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| Sunday, 23 November 2003 |
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Features |  |
| News Business Features Editorial
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Towards a better-managed health service Excerpts of Sri Lanka Medical Association E. M. Wijerama Endowment Lecture 2003 delivered by Dr. Lucian Jayasuriya at SLMA auditorium on Friday, November 14. I am aware that a document called 'The strategic framework for health development in Sri Lanka from 2004 to 2015' has been developed. It was a combined product of two exercises by the Japan International Cooperation Agency (JAICA) and the World Bank. I did not have the opportunity to participate in any of the discussions that led to its production. However, when the first draft of the World Bank document was available, I sent my comments. In general it is a good document, but it has some shortcomings. What I plan to do is to highlight some of the issues discussed in this document and some issues that are not discussed at all. Today, Sri Lanka has a health system dominated by "western medicine." Socio-economic Surveys of the Central Bank have shown that the dependence of the population on western medicine is growing, (an increase from 80% in 1986/87 to 86% in 1996/97). The government sector dominates the health system with facilities spread all over the country. It is estimated that about 95% of indoor care and about 50% of the outdoor care is by the government health sector. In terms of expenditure on drugs, it is estimated that about equal amounts are spent in the government sector and the private sector. The expenditure in the private sector includes drugs purchased on chits from the government sector. The funding of the health sector has been poor for a long period even by developing country standards. The percentage of the GDP spent on health in Sri Lanka is estimated to be about 3.5%. About half of this is spent by The government. The expenditure on health is about US$30 per person. The structure of the government health sector that we have today is what came about with the decentralisation of the health service in 1954. The country was divided into health regions in charge of Superintendents of Health Services who were in overall charge of the health service of their areas. The Provincial Councils Act of 1988 has messed-up the health service of Sri Lanka. Provincial Ministries of Health came into being with a Minister and a Secretary of Health who are laymen. The Provincial Director of Health Services had to take orders from two people above. Though theoretically the Provincial Director of Health Services appears to be more powerful, in fact he is less powerful than a Superintendent of Health Services of the past. Sri Lanka has done well when we view the traditional health indices. Sri Lanka's social indicators are impressive for a low-income country. This is a contribution not only of the free health services but also of many factors including universal free education especially the education of women. I would like to now highlight some of the problems of our health service today. While discussing them I would like to suggest how we can improve the management of the health service. Strikes Strikes are the crucial problem faced by the government health sector. They are the bane of the health service today and have been so for some time in the past. I am sure that we will be in Guiness Book of Records if we apply for it. From my personal point-of-view, I do not condone strikes. I did not become a doctor to harm people either by commission or omission. However much some may say that strikes in the health service could be organised in such a way that they do not cause deaths of people, I do not believe in it. Maintaining ICUs and carrying on emergency surgery during strikes does not absolve us from the guilt of causing deaths by exacerbating conditions that could have been treated earlier. We must also remember that we as doctors have not only to cure but also to comfort and care. We could speak of the right to strike, what about the right to medical treatment and health of the public? This has to be balanced. I request all of you in government health service today to go deep into your consciences and decide whether it is right to strike. Of course we can reply that unless we strike nothing happens. Our demands are not granted. There is some truth in this. The ministry has come to a state that after few days of strike demands will be granted whether they are right or wrong. In this context, I must refer to the proposal that has been there for the past 3 years. The proposal originated from a leader of the GMOA. Dr. Ananda Samarasekera proposed that there should be a method of voluntary arbitration on trade-union matters. This proposal came with the concurrence of all government health sector trade unions. The SLMA has consistently agitated for implementation of this proposal. The present Minister of Health is the 3rd minister to whom we have made this proposal. He has accepted it in principle. However, the apathy with which it is being pursued cannot be explained. While strikes are the main problem in the health service, when a possible solution is proposed, it is not grabbed eagerly. Progress is at a snails pace. Three years have gone by, how many have died during these 3 years? Recently