TOPIC IMPACT OF PUBLIC PROCUREMENT POLICIES AND PROCEDURES ON THE HEALTH DELIVERY SYSTEM IN ZIMBABWE: CHITUNGWIZA CENTRAL HOSPITAL
BY NYEKE DEZMORE B1128603
A RESEARCH PROJECT SUBMITTED TO THE DEPARTMENT OF ECONOMICS IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE BACHELOR OF COMMERCE (HONS) DEGREE IN PURCHASING AND SUPPLY
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CHAPTER ONE
1.0 Introduction Chitungwiza Central Hospital (CCH) is a quasi-government non-profit making organization under the Ministry Of Health and Child Welfare. It is committed to the provision of quality health services, which are promotive, preventive, curative and rehabilitative, advocating and facilitating the provision of cost effective services in a conducive environment indiscriminately. To achieve this it has a purchasing function which its main function is to procure all goods and services for the hospital. The Purchasing function is part of the broader concepts of materials management or logistics management, provides materials, products and services to the enterprises in such a manner that input costs are optimized, the competitive advantage of the firm is enhanced and the welfare of the general community is increased. It is there as a result of the State Procurement Act which states that all government departments should have this function. Though this function is there, Chitungwiza Central Hospital is facing a number of operational challenges. Inadequate medications, lack of back-up spares for diagnostic equipment, poor diet for patients, floor beds in wards are some the challenges hospitals face in their quest to deliver quality healthcare to patients and Chitungwiza Central Hospital is not exempted. Against this background, the research aims at assessing the impact of the public procurement regulatory framework on the health delivery system in Zimbabwe. 1.1 Background of the study Health institutions in Zimbabwe are generally faced with a number of operational challenges. Inadequate medications, lack of back-up spares for diagnostic equipment, poor diet for patients, floor beds in wards are some the challenges hospitals face in their quest to deliver quality healthcare to patients. 3
Public procurement is not a new area in terms of research as there are a number of studies conducted on the subject for instance, Lindskog, Brege and Brehmer (2010), Shui Hui et.al (2010), Lawther and Martin (2005), Caldwell et.al (2005), Tikkanen and Kaleva (2011), Cabras (2011), and Walker and Bremmer (2010). These researchers focused intensely on public procurement in general. The impact of public procurement policies and procedures on health delivery system in Zimbabwe has not been adequately developed and applied. There are some studies done in other countries on issues to do with public procurement but there are no similar cases which were done in Zimbabwe. Thus, generalization for example, Procurement issues in Malaysia to all public procurement scenarios worldwide will result in a narrow approach being adopted. Zimbabwe might not have the same challenges as Malaysia or China as nations vary considerably. It can be noted that results of their investigations are context oriented. In addition, resurgence of diseases like Cholera and Typhoid coupled with acute shortages of drugs and medical equipment in some hospitals bring this research into perspective. Also, this research come at a time when the Ministry of Finance, reiterated the importance of efficiency and effectiveness in the service delivery (Chizu, 2011) . This also coincided with the announcement by the State Procurement Board Chairman about the need to improve competitiveness of tendering system (The Herald, 2011). The resurgence of Cholera in 2008 which claimed thousands of lives and the recent Typhoid outbreak in most parts of the country is a clear testimony of the challenges facing the health industry. Late diagnosis of cervical and breast cancer in women add to the basket of health challenges. Further to this, the countrys Tuberculosis (TB) Mortality rate remains high with the nation ranked fourth in the world with reported cases of patients defaulting treatment over allegations of high consultation fees at hospitals despite the free treatment policy (Newsday, 2011) . Generally high acquisition cost of drugs, surgical and medical equipment seem to be prevalent in most hospitals. Shortage of Anti-Retroviral drugs (ARV) for HIV patients in hospitals and clinics remains a challenge. This is further exacerbated by unavailability of doctors and under-equipped theatres and treatment rooms. Floor beds in most hospital wards are seen scattered and perhaps an indication of 4
inadequate physical infrastructure. There are long queues in sections such as the Casualty and Outpatients departments resulting in longer turnaround time for patients. As for existing medical equipment, constant breakdown and lack of back-up spares to restore the functionality of these machines have been noted especially X-ray Machines and Laboratory Analyzers. There are also cases where patients are booked for X-rays or other specialized tests to be done after a couple of days. Regarding the issue of diet in hospitals, patients have been served in some cases, with food which is not palatable and nutritious in line with their varying dietary requirements. This was well noted in 2008 and 2009 where patients were mostly served with beans or cabbages as relish consecutively. Despite these challenges, there are even cases where the hospitals do have the funds but there are no medicines or specialist modern equipment and this has been highlighted by the Minister of Finance. Other cases involve cancellation of tenders for drugs whilst some take longer to be finalized irrespective of dwindling stock levels.
1.2 Statement of the Research Problem The health sector is facing a multiplicity of issues ranging from unavailability of critical medicines, influx of unregistered medicines, expiry of some drugs in hospitals and clinics to inadequate diagnostic equipment in the laboratories and X-rays. This was evidenced by the health sectors failure to cope with recent outbreaks of Cholera and Typhoid. Despite these challenges, there are cases where the hospitals have the funds but there are no medicines or specialist modern equipment and this has been highlighted by the Minister of Finance. Other cases involve cancellation of tenders for drugs whilst some take longer to be finalized irrespective of dwindling stock levels which result in stock outs. This negatively affect the service delivery to the patient.
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1.3 Objectives To evaluate the impact of public procurement policies and procedures on health service delivery. To assess the adequacy of procurement policies and procedures at Chitungwiza Central Hospital. To examine the causes of the delay in procurement activities and their effects. 1.4 Research Questions How has the Public Procurement Act affected health delivery system at Chitungwiza Central Hospital? To what extend are the procurement policies and procedures adequate for Chitungwiza Central Hospital? What are the causes of delays in procurement activities?
1.5 Significance of the study The rationale behind this study is to fulfill personal, academic and professional interest 1.5.1 The Organisation To the government, this research will have the potential of changing the public procurement terrain by enhancing efficiency and effectiveness in the system. Areas of resource mobilization and allocation will be reconsidered resulting in mega savings in resources and realization for Value for Money (VFM). The general well- being of patients will be improved in hospitals and clinics. In essence, this research will unveil areas where improvement is most and urgently required. And, for the institutions that are used as case studies, the research will actually assist in the identification of all the operational issues impacting the health delivery system at their hospitals. Employees of these hospitals will have an honour or recognition of participating in a research that can alter the history of the country in terms of health delivery.
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Lastly, for the researcher, the approach of the case studies will enable full understanding of the research problem. Skills for analyzing, assessing, investigating will be invaluable for the researcher even for future studies. 1.5.2 The University The research can be added to the library and can be used by other researchers and can be used as empirical evidence by other researchers. 1.5.3 The Researcher The researcher will bring a sense of achievement to the researcher. It will work as a motivation tool as other researchers can make reference to the research on matters pertaining to procurement and this will increase his confidence in the procurement field. 1.6 Assumptions of the study The information that will be used for this research is reliable, accurate, unbiased and will be obtained from relevant authors, persons, and publication. Issues under investigation shall remain constant throughout the period of research The researcher shall get all the information needed for this research All the targeted participants will cooperate All participants will provide accurate information The research shall be carried out within the premises of Chitungwiza Central Hospital. 1.7 Delimitations of the study The major concerns of the study shall be the impact of public procurement policies and procedures on health delivery system. The study shall be carried out at Chitungwiza Central Hospital and shall consider an evaluation of the State Procurement Act. 1.8 Limitations The collection of data was difficult in areas that are governed by law and code of ethics. However the researcher had to seek authority from the CEO who approved 7
the researcher to have access to the required data. Information that is considered sensitive and confidential was difficult to deal with as respondents were not willing to release such information but the researcher had to educate them on the importance of the information as it was purely for academic purposes. Some respondents were not able to return the filled questionnaires on time. The researcher had to persuade them to finish on time. 1.9 Definition of terms Procurement :- it is that function that describes the activities and processes that are done to acquire goods and services Inventory:- these are goods in stock Organisation:- might be used to replace the hospital. Code of ethics:- these are standards, rules and procedures that govern the way goods are purchased Purchasing:- this is the process of ordering and receiving of goods and services (Benton, 2010) CCH- will be representing Chitungwiza Central Hospital. 1.10 Summary This chapter will explore the background of the study, statement of the problem, significance of the study, assumptions, delimitations and limitations of the study.
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CHAPTER TWO Literature Review
2.0 Introduction
This Chapter critically assess and evaluate the published works of accredited scholars and researchers, relevant and applicable in the public procurement. This Chapter is logically organised in two parts namely, general public procurement perspective and health procurement perspective. To fully appreciate and understand the direction of this research, it is deemed crucial and relevant to define public procurement in general and outline its context to give direction to the academic audience. 2.1 Theoretical Literature The review of literature by other authors will be reviewed under this heading. The researcher started by defining procurement. 2.1.1 Conceptual Definition of Procurement
Procurement is the process of acquiring goods, works and services, covering both acquisitions from third parties. It involves option appraisal and the critical make or buy decision which may result in the provision of goods and services in appropriate circumstances (PPB, 2003).
