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COORDINATED HEALTHCARE MANAGEMENT CONCEPT
PREMIER SERVICE MEDICAL AID SOCIETY
Zimbabwe

The Problem

THE PROBLEM

Due to the hyperinflationary situation in Zimbabwe from year 2001, the healthcare industry suffered a major deterioration of healthcare services. The general population was in dire need of care especially the lower classes. There were virtually no medicines and consumables in hospitals. Equipment was becoming absolute and broken down due to funding constraints and lack of access to foreign currency. There was also unstoppable skills flight of healthcare professionals (brain drain). The lack of medicines and equipment created low staff moral for the remaining skilled healthcare professionals. The cost of access to healthcare services skyrocketed and was generally out of the reach for the majority. The industry players pursued selfish interests not benefiting the patients and the country was at risk of off tracking on the Millennium development goals. The patients on Medical insurance policies were paying high shortfalls and copayments further straining their low disposable incomes. The healthcare providers demanded cash for their services which were also substandard. The position resulted in defaulting of treatment sometimes by patients with chronic disease for financial reasons and non availability of services thereby compromising on the quality of life and reducing the life expectancy noting the high prevalence rate of HIV and AIDS infections in the country.

The healthcare delivery system of Zimbabwe could not save the nation. Only a few privileged could afford to seek medicines and care from neighboring countries like South Africa and Botswana.

PSMAS Group is the major contributor to the healthcare delivery system of the country. It covers healthcare requirements for civil servants and their dependants, industrial workers, students and the under privileged. The middle and lower social groups were highly affected by the situation because they could no access foreign currency and if they did, there was not service at healthcare institutions. PSMAS objective of providing quality healthcare services to all could not be realized with aforementioned challenges highlighted above and a solution through coordinated healthcare management systems came up which included provision of both health insurance products as well as healthcare services.

Solution and Key Benefits

 What is the initiative about? (the solution)
Solution
Premier Service Medical Aid Society (PSMAS) is a registered Medical Aid Society in Zimbabwe under Medical Services Act 27/1998, 22/2001 Chapter 15:13 regulated by statutory instrument 330 of 2000 through the Ministry of Health. PSMAS is a member of International Federation of Health Funds, a member of Healthcare Funders of Southern Africa and also a member of Association of Healthcare Funders of Zimbabwe. PSMAS has been in existence for over 81 years initially formed as a Medical Aid Society for civil servants and later on transformed to also cater for the private sector and the general public. PSMAS in year 2001 came up with the innovative idea of forward integration by forming an investment arm Premier Service Medical Investments (Pvt) Ltd (PSMI) with the core business of providing comprehensive healthcare services thereby creating a one stop shop in the provision of medical aid insurance as well as healthcare services better known as the coordinated healthcare concept. The coordinated healthcare concept created a fallback position in challenging times, and affordable services are now accessed through the medical centre once stop shop concept.

