A right approach to health sector reform
In a disorganized and exceedingly bureaucratic health system, it is tempting for the ill-informed policymaker to engage in the “band-aid” approach to achieve quick fixes that appease both the public and legislators in times of crisis. We have discussed numerous examples of this in the past. Furthermore, providers, who have been reluctant to engage in significant attempts to reform the system, except when dealing with matters of remuneration, remain disconnected from the policy-making arena. Indeed, in an environment lacking exposure to even basic education in principles of public policy, management, and economics related to health, understanding the sector as a whole, beyond ones restricted clinical domain, remains a daunting endeavor. For this reason, we will expose a series of articles addressing key concepts in health sector reform using the framework adopted by experts representing institutions such as Harvard University, the World Health Organization (WHO), and the World Bank, among others.
Providers in Kuwait have become habituated to a chaotic practice that allows patients, enabled by a deficient regulatory and legal system, to walk into a busy office unannounced demanding immediate services with total disregard to privacy and confidentiality. Depending on the mood or generosity of the provider, the prohibitory fees of diagnostic imaging studies may or may not be waived, owing to ill-defined financing mechanisms, for the expatriate worker whose health care coverage remains overly nebulous. The black market of drugs prescribed only to Kuwaiti nationals, itself a discriminatory practice, has likely grown due to the increasing cost of living and the worsening poverty of the low income expatriate subgroups. Such problems have lured policymakers into engaging in a vertical approach where a circumscribed problem is dealt with while the rest of the health system is ignored. This is the approach used by major international donors to overcome disease entities in the developing world like malaria, tuberculosis, or HIV. Unfortunately, this tactic has been less fruitful than once hoped and has cost the developed world billions more that it had ever anticipated. Worse, it has cost the developing nations a greater loss in terms of misallocation of resource, brain drainage, and a continued burden of disease. Many now advocate for a horizontal or even a diagonal approach that promotes health system restructuring. Addressing key elements of a given system allows policymakers to better facilitate health sector reform strategies (Roberts, 2004; Reich 2008).
Fed by the sustained politics of exclusion that the nationals have perpetuated to maintain their social superiority amongst the expatriate majority, our destitute populations have developed defense mechanisms as a means of survival in this oppressive society (Meleis, 1979; Longva, 1997). In light of the recent parliamentary elections, these attitudes are now being increasingly criticized and solutions that risk further endangering the low socioeconomic status groups are being considered. The “insurance company hospitals”, funded by private insurers and solely covering the expatriate workforce, or the separation of Kuwaiti and non-Kuwaiti patients in hospitals are such examples. Does this sound reasonable?
Segregation is the word that should immediately and appropriately come to mind. To understand how we have come to this, one needs to grasp the basic principles of health sector reform. To begin, let us take a step back and define the forces that drive reform. The rising cost of health care forms one of the most important driving forces throughout the world today. As people become more informed and exposed to the practices of the developed world, demand for improved services and new technology rises. As our populations grow old (Asia’s 65+ age group is expected to triple between 2000 and 2050) so will our pool of chronic diseases and, consequently, the need for services. Financial constraints are yet another reason to engage in reform. Indeed, as inflation in the Gulf States mounts, governments seek ways to reduce expenditure and burdensome sectors become the rightful targets of reformists. With economic development comes competing budgets for housing, education, roads and other services. A counterargument lies in the unprecedented budgetary surpluses seen in Kuwait which attest to a true misallocation of funds within the governmental budget. Finally, skepticism of the public sector has led many political leaders, encouraged by the business arena, to advocate for a radical move away from the complex government-run bureaucracies, used by corrupt officials as stepping stones for attaining political posts, towards more dynamic, market-driven private health systems.
To better approach health sector reform, strategists should be encouraged to divide a system into the five categories of financing, payment, regulation, organization, and behavior, the so-called ”control knobs” (Roberts, 2004). Some nations require altering only one of these knobs whereas others may need more comprehensive restructuring of their system. Before addressing these categories in detail in relation to the Kuwaiti health system, a clear understanding of two fundamental concepts is required: the ethical principles and political processes guiding reform activities.
A matter of ethics
Indeed, it is only by understanding the core values by which policymakers stand that one can predict the kind of change sought. The first ethical theory, utilitarianism, judges the adequacy of a policy based on its effect on the well-being of a society or group of individuals. Subjective utilitarianism, using cost-benefit analyses, is the model used by economists to promote market driven health care systems. Although we will cover this in depth later when discussing the financing knob, the core problem here lies in the lack of consideration for equity and individual rights. Objective utilitarianism, based on cost-effectiveness analyses, is often adopted by public health experts who use health gains as outcome measures of policy-making. The problem arises in the difficulty in measuring these gains in practice and, while seeking the greater good, such reformists often end up sacrificing the more costly patients within a system. The second theory of communitarianism revolves around the nature of communities. It upholds beliefs that public policy must be assessed by the characteristics of the society it seeks to create. Religions are based on this principle. Finally, the third theory, and the one we adhere to primarily, is liberalism, specifically egalitarian liberalism. This theory focuses on individuals’ right to equal opportunity, including access to care.
