FUNDAMENTALS OF MODERNIZATION OF MODERN HEALTHCARE SYSTEM MANAGEMENT

FUNDAMENTALS OF MODERNIZATION OF MODERN HEALTHCARE SYSTEM MANAGEMENT

Kristina Krivets

Student of doctoral program "Doctor of Business Administration (DBA)

in healthcare" in Al-Farabi Kazakh

National University,

Kazakhstan, Almaty

Modernization as a complex and usually a stage process captures all main fields of the current society: economy, politics, law, culture, science, education and healthcare.

According to one of the Russian dictionaries, modernization is understood as improvement allowing to make something compliant with up-to-date requirements [1].

Healthcare sector of each country has a set of unique features, own development history, achievements and shortcomings. Modernization of healthcare system management becomes real only in connection with the changing role of healthcare in society. Modernization gains the relevance when the importance of activities for formation and development of this system as a component of the socio-cultural complex of the state and society increases.

According to the literature, healthcare system modernization is understood as a scientifically based, socially shared set of activities of authorities at various levels, healthcare authorities and medical community, based on available resources and existing surrounding factors for the purpose of improvement of healthcare system as per world standards and developments of scientific and technical progress, taking into account needs of the population [2].

The researchers distinguish four main types of management of healthcare systems, each of which has its own structure and system of management bodies [3]:

- public administration (the most important and comprehending type);

- local governance (subtype of public administration);

- private management;

- combined type of management, implying a combination of public and private management, for instance, in form of a public-private partnership (PPP).

Therefore, it is logical to assume that the modernization of healthcare system management is a scientifically based set of documents, arrangements and activities of authorities, aimed at improvement, including optimization, of management structures and bodies, which may be manifested by amendments in the legislation, reforms, development of new policies, strategies, concepts, programms, projects, reorganization of healthcare management bodies and its structural subdivisions at local level.

Vorontsova Ye.V. [4] considers modernization as the main condition for the implementation of the constitutional right to health protection. In particular, in Kazakhstan, this right is enshrined in Article 29 of the Constitution of the Republic of Kazakhstan [5]. Citizens of the Republic have the right to receive a guaranteed extent of medical care free of charge.

Upon the analysis of modernization issues of healthcare system management, Filipchenko A.M. [6] concluded that, firstly, modernization requires the improvement of the regulatory and legal framework of healthcare sector, which shall cover all aspects of activities of medical facilities.  Issues of increasing the labor motivation of medical workers, including improvement of the remuneration system, may be pointed out. According to the author, the updated regulatory framework will allow to optimize the network of medical and preventive institutions, to withdraw financially unsecured capacities of public medical facilities from the state budget financing system, to ensure their economical independence, to increase efficiency of the use of financial, material and labor resources.

Having analyzed the variables included into the indices of management modernization, Lastochkina M.A. identified two main indicators that directly or indirectly affect the health of the population - environmental efficiency and availability of doctors. Based on the papers of leading domestic and foreign scientists, the researcher identified the most significant factors affecting the health formation:

- socio-economic conditions and lifestyle (50% of the impact);

- biological and genetic causes (20%);

- environmental state (20%);

- medical support (10%).

The health of the nation is reflected in the morbidity, mortality and life expectancy of the population. Two of these indicators are also present when assessing the level of modernization of the territory – life expectancy at birth and infant mortality. Also, according to Lastochkina M.A., in addition to technological and innovative development, modernization is a process of transition of the population to new high-quality life conditions and civilizational changes [7].

Pushkarev O.V. believes that the indicator of sectoral management modernization efficiency is human capital [8].

Shishkin A.S. considers that the important direction of improvement of healthcare management is improvement of HR management system in healthcare institutions. The main activities should be related to improvement of management of medical personnel training, optimization of a network of medical educational facilities and non-commercial professional associations, development of innovations in the training process, enhancement of HR service, increasing the awareness of medical personnel of current processes in the healthcare system [9].

