GHF2006 – PL04 – A Critical View on the Role of Hospitals in Increasing Access to Health

Session outline

Plenary session, PL04, Thursday, August 31 2006, 18:00-19:30
Chair(s): Peter Saladin, Switzerland, Elisabeth Leforestier, France
Hospitals Promoting Access to Healthcare
Gillian Morgan, The NHS Confederation, London, United Kingdom 
Adeleke Olusegun Pitan, Honourable Commissioner for Education, Lagos State Ministry of Education, Lagos, Nigeria 
Redesigning Hospital Care to Meet the Needs of the Community
Wim Schellekens, Centre for Innovation and Development, Dutch Inspectorate, Leiderdorp, The Netherlands
Optimizing Hospitals in the Health Sector
Saleh Meky, Minister of Health, Eritrea 

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Session report

Submitted by: Irene Amodei (ICVolunteers); Contributors: Melissa Bonnefin (ICVolunteers)

"Brain drain in health systems is a political issue". Image: Viola Krebs, ICVolunteers.org

Hospitals have always played a pivotal role in the global healthcare system. They have power, authority and professional competences in both the rich and poor worlds. But what if we all begin to re-think the mission of hospital care and re-design the way we deliver it in order to increase access to health? The moment has arrived for reform in order to achieve optimal care, to learn from examples of real innovation and disseminate this knowledge, sharing ideas as well as best practices.

Mr. Adeleke Pitan, Honourable Commissioner for Education in Lagos' State Ministry of health from 1999 to 2006, began the plenary session with a detailed overview of the state of the health care delivery system in Nigeria and urban Africa. "Access to health has always been, and still remains, a problem in many urban areas" stated the former Minister, "due to uneven distribution of hospitals, inadequate health personnel, limited financial resources and weak motivation of the workforce". He then narrowed his focus criticizing the current inadequate knowledge and health education of the population (estimated at 150 million people) who still prefer alternative medicine practitioners. About 75% of Nigerian government hospitals are in urban areas and 25% in rural ones and on average 2.2 million patients are treated each year. The need to increase access to health has pushed the government to develop 'packages' to attract the elderly and most vulnerable groups; to introduce a number of free health services including free anti-natal care, free medical treatment for children aged between 0 and 12 years and for people over the age of 60. The Health Sector Reform programme also included free heart surgery for patients with heart defects, free eye treatment including surgery for cataracts and glaucoma and free breast cancer screening. Mr. Pitan described the opportunities that the reform offered such as Public-Private Partnership initiatives (PPP's),  the B-O-T system (build, operate and transfer), transfer of technology, training and re-training of health personnel. While the reform process has helped to assist the most vulnerable part of the population, trying to bring health to the doorstep of all citizens continues to be a major problem due to the small number of hospitals, shortage of specialist manpower, the lack of equipment and under-funding of the health care system.

'Reform' was also the key word of the presentation by the Minister of Health in Eritrea, Mr. Saleh Meky, who explained in detail the series of strategies adopted nationally in order to increase the cost-effectiveness of the health system and of its delivery services. "Change means new ways of thinking and acting", stated Mr. Meky, "and must be managed to ensure the result is a real improvement. Moreover, the quality of clinical services must not suffer during periods of rapid change". As a result of the concerted efforts made in Eritrea to build new health facilities and give them the necessary equipment and skilled health personnel, access to primary health care within 10 km from the health structures increased in the last years to around 70%. A good deal, given that 50% of the population lives within an area of 5 km.

Mr. Meky illustrated the main goals of the national reform, namely:

  • To ensure the equitable distribution of health services to rural and urban areas;
  • To strengthen Primary Health Care especially in remote and inaccessible areas;
  • Actively to promote the dissemination of accurate information on health practices;
  • To use a strong evidence-based decision-making process.

According to Mr. Meky, the basic principles of any health system reform are the improvement of management (namely the Health Management Information System, HR management, quality and financial management) and the decentralization of functions "to that level where optimum value can be attained". A country in transformation, like Eritrea, has to deal with additional challenges, for example the urgent need to control both tropical (historical) and 'rich-countries' (new to Eritrea) diseases. For that reason, the decentralization process is often not easily manageable. As a solution Mr. Meky introduced the concept of "hospital autonomy", an alternative method of organizing and financing health care services. Hospital autonomy could also be seen as an effective merge of the best elements of the public and private sectors; a kind of parastatal hospital that works in a private way from the point of view of finance and bureaucratic reduction, which when properly implemented, enhances effectiveness and efficiency.

Mr. Meky ended his presentation by stressing the need for stronger community involvement as the only way to overcome the always present danger of brain drain. "Brain drain in health systems is a political issue" stated the Minister. "If we want to have some chance to stop it we must provide a comfortable ecological and financial environment, to train as many people as possible, to appeal to people's nationalism and, most importantly, to make people think that they really are the owners of their hospitals".

Mr. Wim Schellekens, CEO of the Center for Innovation and Development in The Netherlands, offered the plenary a mostly self-critical 'first-world' point of view. "How effective and safe is hospital care?" questioned Mr. Schellekens, "How to do a better job?".

Despite the progress of medical science, we still see a huge amount of errors in the way we deliver care (overuse, under use or misuse of drugs), in the way we organize care (coordination problems and delays) and in the way we take care (absence of transparency, empathy and patient-involvement). In the USA, there are 44,000 to 98,000 deaths in hospitals each year (8th-3rd cause of death) and there is no correlation between cost and mortality. Care for patients should be safe, effective, patient-centred, timely and efficient, with equity for all. Patients, of course, do not expect needless deaths, needless pain, unwanted waits and helplessness. In short, quality is the big issue. To support his claims Mr. Schellekens described the successful IHI Boston experience in 2004, which, with six simple interventions (like the creation of a Rapid Response Team), resulted in 122,300 lives saved in the 3,000 hospitals involved. The key to success is to have vision, a strategy and leadership ("First study, then act; first plan then do!"). The theory affirms that when we have convinced 20% of our target, the rest will automatically follow. In The Netherlands the "Better Faster" programme, that aimed to get breakthrough results in 20 % of Dutch hospitals in four years, succeeded by acting at four levels of intervention: system level, institutional level, level of care-process and patient level. According to Mr. Schellekens the mission of hospitals has shifted from "delivering specialized care to our patients" to "responsibility for the care in our region" to "promote health to all our citizens".

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