Our health care delivery at cross roads - Need for System Thinking or Status Quo ? (Post 3 / 2019)

Prologue: 

A previous blog post for January 2019 focused on policy formulation and its minimum processes that we need to follow to build a policy framework based on a robust evidence base. So, we will be able to translate peoples' health needs and demands into strategies, programs, and activities. Above all, the well-formulated policy paves forward clear direction. In this light of reasoning, let me reiterate here again "After decade long political struggle post-1992 popular movement, Nepalese people have suffered immensely such that we have lagged behind by several decades in socioeconomic scale when we compare ourselves in every metric with neighboring countries. All these upheavals brought so much unaccountable and unmeasurable social sufferings we can't measure and sometimes, it seems we fail to contemplate this aspect of our story. Despite all these hardships and sufferings, Nepalese people have compromised with all the changes wanting peace and prosperity so we are able to fulfill our basic necessity. With these aspirations harrassed by repeated political stalemates  - we have been able to proclaim our basic rights for peace, livelihood, dignity, education, health, food and justice through the new constitution of 2072 BC." While the blog post for February 2019 touched upon on evidence synthesis for health policy and system strengthening, which are commonly used terms these days in our business of global/public health delivery of which "Health Policy and System Research (HPSR) is a new term that is a tall order in the global health agenda. In the sea of this new field of system research, one of the approaches of a realist review is based on our sound understanding of the local context and its mechanism in the functioning of the health system with the influence of background socio-economic as well as political landscape. The mixture of which and its interplay results in consequences, which could be either positive or negative depending on how well we do our homework. In order to untangle the dynamics and its complexity, we need to simplify our understanding of the current health system and for that, we need to lay a solid foundation for the study of health policy and its implementation. We should also remind ourselves again and again that health policy and its implementation research is not an easy task and is said to be of complex nature, which needs perseverance and extraordinary patience to untangle its hidden components, context, and its mechanism." 

System thinking:

What is a system? is a primary question we need to understand first before we try to explore and share our opinion with regard to the "huge" field of health system strengthening. Simply, I understand "a system" like a motorcycle engine, which comprises of various parts working in a coordinated, well regulated and controlled manner such that it serves our purpose with the desired output, results or outcome with lasting impact in our personal or institutional life history". Also, we need to understand any system such as in mechanics or engineering, there is a lot of energy, imagination, perseverance, hard work, countless sleepless nights are spent in its design and testing. Only then, the engine functions like we want and needs lots of inputs in order for it to function satisfactorily. 

Usually, we are trained or habituated to think or look at a problem that we face from our own understanding or view or experience and many of times, we tend to fix or try to solve a part of, not the whole of the problem. As a result, we fail to understand the real issue that leads to the problem. Now on, we need to train ourselves to look at any problem or issue or challenges through system lens. For this, system thinking is "one of the popular tools for system analysis. Basically, system thinking is a way of helping a person to view systems from a broad perspective that includes seeing overall structures, patterns and cycles in systems, rather than seeing only specific events in the system."

As I have expressed enough about the changes within the health system as well as all other public-private sectors that we are dealing with, we are in fact 'in the best of time' to tackle those health delivery issues, which are directly related in the delivery of our basic rights stated in the Nepal Constitution 2072 BC. Yet, it seems we are drowning ourselves in the sea of problems daily with access, availability, equity, distribution, quality, safety issues. For example, there was a huge public debate in relation to quality health education (Mathema Final Report), which attracted the attention of the whole nation.

We all know, we have a long way to go in this journey of enjoying peace and prosperity through good health and wealth. For this to achieve, it is basics that relate to our daily living like health, education, water and sanitation, security and so, which we are struggling every day such that we are fighting even to breathe a clean air !! Forget, when are we going to receive quality care and services in the public service centers like Bir Hospital or District Transportation Office? Based on my recent visit to Bir Hospital, I felt we have work culture issues at large, not human resources or money issues, which we usually tend to point finger at.  

Health System:

Often I say to my colleagues, our governance system is like a universe among many other infinite universes. Within the universe of our state machinery, which we call the government, the Ministry of Health and Population (MoHP) is one among many galaxies so huge containing numerous systems of equal or unequal importance that are hard to dissect and simplify its complexities. However, we need to be careful that these complexities should not come in our way to understand its true nature. Instead, it would be our inability or complacency or incompetence not trying hard enough to understand the system as a whole. Take an example of traffic chaos of Kathmandu valley, there is so much chaos, disorders, noise, struggle, ruthlessness, indiscipline, insecurity and so on. Every day is like a war, we have to remain vigilant and cautious that we may lose track of our position, safety, and coolness. Look at how Japanese, Europeans, American, even Rwandan have been able to control and regulate the traffic system in their big cities. After all, this is a system understanding. In this respect,  if we imagine a well-functioning health system working in harmony, then it is built on "having trained and motivated health workers, a well - maintained infrastructure and reliable supply of medicines and technologies backed by adequate funding, strong health plans, and evidence-based policies" In more layman terms, Paul Farmer says that for a health system to function well, we need to ensure 4 S - staff, stuff, space, and its system must be taken care in its fullest capacity as well as capability. While in chaotic countries, where governance seems to be at loose, all these basic building blocks for a health system to function efficiently would seem a distant dream. So it is time for us to question ourselves, where we stand in these areas through health system strengthening (HSS).

