Kuwait Health Initiative
Promoting Equitable Health Sector Reform in Kuwait
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In keeping with the KHI’s principal objectives of identifying the most effective means of facilitating sound policy-making to improve equity and promote universal coverage, this page will be dedicated to providing our readership with the most accurate information related to health policy issues in Kuwait. Articles of interest written by KHI members and a list of suggested readings from renowned authors and scholars in the field can be viewed on this page.
Rare are those who have never complained of the heavy administrative load we are all subjected to in our respective ministries. Believe it or not, the current administration is based on an ancient system that was imported to put some order in a rather chaotic society. Unfortunately, little has changed since the days our forefathers discovered oil and, due to rapidly changing population dynamics, growing competition within the GCC nations, and the ever so demanding globalization, the benefits of a once innovative system have long faded away to be replaced by what is now a cumbersome burden.
Other sectors have understood this and, with profits in mind, have upgraded their systems and are flourishing. Health care, on the other hand, has lagged behind and continues to exasperate its fragile workforce. When focusing on the process by which medical doctors (physicians) progress within this system, we come to realize that the hierarchical process is vastly counterproductive and has promoted stagnation within the system leading to countless resignations including that of the few motivated employees. Many well-trained physicians who were seen returning to Kuwait with a passion for change and overflowing motivation were stripped of their enthusiasm after falling victim to this destructive and inflexible machinery.
In brief, the trained physician who graduates from, say, a North American program and who could easily take on a job as a specialist (board-certified physician; often referred to as a consultant in Kuwait) where he or she trained, returns to Kuwait to be demoted to a registrar or senior registrar level awaiting an often lengthy evaluation process by superiors who, at times, may be less qualified.
In an attempt to open people’s eyes to the options available to simplify our medical doctors’ promotion system, we have put together a scheme that allows for greater flexibility and encourages positive change. It uses the simplicity of the North American model whereby fewer levels exist and a clear-cut distinction is made between the trainee (i.e. physician-in-training) and the staff physician (i.e. board-certified physician).
Proposal for a simplified promotion scheme
Books & articles of interest:
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.
Reich MR. The politics of reforming health policies. Promot Educ 2002; 9: 138-42.
Reich MR. Reshaping the state from above, from within, from below: Implications for public health. Soc Sci Med 2002; 54: 1669-1675.
Richter J. Public-private partnerships for health: A trend with no alternatives? Development 2004; 47: 43-48.
Reich MR. Public-private partnerships for public health. Nat Med 2000; 6: 617-620.
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.
Neilson GL, Pasternak BA, Van Nuys KE. The passive-aggressive organization. Harvard Bus Rev 2005; 83: 82-92.
Transparency International. Global Corruption Report 2006.
Longva AN. Walls built on sand: Migration, exclusion, and society in Kuwait. Boulder, CO: Westview Press, 1997.
Meleis A. The health care system of Kuwait: The social paradoxes. Soc Sci Med 1979; 13: 743-749.
Hsiao WC. ‘Marketization’ – The illusory magic pill. Health Economics 1994; 3: 351-357.
Hsiao WC. Why is a systemic view of health financing necessary? Health Affairs 2007; 24: 950-961.
Coming soon:
Proposing initiatives to expedite health reform;
Creating institutions to help sustain our development;
and lots more…
Faisal Al-Terkait said
Dear Dr Nadeem
I read your simplified promotion scheme and I would like to make the following comments:
1) you ignored the diversity of doctors training in Kwuat, you have not proposed anything for Doctors who qualified in Europe, e.g. UK. or even Kuwait University. I know you graduated from Canada but also had your undergraduate training in Switzerland and surely North america is not the only recognised training in the world
2) what are you going to do with current doctors in kuwait?
3) I disagree with not counting years of experience, Dealing with patients is the only speciality where experience counts, However, I agree with you when you say consultant stopped training, I stand up against doctors who repeats years of one experience( i.e. He say I have 10 years experience where actually he have 10 years of repeating 1 year of experience because he stopped CME.
4) I need clarification if you don’t mind on why you call the proposed scheme a SIMPLIFIED ?
5) On the second paragraph there are contradiction e.g. “Responsibility is diluted within a very complex system; employees lose their focus and become too dependent
on their superiors” and what follows “he the consultant (i.e. head of a unit) distances him or herself from the day to day clinical work by delegating responsibilities to their senior registrars”!
they can’t become dependent when responsibilities are delegated!
