Corporate model of healthcare is an industrial economics model as I mentioned in my earlier article (http://jamsheed.org/article/330). Managing health facilities is not the same as managing a business entity as there are very specific and unique characteristics inherent to healthcare. If these differences are not understood, we will be putting the limited financial resources in wrong places at wrong times due to a failure to understand the ‘real’ needs and priorities of a health facility! There are several issues that need to be discussed in the debate of an appropriate healthcare model. While such a discussion should be much broader than what I have discussed here, this article mentions few important issues.
Do we need private and corporate hospitals?
Private and corporate hospitals are very important contributors and should be part of the national healthcare system. These institutions have their own strengths that will contribute to the overall effectiveness of the service delivery at a national level. However, not all the health facilities in the country could be switched to this model, as there are inherent weaknesses and issues of this model that should be addressed and tackled differently. Healthcare delivery should be geared to cater the needs of all the socioeconomic groups in the population.
Can the current health corporations be self-sufficient?
The government stated that switching to a corporate model would make the hospitals and health facilities more efficient and relieve the pressure on the government budget, that the government would support the corporations for few years and thereafter they would be largely self-sufficient. However, there are very few hospitals in the Maldives where sufficient revenue could be generated (even theoretically) to survive on their own. This means that the government would have to keep injecting money or subsidize the service or provide an additional revenue-generating source. There’s no doubt that all the public (or corporate) health facilities (urgently) need to be made more efficient in all the fronts, but I do not believe this is being achieved with the recent changes. Moreover, I believer it has made the health facilities less efficient and ineffective!
Managing health facilities requires specific knowledge and experiences of health and healthcare. Where the managers lack this expertise, they would often be taking wrong decisions and making inappropriate investments further deteriorating the service. With the new changes, what we saw was a replacement of almost all the experienced health managers, by people who either lack this knowledge and/or experience. The outcome of this has become too familiar to most of us and is seen in almost all the hospitals in every front. In many cases the new management has not been able to manage the professional staff either, leading to disobedience and mass resignation threats. Professionals cannot be managed with the same attitude and approach as labourers. If one cannot understand and respect this, then we will find ourselves with persistent and acute shortage of professional staff. I don’t think there is any room for argument that the corporation boards and hospital managers in most of the corporations lack the wisdom, knowledge, skill and experience needed to manage healthcare delivery either; mostly because the country simply don’t have enough of such expertise but also because the government has either refused to take those with the right knowledge and experience onboard, or the professionals have refused to take up such posts for various reasons. The other worrying fact is that few educated and capable people who were recruited by the corporations have and are quitting, which is something that the Government needs to seriously look into.
Health supplies and consumables are becoming more expensive everyday. The cost implications could be minimized to some extent by having a centralized health supplies and procurement mechanism. Unlike in neighbouring countries like India, our requirements are very low, that could easily be managed and be more economical if we keep this function centrally. However, this has to be managed by people who understand the health requirements, priorities and have knowledge of the market availability as well as alternatives that could be used ensuring that there is no supplies disruption leading to discontinuation of service (which we have been witnessing too often).
Lack of coordination
Two important incoordination issues, which many of us predicted and alerted earlier, have emerged now. One is coordination between different health corporations. Previously all the health facilities were under the administrative control of MoHF. Hence doctors and paramedical staff from one facility could be mobilized to another facility to fill a temporary gap or increased demand as in disease outbreaks. This is crucial to avoid service disruptions in a resource poor country with a demanding and challenging healthcare delivery system. Also this model ensured round the clock tele-support and advises from doctors and experts working in IGMH and regional hospitals as well as MoHF to doctors and managerial staff working in smaller facilities. With the formation of individual corporations (especially with no formal inter-corporation understanding or arrangement) this has practically ceased to exist leading to disastrous outcomes at times.
Secondly, there is lack of coordination between the councils and the corporations. Some of the patient groups (TB patients, pregnant mothers, children for immunization to name few) need to be followed up and traced if they failed to turn up for scheduled service. Health corporations are not doing this (not their mandate either) and public health staff in the councils are not aware of it (as there is no feedback mechanism from corporations to council). This is leading to serious issues. One major problem noted (just the tip of iceberg) is increase in default rate of TB patients and reduction in TB case detection rate! This is alarming not only at national level but also at a regional and international level; because the TB control programme in the Maldives had been an exemplary one with impressive performances.
Weak regulation and poor central control
For a safe and effective healthcare delivery, there has to be a strong and efficient regulation. This is more critical in private and corporate health services where MoHF will have less or no say in organization and delivery of services. The country has no regulatory capacity to monitor and take corrective measures, not even at the capital let alone in the whole country. Another worrying reality is that MoHF has largely lost its control or say over healthcare delivery as many corporations have repeatedly refused to oblige. MoHF should remain as the supreme authority in health, whatever model of service delivery we adopt!