THE World Bank has given Queen ‘Mamohato Memorial Hospital (QMMH) the thumbs-up.
However, the bank has called on the government to resolve challenges facing the Public-Private Partnership (PPP) which gave birth to the hospital to ensure its financial sustainability and maintain important health gains.
The institution was opened in October 2011 to replace Queen Elizabeth II (QEII) Hospital as the country’s major referral healthcare facility. South Africa’s biggest private hospital group, Netcare, is the majority shareholder of the Tšepong consortium, which won the bid to build and run the hospital in 2009.
In the report released last week, the World Bank notes QMMH and its filter clinics provide better services “including more advanced medical technologies than were previously available in Lesotho”.
“Maternal and child health results have dramatically improved through the QMMH PPP network, which has greatly surpassed health outcomes provided by previous facilities,” the report states.
“The overall death rate at the PPP facilities fell by 41 percent compared to QEII. Maternal deaths at the facilities fell by 10 percent, while there has been a 17 percent decline in hospital deaths within 24 hours, indicating better access to lifesaving medicines, surgery, and emergency care.”
The health network, says the World Bank, is treating far more people than previous facilities with a 30 percent increase in the number of patients seen every day, 110 percent increase in total annual outpatient visits and 45 percent increase in deliveries.
“The clinics and hospital are fully accredited by the Council for Health Service Accreditation of Southern Africa (COHSASA) – a globally recognised accreditation body – joining a small group of public healthcare facilities in sub-Saharan Africa that have achieved this recognition,” notes the report.
“Other considerable improvements include:
- Availability of most laboratory results within one hour;
- 84 percent of patients are triaged within five minutes of their arrival at the casualty department;
- Improved cleanliness of facilities for less infection-risk to the patients, staff and visitors;
- Better and adequate equipment for staff which results in improved diagnoses.”
However, the report also highlights the challenges facing the PPP such as the “considerable financial burden” the government is carrying to keep it operational.
“Despite these substantial improvements, the health network is also facing numerous challenges and has become a considerable financial burden for the government of Lesotho,” the report notes.
“Recognising these challenges and finding ways to overcome them will be critical to maintaining important health gains, while ensuring its financial sustainability for the government and people of Lesotho.”
The World Bank notes that the PPP served a greater-than-envisioned public demand.
“Under the PPP agreement, Tšepong agreed to treat up to 20 000 inpatients and 310 000 outpatients per year in exchange for a lumpsum payment.
“However, these numbers have been exceeded each year since the PPP became operational, with more than 27 000 inpatients and nearly 350 000 outpatients treated in 2015 alone,” the report says.
The PPP’s “better quality of care” was indirectly working against it because many patients were bypassing other hospitals, the report adds.
“As Lesotho provides universal health coverage for its citizens, people pay the same fees for care at QMMH and its clinics as they do at any other hospitals in the country. Given the choice, people are seeking to be treated through the PPP health network,” states the World Bank.
This was compounded by inadequate primary care facilities and numbers of specialists, equipment and supplies apart from QMMH and its primary care clinics, the bank adds.
“From the beginning, IFC (International Finance Corporation) and the government of Lesotho recognised that providing significantly improved health services through the network would increase patient demand at the facilities.
“So the health network PPP was developed in parallel with an initiative to refurbish primary care facilities across the country with the Millennium Challenge Corporation (MCC).
“However, there was a significant gap between the health network PPP and these improved facilities coming online, leading many patients to seek treatment through the PPP facilities. Today, even though the health infrastructure has been improved outside of Maseru through the MCC funding, there are inadequate numbers of specialists, equipment and supplies, which continues fueling demand for services through QMMH and its primary care clinics.”
Other challenges include an inadequate referral system which has resulted in patients “self-referring” to QMMH, the report continues.
“It is estimated that roughly 70 percent of all cases treated at QMMH bypass primary care. This means there is no effective system to filter patients and treat non-severe cases at primary level,” the report says.
“The cost of treating these extra patients has a direct impact on the health budget.”
In addition to a longstanding disagreement between the partners concerning the base price upon which yearly inflation adjustments should be calculated, the increased referrals to South African hospitals at the government’s expense is another bone of contention, the bank says.
“In the original contract, there is a list of eight excluded services, which notably includes all invasive cardiac care and cancer treatment. Since 2011, QMMH staff have referred patients showing up with these symptoms to public hospitals in Bloemfontein, South Africa,” it states.
“However, the PPP contract does not establish a clear, practical procedure for ‘authorising’ such referrals by the Ministry of Health, and so Tšepong has not informed the ministry of many of these referrals. As a result, there is now a backlog of unpaid referrals to the South African hospitals which were not explicitly approved.
“This has become an issue between the partners and must be resolved for the partnership to continue to provide the greatly improved health services, which were primary goal of the government of Lesotho from the outset.”
The World Bank advises the parties to address the matters under dispute as a matter of urgency.
“The PPP contract sets out clear dispute-resolution procedures, and those need to be applied, including evaluating options for renegotiating some contractual clauses to make sure that the PPP scheme remains fiscally sustainable,” says the global financial agency.
“To help address these issues, the World Bank Group is in discussions with the government of Lesotho about providing technical assistance on contract management.
“This initiative would support the Ministry of Health in day-to-day contract management, help the two partners sort out contract disputes, and, if needed, support contract renegotiation to ensure the sustainability and continued effectiveness of the health network PPP in delivering substantial health benefits to the country.”