6) “scientific publications” reflect the amount of research a unit does, but unfortunately in Kuwait it misused and abused, it does not reflect research in Kuwait because research is not allowed (at least in oncology), I believe scientific publication is crucial if you want to implement quality control to the units.
Finally I understand what you are proposing and I agree that the current situation is an old british system, but it is older than the british themselves, the system every where in the developed world advances but in Kuwait the story is still seen in “BLACK and WHITE pictures and every where else it is becoming 3D.
nadeem said
Fantastic! I’m finally getting some great feedback on this crucial topic. The only way we’ll be able to reform our system is through constructive debate and the critical analysis of the issues and solutions. Thanks for your spirited input Faisal.
The scheme I propose is more of a framework on which we, all the physicians of Kuwait, can build on and fine-tune. In my humble opinion, it represents a transitional hybrid between the current system in place and one that allows for more flexibility and innovation such as the Canadian or American model. Make no mistake, I hold the utmost respect for Kuwaiti, U.K. and other European-trained MDs as they undergo a similarly structured training process. What I propose is universal. If you have completed your postgraduate medical training and achieved board certification, then you should be granted a leadership role within your system.
By carefully reviewing the proposal, you will notice that all the medical doctors of Kuwait can fit into this model. The difference between a resident and house officer lies in their enrollment in a post-graduate training program. I agree that some of the older generation docs, including many of the expatriates, who have no formal training, will have a rough time accepting a title of house officer. This being said, what our authorities need to do is enforce rigorous training regulations and make sure that all MDs get trained after their intern year. Also, forcing all trained doctors to undergo regular CME certification and board recertification will guarantee higher standards of care across the board. The KIMS/MOH need to be more cautious when recruiting and accrediting foreign medical doctors as a significant percentage of the expatriate workforce comes from nations with either limited or substandard graduate medical education capabilities.
I am by no means dismissing the years of experience, which is a criterion included in the proposed scheme. What I am trying to relay is that we continue to place too much emphasis on this factor simply to protect our “territory” or individual benefits. Experience is important when placed in a certain context. For example, when you want to put together a study to test a hypothesis based on observations you have made during your career or, to some extent, provide an insight into a rare clinical entity. We all know of the mistakes that result from basing our practice on our past experience. Based on this experience, many docs practice a dangerous medicine (e.g. theophylline, pethidine, etc “work well in my patients”). We need to teach our colleagues to pay more attention to the evidence that exists. This includes encouraging them to regularly review the literature, participate in journal clubs, give presentations, and, more importantly, we need to grant them the freedom (i.e. time) away from clinical responsibilities to engage in such activities.
I agree that at first look this proposal may not seem that “simplified”. However, it highlights a very simple point: The importance of distinguishing the trainee from the staff physician and it does so by cutting out the unnecessary steps in between. To use a more familiar example that most of us will recognize, the Canadian graduate medical education system and clinical structure has taken the classic British system and improved it to do just that, avoid redundancy.
As a general rule and this can be applied to other sectors, the more levels you have, the less well defined are the responsibility assignments. Both our junior docs and consultants seem detached from the day to day care of patients. The clinical responsibilities are relegated to a nebulous middle layer of senior assistant registrars, registrars, and senior registrar. But these remain dependent on the almighty consultant for administrative and legal purposes as they more often than not do not have the freedom of engaging in departmental development plans. This certainly varies from one specialty to another but remains fairly consistent. On the other hand, the consultant’s clinical role has somewhat faded as many in the public sector do not take call nor do they necessarily perform comprehensive daily rounds on their patients.
As you correctly put it, scientific publications are indeed crucial for the development of our health care system. As you may have noticed from our previous posts on the site, we are all firm proponents of medical research. It is only through quality research that we will be able to better assess our needs and plan health care delivery. However, like experience, it should only be a component of the medical doctor’s evaluation process when assessing promotions. As you know, many clinicians are not interested in academic careers and that should be widely accepted. In the U.S., like in Canada and the U.K., trained docs choose between community, academic, and hybrid jobs. We cannot expect more from our own physicians than what is accepted in the more developed systems. But I agree that, when working in teaching/tertiary facilities, research is fundamental. To get back to my previous point, if we grant increased responsibilities and leadership roles to trained docs, they can be assigned individual tasks to promote areas like quality control, education, research, etc.
