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.

Final Nail in the Coffin of Public Healthcare System in Kenya ?

On 7^th March 2017 the President of Kenya, H.E Mr. Uhuru Kenyatta issued an open threat to doctors in the public sectors who were on strike, ”Resume work or get fired”. This act just when some mediation activity was being finalized courtesy the religious leaders signaled a government unwilling to give resolution of the strike a chance. Whatever the legality or genuineness of the strike ,we have to look at this utterance by the President during the Devolution Conference as one that emboldened county governors to take drastic steps to fire doctors and with it reduce the high wage bill they were possibly asking for. What many people don’t understand is that the net impact of such an utterance may have just cost a few thousand patients their lives as the consult of a specialist in a public hospital was a treasured and very rare occurrence that many spend months on the waiting list for a specialist appointment, but It was all lost in one statement.

I hate to say I told you so, but….I told you so. With the imminent sacking of most Kenyan doctors and the promise to the populace that the government will hire foreign doctors to fill the gap left, you have to realize that the second phase towards full privatization of healthcare will be complete soon. Phase three of the privatization involves actively seeking out doctors to join group practices and form consortiums that can provide consultancies to the government hospitals at a fee. This is the way, the breakup of the doctors union will be achieved. Doctors who want in on the action in the consortiums will be asked to renounce their union membership before being allowed to share in the new arrangement of doctors- for-hire. At individual level doctors would have nothing to lose in accepting the new arrangement as they would be assured of better terms of service and better conditions of work. However, Kenya has a deficit of medical doctors and is struggling with a disproportionate illness as compared to the rest of the world. The country is emerging as a major focal point of increased cancer cases in the world. This together with the non-communicable diseases increases call for greater investment in tackling the problem and to safeguard the economic growth of the last decade towards an industrialized nation by 2030.But the moment the government turns back the hand of time and rolls back the gains in health outcomes such as maternal mortality, infant mortality and general health indicators you have to wonder at the sanity of it.

Doctors want improved service provision

Sacking doctors does not in any way help the economic growth of the nation because economic growth is related to level of healthcare improvement in a country. Doctors have all along been advocating for greater government investment in ensuring better healthcare to the bottom of the pyramid Kenyans whose only source of healthcare provision is the local dispensary and district hospital. Proper equipping of the facilities, availability of supplies and sound oversight holds the promise of better health outcomes with minimal per capita cost. However if the intention of anyone is to alienate healthcare from the lives of the poor and to commodify health service provision, many will be left without proper healthcare and facing reduced  greater burden of diseases.

 Creating commercial health workers

Doctors are intelligent knowledge workers who cannot be held captive to any machinations to try and castrate their desire for better terms of service and conditions of work. They will find ways to adapt and already many doctors have started thinking beyond the confines of the borders of the country and we only have to expect a big brain drain soon. Moreover, the nudge they are experiencing will force the few remaining doctors and specialist to move to the private sector and group practices with market-oriented service provision. This will mean fewer doctors and specialist in public hospitals and reduced quality of care and outcomes for the poor unfortunate enough to seek care in government facilities. The private health sector in the country will however will grow in leaps and bounds with market-dynamics forcing focus on lifestyle diseases and aesthetic medicine industry. The specializations involving the diseases of the poor will be neglected and the morbidity and mortality associated with them will be greater.

Public-Private Partnerships

In the spirit of Private-Public-Partnerships (PPPs) most district hospitals will have a private wing dedicated to the provision of better healthcare to those with the financial ability to pay the charges and managed by private firms to ensure “efficiency” instead of strengthening efficiency within the public sector. Later, more government facilities will be urged to give space for PPPs in the false hope that it would ensure provision of quality care at affordable rates. Mercenary doctors will be on hand to treat patients as long as their share is assured. As for the other Kenyans unable to afford the amenity wing, they will not be able to access the same level of care and will just receive palliative care for malignancies, and symptomatic treatment for chronic conditions. The law of demand and supply will obviously make it impossible for the poor to afford specialist care unless they can sacrifice all their little earthly possessions to seek care in the private facilities of the country. So, again I ask, how will the doctors be adversely affected?

Reduced payroll expenses for governments

For the governments both at county and national level however, they only see the reduction in the payroll expense from the offloading of the baggage of doctors’ salaries as a line item in their budgets. This myopic thinking will be the norm and groupthink among governors will ensure uniform implementation of the sack order and replacement of doctors with other cadres of health workers involved in primary care provision. One day in the future, current governors and other government functionaries will regret it because in life you can’t always be on the top of the ladder and one day, they will taste the feeling of not getting a doctor to attend to them when they need it the most.

Private healthcare investment

Another possible enticement for the government is that a market-oriented approach to healthcare will ensure that the populace ceases to look at health service provision as a merit good and instead as a personal good subject to the faulty law of demand and supply. With this thinking the government will be assured of reduced expenditure in the form of payroll expense and increased foreign healthcare investment in line with the recent statement by World Bank President of the availability of $1billion for investment in the next five years. These investments together with others of a similar nature will make doctors lose their sense of social justice and be more inclined to sell their souls to the devil.

