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Op-ed: the KTH mishap; do we need a new set of hospital reforms?

The December 6th unfortunate incident at Khyber Teaching hospital (KTH) - which was very much avoidable and unnecessary, is a big eye-opener for the reform's protagonist for doing more?

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Healthcare reform involves orchestrating a policy change, mediated through governance, management, and financial interventions. The aim is to improve the ways in which health care is better delivered to patients.

Any successful health reforms process is underpinned by some key principles, 1st is the best interest of the patients, 2nd The ‘acorn-to-oak tree’ principle (introspection and deep system analysis); the 3rd is the data-to-information-to-decision making pathway, and the 4th one the ‘many-hands’ principle (stakeholders coordination).

It seems simple; however, reform is not linear, but rich in complexity. It presents many challenges to its proponents. Nobel-prizewinning psychologist, Daniel Kahneman said, “Reforms always create winners and losers … and the losers will always fight harder than the winners.”

It’s not the responsibility of one or few but everyone associated in any way to play his/ her part in reforming our systems for the betterment of Pakistan.

Change is often painfully slow

Complex systems exhibit various forms of inertia and their progress with change is often painfully slow. Sometimes change is impossible to predict accurately, or at all. Whether reformers are trying to enact minor tweaks or major transformations, they invariably need technical support, expert input, and cooperation between parties to realize the envisaged change.

Every change involves politics, cultural shifts, the mobilization of power and resources reallocations. Explaining whether or to which extent a reform initiative has been successful is dependent on the end results.

Health care reforms are one key component of the ruling PTI manifesto, and this effort was initiated back in 2013 when PTI took over the KP government. The focus of the reforms was enacting institutional and structural changes in the system and hospitals so they can better serve the poor more efficiently and effectively.

Read more: Are Pakistan’s health systems prepared for a COVID-19 vaccine?

Does one reform fit all?

Through an act of the parliament, Medical teaching institutes (MTI) was promulgated. Initially, all the three tertiary care hospitals in Peshawar were reorganized into autonomous units, managed through their own management structure, and governed by a governing body.

Like any reform process health reforms to is not ‘one size fit all’ and ‘Magic bullet’ process rather a continuous process of reviews, introspection, and more reforms as needed for attaining the end results.

The December 6th unfortunate incident at Khyber Teaching hospital (KTH) – which was very much avoidable and unnecessary, is a big eye-opener for the reform’s protagonist for doing more?

The inquiry report of the unfortunate incident in which seven persons died concluded that it was a “ system failure.” The impromptu report came out with the suspension of 7 officers, more detailed information would emanate from the detailed report to be published in a week’s time. This is not a 1st of its kind and neither would be the last, it is important what we learn and what we change in return?

Healthcare reform involves orchestrating a policy change, mediated through governance, management, and financial interventions. The aim is to improve the ways in which health care is better delivered to patients.

Science of managing hospitals

In each adversary, there is a silver lining and enough of learning to ponder over, asking for course correction and starting afresh. This incident is not an exception to that universal rule, and it would only be a disaster sans measures if nothing is learned for future course of action.

Management of hospitals is a science even in normal circumstances but an emergency especially a pandemic of this scale arguments the requirements and put a big strain on the resources. This calls for certain pandemic-specific management interventions to better prepare, equip, and respond to the unexpected heavy patient’s load and myriads of needs.

The 1st element is stock-taking of existing Human resources, infrastructure, essential emergency medicines and equipment, hospital beds, support structures, and logistics systems. Based on the initial rapid assessment a comprehensive “hospital emergency preparedness and response plan” is developed meticulously with the help of technical expertise of emergency specialists, intensivists, management gurus, and other subject matter specialists. Not only a plan itself but its regular review and monitoring is the best course of action. Since emergencies usually evolve unexpectedly, they require a contingency plan to cope with the unplanned scenarios.

Read more: Sehat Sahulat Program: The incredible story of Universal Health Coverage in Pakistan

Should hospitals be granted too much autonomy?

This incident did question the governance structure at KTH; social media was flooded with some queries on the BoG (Board of Governors) of the hospital.

A BoG composed of political appointees devoid of technical expertise and exposure would deliver what they are best at and eventuality like this is not a surprise but a natural outcome.

Regardless of the social media uproar, depoliticizing the BoG and making it more a neutral, technical advisory apex body would pay dividends in the long run. BoGs are not supposed to play “an arm chair quartermaster” role but a group of dedicated, professional and neutral persons who give their hearts and brain to the hospital.

It is important that the Government develop Key performance indicators for the BoG members for making this body more accountable.

Granting hospital autonomy doesn’t exonerate the government from the stewardship and oversight role. It is highly important that a mechanism of regular joint review and planning with health sector leadership is put in place, as ultimately it is the government who would be held responsible for any debacle.

Complex systems exhibit various forms of inertia and their progress with change is often painfully slow. Sometimes change is impossible to predict accurately, or at all.

Hospital reforms revisited

For effective execution of policies and plans, the hospitals need an efficient, skilled, and effective management team. Many experiments with the management structures were made, some may look fancy on papers but least on results.

A corporate style performance management system is badly needed to address the performance gaps comprehensively, one with both carrot and stick based on measurable performance and quality indicators.

The hospital monitoring mechanism is usually limited to process and outcome indicators, like daily patients’ attendance, morbidity, mortality, and bed occupancy data. This needs a prompt enrichment to include monitoring of input indicators as well, like indicators on HR, medicines, equipment, auxiliary support would provide impetus to the better execution of services.

For all lifesaving interventions and support services, certain triggers are identified and monitored regularly so to avoid any mishap, more so in a situation like this pandemic. Had this been installed at the outset, threat alerts would have been raised and the responsible teams would have been alerted in advance of this situation through that system. Installing a trigger alert system would avoid such eventualities and would better monitor the whole critical pathway of the events should an awkward situation develop?

Largely our hospitals suit routine management very well but it direly needs to inculcate an emergency culture so when an emergency strikes it is not swept off its feet.

Read more: Pakistan’s polio conundrum, only reforms can help

Unfortunate incidents like the KTH one is a stark reminder for decision-makers to change their lens and see the world through the real one rather than that of social media.

It’s not the responsibility of one or few but everyone associated in any way to play his/ her part in reforming our systems for the betterment of Pakistan.

Mother Teresa once beautifully put it in “I alone cannot change the world, but I can cast a stone across the water to create many ripples.”

Ahmad Faraz sb has exactly the same message:

Shikwa e Zulmate shab se to kahin behtar that

Apne hisse ki koe  shama Jalate jaate

Dr. Nadeem Jan (Tamgha I Imtiaz) is the most decorated health & polio expert, who has an illustrious career with UN, USAID, World Bank, Gates Foundation and Governments of Pakistan, Somalia,Kenya, South Sudan, Afghanistan and Philippines. He can be reached at Nadeemjan77@hotmail.com.

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