‘The constant gardener’, Centre for Global Education, 2007, http://www.developmenteducationreview.com.
(34) ‘Corruption in the pharmaceutical sector’, Transparency International, 2005, http://archive.transparency.org.
(35) ‘Innovations for successful societies’, Series: Governance traps, Interview H1 with Dora Akunyili, Bobst Center for Peace and Justice, September 2009,, http://www.princeton.edu.
(36) ‘Medicines: Corruption and pharmaceuticals’, World Health Organization, December 2009, http://www.who.int.