1) ONE STOP SHOP CONCEPT
The one shop stop concept for Healthcare services is a concept where Medical Centers offer comprehensive services under one roof from primary healthcare to the tertiary healthcare in the treatment cycle. The following Healthcare Services are offered in the Medical Centers:-
 Primary and family healthcare services in medical clinics
 Laboratory services
 Imaging/Radiology services
 Pharmaceutical services
 Dental services
 Emergency evacuation services (pre-hospital care) both ground and air evacuation services
 Rehabilitation services
 Renal services
 Hospitalization services
 Optical services
The one shop stop concept created the following benefits to both the clients and the business
a) Convenience through elimination of travel from one Health facility to another.
b) Improve turnaround time through sharing of databases and information leading to once off patient registrations as well timorous release of investigative results from ancillary services, the Imaging and Laboratory services.
c) Cost effectiveness to the customer through reduction in travel time and related costs and to the business through shared administration, IT and other overhead costs.
d) Easy to resolve referral queries in the value chain as all services will be offered within the Medical centre.
e) Created easy platform to standardize quality of services through shared administration and supervision.
The Healthcare facilities are approved by environmental agencies and local authorities to ensure compliance with environmental regulations. The PSMAS Group always carries out environmental impact assessments for all new projects and follows best practice in waste disposal.
The PSMAS Healthcare facilities always follow best practice in healthcare management and have an effective administration structure. PSMAS Healthcare facilities are working towards meeting the World Health Organization (WHO) standards such as the nurse patient ratios and other parameters. The Healthcare facilities also adhere to the Ministry of Health guidelines towards meeting the Millennium development goals, especially Millennium goals 4, 5 and 6.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The key development in strategy was forward integration and diversification of healthcare services. The concept entailed the formation of an investment arm (PSMI) responsible for acquisition of healthcare facilities from year 2001, creation of new health facilities, registrations with regulatory authorities, Healthcare facilities upgrading and renovations, equipping and stocking of Healthcare facilities, staffing, training and development, ICT development, business process reengineering, research and development and innovation in products structuring.
a) Acquisition of Health facilities
PSMAS adopted a concept of acquisition of strategically located healthcare facilities in all major towns and cities covering primary healthcare, dentistry, Optical services, Evacuation services (pre hospital care), retail pharmacies, hospitals, rehabilitation services and Radiology and Pathology services. PSMAS after acquiring these would then upgrade , train staff and run the facilities.
b) Modernisation of Health facilities
PSMAS after acquiring healthcare facilities modernised them through intensive renovations to meet standards, proper equipping in all facets, proper stocking and branding the Healthcare facilities to PSMAS standards.
c) Human Capital Development
PSMAS introduced appropriate structures, created effective training programs for competency gap closures. PSMAS came up with various mechanisms for performance management and adopted a transformation strategy for Years 2010 to Year 2012 which adopted the employee as the number one stakeholder and provided requisite incentives. PSMAS developed a customer centric approach across the board.
d) Products Innovation
PSMAS development new products to promote equity in healthcare services as already enumerated through market development and continuous research on healthcare products and changes happening elsewhere.
ICT DEVELOPMENT
a) Medical Aid Software System( MASS)
PSMAS believes in ICT development. The following benefits are through the mass system realized;
1) Provision of a 24 hour service to clients through online benefits and member verification exercise thereby eliminating delays in service provision.
2) Reduced claims adjudication time before payment.
3) Elimination of duplicate claims, irregular claims and over-servicing.
4) Elimination of bogus providers and bogus patients through online verifications.
5) Elimination of travel to Health insurance offices by patients for authorizations.
b) Appex Healthcare Solution for healthcare services
The Apex Healthcare Solution is a healthcare services operations application which automated processes with the following benefits;
 Creation of PSMAS Group wide database with demographic data for all patients accessing PSMAS Group healthcare services, enabling single patient registrations for all services.
 Access of clinical records in PSMAS Group healthcare facilities throughout the country thereby ensuring easy access to correct clinical records by healthcare practitioners.
 Linking all PSMAS Group healthcare disciplines (division wise platform) thereby creating intergroup connectivities
 Portal to link with all healthcare insurance companies for online authorizations as well as electronic submission of claims and payments.
 Tracking of disease patterns, associated costs and related medicines thereby creating a platform for research and development through provision of correct statistics to Government and research agents.
 Functionality to carry out clinical audits for continuous improvement.
e) Provision of quality reporting tools for operations management.
f) Electronic data Interchange linking Providers and funders for payments.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
PSMAS came up with a low cost leadership strategy with following objectives
1) Increased access to all covering all provinces in Zimbabwe
2) Improving healthcare services quality in all PSMAS healthcare facilities through equipping healthcare facilities, training personnel, adequate stocking.
3) Creating a performance culture in all Healthcare facilities
4) Working with Partners and collaborators through effective networking and relationship building
5) Containing costs and influencing a downward trend of Medical inflation in Zimbabwe
6) Reducing skills flight (Brain drain) by ensuring good working conditions to staff and providing proper tools of trade