Procurement is to purchase the right quality of material at the right time, in the right quantity, from the right source, at the right price. The main objectives of procurement include: supplying the organization with a steady flow of materials and services to meet its needs, to buy efficiently and wisely, obtaining by ethical means the best value for 9
every money spent, to manage inventory so as to give the best possible service to users at lowest cost and protect the governments cost structure (Barly, 1994).
2.1.2 Definition of Public Procurement Public procurement has been defined as, a process whereby public authorities- including all levels of government and public agencies-buy goods and services or commission work, Kastanioti et al.( 2012,p.1). Public procurement can be described as centrally negotiated legal processes which are guided by political decisions and practically implemented by various local purchasers. It should be acknowledged that public procurement has both economic and social benefits, but the social benefits of public procurement are primarily seen as indirect positive effects from economic savings and environmental improvements (Bjrn Wickenberg 2004). Procurement is a potential instrument of integrating socially and economically sustainable benefits to stimulate employment programmes. According to Waara (2007), Public Procurement is any purchasing performed by any public authority within the classical sector or within the utilities sector. The public procurement rules applicable to purchasing entities also depend on whether the total purchase value is over or below certain so-called threshold values, which differ as regards goods, services and construction works. All procurements above the threshold values apply procurement directives and must be advertised in the Supplement to the Official Journal for public tenders. There are a number of different procurement procedures to choose from, depending on whether it is a purchase above or below the threshold values. Many minor purchases are subject to so-called direct procurement, which do not have to be publicly advertised. However, due to principles of market competition, direct procurement should not take place repeatedly, and purchases should not be divided into smaller units in order to avoid exceeding the threshold values.
Again, according to Ghana Integrity Initiative (2007), Public Procurement is the acquisition of goods and services at the best possible total cost of ownership, in the right 10
quantity and quality, at the right time, in the right place for the direct benefit or use of governments, corporations, or individuals, generally via a contract. It can be said to be the purchase of goods, services and public works by government and public institutions. It has both an important effect on the economy and a direct impact on the daily lives of people as it is a way in which public policies are implemented (Ghana Integrity Initiative, 2007). It is interesting to note that purchasing by government departments and agencies represent a substantial contribution to the countrys Gross Domestic Product (GDP). In most developed countries, it is estimated that GDP contribute about 10-15 percent while in developing countries it is approximately 20 percent (Mukhopadhyay 2011). The funds that are utilised in the procurement of goods and services are mainly harnessed from income tax, companies tax and duties on imports (Hui et al. 2011). In some countries the parliament approves the budget prior to disbursements to individual government departments. Generally the decision making process in public purchase is cumbersome, tedious, complex and time consuming primarily because of extensive authorisation procedures and also multiple stakeholders (Van Weele (2005). Further, there is pursuance of political, budget policy and public accountability objectives in public procurement as given by Van Weele (2005) and it is of paramount importance to review these objectives. 2.2 Critical objectives in Public Procurement Public procurement has its objectives and the researcher saw it worth to look in to these objectives. 2.2.1. Political Objectives Political objectives play a pivotal role in shaping procurement policies and procedures in the public sector. Issues relating to employment creation, development of and protection of local industries are at the heart of government iniatives. The moves by the Zimbabwean government to adopt the Look East Policy where certain products are procured mainly from China clearly illustrate the encroachment of political objectives into public procurement framework. This is a very contentious issue though defended by the State Procurement Board (Langa 2012). The Indigenisation and Empowerment policy 11
where a certain percentage of the public tenders are reserved for local companies again poses serious implications in public procurement. Indigenous companies should not be synonymous to brief case companies whom when contracted fail to meet up to the contractual obligations. The recent awarding of tender to a South African company by Zimbabwe Electricity Supply Authority (ZESA) ignited debate and criticism in line with the Indigenisation and Empowerment policy. Further, the Cabinet instruction for all public institutions and parastatals that all vehicles should be procured from local manufacturers such as Willowvale Mazda Motor Industries and Quest Motors, while protecting local industries may impede service delivery particularly that the former manufacturer was brought before the parliamentary portfolio committee on health for failing to manufacture ambulances for hospital within the agreed time-frame (Government of Zimbabwe 2011). While political objectives may be addressed, issues relating to efficiency can be lagging behind. Therefore a balanced approach needs to be adopted especially when political objectives are at variance with economic objectives. It is imperative to take cognisance of the fact that how suppliers are selected determine the performance of government departments particularly that the Zimbabwe Finance Minister registered displeasure over incomplete projects by contracted companies despite advance payments. Therefore, performance of public hospital or any department hinges heavily on the competitiveness, novelty and capability of its suppliers (Vonderembse and Tracey 1999). 2.2.2 Budget Policy objective As mentioned earlier on, funds used for the procurement of goods and services are levied from taxpayers. These funds are then passed through parliament for endorsement prior to disbursements. Once approved, the budget for each department is like a license to spend as noted by Van Weele (2005, p.341) What this entails is that all funds allocated for that particular year must be exhausted failure of which may lead to the funds reallocated for other purposes. Also, failure to appropriately and fully utilise the funds will impact negatively on the next years budget allocations (Van Weele 2005). And so, the strategic role of purchasing in this regard is detrimentally and regrettably missing in 12
all government purchases. Savings through negotiations or use of innovative supply chain strategies will not be credited to the respective department ( Van Weele 2005). 2.2.3. Public Accountability objective The procurement activities by government institutions or agencies are under intense scrutiny from the general public primarily because it involves the use of tax payers funds which parliament endorses (Erridge and Nondi 1995). The Office of the Comptroller and Auditor General verifies all expenditure and that explains why government departments must meticulously and religiously follow the laid down procurement policies and procedures resulting in the officers discharging procurement duties to be procedure oriented rather than results oriented (Van Weele 2005,p.342). The development of stringent legal and policy framework is carefully crafted towards the achievement of an economical, effective, transparent and efficient delivery system. In some cases, the regulations are specifically designed to reduce fraud, corruption, abuse of office through establishing an audit-trail procurement system (Mukhopadhyay 2012; Lindskog, Brege and Brehmer 2010). Corruption has been of major concern particularly in the public sector and for that reason it is necessary to briefly examine its extent and implications. 2.2.3.1 Corruption in the Public Sector Despite the strict jurisdiction, incidences of fraud, bribery and corruption has been unearthed either through audits or traps by the Anti-Corruption Units in various nations. As claimed by Auriol (2006), the research conducted by World Bank uncovered that about $US 200 billion per year are fleeced from government expenditure worldwide through bribery and corruption. It will however, remain unclear as to what was the actual purchase price because it is the biggest briber and not the most appropriate supplier who is awarded the tender (Auriol 2006). However, the emergence of corruption practices in many governmental departments, everything else being equal, can be an indication of gross institutional performance gaps or deficiencies and that probably explains why public officers circumvent the 13
procurement procedures. The probing question is why the institutions lacking in the first instance (Aidt, Dutta and Sena 2008). Raymond (2008) strongly contends that corruption is rife in developing countries than developed countries. Poverty and weak enforcement of the procurement regulations could explain such as scenario. Whichever way one may explain the reasons, corruption has far reaching effects particularly in public hospitals. In some cases it takes the form of gifts, but, as noted by Brennan (2009) the value of gifts could be borne proportionally by the patients in the form of higher prices. In addition, evidence of corrupt tendencies frustrate donor support particularly vaccines and pharmaceuticals supplies bringing fiscal pressure to the government to provide for any procurement activity. When corruption goes to astronomical levels as reported by World Bank, it necessitates the review of ethics in purchasing. 2.2.3.2 Ethics in Purchasing Ethics is defined as, the principles of conduct governing an individual or group; concern for what is right or wrong, good or bad, Lysons and Farrington (2006,p.655). The importance of ethics in purchasing has not been central as compared to other established professions such as medicine, surgery, law, accountancy and architecture (Lysons and Farrington 2006). For instance, a medical doctor or registered general nurse, the right to practice is subject to appropriate professional membership. Malpractice in these professions, unlike purchasing, has serious repercussions. Michael Jacksons Physician, Dr Murrays practicing license was revoked when convicted of ethical breach. Of course, there are reasons or developments highlighted below that necessitated the pursuance of ethical codes in purchasing. Susceptibility of purchasing professional to corruption because of their position as organisations representative to the external suppliers and also the volume of financial resources at their disposal. Importance of trust and unimpeachable level of integrity in maintaining and sustaining relationships in the supply chain network. Demand for accountability and transparency by the stakeholders. 14
