Culture Change Crucial for Better Health Services

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.