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April 4, 2016

Implementing healthcare reform


April 4, 2016

It has been more than a year since the Khyber Pakhtunkhwa Medical Teaching Institutions (MTI) Act was passed. It might not be perfect but there is no denying that it is indeed a bold legislation seeking to overturn the prevalent tertiary healthcare administration dogma in KP.

The sense is that it was enacted upon direct intervention from Imran Khan, the PTI chairman. Already having established the best charity hospital in the country, perhaps he wants to showcase an improvement in healthcare as the Khyber Pakhtunkhwa government’s flagship project.

There have been attempts in the past at improving tertiary care hospitals. In the recent past, hospitals were given half-baked autonomy during the MMA’s government and then the ANP-PPP governments and institution management committees or IMCs were formed. These IMCs were analogous to the Board of Governors (BoG) of present day. Those previous attempts were probably well intentioned but failed, chiefly because the change was entrusted to the status quo itself! The political leadership either chose to stay ignorant or failed to realise that the world in the twenty-first century has moved far beyond what was sold to them as healthcare reform in Peshawar. The result was the further degradation of public services with each passing day.

Imran Khan to his credit, took a different route. He brought in an outsider with proven credentials. He appointed the chief architect of the administrative structure of Shaukat Khanum as his point man on healthcare. The bureaucracy and political leadership of the province were told to facilitate his work. The usual stalling methods of the health bureaucracy were overcome by direct access to the chief secretary, health minister and, most importantly, Imran Khan himself. The result has been the MTI Reform Act of 2015.

The dilemma of this country is the implementation of laws. A similar situation now faces the MTI Act. It is a good piece of legislation but, as they say, the proof of the pudding is in the eating. It will be worth nothing unless it delivers to its ultimate intended beneficiaries: the general public. Implementation, in the true sense, will really test its authors and backers. The legal challenges and other impediments created by the vested interests and their proxies have largely been overcome. Now, it is time to deliver and failure is not an option.

The BoGs formed under the MTI Act have thus far been working with good intent. The Lady Reading Hospital (LRH) board has been spearheading the effort and is the trendsetter for other hospitals. Rules have been framed, based on the pattern of hospitals in the developed world. An administrative structure, defining the responsibilities of various offices, has been proposed. Basically, the hospitals are to be run by a medical director, responsible for clinical affairs and a hospital director, responsible for general administration etc. Both positions are to report independently to the board. These positions are critical for implementing reform.

The appointments against these key posts is a milestone moment for the BoGs. There is no doubt that these appointments will either make or break the whole reform exercise. The success or failure of all the good work done until now hinges upon the capacity and vision of the teams to be installed. In our society, individuals do matter – at least in the initial stages, until the institutions take firm root and a system is established in the true sense of the word.

The obvious example is the BoGs themselves. They are different from the IMCs of yesteryears and have been effective thus far only because of a few dedicated individuals with a true desire for change, a vision and a capability of thinking outside the box. They have brought a newer perspective to this reform endeavour. If not for them, the BoGs would surely be yet another cosmetic affair,with neither the desire nor the capability for fundamental changes.

People with a fresh and modern perspective are important for these reforms to succeed. The Shaukat Khanum model succeeded in large part because a totally new team was brought in to run its affairs. It will be the people appointed to these position who will be implementing the policies framed by the boards in real time. Patient management, quality assurance, clinical protocols etc. will all be led by these teams. There is a genuine fear that the whole reform exercise will come to naught if the same tried and tested people are appointed to key posts. Finding the right people with fresh ideas is absolutely crucial. You cannot move forward with minds that are frozen in time.

It is imperative that the boards take a more proactive role in this whole recruitment exercise. They need to try to court and entice good candidates actively, rather than just using passive advertising. Taking a cue from Shaukat Khanum, road shows can be held abroad. Locally, people with fresher perspectives and enthusiasm should be encouraged. The younger lot needs to be encouraged for leadership roles and assured of full support. The search committees need to dig little more and think in terms of change. Experience with nothing else to show but the status quo should be counted as a definite negative. The whole exercise is directed at breaking the stagnant mould and the proponents of the status quo should be discouraged.

Too much is at stake for these reforms to fail. A good foundation has been laid. Competent, visionary teams should be installed to help build upon that foundation. The boards cannot be expected to micromanage the administration of hospitals on a day to day basis. They need accountable leadership teams to follow through. Change is the word du jour. Assuming the worst case scenario, the new teams might fail but that would still be far better than trying the proven failures yet again. As the saying goes, fool me once, shame on you; fool me twice, shame on me.

The writer is a former president of the Association of Pakistani Cardiologists of North America.


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