In conclusion, the purpose of the proposal is certainly not to make distinctions between the North American model and other systems but it is uniquely to expose the importance of keeping things simple. We all have a lot to learn from each other and from our own individual experiences. Together, we can enhance our health care system by taking the best of all worlds and establishing a more efficient scheme.
Once again, I’d like to thank you for adding a very thoughtful input to this nascent debate. I hope that my response appropriately addressed your concerns. I look forward to reading your future comments and those of our colleagues from around the world.
Ebaa said
Dear Nadeem and Faisal,
I am glad to see while the discussion was very spirited; the most amicable feelings were displayed on all sides. Well done!
Having had a chance to consider Nadeem preliminary proposal and its recommendations, I fully endorse both the spirit and the substance of his ascertainment of the problems that arose in relation to the recent problems at MOH. However I would join my colleague suggestion Dr Faisal in making the proposal more universal including our colleagues who are training in Kuwait and taking into account his valuable input. I disagree with leaving any trainee in Kuwait in untrained posts (house officer status I believe in Nadeem proposal), apologies if I misunderstood this stage. It is essential that all neophytes receive training whether they will join Kuwaiti Board or awaiting their placement in overseas boards. As with regards to expatriates who have not been under formal structural training we need to place them in the proposed system with the need to take some formal training similar to the IMG coming to UK, US or Canada, It would be great if you can both work together in putting more unified proposal taking into account all steps in hopes that these recommendations will be implemented in full, without any dilution or cherry picking!! Nadeem you would certainly need to modify your flowchart and beef it up.
In addition I want to draw your attention that in Kuwait they have 2 senior posts: specialist which is very different to consultant post.( Do not even ask me what is the difference!!)
Lastly although the current system in Kuwait has always been tagged to the old British System, I can confidently say that it has no resemblance to it at all. Yes they have taken some of the titles (Reg, senior Reg), but neither the promotions nor the hierarchy ladder holds any truth even to the old British system. Why officials in Kuwait are still adamant to stick to it, taking into account that the UK medical training has undergone many reforms over the years.
Modernisation has done wonders, though not for Medical Careers! The medical field is somewhat grumpy right now – seriously disillusioned with officials at MOH and unimpressed by the public services.
nadeem said
Ebaa, it is always good hearing from you. Thank you infinitely for your input.
Once again, the proposal was created to allow for criticism of our current system and trigger thoughts of novelty and change. There certainly is a long way to go before final recommendations can be made. Moreover, don’t you find it striking that the only efforts undertaken in this matter are by young “revolutionary” clinicians and not by experts in health sector administration, who ought to be hired for this task?
The document, along with my past comments, highlights the importance of incorporating our graduates into GME programs. It is simply essential. However, as you have stated, some are awaiting overseas positions which, today, for reasons already discussed, continue to be lacking. Until we are able to guarantee training positions in every specialty either in Kuwait or abroad, we are bound to assume the responsibility of this load of trainees who are trapped in a state of “clinical limbo”. It is this group that I suggest placing in an intermediate, transitory position of “house officer”.
I totally agree with the idea of enforcing proper licensing/training regulations for expatriates. Furthermore, if the KIMS/MOH is adamant about maintaining the Kuwaiti Board, which may or may not be the best idea (although a topic for another day, one can argue that standardizing training throughout the region would be a more appropriate step; some of our neighbors have already initiated efforts towards that objective), then licensing examinations like the USMLEs and acceptance of foreign nationals into Kuwait Board specialty programs to standardize practice is the way to go. The one major drawback to that is that, for years to come, we will continue to lack workforce limiting our ability to be selective. There is simply no easy solution to this. Clearly, the current processes are inadequate and create no incentives what so ever.
I also concur with the fact that the structure and processes of the British medical system have much changed over the years. The recent introduction of a novel medical training system, the Modernising Medical Careers (MMC), is an additional step towards a more well-defined process. Interestingly, an independent taskforce led by Prof. Sir John Tooke, recently assembled to investigate the failed introduction of the Medical Training Application Service (MTAS), published a rather striking report last month http://www.mmcinquiry.org.uk/MMC_FINAL_REPORT_REVD_4jan.pdf Their recommendations included abolishing the Foundation Year 2 (FY2) and incorporating it into the Core Specialty Training (a term used for graduate medical education), better defining the role of the individual physician within the system, allowing for the “interrupt[ion] [of] their training for one year or longer by agreement to seek alternative experience that enhances their career and contribution to the NHS…”, among other things. It sounds like they are moving towards a structure similar to that in place in Canada, for example. Interesting stuff.