The objectives were implemented through acquisition of healthcare facilities throughout the country, innovation of products, equipping all facilities, human capital development, Partnership with Government on various healthcare related issues, corporate social responsibility programs, Capital raising through working with Financial institutions and ploughing back surpluses. The strategies were crafted after performing environmental scanning of Zimbabwe and dealing with opportunities, threats arising from the political, social, economic, legal and technological environment. PSMAS performed a detailed industry analysis of healthcare sectors in Zimbabwe from both the public and private sector and crafted strategies to deal with outcomes in the analysis. PSMAS carried a detailed analysis of the needs and expectations of all stakeholders in Zimbabwe and crafted strategies to satisfy their needs and expectations through a detailed strategic plan. PSMAS works with various Partners in the value chain of the business and adopted best practise in corporate governance to achieve the highlighted objectives. Products innovation was achieved as follows
In order to meet its low cost leadership strategy without compromising quality and meeting all aspects of primary healthcare
A)Created products for vulnerable Groups such as pensioners, the chronically diseased as well as products for students at universities for health insurance.
a) Created benefits limits for each major class of services using a structured cost build up approach.
b) Created a specific fund for chronic diseases known as The Prudent Fund to cater for renal failure, hypertension, asthma, epilepsy, heart failure, HIV and AIDS management, diabetes, to protect members from benefits exhaustion, defaulting treatment and payment of shortfalls on accessing services.
c) Created products for the informal sector allowing small scale enterprises even without bank accounts to subscribe by cash or stop order facilities through their banks.
d) Provides courtesy vehicles to transport discharged patients from hospitals thus, providing convenience to the patients and creating cost savings for them.
e) Introduced home deliveries for medicines, home visits and home follow up schemes on patients to check on progress.
f) Introduced health education in healthcare facilities with emphasis on preventive healthcare as well as encouraging frequent health checkups to ensure early detection and management of diseases.
g) Formulating a health insurance product for preventive healthcare, a first in the market and carrying out corporate wellness programs.
h) Currently working on Women and Men wellness clinics, Health spars, sports and exercise medicine, nutrition medicine and health tourism in line with the one stop shop concept.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The key development in strategy was forward integration and diversification of healthcare services. The concept entailed the formation of an investment arm (PSMI) responsible for acquisition of healthcare facilities from year 2001, creation of new health facilities, registrations with regulatory authorities, Healthcare facilities upgrading and renovations, equipping and stocking of Healthcare facilities, staffing, training and development, ICT development, business process reengineering, research and development and innovation in products structuring.
a) Acquisition of Health facilities
PSMAS adopted a concept of acquisition of strategically located healthcare facilities in all major towns and cities covering primary healthcare, dentistry, Optical services, Evacuation services (pre hospital care), retail pharmacies, hospitals, rehabilitation services and Radiology and Pathology services. PSMAS after acquiring these would then upgrade , train staff and run the facilities.
b) Modernisation of Health facilities
PSMAS after acquiring healthcare facilities modernised them through intensive renovations to meet standards, proper equipping in all facets, proper stocking and branding the Healthcare facilities to PSMAS standards.
c) Human Capital Development
PSMAS introduced appropriate structures, created effective training programs for competency gap closures. PSMAS came up with various mechanisms for performance management and adopted a transformation strategy for Years 2010 to Year 2012 which adopted the employee as the number one stakeholder and provided requisite incentives. PSMAS developed a customer centric approach across the board.
d) Products Innovation
PSMAS development new products to promote equity in healthcare services as already enumerated through market development and continuous research on healthcare products and changes happening elsewhere.
ICT DEVELOPMENT
a) Medical Aid Software System( MASS)
PSMAS believes in ICT development. The following benefits are through the mass system realized;
1) Provision of a 24 hour service to clients through online benefits and member verification exercise thereby eliminating delays in service provision.
2) Reduced claims adjudication time before payment.
3) Elimination of duplicate claims, irregular claims and over-servicing.
4) Elimination of bogus providers and bogus patients through online verifications.
5) Elimination of travel to Health insurance offices by patients for authorizations.
b) Appex Healthcare Solution for healthcare services
The Apex Healthcare Solution is a healthcare services operations application which automated processes with the following benefits;
 Creation of PSMAS Group wide database with demographic data for all patients accessing PSMAS Group healthcare services, enabling single patient registrations for all services.
 Access of clinical records in PSMAS Group healthcare facilities throughout the country thereby ensuring easy access to correct clinical records by healthcare practitioners.
 Linking all PSMAS Group healthcare disciplines (division wise platform) thereby creating intergroup connectivities
 Portal to link with all healthcare insurance companies for online authorizations as well as electronic submission of claims and payments.
 Tracking of disease patterns, associated costs and related medicines thereby creating a platform for research and development through provision of correct statistics to Government and research agents.
 Functionality to carry out clinical audits for continuous improvement.
e) Provision of quality reporting tools for operations management.
f) Electronic data Interchange linking Providers and funders for payments.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Obstacles
PSMAS faced a number of obstacles including convincing stakeholders on understating the coordinated healthcare concept, its benefits to society at large. PSMAS faced funding constraints linked to the state of economy in the hyperinflation mode, shortage of foreign currency to fund capital projects and imports, shortages of drugs and consumables in the country, policy shifts, skills flight, shortage of Specialist in the country, high funding costs, poor employee culture, industry rivalry, poor systems and poor technology. The challenges slackened the pace of internal growth and development.
PSMAS had to be innovative to deal with the obstacles. PSMAS came up with an effective corporate governance structure which included a balanced and knowledgeable Board to deal with strategic and policy issues and guiding management. PSMAS recruited competent Executive directors in areas of healthcare management, Finance, ICT, marketing and public relations, Human resources management and legal. The management structure then adopted the strategy and implemented effectively.
In order to overcome the problem of stakeholder perceptions, PSMAS Group had to meet various stakeholders and explained the business rationale in detail, obtained feedback and convinced the various stakeholders including Government and competition and Tariff commission.
PSMAS in order to overcome the challenge of funding utilised its immovable properties to secure funding at reasonable terms acceptable from local banks and regional banks such as PTA bank. The Group accessed funding through leasing arrangements for equipment and vehicles; however the problem is ongoing and is a challenge for major projects requiring amounts over USD10M due to the current country risk profile. PSMAS had to engage the Government and Reserve Bank of Zimbabwe for special considerations for foreign currency allocations for equipment purchases before the adoption of the multicurrency system in Year 2009 and succeeded in some cases.
PSMAS signed Service Level Agreements with Specialists for the provision of services to the Group as Consultants and came up with a pool of Locum cover on a rotational basis to improve in this regard. PSMAS is now funding Healthcare professionals to Specialise and bond them as another option of skills retention.
PSMAS conducted comprehensive training on service delivery, technical knowledge upgrades, strategic awareness, employee participation and involvement, customer centric training and productivity culture. The results were positive in changing employee attitudes as demonstrated by high performing and enthusiastic staff.

