IPPA | Health care in Zimbabwe

HEALTH CARE IN ZIMBABWE

CHALLENGES TO PRIVATE PRACTICE IN ZIMBABWE

Diana Macklin

With special attention to changes in healthcare funding and government policy and a rationale of how the profession has managed the changes.

INTRODUCTION

Challenges

The Health Professions Act

Zimbabwe's Economy

Health Care Funding

Managed Health Care

Continuing Professional Development

Management of Challenges

Practice Approval

Disciplinary Protocol

Continuing Professional Development

Education of Fellow Medical Professionals

Education of the General Public

CONCLUSION

INTRODUCTION

Of the 12 million people that populate Zimbabwe, approximately 20% have medical insurance and therefore access to private physiotherapy treatment. These services are provided by a total of 126 registered practicing physiotherapists. There are 126 ZPA (Zimbabwe Physiotherapy Association) members, 46 of whom are PPA (Private Practitioners' Association) members.

CHALLENGES

The Health Professions Act

All health professionals in Zimbabwe have to be registered with the Health Professions Council. The Health Professions Act, by which this council operates, is being rewritten so as to restructure the governing body of the Health Professions Council. This will allow a certain amount of autonomy for the health professions and means that physiotherapists will be involved in the approval of registration and the disciplinary hearings of their peers. Until this process is complete, the Council, which consists of a general body, not necessarily including a physiotherapist, continues to make decisions on the plight of physiotherapists in the country.

Zimbabwe's Economy

A comment on the general economy of Zimbabwe will help the delegates understand our challenges in the financial world. It must be understood that this is not a commentary from an economist, but from a group of private practitioners.

Approximately seven years ago, the policy of Zimbabwe's economy was radically altered from a secure but confined closed economy to an open, free trading economy. For physiotherapists, this expedited our acquisition of books, new equipment and educational materials. However, the change has meant our currency has been vulnerable to external and internal forces, which have resulted in major currency devaluation, spiraling inflation and high interest rates over the last 18 months. The Zimbabwe dollar has fallen by two thirds, interest rates are above 40% and inflation is approaching 50%. These factors combined make it impossible for practices to budget accurately for any length of time and for new practices to be set up.

BAR CHART OF INFLATION WITH SUPERIMPOSED LINE GRAPH OF CURRENCY DEVALUATION

In addition to the devaluation of our currency, importation taxes have been increased drastically, which has affected the cost and availability of physiotherapy equipment and maintenance. There has been an average increase of 150% in the cost of new equipment over the past year.

On a smaller scale, the price of consumable items has also risen by 120%, on average, over the past year, adversely affecting the cash flow of private practices in an unprecedented manner.

Health Care Funding

Medical Aid (Insurance) companies provide Health Care funding. In this system, the patient subscribes to their selected Medical Aid Society monthly and either pays cash for treatments, which are then either fully or partially refunded; or the health care professional receives direct payment from the Medical Aid Society. Physiotherapists generally rely on direct payments but there is a limit on treatment fees and medical professionals are not permitted to charge for shortfalls. Furthermore, the payments from Medical Aid Societies are both erratic and delayed, further affecting cash flow. This results in some practices having to maintain an overdraft facility at 40% interest, which further decreases financial viability.

NAMAS (National Association of Medical Aid Societies) determines the fees that will be reimbursed for treatments and reviews and increments these only once a year. In 1994, the Chairperson of the PPA negotiated a substantial 80% increase in our fees and restructured our tariffs, which are now time-based. However, since then, the annual increases awarded have not kept pace with inflation, and currently private practitioners are worse off in terms of buying power that they were before the 1994 negotiations, with our fee for a 30 minute treatment session being the equivalent of US$ 4.10. In simple terms, the majority of practices are struggling as the fees paid are too low to sustain practices indefinitely.

Due to the problems described above with low tariffs, procuring equipment and consumables, there has been an increase in fraudulent claims by both practitioners and patients and a lowering of standards in the health system in general.

The Government Health Care Scheme for civil and public servants is experiencing major financial difficulties due to excessive fraud. This has resulted in delays and inability to settle many claims submitted by private physiotherapy practices, to the extent that members of these schemes are now required to pay cash for their treatments.

Remuneration for Government-employed physiotherapists is very low which does little to encourage long term contracts. Consequently, turnover of staff is high, with some Government physiotherapists opening their own private practices to supplement their income, while continuing to be employed by government. In addition, the Government has recently reduced the number of posts available in the hospitals for the 20 new physiotherapists graduating per annum from the local university. The combined effect of these elements is already leading to further expansion of private practices, with uncontrolled emergence of many "one person" practices and the very real danger of a drop in professional standards with the inability to equip practices adequately.

Managed Health Care

NAMAS has recently, with the aid of a team from Harvard, identified the major problems experienced with the present system of funding healthcare for the members of Medical Aid Societies and changes to be implemented. Amongst these are fraud and abuse from both the members and health service providers. As a result of this investigation, there has been a proposal to move towards Managed Health care with the following in mind:

Medical Aids and health service providers MUST be partners

Fees should be brought to an appropriate level

Clinical guidelines should be developed

A bonus system should be installed to reward health service providers dedicated to good management.

