One
of the key pillars of a strong and resilient health system is a dedicated, competent
and empowered health workforce. There are a lot of learning points from the
private sector that can be applied to public service to improve both the
systems, processes and outcomes. Private sector has adopted the principles and
to good effect (and profits).
With
a focus on health sector it’s worth noting that in as much as investment in the
other pillars of health system are crucial, Human resources for Health #HRH deserves
clear and strong focus. Without a competent and committed workforce all gains
towards #UniversalHealthcareKE will prove to be transient and unsustainable.
Taking an example of the two adjacent hospitals on Ngong Road, one a public, tertiary
hospital and the other a privately run “not-for-profit” hospital. With the limited
number of specialists in our country some of the doctors admitting at KNH also
have admission rights in Nairobi Hospital. However the way they would treat
patients in KNH is markedly different from across the road. You may attribute
that to various factors including the money is king mantra. I beg to disagree
as to the extent that contributes to the way they handle patients. It all boils
down to organizational culture also.
In
private institutions, there are a laid down structures of interactions between
consultants and hospital based doctors and patients and that is adhered to very
well. However in the public service ,there being either a lax oversight role by
the management and/or lack of control on the conduct of what can or cannot be done
in the facilities, the standards plummets. If public hospitals and public
service in general could just adopt the implementation plans of private
hospitals, there would be a world of difference.
Meritocracy
In
the private sector there are some conduct that would not be tolerated but in
public service form the norms. Promotions and increments are mostly after
accomplishment of set targets. However in the public service there is the
expectation that there is a continuous promotion ad infinitum as long as one
has a pulse and clocks in for work. This breeds a laissez faire attitude that
with time generates a systemwide breakdown of ethos as a subculture of
minimalist job performance is adopted.
Performance contracts
Highly
successfully used in the private sector, no individual should be above a performance
contract. If a practitioner cannot meet certain standards expected of them as
set by peers and with clear goals set at the start of a given term they should
be reallocated to other areas where they might perform better rather than have
a security of tenure of employment for mediocre staff who do not aid the
achievement of any long term vision of better health outcomes.
The
health system practitioners (who ideally would be technical health workers
themselves) are not and should not be seen as just managers out to ensure
budget preparation and operational supervision of the institutions. They should
be given greater autonomy and oversight to improve their institutions and
departments without a constant either political patronage that clips their
wings and turns them out to be zombies, rubber stamping unrealistic programs without
giving a contrary knowledgeable opinion.
Oversight and control
Another
reason private-sector like structures would work in public service given the
proper backing is that, with oversight of personnel transferred to the
institutions, decision-making and performance standards can be locally
formulated taking into consideration the areas health needs and outcomes to
aspire for. The empowered health system managers are able to therefore
implement more measures that would avoid the present great variability of patient
experience and quality of care between two adjacent hospitals.
Distribution of
health workers to counties
There
are other factors too that contribute to variability of healthcare provision
but public service culture needs to be reshaped and improved. I do admit that
there are many honourable and dedicated health workers in public service but the
organizational cultures and subcultures increase their burn-out rate and some
even might be tempted to move over to the private sector where their handwork
and initiatives will be appreciated.The devolution of health services to the counties without a
structure of addressing shortfalls in staffing in various areas resulting in
lopsided distribution of health workers and lack of autonomy by the hospital
heads because of local politics hindering their vision for better services has
also constituted to the current chaos we have.
There
are various ways in which such a debate could be pursued and a new, vibrant public
health system culture redesigned from the models of private sector without the
burden of pursuit of profit but instead greater efficiency and quality of care.
I
hope I live to see the day when the Profs won’t have to cross the road to be
humble and smile at the patients in equal measure.