This leads me to another interesting report published this month in The McKinsey Quarterly addressing management practices in NHS hospitals http://www.mckinseyquarterly.com/PDFDownload.aspx?L2=19&L3=69&ar=2101&srid=17 This study was a joint effort between the London School of Economics and the consulting firm McKinsey. It compares the practices of the public and private health care sector with private non-health care corporations and found that the public hospitals lagged behind the private sector in lean operations, performance management, and, more significantly so, in talent management scores. These parameters correlated well with cost-effectiveness, patient satisfaction, and rates of infection. They make the argument that hospitals should promote expertise in health care management within their physician workforce using the private sector as an example.
All this ties in well with the issues we covered previously about promoting leadership skills in our workforce and granting our trained doctors a greater degree of freedom to focus on areas of interest. As Amartya Sen puts it, freedom is both constitutive of development and instrumental to it.
With this, I wish you all a good one.
Raed Alroughani said
Salam all
Let me participate in this productive discussion. I have read the proposal several times to understand the basic reasons for its development. It clearly meant to advance our medical system towards the 21st century. I fully support many aspects of this proposal but at the same have few comments that may fall in Dr Faisal’s pocket.
1. Kuwait and UK physicians
I don’t think Kuwait & UK physicians are exempt from this proposal. Each one of them will fit nicely in a category. For example, MRCP-eligible physician would be appointed SR regardless whether she/he has her/his training in Kuwait or the UK. Once certified, then she/he would be automatically an attending. The problem lies in those who are already consultants and senior specialists who are not head of units or chairs in Kuwait, they would not agree to be downgraded to a new name “attending”.
2. Experience
I agree with Faisal in that experience does matter although you can argue that if this physician is very smart and got the certification in 3-4 years, she/he should not be compared to someone who spent 10 years to be certified. I can understand that. However, you can compare a smart guy who had his certification in 3 years and only seeing 10 patients a week with another smart physician who finished his certification in the same time but sees 50 patients per week. You have to award this smart and hard-working physician. Same applies for years of experience if both physicians are comparable in terms of their smartness and certifications. At least, when you first start implementing the scheme.
3. Publications.
Although, I tend to agree with the fact that those physicians who work hard to publish and spend their own time to explore a hypothesis should be awarded but at the same time I cannot place this as a condition for promotion or salary increment or a requirement for a chair position. This is simply due to the fact we do not have the infra-structure for research and ethics in Kuwait. You can not compare an academic person to a clinician. I am not here to list the difference since they are well known to us. Maybe, in the long term, encouraging physicians to be involved in research trials and publication would make a small cornerstone for promotion and heading some committee especially for the sub-specialties.
4. MOC/CME
I agree with you all that we have to enforce the MOC and CME aspects. I am not going to expand this issue.
5. Specialty & Family Practice
As you know, the world is moving toward a specialty and sub-specialty based systems. To be honest, i don’t like this idea because the most of the physicians will end up in a very small corner of knowledge about their sub-specialty and forget at least his/her big specialty aspect. For example, if you sub-specialize in Multiple Sclerosis and strictly isolated yourself seeing MS patients or those who are meant to MS-like patients, you will first forget most of the knowledge you acquire for the general neurology and most importantly the knowledge for general internal Medicine. How can i expect you to know the effect of for example of hypoglycemia on this patients at least neurologically if you have not seen or even went through the thinking process for a long time ? Why not trying to stay in general neurology for example while seeing MS patients on a regular basis since you like this sub-specialty and you can be productive but at least, you are still engaged in your major field and not missing important diagnoses that might be fatal.
This whole story leads me to add some points about the simplified proposal. We have to encourage physicians staying at the major fields such as Internal med, Surgery and not forcing them to specialize. Who will be covering your medical or surgical wards. We also need to encourage the family practice system since this is the first major defense system. The primary health care system in Kuwait is overwhelmingly defective. I do not want to propose systems for the hospitals and university staff while ignoring the family physicians.
Finally, sorry for this long email, although there are still few points to address but will keep them for another time.
Wish you all a good weekend.
Raed Alroughani
Vancouver
roni said
hi…
i think tou are a good writer
good luck