PSMAS adopted a strategy of direct imports to reduce costs and deal with shortages and signed contracts with suppliers from Europe, India, South Africa and the East which has improved availability of modern medical equipment
PSMAS acquired better technology and implemented ICT products which improved processes and efficiency in the Group

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Resources used
PSMAS ,in order to achieve its strategic objectives used Financial resources from lending and own resources, human resources which include training and development, acquisition of equipment and tools of trade, purchase and development of ICT products relevant for the industry, relationships, consultants and research agents.
The resources used benefited PSMAS in accelerating progress in the implementation of its strategies. The financial resources included acquisition of immovable properties estimated at USD 15M, acquisition of ICT products estimated at USD 5M including training and implementation costs, acquisition of equipment estimated at USD 6.5M and training estimated at USD2.0M annually. The use of consultants benefited the Group in upgrading industry knowledge, resource mobilisation and provision of scarce skills, consultancy costs are estimated at USD 1.8M per year. The benefits of these resources are well equipped medical centres providing confidence and correct diagnosis, improved process through ICT development and process reengineering, performance culture, improved business knowledge from employees, improvement in strategy execution, improved access to healthcare through the various healthcare centres in all major cities, reduction of costs in the provision of services. The Group also benefited in market visibility and awareness its products through repeat business and compliments in the industry. The Group also realised the change of once negative perceptions to positive perceptions by the publics.
The Financial resources were mobilised through lending from financial institutions using immovable property as collateral as well as ploughing back surpluses on trading. The ICT applications and systems were purchased on the market from India and other sources after due diligence on the products. The training is both in-house and from Consultancy engaged on these areas. The procurement of equipment is guided by Strategic engagement, supply chain management policy as well as investment policy. The procurement is through lending, leasing and advance payments depending on agreed conditions with the suppliers. PSMAS strives to meet its terms in the contract.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
PSMAS has the following sustainable programs:


1) PRODUCTS INNOVATION

The product innovation and market development is key to sustainable growth and currently the following projects are in progress
a) TELERADIOGY
The project entails digitalization of all radiology equipment to capacitate functionality to link with reporting centers in Zimbabwe and outside to circumvent the shortage of radiologist in the country.
b) Mobile Clinic
The project entails use of a Van equipped with all primary healthcare facilities accessing remote and disadvantaged communities thereby taking medical treatment to the people
2) RECAPITALIZATION PROGRAM
PSMAS imports modern Medical equipment and power backup.

3) THE EXPANSION PROGRAM
PSMAS is pursuing the following expansion programs
a) Urban medical centers in populous residential areas to bring services closer to the people and decongest city medical centers.
b) Growth point medical centers with sufficient critical mass required to run a medical centre viably
c) Expansion of hospitals of sufficient bed capacity in outlying areas including Selborne hospital in Bulawayo
d) Highly specialized hospital (Parkview hospital) in Harare to cater for all specialized procedures currently referred outside Zimbabwe.

4) HUMAN CAPITAL DEVELOPMENT
PSMAS believes the employees are key assets in the value chain of its business and adopted the employee as the number one stakeholder. The PSMAS Group employs over 1600 employees and retain them conditions of service are always improved and checked through employees annual satisfaction surveys. The group has several incentives and introduced performance management systems.

