A typical case of "rich inputs on poor strategies lead to poor outcomes"

Health System Enhancement Project :

By Dr. K. M. Wasantha Bandara-March 5, 2020, 8:26 pm

Recently the Cabinet of Ministers have approved a cabinet paper requesting approval for rewarding a contract for monitoring and evaluation of Health System Enhancement Project (HSEP) to a private consultancy firm, Sri Lanka Business Development Centre. The contract which is valued at Rs. 94 million is less than 1% of the overall project cost of USD 60 million, out of which USD 50 million is funded by Asian Development Bank (ADB) and USD 10 million by the government of Sri Lanka. Although the cost of consultancy is comparatively low, there is a doubt as to whether hiring of a private firm for that purpose is warranted, especially because the Ministry of Health is named as executing agency and the implementing agencies are provincial health departments in the project area.

Anyway, there is no doubt that hiring a third party or a private firm as a consultant is a condition enforced by the funder, the ADB. Generally, a third party consultant is suitable if there are clearly measurable and tangible objectives to be achieved within the project implementation period which in this case is five years. However, one can argue that although it is named as a system improvement or enhancement project, what is really done is provision of vehicles (9 trucks, 44 double cabs and 9 vans) and medical equipment to laboratories, dental clinics etc; and upgrading of Physical facilities of healthcare proving institutions. As such, there seems to be a contradiction between the strategic objectives and the activities.

In the Project Proposal of HSEP the objectives of the project are not explicitly identified or underlined, but vaguely mentioned in the introductory narrations. According to those texts the project is meant for improving the efficiency, equity and responsiveness of the Primary Health Care System. Achievement of those broader objectives is to be measured by quantified inputs as mentioned above in selected four provinces. Since the project is aiming at the overall improvement of the system, it is obvious that the interventions, improvements or modifications must be done wholistically within the system and not in selected few provinces. That can only be justified to some extent only if it is named or identified as a pilot project. Also, the project proposal emphasizes the efficiency of System but strangely there is no mentioning of enhancing the effectiveness of the system.

However, the specific objectives found in the narrations are meant for enhancement of the effectiveness of the system and strategies to achieve them cannot be implemented without a systematic approach covering the whole system. Especially the objective of effective integration of preventive and curative care, which is a fundamental requirement within a system and involves fundamental policy alternatives applicable wholistically in the system. Then, the second objective, the continuity of care which is guaranteed only when there is well defined referral system and a general medical practice is established as the patients’ entry point to the system, irrespective of whether the practitioner is in the government or private sector.

In the Project Proposal it is mentioned that at the end of the project implementation period, the impact of the reforms must be evaluated. For that purpose, a baseline survey is also to be done initially to compare the final achievements with what was at the beginning. But there are no clear and measurable indicators of achievement identified in the proposal. As such there is no way to reliably measure the performance of the system by the consultancy firm in relation to interventions done within the project implementation period. As far as the broader objective of equity in the system, especially the financial access to the services is concerned, our system is considered to be one of the best in the world, although there is a degree of rationing or waiting lists in the delivery system. However, the equity in terms of geographical access is compromised to some extent due to lack of a proper referral system for secondary care.

The objective of reducing the bypass of the primary health care facilities or minimizing the underutilization of those institutions is very critical, not only in terms of efficiency of the system but also in terms of the effectiveness of the system as a whole. As such, that objective also cannot be achieved in isolation in a limited geographical area identified by the project. And as mentioned above, in order to introduce a proper referral system and systematically integrate preventive and curative care, there must be a "systems approach" and it cannot be achieved in isolation in a particular project area.

It is understandable that the most of the foreign funded projects are forced upon nations to spend the money irrespective of what are the real needs and the gaps in the systems. Yet, there is no doubt that our health care delivery system is one of the best in the world in terms of equity and cost effectiveness. However, there is a need for improvements in the delivery process and in the administrative procedures which are more important than the transport facilitates or equipment or upgrading physical resources and buildings envisage by the project proposal. Anyway, provision of equipment or physical inputs can be measured, monitored and evaluated by a private company irrespective of what are the strategic outcomes in terms of improvements in the system.

As such input based approach to improvements in selected geographical areas may hardly have any impact on the effectiveness of the system as a whole in terms of three main specific objectives identified in the project. In a situation where government of Sri Lanka or the public is investing USD 47.5 million we all have an obligation to make sure the project is not derailed by the so-called USD 12.5 million grant. Therefore, this writer would like to plead the top officers in the ministry of health and the new minister of health to amend and specify the overall objectives and strategies of the project.

If that plead is heard the first thing they should do is to bridge the strategic gap between the objectives and the activities and also to identify the indicators of achievement in terms of effectiveness of the overall system. In that exercise there are three main aspects to be emphasized. First one is to introduce well defined referral system covering the whole system. That is the most essential precondition to guarantee the continuity of care, equitable geographical access to care and cost effectiveness of the delivery process, which are all ultimately dependent on efficient and effective integration of primary and secondary care.

The concept of continuity of care will be meaningful only if legible record keeping and prescribing is guaranteed by way of introducing universal record keeping formats across the system where using universal codes and compulsory legible writing, i.e. use of block letters or printing especially when drugs that are prescribed, are considered as essential aspects. In certain countries, although Sri Lanka has not done being in the top in terms of systems characteristics, have legally enforced the legible writing in issuing prescriptions and reconciliation of drug discrepancies that take place when patients are referred back and forth for specialist care.

The second strategic intervention is to establish general medical practice which is the entry point to the system and as mentioned above can be established using both government and private outpatient care providers where general practitioner of patients’ choice can be selected. So the general practitioner will be responsible to maintain the continuity of care at the PHC (Primary Health Care) level and guarantee systematic referral for secondary care.

As such, as mentioned above introducing a proper referral system and establishment of a general medical practice are considered to be preconditions to guarantee the provision of equitable and cost effective secondary and tertiary care and also the continuity of the care. However, all that approaches will be meaningful only if the referral system is legally enforced and administratively guided and monitored, a situation where a specialist cannot be consulted by a patient without being referred by a general practitioner.

Third one is to maintain clinical excellence at all levels of care from primary level to tertiary level which is guaranteed by maintenance of service delivery standards and high standard of professional conduct of all categories of healthcare providing man power. However, the guarantee of high level of ethical and technical standards among medical professionals must be the key to all other aspects of improvements in the healthcare delivery systems. As such, introduction of specialist register, recognition of part specialties and specialized training of grade medical officers will be priorities in terms of guaranteeing clinical excellence in the healthcare delivery system. It is a waste of public funds and the system capability if a medical officer who has reasonable experience in a particular specialization is indiscriminately used for other duties in the system. All those deficiencies will not be rectified just because an electronic patients record system or a data burial ground is created using overseas funding even if it is not meant to be repaid.

(The writer is a Dental Surgeon who holds post-graduate qualifications in three different fields in management, namely Financial Management, Health Systems Management and Quality Management. He is a certified Quality Manager specialized in healthcare)