Fixing our health care system is a lot like wrestling an octopus: two arms are squeezing you, two arms are trying to strangle you, and who knows what the other four arms are doing. And whenever you think you've made some headway, another arm reaches out, grabs you and pulls you back.
It is clear that we cannot solve our problems by attacking one aspect only. We need to employ a diverse set of strategies if we are to win this battle.
At the end of the day, we want an environment in which our people can be healthy, live long, happy and productive lives. Good health while a goal in itself, is also key to our national economic development. Healthy people have improved capacities and the ability to contribute to the building of society for a longer period. Unfortunately, sometimes it appears as though decision makers in the health sector fail to recognise the link between health and economic growth.
Our vision for the health sector should be one that is more people focused, responsive, caring, proactive, accessible, affordable, knowledge driven and technologically in keeping with current advances. Fundamental pillars of this vision are proper management and controls, capable and trained human resources and the efficient use of information and data for evidence-based decision making.
We do not believe that the problem of poor health care quality is the fault of isolated health professionals or is attributable solely to limited resources. Quality problems are generally systemic and are consequences of gaps in knowledge, training, supervision and incentives. And these issues persist if we do not have a system to consistently monitor the quality of health care and take the necessary remedial action. Currently, the system we have in place for formal quality assurance and medical audits is simply too limited, and should itself be reviewed for increased effectiveness. Stock and equipment deteriorates or is misappropriated, money is not spent in an efficient manner, spending is not prioritise based on need, medical practitioners are not obligated to keep abreast of advances in their field, public sector supervisors for various reasons, feel constrained in their ability to recruit or discipline staff and so on. It is necessary for us to set up an independent and properly comprised independent body with the responsibility to consistently monitor, measure and ensure delivery of quality health care. For example, while we commend the government's efforts in setting up CDAP, are we able to measure the success of the program and answer questions relating to its use of generic drugs which are not as effective as the real thing.
There are various policy interventions which can be made to improve quality. Some of these include the promotion of a health care culture that promotes evidence-based decision making. In other words, we should on the basis of research and data be able to identify priority areas for attention and ensure that appropriate, cost-effective responses are employed to address these areas.
If one must improve the attitude and behaviour of health care providers we may have to alter the structural conditions and/or financial incentives as apply to this sector. Performance based remuneration is one way to induce care providers to provide a better service.
We also need to set legal standards for care. Accreditation, periodic recertification of knowledge and competency, and administrative regulations can establish minimum standards by stringently controlling entry into practice and establishing conditions for license renewal. However, although these measures may bar unqualified persons from practicing they would not significantly impact the quality of care among those already in practice. Professional oversight, peer review and inspections are effective ways to get information about the quality of care. Of course, targeted education and professional training is probably the most direct way to affect the practice of medicine.
In its 2006 "Priorities in Health" Report the World Bank noted the effective use of organisational changes to improve the quality of health care including adopting modern management techniques like total quality management, collaborative improvement models, and plan-do-study-act cycles. It found that these programs resulted in increased coverage rates, better prescribing patterns and increased adherence to clinical guidelines. Undoubtedly, there are many tools used in private sector management relating to training, performance, incentives, monitoring and measurement which could be implemented within the health sector with positive outcomes.
Whatever we implement must also be able to reduce medical errors, many of which lead to unnecessary admissions, readmissions and deaths. To correct errors we need to understand them. National, published standards of care and frequent performance review of practitioners and hospitals can assist us in this endeavour. But we don't want to create a culture in which reporting an error leads to a law suit. Rather medical practice-reform must take precedence over medical malpractice reform.
There is as well an urgent need for the use of information technology in the health sector. We need IT. IT will help us to answer critical questions like: Are we sure that 90 per cent of our children under 5 have been given all recommended vaccines? What are the likely major causes of death over the next 10-20 years? What can we do to address these major causes? Where is the public sector expenditure going? What interventions are necessary against a particular disease? Are more cost effective methods available?
Beyond this, medical records are still largely kept on paper. Most prescriptions are still written on a pad. While a hospital private or public, may have functioning internal IT systems, it also has to be able to communicate externally, with other health care providers, with pharmacists and so on. We should get to the stage where we are e-prescribing so that drugs prescribed are legible, easily stored at the pharmacy and on the computers of other doctors involved in the patient's care. This is of course only part of the larger problem of making prescription drugs available and easy to access. While IT can be expensive, it pays returns almost immediately and saves us in the future.
Another key strategy for us has to be the promotion of good health from infancy onwards. It is said that "Osteoporosis is a pediatric disease with geriatric consequences". Don't drink your milk in your teens and you can wind up with fragile bones when you're older. The same is true of an unhealthy diet, smoking and being a couch potato. Time and money has to be spent on developing strategies for changing attitudes and behaviour. People generally need to reorient their thinking and accept responsibility for their health. Our population needs to change its mindset from one in which health is seen as the responsibility of health providers and not the individual's. Investment should be made in building this kind of awareness and in health promotion activities. Health should be refocused on the entire population and not only on sick people as is largely the case. This should involve not only individuals but the mobilisation of communities through their leaders.