While there are professional bodies in the field of purchasing like the Institute of Supply Management (ISM) in the United States of America and the Chartered Institute of Purchasing and Supply (CIPS) in the United Kingdom that provide enough guidance on ethical issues in procurement, they have not yet developed a comprehensive sanction system for those who deviate from the prescribed code of conduct. Considering purchasing being prone to corrupt activities, it is expected that penalties are attached to malpractice particularly that there are far reaching effects in terms of service delivery. The other reason given by Lysons and Farrington (2006) is that a conflict of interests may arise in that the professional codes of conduct can be superseded by the organisational ethics standards. 2.2.4. Competitive Objective The underpinning principle of regulatory framework in both national and international laws (including European Commission Directives) is to promote competition (Tadelis 2012). The establishment of legal system in public procurement is to impede preferential procurement tendencies (Christopher 2005). When many players participate in tendering undeterred, prices go down and Value for Money (VFM) is enhanced. This competitiveness objective is contended by Caldwell et al. (2005, p.243) that in public markets it is still difficult to achieve especially when tested against the economic models of perfect competition and low barriers to supplier entry or exit. It is therefore crucial to evaluate the concept of Value for Money (VFM) because of its centrality to all government purchases. Budgetary constraints are also critical to that concept. 2.2.5 Value for Money (VFM) In order to fully understand the Value for Money concept in relation to public procurement, it is essential to define it. Definition of Value for Money: Value for Money is the optimum combination of whole life costs and quality UK Government (2004, p.17) 15
From this definition, it is very important to underline that the VFM concept is premised on the idea of whole or total costs and not on the lowest purchase price. The EC procurement directives have taken cognisance of the total life cycle costs. Whole life costs encompass the acquisition, possession, use and disposition of a commodity (Ellram 1994) 2.2.5.1Implications of the Regulatory Framework The highly prescriptive nature of the procurement policies and procedures have been criticised mainly because of the burden it exerts on public institutions in the process of acquiring commodities and also the suppliers participating in the tendering. The recent Zimbabwean court case where the Minister of Energy and Power expeditiously procured the much needed fuel amid revelations that the countrys reserves had reached critical levels, as a result, a criminal charge was filed against the Minister for failing to follow procurement procedures. As such, the procedures and policies may not be consistent with the urgency and criticality of the item required. Medicines, surgical consumables can fit in that category where sickness cannot be postponed to a future date to allow complete authorisation. Gerson (2004) as referenced by Cabras (2011) suggested public procurement efficiency by reducing the number of inputs without compromising on quality. After considering the contribution of procurement, for instance, to the countrys GDP, it is of paramount importance to examine the strategic role of purchasing in enhancing the competitiveness of an organisation. 2.3 Empirical Literature 2.3.1 Strategic role of purchasing in Enhancing Competitiveness Over the past decades, purchasing in general was perceived to be not strategic in some organisations and industry segments. This was evidenced in the employment of non- purchasing staff who may not even sit in a purchasing department and might not call the process purchasing, Zheng et al. (2007,p.76). A Clinician performing procurement duties was the scenario one could find in some organisations. A survey conducted by 16
Cammish and Keough (1991) unearthed that in some industries such as pharmaceuticals, consumer products and laboratory suppliers, the strategic role of procurement appeared to be marginalised. Despite the above low perceived value of purchasing, the recognition of purchasing as a strategic function has increased notably in recent years to reflect broad external and internal business trends (Van Weele 2005). Deregulation of trade as a direct result of globalisation by most governments has intensified competition hence need for exploiting purchasing function in positioning the competitiveness of the organisation. The above is further exacerbated by changing customer needs and preferences where customers developed an extended value concept that incorporated flexibility, dependability, convenience, novelty of their product or service (Van Weele 2005). Thus, the procurement function in any organisation is strategically positioned to mitigate the environmental and industry risks, Chen et al. (2004) as quoted by Lawson et al. (2004 ). The work of Porter (1980); the Five Forces Model further uncover the strategic role of purchasing in enhancing organisations competitive position on the industry market. Out of the five forces, two; the competitive nature of the industry and the bargaining powers of buyers and suppliers are directly linked to the procurement department (Mol 2003). Speckman, Kamauff and Salmond (1994,) also illuminated on the competitive and strategic position of procurement in organisations in the light of the new competition. This concept is premised on the idea that companies or organisations will not tomorrow compete in the same manner they did yesterday, hence exposing the strategic role purchasing has in exploiting the unique competencies of the suppliers that keep them competitively afloat (Speckman, Kamauff and Salmond 1994). However, there is need to examine some of the key drivers that have triggered the recognition of purchasing as a strategic function in both public and private sectors. 2.3.2 Key drivers for the recognition of purchasing As mentioned earlier, globalisation and the demanding nature of customers have unravelled the issue of cost management as a driver for the recognition of the purchasing function. Also, the emergence of supply chain related risks necessitated the proper 17
positioning of purchasing department. Hence the two major drivers; cost and supply chain risks need to be critically examined. 2.3.2.1 Cost The purchasing department is the conduit of expenditure of an organisation and for that reason it will be suicidal if not catastrophic to neglect this department given the volume of resources at their disposal. Governments are also reviewing their budgets upwards to maintain accommodate additional expenditure. Analysis of a cost structure of either a manufacturing or service organisation indicates a larger cost percentage of goods and services (Van Weele 2005). Thus, the cost structure of an organisation necessitated the recognition of purchasing in spearheading cost reduction. Involvement of suppliers in the previously sacred territories of research, product or system design by the procurement function signifies the importance of the department in terms of cost competitiveness. 2.3.2.2 Supply Chain related risks Due to globalisation, the diverse nature of business operations where organisations can be supplied by seller who in turn is supplied by a manufacturer with facilities all over the world means that many participants or even products are involved and this complicates the entire supply chain. Even the patient, for instance, on Anti-Retroviral therapy in Zimbabwe feel the impact of these supply chain related risks if the treatment delays to reach the hospitals. In 1994, Toyota realised the importance of purchasing in maintaining and sustaining supplier relations when fire gutted their factory destroying one essential component that brought the entire supply chain to an instant halt. The resuscitation of operations at Toyota following that incident unmasked the unique role of purchasing (Wilding 2008). Therefore, the procurement function offset these supply chain related risks and maintains competitiveness of the organisation. Having assessed and evaluated public procurement literature from a general perspective, the nature of procurement in the health sector can now be critically examined. 2.3.3 Public procurement in the Health Sector 18
As highlighted by the United Kindgom Office of Government Commerce (2008), procurement is arguably one of the most important indispensable mechanisms to deliver policy and this encompasses health delivery to citizens. Issues relating to provision of affordable healthcare services to the patients are at the core of the health departments. In recent years, health institutions around the globe faced challenges in terms of cost containment of medical products, efficiency and budgetary constraints and responsiveness in the medical supply chain (Saltman et al.1998 as quoted by Figueras, Robinson and Jakubowski, 2005, Brennar, 2009). DeRoek et al. (2006) particularly singled procurement of pharmaceuticals and vaccines as a challenge in low- and middle- income countries. The rationale behind procurement challenges as noted by Woodle (2000) could emanate from the historical assumption that the vaccines were donor- supplied and as such were not budgeted for. But given the budgetary constraints on the part on the donors, the procurement responsibility is now shifting to the government (Cohen, Reeh and Neroutsos, 2011). Apart from low and middle-income countries, in New Zealand, the growth of pharmaceutical expenditure has been a great source of concern in hospitals (Tordoff, Norris and Reith, 2008). Further, in the UK, the government through National Health Service (NHS) put measures and strategies that seek to regulate expenditure in the health services. Some of the measures included standardisation in the purchase of medical equipment and accessories (Clark 2011). Ghana in the Medium Term Health Sector Strategy also recognised the strategic role of purchasing in reducing expenditure on drugs, surgical and other related hospital consumables (Verhage et al. 2002). In South Africa, the Minister of Health reported a reduction of the price of Anti-Retroviral drugs by more than half of the previous expenditure (Albert 2010). It is against this background that the World Health Organisation (2000) report inevitably suggested strategic purchasing in the public sector as capable of improving medicines availability and reducing costs of acquisition. This also coincided with the budget statement by the Zimbabwe Finance Minister, Tendai Biti that efficient procurement is key to service delivery (Government of Zimbabwe, 2012). World Health Organisation(2006) further acknowledged the importance of purchasing and supply chain management in ensuring availability of Vital, Essential and Necessary (VEN) drugs in 19
Africa. Pazirandeh (2011) argued that unavailability of drugs could be could be due to uneven distribution within the supply chain network. This could be most relevant in humanitarian situations than normal health care delivery in Africa but Tetteh (2009) argued that even in normal situations, drug supply chains have a direct impact on availability and affordability of medicines. Therefore there are pertinent procurement issues in developing countries that were highlighted by both World Health Organisation (2006) and Cohen, Reeh and Neurotsos (2011) and these should be addressed to streamline procurement activities. Key issues highlighted in the World Health Report (2006). Unclear tender specifications for products Inadequate tender terms and conditions. Procurement laws and regulations lack relevance in addressing purchasing of pharmaceuticals. Lack of transparency, integrity and good governance. Co-ordination in the medical supply chain Inadequate use of Information Technology (IT) in the procurement of medicines. Key issues reported by Cohen, Reeh and Neurotsos (2011) Technical competent procurement staff. Legal, policy, regulatory frameworks. Transparency and prevention of corruption in purchases. Budgetary issues (Financing).