In a nation consumed by decades of segregation that continues to be blacklisted by human rights agencies, the reformist must be encouraged to adopt egalitarian liberal beliefs to focus on promoting equity throughout our community. As we will come to understand, priority given to equity and rights will shift focus away from marketization strategies, such as privatization, towards a more socialized form of medicine.
The politics of reform
Our recent experimentation with health sector policy-making has led to a simple, yet crucial conclusion: reform is an excessively political process. Failure occurs whenever reformists promote an evidence-based approach to policy-making without considering the politics involved, which often hide vested interests, or, conversely, when politicians venture into the health policy arena without a clear notion of the underlying scientific evidence. Effectively, a mismatch between science and politics often leads to a collapse of the policy-making process. Experts have repeatedly concluded that a careful political analysis is an unavoidable step for sound decision-making (Reich, 1996).
Such analysis involves identifying the key stakeholders and pinpointing their position vis-à-vis the proposed policy. Understanding the influence and balance of players who favor and oppose the plan will help gauge its viability before implementation efforts are undertaken. Uncovering strategies that either convince opponents or, alternatively, diminish their power has only rarely been successful yet should be fervently encouraged. Additionally, the skillful empowerment of proponents and non-mobilized groups is a potent tool to master. Manipulating the media and informing key external organizations are additional instruments the reformist must secure in his armamentarium.
In upcoming articles we explore the five control knobs individually and provide detailed analyses of current deficits while proposing strategies of reform to the Government of Kuwait.
References:
1. Longva AN. Walls built on sand: Migration, exclusion, and society in Kuwait. Boulder, CO: Westview Press, 1997.
2. Meleis A. The health care system of Kuwait: The social paradoxes. Soc Sci Med 1979; 13: 743-749.
3. Reich MR. Applied political analysis for health policy reform. Current Issues in Public Health 1996; 2: 186-91.
4. Reich MR, Takemi K, Roberts MJ, Hsiao WC. Global action on health systems: A proposal for the Toyako G8 summit. Lancet 2008; 371: 865-69.
5. Roberts MJ, Hsiao W, Berman P, Reich MR. Getting health reform right: A guide to improving performance and equity. New York: Oxford University Press, 2004.
The Kuwait Health Initiative team is proud to announce the opening of its new online home at www.q8health.org. Since the KHI strongly relies on feedback from its readers to improve its services, please visit the site and send us your comments and suggestions.
The World Health Organization lists Kuwait as the 8th fattest country in the world with a 74.2% prevalence of overweight individuals, behind Nauru (94.5%), Federated States of Micronesia (91.1%), Cook Islands (90.9%), Tonga (90.8%), Niue (81.7%), Samoa (80.4%) and Palau (78.4%). This small group of Pacific Island countries has a genetic propensity for larger muscular physiques, and abdominal fatness has long been considered a symbol of wealth and prosperity for Pacific Islanders. Second to this cluster of small Pacific Islands is Kuwait. We are heavier than the Americans and report the highest rate of obesity of all Gulf Arab countries. We have the highest prevalence of hypertension and elevated cholesterol levels in all the Gulf region and we rank 5th for the global prevalence of diabetes behind Nauru, UAE, Saudi Arabia and Bahrain. Small-scale national studies report that only 2 – 5% of our population is physically active despite the fact that International Diabetes Federation tells us that up to 80% of type 2 diabetes is preventable by adopting a healthy diet and increasing physical activity.
Shall we go to bed… Doctor?
In 2001, a Pakistani woman was publicly gang-raped and later forced to walk the streets of her village unclothed, exposed to the rest of the villagers. This atrocity was perpetrated by individuals who claim to be faithful Muslims and who begin their sermons with the mention of God and the prophet Mohammad, PBUH. The first question that jumped to mind was how a group of people could approve of such a horrendous crime. You would assume that your social network would guide you back in track when deviating from a righteous path. However, the reality is that it is easier to commit an immoral act collectively where the responsibility is diluted in the masses and the appearance of diminished individual accountability often prevails.
Certain generalizations can be made from the analysis of our system. There seems to be a trend towards an ultraconservative approach to decision-making. Risk taking is discouraged and our policy-makers have adopted the “band-aid” technique to solve conflicts whereby essential rights are consistently being withdrawn when complaints are filed by both laypeople and uninformed politicians instead of engaging in educational campaigns. Dramatic examples include the withdrawal of the rights of emergency physicians to order important diagnostic tests such as CT scans or ultrasounds due to some past excesses and to unwarranted resistance exhibited by our more established radiologists. Paramedics, who in other nations perform life-saving procedures and provide critical medications, have seen their responsibilities downgraded following complaints by family members of transported patients. More recently, a new computer system introduced to a major teaching hospital to facilitate patient care was rapidly dismantled after components were stolen. This habit of bypassing core problems and placing a band-aid on a hemorrhaging wound is an example of passivism and poor judgment from the part of our leadership. The outcome is a system in failure due to repeated mistakes resulting from the lack of awareness.