AFRO-NETS> Food for the poor minister's thought

[Claudio Schuftan <aviva@netnam.vn>]

Food for the poor minister's thought
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Triage management in third world health ministries

Keeping services running by juggling items of expenditure in the 
budget of a ministry of health can only go so far. The often prac-
ticed 'management of cuts' makes running health services an impossi-
ble task. Management options reach a point where triaging is the only 
alternative and selected health services are the clear victims of 
such a slashing exercise.

In times of severe resource constraints health managers face chal-
lenges for which they are ill-prepared. There is no training that 
prepares them for operating under such tight financial decision-
making options. What keeps being ignored is the dire constraints un-
der which health ministries work in the South. Here, government man-
agement simply does not obey the golden rules of 'good management' as 
they have been set in the North. Existing theories and recommended 
practices do not seem to work.

In the 1990s, and under structural adjustment, managing a health min-
istry in Africa simply was (and still is) a monumental task. It would 
be monumental even for the top-paid champion managers of Europe or 
North America...

The reason is that ministries are managing their affairs under condi-
tions of extreme poverty; they are practising management under condi-
tions of severe financial constraints, with an extreme scarcity of 
cash resources. To this, add each country's chronic problems with an 
inflated civil service that uses over 70% of the recurrent budget and 
this 'catch-22' scenario becomes fully apparent.

Unfortunately, the type of critical (triage) management skills needed 
are taught nowhere! No university teaches this brand of management 
that could prepare public managers to make difficult daily decisions 
when scarce resources have to be allocated among so many vital com-
peting, real-life priorities.

Triage management is several steps worse than 'management by crisis'. 
No financial forward planning holds when one gets the news that the 
water supply of a major government hospital was cut for non-payment 
of bills for the last year...

Health ministries not only start the fiscal year with scarce finan-
cial voted resources, but with an accumulated debt of unpaid bills 
skilfully carried over to the current fiscal year. This debt further 
erodes already skimpy budgets. Further, when senior management tries 
to call-forward its voted budgetary allocations, it finds the Treas-
ury has a cash-flow problem and delivers those funds late (or never). 
When Treasury cannot balance its own books anymore, it may even 
'close' the fiscal year a month or two ahead of its usual date of 
closure. Even the 'Fortune 500' managers would not be able to cope, 
and yet the 'Misfortune 100' ministerial managers in Africa somehow 
do.

Donor funds-typically already comprising over 70% of development 
budgets of health ministries - actually also get affected by triage 
management. If and when Treasury makes these donor funds available 
they are often used as temporary stop-gap measures to manage the lat-
est crisis thus being, at least temporarily, siphoned away from their 
intended purpose.

All the above is not an apology for Third World ministries of health 
mismanagement or despondency, of which there is a fair amount. This 
is rather a desperate call for technical support, for a search of new 
avenues that can come up with realistic managerial triage techniques 
to cope with this kind of extreme adversity. What this calls for is 
an effort commensurate with the challenge economists had to face to 
cope with the unknowns of hyperinflation. Some of their theories had 
to be revised from scratch in the places where this was happening, 
and not in their own ivory towers.

I am aware that there will be no miracle management techniques coming 
up from such a search, primarily because the main challenge remains -
- i.e. solving the chronic fiscal insolvency issue. However, perhaps 
a South-South sharing of tricks can yield some collective wisdom from 
which to select coping interventions that can be tried elsewhere, es-
pecially as relates to identifying no-cost or minor-cost interven-
tions that show or make a difference. Perhaps there is a recipe that 
can maximize the utilization of human and other resources already in 
place; direct fund-raising techniques (e.g. tobacco taxes) may have 
to be considered as a realistic alternative. A more systematic survey 
of such palliative measures is needed. Perhaps some readers are will-
ing to share their experience with the rest of us or to influence an 
academic institution to start such a research. I believe most poten-
tial help will come from a South-South sharing since the prospects 
for more structural adjustment-like measures will continue to squeeze 
public funding in the Third World in the foreseeable future.

Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.vn

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