I have seen that the Minister of Public Administration plans to establish an Independent Arbitration Commission for the government service This is a good move. However, I am of the opinion that the health service needs a separate Arbitration Board. Something more, about strikes. It is we, the doctors who started what is called 'work to rule.' It is we who started the ridiculous thing called 'sick notes.' Sick notes en-mass is nothing but a strike. I can remember when I was in the Ministry of Health in 1996, with my encouragement, the Minister of Health, Hon A. H. M. Fowzie, sent a Cabinet Paper to say that sick notes en-mass should be considered a strike. I remember the Minister of Public Administration agreeing. The President as the Minister of Finance also agreed. However, when it came to cabinet, a committee of ministers was appointed to look into it. I can tell you that the committee never sat. This is an example not only of poor governance, but of avoidance of governance in our country. To complete my discourse on strikes, I may remind every government doctor that they do not have to work in the government health service. If they are unhappy with the terms and conditions of service, and if they cannot get them rectified, it is possible to leave. I think that it is the ethical thing to do rather than strike. I would even go to the extent of proposing that the government bans strikes in the health sector. I am sure that the major opposition parties would agree. Of course to compensate, the government should have an established conflict resolution mechanism as discussed earlier. Indiscipline Indiscipline is becoming worse; many health care workers come late for work. Some do private practice during working hours. Very little is done about it. The numbers of people who break the rule are increasing. The honest workers wonder why they should do a job of work. They gradually join the shirkers. The management of the health service has failed to curb indiscipline. We hear of officials form the ministry going to far away places to trap government doctors doing private practice during working hours, while some doctors in the cities are doing the same thing in the private hospitals. The people who get caught get away with minor punishment. Deterrent punishment is necessary to prevent further spread of this malady. In this context it is necessary for the government to consider phased withdrawal of the state sector personnel from the private sector. This has been recommended by the Presidential Task Force on Health Policy Implementation appointed in 1997, and again by the Committee Appointed by the Cabinet to make Recommendations on the Employment of Medical Graduates in 1999. Employees of the government health service have no agreement with the employer. The duties and responsibilities are written in outdated manuals and circulars. The employee does not sign a comprehensive document giving his duties and responsibilities. Every category of health worker and every post should have a job description. Centralisation of Power Power has got more and more centralised in the Ministry of Health. The delegation of power that was implemented in early 1980s, has been withdrawn by the Ministry. When I was Director of General Hospital Colombo during 1982-1984, I had power to appoint labourers, promote labourers to watchers, attendants, overseers etc. This power was taken away in the early 1990s. This remains so, even now. Today even when a casual labourer is to be made permanent his personal file has to be sent to the ministry. The institution has no role in promotions. The Director of the institution is only by name. He is powerless. There are endless delays in the ministry. What I am saying is that the ministry is micro-managing the institutions: The head of an institution has very little power over his staff or over finances. Initially what the ministry has to do is to give back the power that the large health institutions had in the early 1980's. Later, all teaching hospitals should be decentralised with large amount of power with the director. Problems between central and provincial health ministries The strategy document states thus "one major issue is the confusion and attendant conflict over the roles, responsibilities and lines of accountability between central and provincial levels of the Ministry of Health consequent to devolution." This is in 2003 - 14 years after devolution. Why can't we resolve these issues? This is because we are not really interested in resolving them. Provincial councils were foisted on us in 1989. Now, however even though they are found to be white elephants they have come to stay, mainly because they benefit politicians. Both the government and the opposition will continue with them. Today the Provincial Councils virtually control only primary and secondary care. For example, in the Southern Province, the Provincial Director has no control or role in the two teaching hospitals in Galle and in the Matara Hospital. Why do the provinces hand over their big hospitals to the centre? When the centre wants, most of provinces hand them over because they are under-funded. Their financial allocations virtually allow them only to pay staff salaries. There is very little left after that. If we are going to have a system of provincial health services, they have to be properly funded. All health institutions, including