Transition Issues for Countries in Transition

1. Transition Issues for Countries in Transition And a lesson from Celtic Folk Legend“ A foben did bont” George Boulton Ivan Jekic

2. Introduction • Systemic and systematic development of primary health care should be a ‘no brainer’ for countries in transition in central and eastern Europe; • Weak economies struggle to provide a comprehensive health system to contain demand from escalating social, demographic and epidemiological pressures; • National health policies consistently ‘talk the talk’. Yet in many countries whole health system transition has been slow since the major social/political changes of the 1980’s and early 1990’s; • Common barriers to and weaknesses in health system transition strategies and potential solutions are discussed in the following slides: The Future of Primary Care Europe IV: Gothenburg

3. Policy & Power • Power remains in state or parastatal institutions using prescriptive laws, rules, regulations, norms and resource supply, despite commitment to decentralisation/devolution; • Prescriptive legislation is not conducive to a fast changing medical environment; • ‘Hierarchical’ professional power remains in the tertiary institutions. Some countries still lack chairs and departments of primary care medicine in medical schools and specialist training programmes; • Evidence-based policy and allocative efficiency (health promotion, prevention, health maintenance) does not produce politically ‘sexy’ solutions ); • Populations in transition countries have yet to exploit modern IT and communications to achieve wider knowledge dissemination and influence the balance of power in the professional/patient relationship. The Future of Primary Care Europe IV: Gothenburg

4. Financing Strategies • The financer/insurer role often limited to contribution collection and acting as a conduit for passing money around a health system; not a purchaser of ‘value’ from scarce resources and advocate for insuree health improvement interests; • There is a failure to use finance as a major strategic lever and tactical tool to achieve health policy goals, influence provider behaviours, stimulate innovation, and achieve continuously improving levels of efficiency, effectiveness, quality and safety; • Inflexible ‘old style’ subjective line item accounting systems, and structures do not provide the management accounting, costing, pricing performance management needs of a modern primary health care system; • Maintenance of a ‘free’ capital approach in public systems sustains an overly ‘institutional’ approach rather than a service-based approach and limits competition. The Future of Primary Care Europe IV: Gothenburg

5. Human Resource Development • Lack of appreciation of the role and cost of HRD in deep cultural change (PHC providers have no budget line for training and continuous development); • Strategic manpower planning is lacking to plan future modern health system needs, including strategic groups such as doctors and nurses; • Low status of primary care (the cornerstone of international health policy and health system development) and the low status of nurses and technical professions in primary care; • Ill designed (often civil service-based) and low level remuneration systems fail to stimulate individual and corporate performance and development. The Future of Primary Care Europe IV: Gothenburg

6. Organisational Development • The institutional legacy of the Semasko system is not conducive to service-based, patient-focused integrated care models; • Institutions remain highly compartmentalised and resistant to more efficient and effective integrated team-based, more efficient and effective health maintenance and health care delivery models; • Centralised, vertical solutions continue to be used for new preventive and other programmes rather than horizontally integrated, patient-focussed approaches, despite WHO advice on vertical programmes. • Lack of understanding of the concept of health organisations as ‘learning organisations’ in a fast changing health care environment; The Future of Primary Care Europe IV: Gothenburg

7. Planning & Knowledge Systems • Input-based and poorly integrated health system planning and financing systems are retained; little concern for output and outcome; • Approaches to decentralisation fail to exploit its benefits: ministries find it difficult to ‘let go’ and ‘performance manage’ rather than ‘micro manage’; • A lack of integration of basic data systems inhibits information production for operational planning and management and performance management; • Underdeveloped EBHC, EBMHTA, CIA, CEA, CBA, modern public health technical skills for evidence-based planning and financing; • Information systems initiatives all too often focus on IT, often ignoring the more important issues of information needs for clinical practice, service delivery, planning, management and performance management. The Future of Primary Care Europe IV: Gothenburg