After evaluating procurement in the health sector from a broad context, it is now imperative to consider the procurement system in the health sector in Zimbabwe. 2.3.4 The Procurement System in the Health Sector in Zimbabwe The Ministry of Health and Child Care (MOHCC) is responsible for ensuring service delivery in all government hospitals and clinics nationwide. Its mandate is to ensure the 20
provision of quality and safe health services through a network of health facilities organised throughout the country (MOHCC 2012). Adequate and constant supply of safe, efficacious medicines, surgical sundries, laboratory reagents and diagnostic equipment remain the top priority of the Ministry. The table below indicate the public health facilities in Zimbabwe. Table 1. 2.3.4.1 Public Health Institutions Provinces Primary Level 1 st Referral Level 2 nd Referral Level 3 rd Referral Level Total
Procurement of drugs is initially through the National Government Medical Stores (Natpharm) which procures all the medicines, surgical sundries and reagents on behalf of the above public health institutions. In the event that Natpharm does not have the stocks of the required item, the hospital can tender for the required items in tandem with the Procurement Act and Regulations 171 0f 2002 together with further guidelines from the Medicines Control Authority of Zimbabwe in the case of drugs. For the reason that procurement is guided by the Procurement Act and Regulations, it might be necessary to review briefly the tendering system in the country. Four forms of tender namely Competitive, Informal, Special-Formal and Formal are commonly used in government purchases by various hospitals. The distinguishing factor among the various forms of tenders is mainly value of purchase and urgency of the item. Competitive and the Informal Tenders are prescribed to be done by the individual hospitals without the interference of the Government Tender Board (State Procurement Board). The threshold limits for those tenders are $US 10,000 and 50,000.00.00 respectively. Any purchases that are outside these threshold limits are to be administered through the State Procurement Board on behalf of the procuring entity. It is imperative to note that the various health institutions mainly rely on Natpharm for the bulk of the pharmaceutical items but unfortunately, the stock levels at Natpharm as shown by the table below is a great cause for concern at all public institutions. 2.3.4.2 Stock Status of Vital, Essential and Necessary (VEN) drugs at Natpharm Table 2
200 4 200 5 200 6 200 7 De c 07 Ja n 08 Fe b 08 Ma r 08 Ap r 08 Ma y 08 Ju ne 08 Se pt 08 Oc t 08 No v 08 Vital 63 % 72 % 82 % 42 % 22 % 29 % 35 % 32 % 36 % 38 % 42 % 52 % 58 % 42 % Essent 21 56 62 23 16 16 18 16 16 28 34 34 38 40 22
VEN is the classification of medicines and surgical consumables in the Essential List of Medicines in Zimbabwe (EDLIZ).
Vital Drugs means life saving drugs, non-availability may lead to death/disability, optimum availability to be 100% Essential means non-availability of these drugs lead to pain, optimum availability to be 80% Necessary means that these drugs are required but of lower priority than the above drug classification. From the above table, it is indicated that for all drug and surgical categories, stock levels were well below the expected levels and what is more worrying is that the Vital Category prescribed to be 100% has in 2007 dropped down to 23%, giving a variance of 73% and these drugs a deemed life saving; non-availability has serious implications on the patient. Thus, failure to provide drugs at public hospitals may also mean that patients will have to source the drugs from the private pharmacies who may charge exorbitantly relative to public hospital drug costs. Therefore the procurement system in Zimbabwe depicts a semi-autonomous situation in that the individual hospitals are responsible in part for the purchases because of the involvement of Natpharm and the State Procurement Board. 2.4 Delays in Procurement activities 2.4.1 Bureaucracy
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In discussing public procurement, bureaucracy cannot be left out since it ensures due process and prevents some level of corruption. According to Weber (1920), bureaucracy is an organizational form based on a hierarchy of offices and systems of rules with the purpose of ensuring the permanence of the organization, even though employees within it might come and go. The knowledge, practice and experience of the organization would be preserved in files, thus ensuring permanence and continuity. The organization is hierarchical, with one level subject to control by that above it. Everything done in the name of the organization and its officials is recorded. The purpose of bureaucratic structure is to attain the maximum degree of efficiency and to ensure the permanence of the organization. Failure to do this leads to red tape, excessive procedures and obscure and conflicting rules and regulations. All organizations are bureaucratic in the sense that they all go through some sort of procedure for getting things done.
In state administration, bureaucracy has been used for denoting the prominent position given by the centralized state power to permanently employed public officials and has been applied as an instrument of critique against state power. It is the type of administration in which the officials exert power in order to implement their own interests. For example, the Encyclopedia of the Social Sciences, (1930:70-74) defines bureaucracy as a system of government, which the control power is completely in the hands of officials and that their power jeopardizes the liberties of ordinary citizens. Bureaucracy is used to describe the rational organization. The usage is in accordance with max Webers ideal type, it denotes a form of organization characterized by a hierarchy of officers.
Bureaucracy has the following features; the rules are known by all, the purpose of the rules is clear and based on a valid theory of cause and effect, rules are consistent with each other, it is clear when rules are to apply and the scope for subjective interpretation is limited. In view of the above definitions, bureaucracy is a system of government where professional officers who perform rationalized functions in organizations, especially public institutions go through laid down procedures in performing their duties. Thus 24
organization is said to be bureaucratized when its procedures for actions and decisions have become formalized and impersonal through highly structured rules that are open. Other characteristics of bureaucracy are rules which describe the duties of members of an organization, a set of standard operating procedures, and impersonal relations between members. In bureaucracy, initiatives and policy directions come mostly from the top management. The growth of modern government has been intimately tied to the development of bureaucracy and no modern state could operate without bureaucracy because it checks the abuse of power and regulate peoples activities and conducts in an organization. 2.4.2 Effects of Bureaucracy in Public Financial Management
In public sector organization, bureaucracies produce unintended consequences which may conflict with the goals of those in authority and inhibit the efficient and effective operation of the organization. Bureaucracy can bring dictatorship of the officials, problems of supervision, rules can become ends in themselves and rules can bring inefficiency. One of the criticisms of bureaucracy is that some politicians use it to maximize votes which eventually tend to be expensive (Lawton and Rose, 1994). One of the effects of bureaucratic process is delay. Delay is the extra time taken to complete a task beyond the planned period agreed upon especially a contract between two or more parties. According to Antill and Woodhead (1989), one of the classifications of delay is the origin. Delay can be caused by the owner of the contract, and in this case the contractor receives a fair and reasonable compensation in cost and time. Antill and Woodhead did tell the method to measure the reasonable compensation of delays in contracts. They believe that inflation and interest rates should be used to measure compensation since contractors borrow from banks and loans with interest. Delays due to bureaucratic process affect health delivery since it adds more time of acquiring goods and services. (Colander, 2001).
Procurement Act is aimed at reducing government expenditure and checking leakages of government funds but bureaucratic process in procurement brings delays in procurement 25
activities, which eventually increases expenditure and has detrimental effect on health delivery system. 2.5 Summary of Literature Review This part summarises key issues highlighted in the Literature Review. Public procurement strategy or system reflects the political, budget policy, competitive and public accountability objectives. The Value for Money (VFM) concept is central to all government purchases. The tight jurisdiction is also tailored to curb corruption in the public sector and that corruption also affects adversely the health sector. Purchasing ethics seek to address the importance of trust, honesty, integrity, accountability, transparency and competitiveness in the public procurement. Importance of strategic purchasing in view of costs and supply chain related risks. Criticality of public procurement in the health delivery system.
From the Literature, it is evidenced that public procurement has been explored but the researchers mainly focused from the general perspective and very few studies has been done specifically in the health sector.
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CHAPTER THREE METHODOLOGY
3.0 Introduction This chapter explains the approaches the researcher used to gain information on the research problem and includes the research design, study population and sample size, sampling design and procedure, data collection methods, measurement of variables. Procedure of data collection, data processing, analysis and presentation and anticipated problems to the study. 3.1 Research design This study used a case study research design involving both quantitative and qualitative' methods because it provided detailed knowledge about the impact of the public procurement policies and procedures on the health delivery system in Zimbabwe . The qualitative approach was used to explain the events and describe findings using interviews and documentary analysis. 3.2 Research Strategy: Case Study Approach Since Public Procurement Act applies to all public institutions both the main stream government and also parastatals. There are many hospitals in Zimbabwe and five Central Hospitals which operate almost similarly and in the same environment. These central hospitals are Parerinyatwa Group of Hospitals, Harare Hospital, Mpilo Hospital, UBH and Cgitungwiza Cental Hospital. The researcher decided to use Chitungwiza Central Hospital and generalise the findings on all Hospitals since they operate in the same environment. All public hospitals receive funding from the fiscus and they operate using the same Act hence the findings can be generalised to all the central hospitals. 3.2.1Definition of a Case Study: A case study is a detailed intensive study of a unit, such as a corporation or a corporate division, that stresses factors contributing to its success or failure. An empirical enquiry that investigates a contemporary phenomenon in depth and within its real-life context, especially when the boundaries between the phenomenon and context are not clearly defined, Yin2009,p.18 27
The decision of the researcher to use this strategy is in tandem with the guidelines provided by Yin (2009). The research strategy is most applicable when a how and why question is being asked about a contemporary sets of events which the investigator has little or no control, Yin 2009, p.13. Therefore the area under investigation relates to the impact of the public procurement policies and procedures on the healthy delivery system. The subtleties and intricacies of the health delivery system necessitated the adoption of the case study approach so that a spotlight is concentrated on the selected health facility (Denscombe 2007) which is Chitungwiza Central Hospital. So, this method or research strategy lends itself to the intensive and in-depth analysis of complex environments such as the one investigated (Bryman 2010). There are benefits that were considered by the researcher when the case study strategy was adopted. The approach can unravel the intricacies and subtleties of the health delivery environment (Denscombe 2007). It offers an in-depth analysis rather than a superficial. Critical to the research is an understanding of the processes and relationships and so, this method holistically considers all these important aspects of the research (Denscombe 2007). Further to the above, the case study strategy investigates a phenomenon in its natural setting and not in an engineered environment (Yin 2009; Denscombe 2007). The last advantage of this approach lies in its ability to infuse multiple sources and methods of data collection like observation, interviews, questionnaires and document analysis (Denscombe 2007).