teaching hospitals, (except special hospitals), in each province should be handed over to them. This will make them responsible for the health of their area. It will reduce much work from the Ministry of Health. Management of Health Institutions The larger medical institutions such as the teaching and provincial hospitals are managed by full time medical managers who have opted for management as a career. A study by the Institute of Policy Studies showed that the management of small medical institutions was poor. The officers managing these institutions are junior and untrained. The time has come for us to have a medical management service where medical managers start at the level of the smallest hospitals and rise up the ladder. However, we must recognise that many doctors are reluctant to join medical management because they lose their right to engage in private practice. The compensation is only Rs. 3000 per month. This allowance has to be substantially increased and facilities such as official vehicles and quarters have to be provided to attract doctors to medical management. Till this is done, those who manage small institutions should be regularly trained and supervised. Referral System We have been speaking of a referral system for decades. We recognise that a good referral system will save resources of both patients and the country. However, we have to recognise the constraints against a referral system. They are: . The lack of a system of general practitioners funded by the government. . Facility of private practice by government medical officers. At present a person can see a consultant privately and either get admitted to a government hospital or be referred to a clinic. . Lack of standardisation of facilities in out-patient departments (OPDs). At present the investigations and drugs available at the large hospital OPDs is of a wider range than in the case of the smaller hospitals. People know it and they by-pass the smaller hospitals. As long as it is possible to be admitted to a government hospital or a clinic through private practice of government doctors and as long as there is no equity in the facilities in the OPDs we cannot and should not force a referral system on our people. We have no moral right to do so. My proposal is that all OPDs have the same facilities. It will be necessary to upgrade facilities in some and downgrade facilities in others. Once this happens people will stop by-passing the smaller institutions. Wastage Waste goes on. There is no system to check waste. There is waste in overstaffing. There is no control of usage of water and electricity. There is wastage of drugs There is pilferage but there is also wastage due to poor storage. Drug stores are the last in the priority list of hospital buildings. Any dilapidated room is considered good enough to store drugs. It must be remembered that a large number of drugs have to be stored at an ambient temperature of 25 degrees C. Our drug stores are much warmer. The efficacy and the quality of drugs get compromised. The shelf life becomes shorter. Drugs cannot be stored in a systematic manner in congested rooms. We need a system of planned drug stores in all medical institutions. We could save a lot of money both in terms of efficacy of drugs and in usage before expiry date. The money invested could be retrieved very soon. Human resources The university system expanded medical education. Today we take about 900 medical students per year to our 6 medical schools. However, the training of all other staff for the health sector has remained with the Ministry of Health. The numbers trained have not kept pace with the needs even of the government sector. However, some effort has been made recently to increase the number of trainees in nursing. I have been one of persons who has been consistently saying that we should not expand medical education. I said this in my presidential address of the SLMA in 1995. I said that at that time when the government had decided to open a faculty of medicine in Batticaloa and was proposing one in Anuradhapura. At that time I said: "We are now on the threshold of an excess of doctors. It is not an excess when we consider doctor population ratios; but is an excess of doctors in that the government would find it difficult to absorb them into the health service." I said that "it is also important to realise that the person to doctor ratios have no direct relationship to standards of health care, vital statistics or human development." The shift system was started, but not properly supervised. It collapsed. The ministry without trying to manage the system took the path of least resistance and abolished the shift system. Today it is recognised by many that we have an excess of doctors at least in some health institutions. What we need is an optimum number of doctors with an acceptable work ethic. Every unnecessary doctor is a waste of resources. Extra doctors do not necessarily improve the service. On the other hand it may lead to a deterioration of the services. Some will do their duty. Others will piggy back on them. I am aware that a venues of employment for doctors are now open again in the United Kingdom (UK). Even then the problem of excess of doctors would remain if the government continues to absorb all doctors for the next 6 years. To be Continued |
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