5) FEEDBACK PROCESS MECHANISMS
PSMAS participates in Health Expos which are interactive with stakeholders and feedback is obtained with follow ups on deliberated issues. The PSMAS Group also has an interactive help desk, call center to attend to feedback from various stakeholders. The Group’s Public Relations and Marketing departments effectively deal with the feedback processes which are always taken seriously in the molding of business development.

The PSMAS Group carries out annual Patient/Customer Satisfaction and Employee Satisfaction surveys, using proper research and scientific methods.
a) Patient/Customer Satisfaction Index (Target 95 %, Actual 90%)
The survey deal with key deliverables from patient perspective and check on performance of how well the company is doing on each.


b) Employee Satisfaction Index (Target 75%, Actual 81%)
The employee satisfaction survey deal with issues on conditions of service, soul space, availability of tools of trade, training needs, peer reviews, team building and general understanding of the business.

6) TRANSFORMATIVE ADMINISTRATION
The PSMAS Group embarked on several transformative projects in ICT development, market development, product development and culture development as already highlighted and a Transformation Strategy Years 2010- 2012 which is aimed at inducing a performance culture, a customer centric culture, improving self confidence in employees.
.
7) Corporate Governance
The PSMAS Group always strives to adhere to best practice in corporate governance. PSMAS holds Annual General Meetings, prepared annual audited Financials, have effective Board and Audit Committees.

The PSMAS has several Corporate Social Responsibility programs aimed at assisting the vulnerable groups and promote equity in as far as accessing Healthcare services is concerned.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Impact

The coordinated Healthcare concept produced positive results with a lot of benefits accruing to the Group and the patient. The following is the impact of the strategy
1) Improved staff retention to 99% and curbing brain drain resulting in consistent supply of services from well trained health professionals
2) Introduced well equipped, well stocked healthcare facilities throughout the country and improved access and quality of healthcare services including diagnostic accuracy.
3) Introduced competition among industry players in all provinces leading to better quality and better pricing beneficial to all.
4) Improvement in quality of service as highlighted through the positive feedback from the customer/ patient satisfaction survey.
5) Reduced travel distance for patients to medical centres and for authorisations through the one stop shop concept and ICT interventions
6) Reduced shortfalls and copayments from patients.
7) Creation of patient cards with demographic data, bar coded for swiping at receptions, thereby improving turnaround times
8) Tracking of disease patterns, associated costs and related medicines thereby creating a platform for research and development through provision of correct statistics to Government and research agents
9) Functionality to carry out clinical audits for continuous improvement.
10) Platform to link to mobile telephones for mobile updates, online applications, online bookings and other web based connectivities
11) Provided convenience to patients through the one stop shop concept thereby reducing delays in service provision.
12) Increased efficiencies through ICT development which resulted in improved turnaround times, better payment efficiencies, better authorisation methods, fraud detection and better governance through improved supervision.
13) Eliminated paperwork, redundancy, duplications thereby improving efficiency and reducing costs.
14) Creation of harmony through network organisations in the industry.
15) The impact of the once stop shop concept is increased efficiency, increased turnaround times, cost effectiveness , convenience and improved accessibility of healthcare services
16) Resulted in growth of medically insured population due to increased confidence with PSMAS market share increasing to 60%.
The key element for success was rigorous follow up on key success factors i.e. retention, growth, collaboration, leadership, acceleration and innovation. The concept entailed continuous learning, recapitalisation program, training, performance and customer centric culture, ICT development, market development and products innovation. The measures improved market perception and uptake of the products through realised benefits and support from all stakeholders
The concept provided key lessons, the key being the following:
1) The importance for all stakeholder participation in the strategic mapping for ownership and support.
2) The importance of relationship building particularly with Members, Lenders and Partners.
3) The need for continuous interaction with communities.
4) The importance of continuous feedback through surveys for sustainable growth
5) The need for compliance and sound relationship with Regulators as a way of risk management.
6) The coordinated healthcare concept is capital intensive
7) The importance of ICT development in creating competitive advantage, process improvement and cost efficiencies
The Group’s initiative is a real indicator of the adage “Where is there is a will there is a solution”.

Contact Information

Institution Name:   PREMIER SERVICE MEDICAL AID SOCIETY
Institution Type:   Public Organization  
Contact Person:   DR CUTHBERT ELKANA DUBE
Title:   GROUP CHIEF EXECUTIVE OFFICER  
Telephone/ Fax:   002634731674
Institution's / Project's Website:   www.psmas.co.zw
E-mail:   joycemu@psmas.co.zw  
Address:   47 GEORGR SILUNDIKA AVENUE
Postal Code:   00263
City:   HARARE
State/Province:   HARARE
Country:   Zimbabwe

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