3.2.2 Lack of access The researcher has noted the importance of access to information regarding the case and negotiated complete access to the hospital which was granted unconditionally by management. Access to participants, minutes and policy documents is critical in the data collection stage. The letter attached as Appendix A confirms the approval. 28
3.2.3 Resource limitations Case study approach, by its nature, is time-consuming and also requires resources. The choice of a single case has taken consideration of these resources limitation.
3.3 Study Population The researcher targeted to get the information from thirty people. Out of the thirty people the researcher saw it necessary to use judgemental sampling method to come up with the sample which was of twenty people. The people included in the sample are those who are involved in the procurement process at Chitungwiza Central Hospital including those from the buying department and those who sit in the procurement committee. Different research instruments were applied to the different individuals with more than one instrument being applied to some individuals. The population included those directly involved in the procurement process and those who are the users of the products and or services. The pollution included the procurement committee, the buying staff, user departments like sisters from different wards and heads of other departments. Table 1 TITLE NO OF THOSE INVOLVED 1. Director of Operations 1 2. Director of Finance 1 3. Director of Human Resources 1 4. Director of Clinical Services 1 5. Principal Nursing Officer 1 6. Chairperson of the Procurement Committee 1 7. Chief Procurement Officer 1 8. Sister-In-Charge (all wards) 7 9. Head of Canteen Services 1 29
3.4 Sample Trochim (2006) defined sampling as, the process of selecting units (eg.people, organisations) from a population of interest so that by studying the sample we may fairly generalise our results back to the population from which they were chosen. This explanation by Trochim (2006) was well represented by Saunders, Lewis and Thornhill (2008) on the diagram below. The researcher decided to use a sample of twenty as it gives a fair view of how those involved in the procurement processes view the procurement process. The total number of those involved is thirty and twenty is a good number to give the views of those involved and make decisions based on that information. The researchers decision to use a sample emanated from impracticalities associated with collecting data from the entire population, in this case, all hospitals and employees working within those health facilities. Limitations in terms of time, resources and access were central to the decision. The total number respondents selected is shown in Table 1 below. 30
Table 2 Category of staff Population size Sample size Percen tage Directors and Top Nursing Staff 8 5 25% Managers and Sisters In Charge 22 15 75% Total 30 20 100%
Sample size Table 3 Below is a table with all those who were interviewed and given the questionnaires. 1. Director of Operations 2. Director of Finance 3. Director of Human Resources 4. Director of Clinical Services 5. Principal Nursing Officer 6. Chairperson of the Procurement Committee 7. Chief Procurement Officer 8. Sister-In-Charge (Operating Theatre) 9. Head of Canteen Services 10. Accountant (Expenditure) 11. Administration Manager 12. Chief Pharmacist 13. Assistant Pharmacist 14. Assistant Administrator 15. Assistant Stores Administrator 16. Assistant Procurement Officer 31
3.5 Sampling Design and Procedure Probability sampling focusing on random sampling technique was used to select low- level staff to participate in the study. Non-probability sampling focusing on purposive sampling technique was used to select high-level staff. Probability (representational) sampling In probability sampling, the chance of each case being selected is equal and as highlighted by Saunders, Lewis and Thornhill (2008), this technique is most ideal when the investigator assume that the sample selected will be representational. Surveys and experiments are some of the strategies under probability sampling. In other words, this method employs some form of random selection (Trochim 2006). Probability sampling methods include random, simple, stratified and cluster. Non-probability (judgemental) sampling There are situations where the researcher was uncomfortable with random sampling because of the impracticalities involved with probability techniques. As a result of this, non-probability sampling was the most appropriate specifically the purposive sampling technique. The decision of the researcher concerning the composition of the individuals to be interviewed was based on the specialist knowledge of the respondents regarding issues of public procurement policies and procedures and the general health delivery system. Participants capacity and their willingness in this research further necessitated the -adoption of purposive sampling (Jupp 2006). In summary, the decision to choose the non-probability sampling route heavily hinged on feasibility and sensibility of data collection relative to the objectives of this research (Saunders, Lewis and Thornhill 2007). 32
Having explained on the sampling methodology adopted for this case study, data collection methods can then follow. 3.6 Data Source and Type The study was both primary and secondary data. Primary data was collected from the field using - questionnaires and interview guides while secondary data was collected from available published records such as textbooks, journals, magazines, manuals and internet. 3.7 Data Collection Instruments Data will' be collected using questionnaires covering all the aspects of the study variables and guided questions were used for this study to collect data from low level staff. This is because they will enable the respondents to express freely their opinion about the variables under study. Interviews were also used to gather data from the respondents. 3.7.1 Interviews Kahn and Cannel (1957) as referenced by Saunders, Lewis and Thornhill (2007, p.310) defined an interview as, a purposeful discussion between two or more people. Yin (2009) simplified this by stating that an interview is a guided conversation. Having defined what an interview is, there are many types of interviews as depicted by the diagram below but the focus of this research is on non-standardised type, specifically one-to-one, face to-face interviews.
The researcher decided to use this tool to gather the required information for the study. The researcher decided to interview 15 members of those who are directly involved in the procurement processes at Chitungwiza Central Hospital. Out of the 15 who were chosen he managed to interview 12 members.
Below is the profile of those who were interviewed. Table 4 1. Director of Operations 2. Director of Finance 3. Director of Clinical Services 33
4. Principal Nursing Officer 5. Chairperson of the Procurement Committee 6. Chief Procurement Officer 7. Sister-In-Charge (Operating Theatre) 8. Head of Canteen Services 9. Accountant (Expenditure) 10. Administrator 11. Chief Pharmacist 12. Stores Administrator
Profile of the Interviewees
3.7.2 Questionnaires A questionnaire is a data collection tool, designed by the researcher and whose main purpose is to communicate to the respondents what is intended and to elicit desired response in terms of empirical data from the respondents in order to achieve research objectives (Mugenda & Mugenda, 2003). Questionnaires can cover a large number of people and a researcher can use them to reach a wide geographic coverage. They are relatively cheap and no prior arrangements are needed before posting. They avoid embarrassment on the part of the respondents as it allows them to consider responses, especially where there are pre-coded options. They also allow for possible anonymity of respondent and have no interviewer bias if administered correctly. Interviewer bias is the opinion or prejudice on the part of an interviewer which is displayed during the interview process and may affect the results of the interview (Kothari, 2004; Cooper & Schindler, 2006).
3.7.2.1 Questionnaire Design
The importance of questionnaire design, layout and thoroughness of pilot testing cannot be over-emphasised. Validity and reliability of data collected and the response rate hinges 34
heavily on these important core aspects of the questionnaire: design, layout and pilot testing (Saunders, Lewis and Thornhill 2007). In fact, Ford (1994), concurred by emphasising on the relevance of good question formulation, further indicating the criticality of designing the questionnaire in a way that the respondent will interpret the questions in exactly the same manner the researcher intended. Therefore, the three aspects of the questionnaire: design, layout and pilot testing need to be thoroughly considered.
3.7.2.2 Design and layout of the questionnaire
Starting with questionnaire design, the researcher considered the pitfalls of poor design in that it can affect the response rate and reliability of data. The drafting of the questions started with a thorough review of the research problem, aims and objectives of the research so that only relevant and necessary questions are included. And so, the design of the questionnaire included open, scaled and ranked questions with the majority of them being closed (yes/no) questions.
The researchers strategy of including more closed questions was premised on the assumption that they are relatively easy for the respondent to answer considering the busy schedules some of the clinicians have. While open questions are most ideal in soliciting qualitative data, they have a tendency of producing data which is difficult to analyse. Instructions to complete closed questions included ticking the box that represented the respondents answer. To avoid the frustration in answering closed questions, an option of Other was provided to broaden the respondents options.
In addition, filter questions were also reasonably employed to reduce frustration and confusion by allowing respondents to avoid unnecessary questions. Further to the above, scaled questions were fairly used to measure the respondents priorities while ranked questions were also used for the same purpose.
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It is also crucial to indicate that the author noted the importance of avoiding leading questions, jargon and to use a friendly, polite and persuasive tone in the design of questions.
3.7.2.3 Structure and layout of questions Structure and layout of the questionnaire is indispensable to the success of the research and for that reason, the researcher adopted the following layout:
1. Introduction
An introduction was inserted right at the beginning in the main body of the questions. The rationale being that a separate introductory letter may get lost. The short introduction explained the purpose of the research, why it was of paramount importance to be completed. Assurances of confidentiality and anonymity were offered given the nature of the study which may include very sensitive issues. Instructions on how to complete and return the questionnaire were also contained in the introductory part. That information highlighted will increase the response rate (Saunders, Lewis and Thornhill 2007).
2. Sub-heading
Sub-headings were employed to clearly direct the respondent. The sub-headings were addressing the three objectives of the research.
