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George Moseley’s Dysfunctional Healthcare Systems Entrenched

  Jan 23, 2014

Few countries around the world are completely satisfied with the way that they currently deliver and pay for health care services to their citizens. Whether it is called “health care reform” or “strengthening the health care system”, efforts are in progress in most countries to improve the efficiency, quality, and access of the health care services provided.To make the most of these initiatives, it is helpful to be clear about exactly what features/aspects/structures of the health care sector are proposed for reform.

Health care officials, planners, or leaders often talk about “reforming an existing health care system “ or “designing a new health care system”. The term “system” can be defined as a group of interrelated and interdependent parts that move or work together as a complex whole. By that definition, many countries do not truly have health care “systems”. The United States is one; Kenya is another. Instead, the health sector is composed of a few large segments (public, private for-profit, faith-based, and NGO) that are made up of numerous individual institutions and facilities. While they do interact with each other when patient care requires it, neither the segments nor the institutions truly work in harmony with one another. The same is true of the payors that finance the care that is delivered. In Kenya, these are the National Health Insurance Fund (NHIF), the community based health insurance schemes (CBHI), three types of private health insurance companies, donors to NGOs, and patient out-of-pocket payments. There is no real information-sharing among them.

I believe that this fragmentation of provider institutions and payment sources is a major factor in the inefficiency of the US health care sector. It creates similar problems for any nation that allows its health care providers and payors to operate in such a disjointed, uncoordinated manner.

Most health care reform efforts accept the existing configuration of the health sector, and make changes intended to improve access, quality, or cost. They rarely attempt to create a true system where none already exists –or even to acknowledge that the sector functions unsystematically. As a result, a dysfunctional lack of unified policy and practice is perpetuated in the sector. The Kenya Health Policy 2012-2030 statement admits as much. Some examples.

  • “The capacity of the Ministry of Health was strengthened particularly in planning and monitoring, though limitations remain in other areas such as leadership / management.”

  • “Sub-national management functions have been strengthened to allow them to better facilitate and supervise service delivery, though this mandate has been exercised differently in the various provinces/regions, and districts.”

  • “New statutes, laws, and policies guiding different aspects of the health sector have been introduced, though done in an uncoordinated manner and no update of existing laws undertaken.”

  • “Amount and scope of systems, clinical and biomedical research being carried out has increased, with a number of operational decisions effected. There is however little collaboration amongst different research institutions, and poor linkage between research and policy.”

  • There is no doubt that the operational performance of almost any health care infrastructure can be improved through programs like those described in Kenya’s Vision 2030: restructuring of the sector’s leadership and governance mechanisms; improving procurement and availability of essential medicines and medical supplies; modernizing health information systems; accelerating health facility infrastructure development to improve access; human resource for health development and developing equitable financing mechanisms as well as establishment of social health insurance. However, the improvements will always fall short of what is possible with a fully unified health care sector functioning in unison.

    The Kenya Health Policy statement does include some strategies designed to increase the health sector’s unity. These are examples.

    • Ensuring functional partnership and coordination mechanism at each tier of the health system. This shall bring together all stakeholders in the health sector at the respective levels.

    • Provision of oversight for implementation of functionally integrated, pluralistic health system.

    • Putting in place means for engaging with health related actors.

    • Jointly develop operational and strategic plans. Shall apply to all entities in the health sector.

    Ultimately, I believe that the maximum efficiency and effectiveness results from a health sector that is originally designed as a system or subsequently reengineered as a system. However, once the sector has assumed a shape over several decades, as is the case in most countries, it is politically and practically difficult to start moving the pieces around in an attempt to turn it into a system. I also believe that the most powerful unifying force, the one that can transform a disparate collection of health care organizations and providers into a system, is some form of centralized control over their reimbursement – which may explain the success of single-payer systems.

    George B. Moseley III, MBA, JD is a visiting professor at Strathmore Business School in the Healthcare Department also a Lecturer in Health Law and Management, works in the Department of Health Policy and Management at Harvard School of Public Health.

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