Continuing Professional Development

PostGraduate training opportunities are limited due to geographic and financial difficulties, although the University of Zimbabwe is working on developing a Post-Grad Masters degree. This means that there is a lack of specialization of physiotherapists within Zimbabwe, with those seeking higher education being forced to study outside the country, often to be met with better employment opportunities once their studies are completed.

Within the ZPA, the Continuing Education Committee has worked hard to organize regular courses taught by both local and international tutors. These courses are generally well supported by physiotherapists in private practice, but our small numbers and the enormous cost of international speakers due to the poor exchange rate, limits the number of courses that can be offered in any one year.

MANAGEMENT OF THE CHANGES

Private Practice Approval

Whilst direct intervention in many of the above-mentioned changes is not possible, the PPA has formed a Committee which is in the process of developing a "Private Practice Approval System" which will ultimately lead to Private Practice Accreditation. (A bonus system should be installed to reward health service providers dedicated to good management)

The PPA, realizing that Managed Health Care is inevitable and that NAMAS would not object to guidelines set by physiotherapists themselves, will be presenting the system to NAMAS in order to facilitate and reduce negotiations in the early stages of Managed Health Care. (Medical Aids and health service providers MUST be partners)

Once established, data will be collected from Approved Practices to give informed statistics to NAMAS with a view to redress the imbalance existing in the fee structures for physiotherapists. In bringing fees to an appropriate level, Private Practitioners will be in a better position to deal with the economic pressures presented earlier on.

Additional data will also assist Managed Health Care groups in establishing rationales for treatments of various conditions. (Clinical guidelines should be developed)

In this way, management of physiotherapy private practice should be achieved through the PPA in partnership with NAMAS, rather than being monitored by a body uninvolved in the day to day issues affecting private physiotherapists.

Disciplinary Protocol

In addition, to Practice Approval, the PPA has established a protocol for dealing with problems and complaints encountered by the public and physiotherapists concerning the standard and conduct of physiotherapists and their practices. It will serve to protect our professional reputation and the general public by monitoring standards in the rapid expansion of private practices.

In addition, it will further assist Medical Aids adopting Managed health care to identify "problem" physiotherapists timeously and gives the PPA the responsibility of addressing physiotherapy matters before they are taken to the Health Professions Council.

Continuing Professional Development

Practice Approval requirements include a requirement for CPD and the courses run by the ZPA will be used to accumulate the necessary number of hours. Ultimately, the Health Professions Council will also have CPD requirements for annual renewal of physiotherapy registration.

It should also be noted that some of the "larger" practices (approximately 10 physiotherapists) have regular in-house training to share knowledge and skills. The PPA is also working on developing a "one person" practice support group which will afford physiotherapists working in isolation an opportunity to network with others in similar situations.

CPD is an important part of managing the changes confronting our profession, as the focus on further developing our manual skills, in combination with appropriate substitutions for exercise equipment, will ensure that we will still provide quality health care for our patients.

Education of Fellow Medical Professionals
This has been an ongoing informal process, until the beginning of 1998, when the PPA published a Private Practitioners' Directory which was circulated free of charge to Doctors and Specialists, as well as Pharmacies. Following this, there has been an increase in the number of patients referred for physiotherapy. Although physiotherapists have been awarded "first contact" practitioner status, it is felt that team work is becoming more and more important in developing a holistic approach to patient care and we have a role to play in developing a dialogue with other health professionals. There have been opportunities at the Zimbabwe Medical Association (ZIMA) meetings for physiotherapists to speak about their profession. For example, recently a PPA member spoke to Doctors and Specialists at one of these meetings about the treatment of patients with Lymphoedema.

Education of the General Public

The rapid emergence of many more alternative health practitioners and their accompanying unrestricted advertising is presenting us with further challenges in changing the general public's misconception of physiotherapy. Until now, physiotherapists have limited themselves by the inclusion of an ethics clause in their constitution, which does not permit advertising. However, at the AGM of the PPA held in October 1998 a resolution was passed to set up advertising protocols in 1999.

In addition, the ZPA participated in a Physiotherapy Awareness Week in September 1998 with a lot of enthusiasm being generated by the newly graduated physiotherapists. One of the events during this week was the provision of fitness testing in town for the public. Here, an example of the public's ignorance was clearly demonstrated when one member of the public made the comment that he hoped he did not have the disease Physiotherapy! He was quickly assured and told what physiotherapy means!

The PPA also aims to raise public awareness of who is treating them and promote our reputation as medical professionals through the development of the Practice Approval System.

CONCLUSION

The small number of physiotherapists in private practice in Zimbabwe are confronted with many seemingly insurmountable challenges from all sides. At times it seems we are so far behind that we will never learn to swim, but slowly we are learning to forge ahead - the examples set by other members of the IPPA are there for us to look to and learn from - and our ability to adapt and be innovative is by far our strongest asset. We look forward to meeting our challenges head on and thank the IPPA for their continued support for our practitioners.

OUTLINE OF DATA COLLECTED FOR THE IPPA DATA COLLECTION PROJECT

International Private Practitioners Association Interim Proceedings, May 1999

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