8. Perverse Influences • Communities continue to value ‘old style’ health care above health promotion, prevention and personal responsibility; • Rigid and inflexible personal and organisational reimbursement methods fail to stimulate and reward efficiency, innovation, excellence etc; • Pharmaceutical industry impacts on physician behaviour in low wage economies (little interest in prevention and health promotion); • Corruption and manipulations linked to private practice and lack of sound legal, ethical, financial and management systems to regulate the public/private interface. • Evidence-based aspects of ‘allocative’ health system resourcing for population health status improvement take second place to dominant ‘sexier’ issues of secondary/tertiary care health care service development; The Future of Primary Care Europe IV: Gothenburg

9. Complexities of Major Social System Change • Lasting change in previously rigid centralised social systems is a complex multifactoral issue, needing sustained effort, not periodic and episodic interventional pinpricks and projects; • Lasting change means change to norms, values, ways of behaving at all levels: It is essential to align all facets of the transition equation to a common guiding vision and clear and common goals; • Many Ministries, and health organisations, often with donor support, focus on limited aspects of the change model; • There exists a self perpetuating legacy of bureaucratic, transactional and administrative management - transition needs transformational leadership. The Future of Primary Care Europe IV: Gothenburg

10. Leadership and Management Deficits • Absence of meritocracy – senior appointments often linked to political patronage rather than personal development, training and ability leading to a lack of strategic coherence and consistency; • A qualification ‘fixation’ determines fitness for a post rather than career pathway, experience, education, training , personal development and achievement record; • Chronic weaknesses exist in the ‘how to do’ aspects of management rather than the ‘what to do’ – yet many development initiatives focus on education rather than training, coaching and personal development; • There is a fear of, yet a need to create and manage ‘churn’, in order to transform and modernise major social systems such as health and primary care; • Many health systems in transition lack a critical mass of transformational leaders: trained leaders and managers lack career pathways and mobility; The Future of Primary Care Europe IV: Gothenburg

11. A Lesson from Celtic Folk Legend • Bran the ruler of Britain had a sister, Branwen. She married the King of Ireland and moved to live in Ireland. • Mistreated in marriage, Branwen trained a starling to carry a message of her unhappiness and mistreatment back to Britain. • Bran, a giant, like Orion from Greek mythology, set off for Ireland to rescue Branwen. The Irish king was so alarmed at the approach of Bran that he retreated and destroyed the bridge over the River Liffey to foil Bran’s rescue attempt. • The giant Bran lay across the river to enable his men to reach and rescue Branwen. In doing so he summarised the essential role of transformational leadership and transition: The Future of Primary Care Europe IV: Gothenburg

12. A Celtic Proverb “ A foben did bont” (The one who would be a leader must also be a bridge) Further enquiries or comments to: georgeboulton@yahoo.com jekiment@eunet.rs The Future of Primary Care Europe IV: Gothenburg

13. References • Implementing Health Financing Reform: Lessons from Countries in Transition; Ed. Kutzin J, Cashin C, Jakab M; WHO and European Observatory on Health Systems and Policies, 2010 • Working Together for Health: WHO report 2006 • Primary Health Care: Now More than Ever WHO Report 2008 • WHO Health Financing Policy: Health Financing Policy Paper 2008/1 • ‘Better Primary care is key to Improving Koreas Healthcare System’; OECD Reviews of Health Care Quality: Korea 2012 • Primary Care in the Drivers Seat?: Organisational Reform in European Primary Care; Ed. Saltman RB, Rico A, Boerma W; WHO and European Observatory on Health Systems and Policies, 2006 • Lawrence PR and Lorsch JW 1967 • Comparison of Transactional and Transformational Leadership; Covey S. 1992 • Rosabeth Moss Kanter: “When Giants Learn to Dance”. 1989 • Changing the Essence: The art of creating and Leading Fundamental Change in Organisations; Beckhard R, Pritchard W. The Future of Primary Care Europe IV: Gothenburg

14. At a Time of Economic Crisis a Message for Politicians from a Politician "...the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life; the sick, the needy and the handicapped. " ~ Hubert H. Humphrey The Future of Primary Care Europe IV: Gothenburg

15. “Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous.” Professor Sir Cyril Chantler; The Role and Education of Doctors in the Delivery of Health care, Lancet vol. 353 (1999) p. 1181 The Future of Primary Care Europe IV: Gothenburg