3.7.2.1 Pilot Testing It will be a rare scenario if a customer purchases any electrical appliance without being tested for functionality. It is in the same vein that Saunders, Lewis and Thornhill (2007) prescribed pilot testing before the final questionnaire draft is used to collect data for the reason that the suitability and reliability of questions asked. In view of the above, three knowledgeable people in the area of investigation were given the draft and the following were highlighted and incorporated into the final draft after the pilot testing. 36
Some of the questions appeared to be vague and so, they were re-written so that the respondent is clear on what is being asked. The pilot test unearthed that there was need to broaden the respondents view by including a None of the above on closed questions, giving also enough space for the respondent to describe. Also, questions that appear to be too technical were re-organised so that the respondent could interpret them in the same way intended by the researcher. Additional questions were added to incorporate issues that are pertinent to the research aims and objectives.
After the amendments to the questionnaire, it was distributed to twenty people personally and expected to be completed in two weeks. The period of two weeks was to given ample time for the respondents to unhurriedly complete the questionnaire, giving enough detail where necessary. The researcher chose to hand-deliver the questionnaire in an effort to overcome potential difficulties in terms offering face to face explanation. This way, the respondents can also be persuaded and reminded about completing the questionnaire (Walliman 2010).
3.8 Procedure of data collection A letter of authorization from the CEO was provided as a request for permission to conduct the study. A covering letter accompanied the questionnaires explaining the purpose of the study and the questionnaires was distributed directly to the respondents in their respective areas for filling and was collected after two weeks following its dispatch and filling. The data collected was edited and decisions made on whether to use it or not 3.9 Document Analysis The study will also review existing literature related to the study problem and variables in form of reports, journals, websites and databases to gain information on the topic. Documents such as hospital management meeting minutes that were generated weekly, letters, memoranda, departmental reports, strategic and business plans provided invaluable data relating to the issues investigated. While it is true that these documents 37
were not specifically produced for the case study, they provided quite useful data worthy following up with interviews. The researcher reviewed these documents with full knowledge that they were intended for another purpose (Yin 2009).
3.10 Data Analysis Two types of analyses was conducted and these are quantitative and qualitative analysis. The following sub- sections explains the analyses, in detail. 3.10.1 Quantitative Analysis Quantitative data was collected, edited and coded. Two types of analyses was computed. The first will include descriptive statistics (frequencies and percentages) and the second will include inferential statistics (correlations). The frequencies and percentages were used to determine the respondents' views on each of the study variables. Pearson correlation tests was used to test for significant relationships between the variables. 3.10.2 Qualitative Analysis In qualitative analysis, content analysis was used to edit the data and reorganize it into meaningful shorter sentences. This will then be presented as quotations to supplement the quantitative data in order to have a clearly interpretation of the results. 3.11 Anticipated Problems to the Study 1. These include financial problems in terms of photocopying, secretarial services, transport costs. 2. Inadequate time to exhaustively conduct the research since it is done in the course of the semester. This was overcome by putting more effort and spending conducting research. 3. The research will encountered problem of non responses from some respondents.
Summery 38
This chapter began by stating the philosophies employed in carrying out the research. A detailed explanation of why that philosophy was chosen then followed. Tools for gathering data were discussed but the data analysis and results were not demonstrated here as there are dealt with in the next chapter which is chapter four. CHAPTER FOUR DATA PRESENTATION, ANALYSIS AND DISCUSSION
4.0. Introduction This Chapter simply presents the qualitative and quantitative findings extracted from the questionnaires, interviews and hospital documentation. First, the response rate for both questionnaires and interviews will be given, followed by the profile of the respondents and thereafter, presentation of findings on an issue by issue basis. Pertinent issues that emanated from the research will be presented in turn.
4.1. Questionnaire response rate Starting with questionnaires, twenty were distributed with fifteen being returned and fully completed from the respondents. This represented a response rate of 75 percent. The high response rate could be attributed to the proper design, layout and distribution strategy adopted by the author. Ample time were given to the respondents and often reminded weekly about completion of the questionnaires. The table below simply summarises the questionnaire response rate.
Table 4.1. Questionnaire Response Rate Name of Respondents Sent Questionnaires Responses Obtained % Response Rate Purchasing, Operations/Admin and Clinical staff 20 15 75 Total 20 20 100
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It is also imperative to indicate that the questionnaire itself was sub-divided into four categories namely: the profile of the respondent, role of procurement, tendering and procurement, and ethics. These categories reflected key issues noted in the Literature Review and also the research objectives. 4.2. Interview Response Rate Switching to interviews, the author selected fifteen individuals for interview and twelve were successfully interviewed, translating to an 80 percent response rate. Setting of flexible appointments well ahead of the actual interview date could be attributed to the high response rate especially for busy clinical and administration staff.
4.3. Profile of the Respondents The profile of the questionnaire respondents is summarised on figure 4.2 below. Table 4.3.1. Profile of the Questionnaire respondents
Question Response category N % Cum % Gender Male 11 73.3 73.3 Female 4 27.7 100.0 Total 15 100.0 Employment period 1 - 5 yrs 2 13.3 13.3 6 -10 yrs 10 66.7 80.0 <10 yrs 3 20.0 100.0 Total 15 100.0 Position Non-managerial 0 0 0 Lower management 0 0 0 Middle management 15 100 Top management 0 0 100.0 40
Total 15 100.0
While the majority of the respondents were males (73 percent) and the rest females (27 percent), the author assumed that their composition will be of no effect to the research outcomes.
4.3.2. Employment Period (Experience) The selection and distribution strategy of the questionnaires was purposively crafted with the view of soliciting rich information from experienced people and that is why the employment period was included in the questionnaire. The graph below (figure 4.3.2) shows the employment period of the respondents.
4.3.2. Bar Graph Showing Employment Period
The time that respondents have been in the hospital can be a measure of their level of experience. Figure 4.3.2 above revealed that most of the respondents have a length of service of 6 to 10 years (66.7percent), followed by those with more than 10 years (20.0percent) and then those with 1 to 5 years (13.3percent). 0 10 20 30 40 50 60 70 1 - 5 6 - 10 10+ P e r c e n t a g e
Employment period (years) 41
Coming to the profile of the interviewees, it was the decision of the researcher to target only senior managers with both clinical and operational knowledge of the hospital with a bias towards procurement-related issues. These individuals, in the view of the author, could not be adequately serviced by the questionnaire hence need to interview them.
4.4. Profile of the Interviewees 1. Director of Operations 2. Director of Finance 3. Director of Clinical Services 4. Principal Nursing Officer 5. Chairperson of the Procurement Committee 6. Chief Procurement Officer 7. Sister-In-Charge (Operating Theatre) 8. Head of Canteen Services 9. Accountant (Expenditure) 10. Administrator 11. Chief Pharmacist 12. Stores Administrator
Thus, the interview conducted aimed at taping into the invaluable experience of the above respondents.
4.5. Research Findings A summary of the questionnaire responses will be provided first, followed by presentation of key themes that appeared outstanding from questionnaires, interviews and hospital documents that were analysed.
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4.5.1. Summary of Questionnaire Responses Question Response Category N % Cum % Is procurement important? Yes 15 100.0 100.0 No 0 0.0 100.0 Total 15 100.0 To what extent is it important? Lesser extent 0 0.0 0.0 Greater extent 15 100.0 100.0 Not sure 0 0.0 100.0 Total 15 100.0 Are procurement laws and regulations adequate? Yes 13 86.7 86.7 No 2 13.3 100.0 Total 15 100.0 Describe the tendering process at your hospital Efficient 3 20.0 20.0 Competitive 1 6.7 26.7 Effective 2 13.3 40.0 Transparent 9 60.0 100.0 Total 15 100.0 Do you sometimes purchase products without going to tender? Yes 5 33.3 33.3 No 10 66.7 100.0 Total 15 100.0 Most common tender type Competitive 10 66.7 66.7 Informal 5 33.3 100.0 43
Special-formal 0 0.0 100.0 Formal 0 0.0 100.0 Total 15 100.0 Question Response Category N % Cum % Number of people involved in tendering or procurement process 1 - 3 0 0.0 0.0 4 - 6 0 0.0 0.0 7 - 9 0 0.0 0.0 10+ 15 100.0 100.0 Total 15 100.0 Why are they involved in the tendering / procurement process? Transparency 14 93.3 93.3 Expert knowledge 1 6.7 100.0 Total 15 100.0 Most important factor in tendering / procurement process Price 5 33.3 33.3 Quantity 2 13.3 46.6 Quality 2 13.3 59.9 Conformance 3 20 79.9 Back-up availability 2 13.3 93.2 Delivery period 1 6.7 6.7 Total 15 100.0 Structure of procurement system centralised 14 93.3 93.3 De-centralised 1 6.7 6.7 Total 15 100.0
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4.6. Importance and Relevance of Procurement The significance of procurement as an important business lever was reiterated by all the 15 questionnaire respondents as shown on the above table. In fact, one of the interviewees indicated that procurement is the heart of all operations and failure of procurement will paralyse the whole system of departments. Another respondent, illuminated on the importance of purchasing by saying, its actually the engine of the organisation. Minutes of weekly hospital management meeting under the action slot put purchasing department as responsible for the sourcing all drugs, surgicals and laboratory reagents reported to be out of stock. Regarding the issue of relevance of procurement regulations to the health sector, the following bar graph (figure 4.6.1) summarises the questionnaire responses.