Health System Strengthening (HSS):

Have been hearing in all global health forums and in Nepal as well, the talks on the importance of HSS in low-income countries. In addition, there is nowadays new terms such as North-South or South-South collaboration are invented and connected through capacity building, be it on the data management front, or health system research, or even social justice. All these changed narrative like those in the early 1990s or during the colonial period are not local in nature, while these initiative are data-driven through evidence synthesis, so our question to ourselves, "Are we able to enforce and work on an idea foreign (partly) to us, if we do not understand the dynamics or complexities of these engagements? or are we sure we understand what we are talking or direction we are heading towards?" In other words, if we run behind the ideology or principles which we do not own or understand well, we are not sure of its consequences in the long run. This is the word of caution not to fall blindly on anything that is alien to us or given to us. 

Our health system is in the phase of transition bringing about changes at the system level. Sometimes, the changes bring uncertainties. At this juncture, whatever or however hard we try to find the answer out of our current state of chaos or confusion, one element stands out in our conversation, "Why we are lagging behind in building or strengthening our health care delivery system?"  The answer could be poor governance, which can only be fixed with good governance "epitomized by predictable, open and enlightened policy-making, a bureaucracy imbued with a professional ethos acting in furtherance of the public good, the rule of law, transparent processes, and a strong civil society participating in public affairs. Poor governance (on the other hand) is characterized by arbitrary policymaking, unaccountable bureaucracies, unenforced or unjust legal systems, the abuse of executive power, a civil society unengaged in public life, and widespread corruption." Why poor governance is one vast area of study, debate or elaborations so I will not go into it now. While when we think and try getting an answer in terms of Principal-Agent framework of the functional structure of governance, then it is our (agents - political machinery as well as bureaucracy) duty to work hard and serve our citizens (principal) within and those living outside of Nepal. Once we understand this relationship in terms of our duty and responsibilities as our core value, then I feel we can straighten the tilted governance structure and function for public goods inherent in our constitution. Only then, anything that relates to HSS will also fare well in the positive direction aligned to the strategic framework of our government's mission and vision. Otherwise, if we continue into "clientele" mindset then we will continue in the same path of "only talking, no action" with no tangible outcome or impact into people's welfare.  

So, for us to fare well in the path of good governance and realize our dream, it is our duty to honestly understand "galactic" vastness of our health system and align our local context and peculiarities with globally accepted key principles in the social welfare sector. For this path to open up "strategic governance" with collaborative leadership is one of the answer so we can " manage to combine a clear vision of what they (political leadership) want the agency to do with the ability to communicate that vision effectively and to motivate the key civil servants to act on it" (page 213 Bureaucracy - James Q Wilson) Also, it is our leadership's duty to understand its (institution) workings, know its people and appreciate its constraints. In addition, our leadership should be bold enough to remove the vestiges of inefficiencies or chronic illnesses of bureaucratic nonsenses implanted within the system as malware. Very important but many of times, we tend to neglect from our part to understand the work culture that organization or institution is comfortable with. The culture could be seen as a lubricant that connects (integrate) or divides (disintegrate) a system of various elements supposed to be working together. It is high time, we also look into this aspect when we talk of HSS. Sometime, it could be this factor which is trouble source despite all resources pouring into the system. Obnoxious cultural traits that we tend to ignore many of time are slow poison with huge negative consequences. Once we understand and fix all variables in relation to leadership, governance, and its cultural linkage and roots, then all acts, policies, directives, strategies, operational plans and standards would have meaning and really deliver its required goals and objectives.

Other key topics that are always in the table for discussion and all experts are a huge fan of this agenda, which is a "health management information system (HMIS)" that needs integration, not fragmentation. I would call this information system as a nervous system of any system. Without a robust and smart HMIS, our system is paralyzed in a sense we will not be measuring what we have invested, what we have been doing and above all, what we have achieved in terms of service delivery. In a way,  HMIS is a radar for our system in order to know where we are going - in the right direction or chaos. Therefore, it is high time that we integrate all fragmented health information systems into one robust, dynamic and real-time data platform, from where we can monitor continuously every aspect of our health system. Imagine, if our leaders at MoHP can visualize real-time data in a central dashboard of all key indicators related to finance, human resources, logistics, as well as programs. After all, this is a direction we have to take at any cost, now or tomorrow. No room for an excuse is acceptable in the name of interest groups or conflict of interests. 

Crossroads:

In all these efforts of HSS, MoHP needs to be dynamic, vigilant and in tune with local as well as regional and global narratives in social welfare sectors, while we also need to be aware of the support from external development partners (EDP) but on our terms aligned with national interests and international commitments. Now more than ever, the Government of Nepal (GoN) is committed to fulfilling the SDG 2030 targets and achieving Universal Health Coverage (UHC). Of course, this is an uphill task given the resources constraints, we can achieve these goals only with good governance, discipline and hard work. On a final note, it is up to us whether we deliver and build a foundation for good health and welfare for our children through the system approach or status quo into chaos, neglect, and poverty for few more centuries. 

Hetauda

16 May 2019