So, the choice is clear, reform and improve public healthcare for future generations or break it down for short-term gains of reduced expenditure but with increased fallout. I urge the government planners to think wisely before trapping future generations in an error that could be corrected now.

Taming Runaway Healthcare Costs

On various occasions I have elaborated my ideas on different aspects of healthcare systems and service delivery. I hold my own beliefs as relates Universal Health Coverage that could be divergent with some of my friends and colleagues but we all agree the status quo in healthcare is not sustainable and should be reformed. Today, I seek to jot a few eye openers to elicit conversation and critical thinking on key reforms in payment and pooling of resources and whether it could be the way to go in health service delivery reforms.

Pooling of resources

The whole idea behind medical insurance is one of pooling resources into a common fund to protect against a future unexpected health emergency. Scholars agree that the bigger the pooled health fund, the better the coverage against unexpected catastrophic health expenditure. This is truly noble and engrained in our cultures. We all engage in it in an informal way through constant medical appeals to which we contribute. This could be considered our “premium”, so that if we ever fell into same situation we would be assisted in the same way. But shockingly the concept of pooled resources in a formal way in Kenya is very low. Medical insurance uptake in Kenya is less than 2%, and if you were to include NHIF as a form of health insurance then 8% coverage. Most of the members of insurance schemes are employees in a fund mostly contributed by the employers. This has its origins in post-World war II America where the labour laws necessitated a cap on salaries but the benefits due to employees were not capped. This made it easy for big corporates to lure the workers through a good medical or dental plan. The same replicated itself all over the world and now the nascent Kenyan economy has to contend with a burden of medical care as a cost of production and it is an important consideration for many while selecting a job.

The extensive use of Out-Of-Pocket (OOP) payments for health services is a recipe for financial ruin for many families. Annually many are forced to sell off their prized possessions including land and driven to bankruptcy due to unexpected high cost of health care in an emergency. So either through my idea of government Universal health coverage scheme or pooled resources in the form of social health insurances or private health insurances, individuals need to cushion themselves against the potential catastrophic expenditure and bankruptcy.

While still waiting for the concept of universal health coverage to be accepted as a mass movement and implemented through improvement of service in public healthcare facilities, I urge you to take up at least an NHIF cover and if you can afford an individual health insurance cover that too.(Don’t Thank me for that).

Review of our healthcare payment system

Further to the above, as healthcare management professions need to call for a review of the payment methods in our health facilities as it contributes to the high cost of care.

Fee-for-Service payment method

The prevalent payment system for health services in Kenya is a fee for service system. This is a demand driven system with the health service providers and users of the medical schemes holding the ace. The providers dictate how much the cost of service will be through costing for overheads and their mark-up. Through this system, providers do not have an incentive to control cost of care because it is not in their interest to do so. As long as the gravy train continuous they are ok with it. These results in increased claim payments or in case of OOP expenditure, high medical bills. The users for whom the insurance is procured do not seem to understand the basics of how modern health insurance works and end up adopting a kamikaze approach. It is not a secret that as the financial year closes most employees make a queue to the nearest facilities to make use of the cover they never utilized because they were healthy throughout the year. The pathetic excuse given in most instances is that, “I am covered for Shs 1,000,000 and I have not been admitted even once, so I should make use of it because it will expire in 15days.” This is called moral hazard in health economics. I guess majority of policy holders do not realize they are slaying their goose that lays the golden egg until itself to late and the goose is already cooked and on the table. A last supper!

Capitation system

One of system that could be used is one of capitation where the health service provider is entrusted with a fixed amount per scheme per period. This would enable cost containment and a level of sanity among providers. But without checks and measures the quality of care provided would be jeopardized.

Bundled payment

Another payment for services system could be the bundled care approach for services. In this system costs of care for a hospitalization episode is batched and one does not need to run like a headless chicken all over the hospital to enquire on the actual cost of hospitalization during discharge. For example if you were to have an emergency appendectomy, you would be able to know the expected number of days of stay in hospital and the cost of treatment on admission. Once the cost of care to the patient is known, hospitals of similar size could be made to standardize their costs or risk getting only partial remittance from insurance companies. This openness in billing system would force providers to look at improving efficiencies of their system to reduce their expenses and thus further reducing the cost of healthcare.

This system is only partially in use in Kenyan hospitals with packages for maternity and other surgical cases. But it can be expanded with stakeholders involvement in order to tame the runaway cost of healthcare.

I do not have foolproof answers to the challenges but I can only hope that attempts are made to reform the system as the current fee for service system is untenable. There is a need to study the Kenyan health seeking behavior and devise a system that takes this into consideration.  

All these can only be achieved if there is better coordination and cooperation among the industry players .The status quo can however be maintained if we seek to kill a useful feature of our health system and to cause a regression in attainment of international standards of life indicators. This is not so bad if we seek to promote the coffin industry and by extension the printing industry, for the obituaries will be many.