Bar Graph Showing Distribution of Procurement Regulations Relevancy and Adequacy.
Figure 4.6.1 0 10 20 30 40 50 60 70 80 90 Yes No P e r c e n t a g e
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From the Bar Graph above, 86.7percent responded Yes to the relevance of the procurement regulation to the hospital with 13.3percent indicating a No on the same issue. However, the main reason indicated by the respondents for the Yes answer was transparency. The regulations foster transparency in the entire procurement system. The interview response corroborated with the questionnaire outcome by indicating that while they are relevant, they are not appropriate to the unique needs of the hospital. One of the respondents added that, the idea of these regulations was to promote transparency in the whole purchasing process and to make sure they are the guidelines for every institution. However, I think these regulations need to be reviewed especially looking at the hospital set-up.
4.7. Supplier Selection Suppliers for pharmaceuticals, medical equipment, detergents, laboratory reagents, linen, haberdashery etc, were primarily selected on the basis of the lowest purchase price upon solicitation of three quotations. Questionnaire respondents clearly ranked price as the main variable in the selection of suppliers. Further to the above, a sample of purchase documents (Comparative Schedule) were selected covering drugs, surgical consumables and laboratory reagents and the following findings were noted.
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4.7.1. Pie Chart Showing the Factors Considered in the Supplier Selection
Out of 100 purchase documents from January to the 5 th of August 2013, 83 were considered on the basis of the purchase price and only 1 had quality ticked as the variable. 9 purchase documents were selected on the basis of the suppliers reputation while 1 was on the availability of stock from the supplier. The remaining purchase documents did not indicate the factor (s) considered in the award of the tenders to the suppliers. The dominance of purchase price as a key supplier selection factor has been echoed by one of the interviewee who highlighted that, according to the regulations, the main variable for selecting a supplier is the lowest bidder. If you could consider other variables just like reputation, quality that invites serious explanation from Auditors. When we look at the lowest bidder, it means the quality is compromised. Almost 20 percent of the suppliers end up with price variations. Every suppliers in the market now know that the government regulation need to select the lowest price and fail to supply. Another Price 83% Quality 1% Reputation 9% Ex-Stock 1% Not Indicated 6% Percentage of purchase documents under same selection criteria 47
respondent, concurred by indicating that, sometimes we are forced to buy cheaper versions of equipment which are not usually the best versions that we can get In addition, minutes of the hospital management meeting held on the 16 th of January 2007 recommended to the Procurement Committee that they should consider other variables like existing stock in selecting suppliers. Evidently the background of that recommendation has issues relating to delays in delivery of commodities hence need to consider availability of a product. Minutes of management meeting also held on the 31 st
of July, 2012 reported that suppliers are not delivering in time further indicating that the Ultra-sound scan machine and the Full Blood Count (FBC) machine were not functional. Regarding the ultra-sound scan machine, the spares were said to be unavailable by the Hospital Equipment department. Obviously, it is an issue missed in the selection of suppliers where back-up services (including availability of spares) should have been incorporated.
4. 8. Purchasing Cycle The significance of the hospital purchasing cycle is that it affects the responsiveness of the services to the patients against the assumption that sickness cannot be postponed to a later date when all the services and products are available. Thus, the hospitals purchasing cycle has three important stages: Request for Quotation (RFQ), Tendering and Ordering. The following flow chart summarises the purchasing cycle.
4.8.1. Flowchart of the Purchasing Cycle Stage 1 Request for quotation
Identification of need (User department) Pharmacy / laboratory / General Stores Head of Departments approval 48
Stage 2 Tendering
Accountants approval Director of operations Chief executive officer Director of finance Floating of Tenders Tender Opening (Appending of Signatures on Quotations) Preparation of Comparative Schedules Adjudication of Procurement Committee Formal 90days Informal 14days Competitive 7days 49
Stage 3 Ordering
Source: Own depiction based on interviews and hospital documentation Director of Operations Accountant Director of Finance Chief Executive Officer Purchase Order Generation (Accountant Expenditure) Purchasing Supplier Delivery (14 30) days Warehousing Inspection of Products (Stores, Requesting Department, Procurement Committee) Issuing 50
Starting with Stage 1 (Request for Quotation), it is very much clear that for the process to be completed about seven signatures should be appended to give full authorization to be next stage which is the tendering. Again on tendering, the process as indicated above seems long and winding particularly if the tender avenue pursued is Informal (14days) or Formal (90days). The entire process of tendering passes through 8 phases up to the Chief Executive Officer who approves the adjudication documents. After that, comes ordering which is the final stage. Research also uncovered that the existing Procurement Act of 2001 suffocated the hospital operations especially during the hyper-inflationary period in 2008 prior to dollarization. Thus, it becomes imperative for the researcher to establish the supply lead-time given the long procurement cycle indicated above. In view of that, a sample of 19 purchase documents was selected to provide an indication of the supply lead-time and so the table below indicate the sampled documents and the corresponding supply-lead time.
Table: 4.8.2. Showing Supply Lead-Time Purchase Document Number and Item Description Supply Lead- Time (days) 1. Dental Cartridges 49 2. Sutures Material 78 3. Crepe bandages 29 4. Hand paper Towels 61 5. Blue Ball Pens 43 6. X-ray films (blue) 15 7. Oxygen Flow meters 239 8. Endotracheal tubes 33 9. 5% Dextrose 108 10. Brown Shoes 199 11. Linen Savers 41 12. 3ml syringes 24 13. Methyldopa 250mg tablets 254 14. Repair of Incinerator 37 15. Abdominal swabs 150 16. Latex Examination gloves 18 17. Anaesthetic machines 134 51
18. Theatre Pendants and LED lights 321 19. Hospital beds &Mattresses 305
Average Lead Time 112.5263158
Line Graph: 4.8.3. Representing the Supply Lead Time as Given Above.
From the above line graph, the average supply time is 112 days. What this entails is that from the time when purchase documents are forwarded either to the Procurement Committee, that is, for competitive tenders or State Procurement Board (Formal and Special- Formal tenders) to the actual delivery, it took an average period of 112 days. For medical equipment, the supply lead-time range from 134 to 321 days. Involvement of the State Procurement Board in the Formal or Special tenders which is normally the avenue for medical equipment because of their high value could explain the longer supply period. This shows that the whole purchasing cycle is netted with bureaucratic rigidities that unnecessarily lengthen supply lead-time. Extensive authorisation protocols are translating to late deliveries. The fact that most medical equipment are sourced from Germany, China, Spain and United Kingdom explains the period considering that most of the equipment is bulky and heavy for air transport and that they can only be manufactured upon receipt of an order. 0 50 100 150 200 250 300 350 1 3 5 7 9 11 13 15 17 19 Lead time (days) Lead time (days) 52
However, of great concern regarding the entire purchasing process are three issues that were highlighted: the length of the process itself, the composition of the adjudication or the procurement committee and the involvement of external parties that include the State Procurement Board and the Ministry of Public Works. These issues will be looked at in that order.
a) Length of the Tendering Process The length of the process itself has been an issue from both questionnaire and interview respondents. When asked to describe the hospitals tendering process as depicted on table 4.4.1, the doughnut below shows how the questionnaire respondents felt about the process. Figure 4.8.4. Doughnut Showing Description of the Tendering Process
From figure 4.8.2 shown above, 60 percent described the tendering process as transparent, 20 percent as efficient, 7 percent as competitive and 13 percent as effective. That also coincided with the view explained by one the interview respondents, Prince Efficient 20% Competitive 7% Effective 13% Transparent 60% 53
who said that in government procurement system, efficiency is secondary to transparency. At times efficiency suffers because suppliers are selected on the basis of the being cheaper. This situation, to some extent, seems to be attributed by auditors who prescribe and enforce that the procurement process be meticulously and religiously be followed. Many respondents decried the straitjacket nature of the procurement process particularly to emergent needs of the health facility. This also was evident to the question that asked why multiple players were involved in the procurement process. 14 people from the questionnaire indicated transparency and 1 indicated expert knowledge.
The issue of multiple players explained on the last part of the paragraph above emerges as one of the major contributors of the long purchasing cycle. Multiple players are a means of inserting checks and balances in the entire procurement process. There are also situations where, the State Procurement Board must be involved to do tender administration when threshold limit surpass the Competitive limit which normally fall under the hospital.
b) Composition of the Procurement Committee Regarding the selection of the Procurement Committee, the Procurement Regulations 171 of 2002 give the discretion to the accounting officer or the head of an institution to choose a committee and so, the composition of the hospital procurement committee includes mainly clinical staff that happens to be heads of departments. Commenting on the composition of the Procurement Committee, E as one of the interview respondents said that these people are not experts. They are selected on the basis of being senior members of staff. So, what then is the role of the procurement professionals if they are not directly involved in the Procurement Committee- mere order placing and expediting? This will be critically discussed in the next Chapter. Therefore, the composition of the committee may be a limitation considering the narrow selection criteria where emphasis is on purchase price.
c) Involvement of External Parties 54
The issue of multiple players is not only internal but also external in the sense that there is need to involve the State Procurement Board for Formal and Special-Formal Tenders to do the entire administration and finalization of the tenders. While the process can be expedited, the interview respondents hinted that, more often than not, this board is overwhelmed and cannot process all the forwarded purchase documents within the expected time-frame. This has resulted in the institution adopting the Competitive route because of its responsiveness hence the diagram below represented the most common type of tender as given by questionnaire respondents.
