The problems identified by Parliamentary Secretary of Health, Mr. Joseph Hamilton a few weeks ago in relation to personnel and materials management are only symptoms of a system that was recognised to be in need of “major surgery” over a decade ago. Notwithstanding the now legally corporatized Georgetown Public Hospital Corporation (GPHC), essentially the old centralised system in which the Ministry of Health is responsible for setting goals, implementing them and then monitoring itself is still very much alive. This kind of incestuous relationship is no longer acceptable in modern public management, and demands for sector reform have been around for much over a decade.
In a 1997 review of the health system, Kenwyn H Nicholls identified the shortages of personnel, meagre regional allocations of finances, managers with neither the inclination nor the knowledge to manage scarce resources, divided loyalties of the Regional Executive Officers and Regional Health Officers and little or no coordination of sector policies between the Ministry and Regional Authorities as some of the constraints preventing the provision of quality health care. According to Nicholls, “a sustained process or policy of institutional development is what is required to improve the performance of Guyana’s public health services” (“Towards Integrated Health Systems Development” Ministry of Health).
The general purpose of health sector reform is usually to improve the quality of health care, to facilitate the more efficient use of health expenditure, to promote equity in both health conditions and access to health services, allow for the democratisation of the health system and of course to ensure its sustainable development. As a result, the reform process is a very complex one, including political, economic, cultural and managerial concerns. It must be designed to suit the specific extant national conditions and to meet new challenges that develop.
Though by no means the only concern, in many countries the main focus area in these types of reforms has been the reorganisation of management, services delivery and the financing of the health systems. A health sector reform project seeks to be comprehensive and tends to support decentralized and intersectoral collaboration. I spoke to some of this last week when I argued that although in such reforms the government retains overall responsibility for health it usually adopts an essentially steering rather than implementing role.
These changes also require social participation not only in implementation but in deciding resource allocation. The emphasis is usually upon equitable access to health care, with the various communities participating in designing basic packages of services based on prevailing epidemiological conditions and resource availability.
Importantly, the modern reform agenda also recognises that rarely, if ever, can public resources satisfy the need of a system that wishes to provide quality health care to the entire population and further, that public financing does not have to be linked to public provision. All other methods of financing – private, local communities, NGOs, diasporas, etc. – which take into consideration the social and economic realities of the country must be adopted with a view to sustaining an equitable health system.
In its treatment of hospitals, the reform agenda tends to emphasise the need to establish these institutions as autonomous service providers with a cost recovery capacity where possible. In relation to the Public Hospital Georgetown, Nicholls had this to say: “This issue of autonomy …at the PHG has been mooted for well over a decade; many past studies of the PHG have recommended this form of governance and management for the institution. … For all the reasons stated earlier in the document autonomy at the PHG is desirable … Simply appointing a Hospital Management Board will be no more successful than the current centralised arrangement in the absence of such an approach.”
Of course, even legal autonomy will be insufficient if de facto managerial control is still exercised by the ministry. To avoid this, what is required, not only in relation to the GPHC but in other places where such legally autonomous bodies may come to exist, are health service contracts between the service providers and the central ministry. These contracts should contain realistically defined and agreed upon development goals, stated as health indicators, against which the ministry and the public can judge how, if at all, such institutions are progressing.
Therefore, if a modern reform agenda is to be properly defined and led, the Ministry of Health must accept a monitoring role. In a nutshell, this requires that the ministry determine national policy and the method of financing the delivery of such services; analyse patterns of diseases and evaluate health programmes; plan and evaluate other national programmes (relating to water, housing, agriculture, etc); develop institutional and health norms and standards and ensure they are maintained; support and monitor the implementation of the various programmes and facilitate the procurement and allocation of adequate, human, financial, material and other resources for the sector. (“The Establishment of Regional Health Authorities in Guyana”, April, 1998, Scope and Issue Paper).
So to create a sensible reform agenda, the Ministry of Health should establish properly autonomous institutions with clear developmental goals at both national and regional levels and place itself in a sensible position to monitor and support such institutions. Maybe given our managerial culture it will be very difficult, but the Ministry will have to resist the propensity to become involved in the day to day management of such organisations if, for example, sector managers are to be properly held accountable for institutional outcomes. While it is clear that the central Ministry must be in a position to direct the sector in the event of unforeseen emergencies, the major element of sector management must be by way of clear policy guidelines.
My investigations tell me that the health sector reform agenda, particularly as it deals with systems management, has not changed much from what is was a decade ago. Human rights and people participation are today given more emphasis but the general drift of the agenda is still towards decentralisation, creative financing and the adoption of realistic benchmarks to allow for effective monitoring.
If our health sector is to provide quality care and severely mitigate the problems identified by the Parliamentary Secretary, he will need to dig much deeper. He will need to investigate where the system is in relation to the various suggested reforms, consider if such ideas are still relevant but at the end of the day present the public with an operational agenda that provides clear developmental indicators against which the system can be properly assessed.