Consumers today are also more knowledgeable and must demand transparency and openness from their health care providers. There is a common complaint that health care professionals do not share information with clients about their own health. Consumers must demand effective consultation. Government also has a role to play by empowering consumers with the information necessary to make valid choices on the basis of quality and price. For example, the Ministry of Health in Singapore publishes selected prices for certain procedures on its website which has led to dramatic price reductions for consumers. Once the government website starts publishing reliable and valid provider data on quality, safety and health outcomes in addition to prices, there will be a major shift in the balance of power resulting in a more stable equilibrium of provider accountability. Providers would be motivated to improve responsiveness to consumers, and consumers empowered to choose freely between providers, both public and private, on the basis of cost and quality.
While all of these strategies attacking certain arms of the octopus are laudable, other arms , like the financing arm, can really kill you. A key question surrounding any health system is how to raise revenue to pay for health care. Whether we rely on public sources (taxes and social insurance) or private sources like private insurance and out of pocket payments, funding has a profound impact on health care costs, quality and access.
With the notable exception of the US, all OECD countries have opted for publicly financed care systems which provide universal coverage, largely because these countries are driven by values leaning towards fairness, equity and solidarity.
The US relies heavily on the private sector to finance health care but in 2002, 15.8 per cent of its population or 42.4 million people had no health insurance of any form. This can hardly be considered equitable.
At the same time they are saddled with runaway health costs under which they continue to struggle.
The British in theory enjoy health care under the National Health Service but 10 per cent of their population purchase private insurance, with 1/5 of all elective surgery being performed in the private sector. Likewise, although New Zealanders may enjoy free health care, 1/3 of the population have private health insurance, with 1/4 of all surgery being performed in private hospitals. In Canada, where the single-tier health care system is mandated by law, increasing numbers are frustrated with the growing waiting lists for surgery and simply cross the border to the US to buy more responsive, private health care.
Where does this lead us? In recent years, the trend in both the developed and developing world has been towards greater private sector involvement in health care provision and financing. Very likely because of insufficient government resources and poor performance on the part of the public sector. There is growing realization that involving the private sector in health service provision could lead to improved systems efficiency. The debate is not only about "who should pay" but also "who can do a better job?"
As we search for working models across the globe, Singapore stands out as unique among developing countries in achieving high quality care and outcomes at low cost. Life Expectancy and infant mortality rates are about the best in the world while spending is around three per cent of GDP.
Singapore's, experience exemplifies an evolving public/private partnership in health care financing and provision. MK Lim in his persuasive works, tells us that in the 1980s, the government of Singapore, reexamined the role of the state in health care financing and provision and conclude that a British styled National Health Service was not a viable option. The Government decided that while it would continue to subsidise health care to bring prices down to an affordable level, the people would have to share in the cost of the services they consume.
Singapore's resulting "3M" system - Medisave, Medishield, and Medifund - was therefore premised on this concept of shared responsibility
In persuading its people to accept this position, the government reasoned that the question "who pays?" is not the right question because ultimately the people pay - whether it is by way of taxes, a portion of wages or insurance premiums.
The demand for health care has increased everywhere with corresponding increases in costs. Singapore's "3M" system of health care financing has proven very effective in mobilising financial resources. Medisave, its state-run medical savings accounts, compulsory for the working population, stood at a staggering $30 billion (Singapore dollars) in 2005, enough to underwrite the country's limited health care expenditure for the following five years.
Access to needed care is explicitly guaranteed for the poor and the state run
Medisheild insurance scheme protects individuals from financial ruin from catastrophic illness. The Government has also added Eldercare and Elderfund to take into account the long-term care needs of the elderly.In summary then, "Singapore's financial system combines universal savings accounts with supplementary programs to protect the poor and address potential market failures in health financing. The interplay of individual incentives, targeted subsidies, and other cost containers is an important factor in the success. The system differs significantly from national health insurance. Employees are required to contribute 6-8% of their salary to individual savings accounts. These accounts belong to the individual, accumulate over a lifetime, and can be used at the individual's discretion. To address the risk of catastrophic illness Singapore complements these accounts with catastrophic insurance. The government also provides targeted subsides for the poor, the elderly and the unemployed. Both the public and private sector provide health care in Singapore and patients can choose their provider at all levels of care." Overall the Singaporean system is therefore no less humane than a state-funded one.
Private sector participation in the provision of health care should be encouraged in our country within, of course, a well thought out regulatory and policy framework. As previously indicated, it is critical that any and all decisions must be based on evidence and research.
If we are to win the battle, we really have to tackle the whole octopus, and not just one or two of its arms. And the octopus isn't going to give up easily. The challenges we face in our health sector seem insurmountable but with the right will and courage to adopt innovative solutions and change, we can do it. Author John Gardner once said "We are all faced with a series of great opportunities brilliantly disguised as insoluble problems." So what appear to be impossible challenges in our health system are really opportunities for us to do the most important thing we can for everyone - to improve the quality of health and health care - for all generations.