Figure 4.8.4. Tender Types
4.8.4.1 Competitive Tender Threshold limit as given by Procurement Regulations of 171 of 2002, is $ US 10,000.00. This type of tender is administered by the hospital subject to availablity of 3 competitive quotations.
4.8.4.2 Informal Tender 0 10 20 30 40 50 60 70 Competitive Informal Special-formal Formal P e r c e n t a g e
Tender type 55
If the value exceed $US 10,000.00 but does not exceed the $300,000.00, the hospital must invite tenders through the newspaper. Normally the tender runs for 7 days before closure.
4.8.4.3 Special Formal When the hospital requires products exceeding the above limit urgently, special formal route is the option. This tender is administered on behalf of the hospital by State Procurement Board.
4.8.4.4 Formal The threshold limit is the same as Special-Formal. The only difference is that this tender runs for 90days before closing and is conducted by State Procurement Board on behalf of the institution.
For the institutions construction work, there is need to involve the Ministry of Public Works to approve all architectural plans and to supervise all works. Involvement of Ministry of Public Works (MPW) has been seen to be slowing the pace of construction at the hospital. Documents originating from the hospital in the form of minutes of meeting ( 17 July 2012) supported that view when they unravelled that the construction of the teaching classroom could not be finalised due to the need seek concurrence from the MPW despite availability of funds from the donor. Furthermore, the purchasing cycle or the procurement process has been noted to have impacted adversely on the quick utilisation of funds particularly with reference to the threshold limits for various tenders. This is confirmed by one of the interview respondent F who uncovered that: 'You can only know that the value exceed the threshold limit after tendering and you have to re-start the process. Ministry of Finance at times say to us you can buy these items while funds are available but if the process take longer than a year, the funds at are availed during the fiscus will fall away on the 31 st of December. So well lose out and at the same time youll have asked the supplier outside the country to orders for you and end up cancelling. This has been quite true regarding the various medical equipment 56
that has been procured under the Ministry of Finances Target Procurement approach where most of the equipment ordered mid-year in 2011 was delivered towards the end of 2012. The budget for that equipment was provided for in 2011 but the invoices accumulated in 2012. The implication therefore is that current 2012 budget will be exhausted by invoices that were supposed to be catered for by the previous years budget. By its nature, medical equipment like Theatre Pendants, LED lights, Patient Monitors and Laparascopy is highly specialised and in most instances, production only commence upon confirmation of an official order.
4.9 Conclusion The central issue on carrying out the research was to assess the impact of public procurement policies and procedures on the health delivery system and in this chapter data was gathered, and analysed. This information will be used in the next chapter to draw conclusion.
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CHAPTER FIVE
SUMMARY, CONCLUSIONS AND RECCOMMENDATIONS 5.0 Introduction
It is the basis the desktop research findings as outlined in Chapter two Literature Review and findings, analysis and conclusions in Chapter four that a comprehensive summary, conclusion and recommendations will be given. These conclusions were based on the study findings and were reflecting the instruments used in the study. Each objective was concluded. Recommendations were basically the probable solutions to the assessment of the impact of public procurement policies and procedures on health delivery system in Zimbabwe. This Chapter presents the major research conclusions drawn and recommendations to the findings. 5.1 Summary The study was centered on assessing the impact of public procurement policies and procedures on the health delivery system in Zimbabwe. The researcher selected of the five referral public institutions in Harare, Chitungwiza Central hospital as a case study. In chapter 1 background of the study was cited. The main cause for concern being many challenges which the health sector is facing indicated in the Ministry of Health and Welfare (2012) report. Research questions and objectives were also established in this chapter. Limitations were identified as the collection of information and resource constraints. The researcher also went on define major terms to be used found in the study. The researcher reviewed the literature associated with the study to shed some clarity and light on the study. Other studies from other nations like United Kingdom and information from the WHO reports were also looked at. This was meant to find information as to other nations and researchers have dealt with similar problems encountered in procurement. Literature reviewed formed the basis upon the methodology was designed. 58
The tools used were the questionnaires and personal interviews. The questionnaire was chosen because it was capable of producing good results since no names were required and the information could be treated with confidentiality. The researcher could physically/personally distribute the questionnaire to individuals concerned. The interview technique was chosen to solicit information from respondents because the interviewer could clarify any contextual meanings to the respondents to avoid misinterpretations. Room for probing was provided using the interview. The study was mainly centred at Chitungwiza Central Hospital purchasing function and those who are directly involved with purchasing decision. The response rate from participants was 75%. Data was analysed using graphs, tables and figures where possible. The findings from the data collected were presented in chapter four on tables, pie charts and graphs. Discussions on the data collected were also made in chapter four. These were the basis upon which conclusions and recommendations of the study were made. 5.2 Conclusions drawn Objective (a): To evaluate the impact of public procurement policies and procedures on health service delivery. It was found out that the procurement policies and procedures have an impact on health delivery system in Zimbabwe. The study reviewed that not only is purchasing policies and procedures key to increased health service delivery but it also enhances competiveness of an institution. The Public Procurement Act is impacting negatively on health delivery system as it does not consider the urgency of the products. It requires three quotations even when the supplier is a monopoly and the process of seeking for approval from the government takes a lot of time. It was also found that other laws like the look east policy is also affecting health delivery system as the government is encouraging buying from countries like China. Objective(b): To assess the adequacy of procurement policies and procedures at Chitungwiza Central Hospital. 59
The study reviewed that the procurement policies and procedures were not adequate. These procedures needs to be reviewed as they are affecting health delivery system. An example was cited were the thresh hold for a competitive tender is US$10 000 but you may require drugs which exceed that amount. Also these procedures require three quotation and it does not give a provision for a monopoly market where there will be only one supplier. The Procurement Act is not adequate as highlighted by some of the respondents who said that the Procurement Act does not allow purchase of vehicles from other companies other than from Mazda Motors even when it is expensive to buy from Mazda. The Act is affecting negatively the health system in Zimbabwe as it is rigid. Another example cited was that of sub standard ambulances which are assembled by Mazda Motors as compared to other ambulances which are being manufactured by other companies. Objective (c): To examine the causes of delays in procurement activities and their effects. The study also found out that one of the causes of delays in procurement activities is bureaucracy . Bureaucracy was cited as one of the causes in delays where many people have to approve for a single purchase even when the products and or services are urgently needed. The research revealed that when the head of the institution is not available no purchases are made as they he is the one who does the final approval. A lot is required to improve public procurement through emphasizing timeliness, appropriateness and proper planning so as to achieve the overall concept of "value for money". Therefore procurement staff and the clients they serve need to get acquitted with the regulations and apply them with utmost good faith so as to have smooth operations. 5.2 Recommendations In light of the discussions, findings and the conclusions, the following recommendations are hereby coined; 5.2.1 Amendment of the Public Procurement Act
The procurement procedures and policies need to be consistent with the urgency and criticality of the item required. Medical surgical consumables may fit in that category 60
were sickness cannot be postponed to future date to allow complete authorization for procurement. Gerson (2004), suggested public procurement efficiency by reducing the number of inputs without compromising quality.
The Public Procurement Act must be amended to address the eminent difficulties facing smooth implementation. To improve on compliance of entities in the region PPA must, as a matter of urgency, expedite action on the review process of the Procurement Act of 2002. The proposed increase in thresholds will give Procurement Entities greater control over procurement decision to reduce lead time. Government should endeavour to review the Act to limit the number of steps in procurement process so as to reduce the level of bureaucracy in the system. Bureaucracy delays the smooth procurement process and eventually affects public financial management since it adds more cost to suppliers and government if they are to pay interest rate. Again, the review is in right direction since people complained on the total threshold of entities head. It is therefore important to increase the threshold.
Insufficient budget and inconsistencies in disbursements disturb health delivery systems. Consideration need to be in innovative strategies of supplementing financial resources such as Public Private Partnerships (PPPs). PPPs may be considered in view of costly medical equipment like the Magnetic Resonance Imaging (MRI) and medical laboratory analysers. 5.2.2 Proper Planning A lot is required to improve public procurement through emphasizing timeliness, appropriateness and proper planning so as to achieve the overall concept of "value for money". Therefore procurement staff and the clients they serve need to get acquitted with the regulations and apply them with utmost good faith so as to have smooth operations. Enforcing Accountability to Reducing Corruption in Procurement
Corruptions and bribes are widespread in government contracts. In public procurement, any violation of standard procurement principles and procedures is considered willful 61
and, therefore, construed as fraudulent and causing financial loss to the state. To prevent corruption in public procurement PPA should seriously enforce blacklisting bidders who have contravened the provisions of the Act and take disciplinary action against public officials who engage in irregularities. 5.3 Further research study This research provides a general notion though it is good starting point but it is not sufficient. Mol (2003)states that current literature on purchasing lack frameworks leading to borrowing of theories form strategic management. Thus the researcher recommends further study in theory formulation on the impact of public procurement policies and procedures on health delivery system . 5.4 Chapter summary This chapter looked at major conclusions and recommendations by the researcher and opened avenues for future research.