Assessing the modernization management practice, academics note that the environment of a certain region, where changes occur, gains the significant relevance in development of modernization plans, programms and projects in the framework of healthcare system in addition to other factors. Any changes may be implemented only with the consideration of specifics of social, economical and political state of a region [10].

The traditional priority of state policy in most countries in the process of healthcare management modernization is to preserve and strengthen the health of the population. However, in fact, this priority often remains declarative. In particular, since the end of the 90s of XX century many post-Soviet countries have implemented poorly developed reforms for "optimization" of healthcare systems, and, eventually, it has lead to multiple reduction of a number of medical institutions, beds, personnel of medical organizations, increasing cost of medical services, reduction of sectoral financing, and to other, mainly, negative phenomena.

For instance, in 1991 Kazakhstan had 1,8 thousand hospitals. The number of medical institutions grew until 1993, approaching the mark of 1.9 thousand. However, in 1994 this indicator began to fall, and in 1999 the number was less by almost 1 thousand hospitals (917 hospitals). By 2019, this indicator has decreased to 749 institutions, i.e. it has decreased by 2,4 times compared to the first year of independence.  The similar negative dynamics was observed for a number of beds.

Figure 1. Investments in healthcare and social services  in the Republic of Kazakhstan, 2014-2019, KZT bln

The healthcare sector reforms in Kazakhstan were accompanied by large investments (Figure 1). But the overall level of costs for this sector as a percentage of GDP has remained low for years, about 3,1%, which is significantly lower than the average indicator in OECD countries (8,9%). The state expenditures for healthcare in the Republic of Kazakhstan are even less, not exceeding 1,8% of GDP, which covers only 58% of total costs in this sector, and the patients bear the rest of the costs on their own. 

In-patient facilities present the main problem in Kazakhstan, as they take 32% of all expenditures for healthcare (26% in OECD countries) [12]. At the same time, as of 2018, the total budget expenditures in the regional context indicated the highest costs in Turkestan region and in Almaty in the pre-pandemic period (Figure 2).

Figure 2. Expenditures for healthcare by regions of Kazakhstan, 2018, mln KZT

Note: made by the author according to the data [13].

It should be noted that at the end of 2019 the expenditures for healthcare by regions of Kazakhstan were not reflected in the Statistical digest 2020, and the digest authors indicated only general expenditure indicators in healthcare KZT 1197343.7 mln (republican budget, including transfers); KZT 104288.1 mln (local budget, excluding transfers) [14].

The World Health Organization has developed the following criteria for assessment of effectiveness of healthcare system management:

— the level of general health of the population;

- inequality (or disproportionality) of the population's access to medical services;

- responsiveness of the healthcare system (meeting the needs of patients, which is associated with the proper functioning of the system);

- distribution of rapid interaction of the population (meeting the needs of people with different income levels in relation to the services provided by the healthcare system);

- distribution of the financing burden for the healthcare system among the population (who pays the costs).

Figure 3. Kazakhstan's place in the world prosperity index by the level of healthcare, 2019

Note: made by the author according to the data [15].

Unfortunately, based on these criteria, the healthcare system of the Republic of Kazakhstan could not be recognized as effectively functioning. In 2019, Kazakhstan ranked only 84th in the world ranking (Figure 3).

It should be noted that even in economically developed countries, the management of healthcare systems is often far from ideal, which, in fact, was demonstrated by the global crisis caused by COVID-19. Experts have many complaints about the healthcare systems of the USA [16] and the European Union countries, some of which were considered as reference before the pandemic.

A pronounced and most important trend in the modernization of management in healthcare systems in the 2000s includes informatization and digitalization. New tools and systems of electronic medical records promise to improve access to services, speed and quality of medical care, but these achievements depend on the basic IT framework, which should be updated at the same rate as clinical technologies. Sectoral management bodies should update server platforms in order to ensure the implementation of potential of these new options aimed at patients and providers, and such updating may cause serious problems as many basic systems are built on embedded legacy components.

It is equally important to provide medical institutions serving patients with the flexibility and innovation necessary for the most effective patient care. It is possible that the most important aspect that changes and updates should follow the path of the end user, i.e. ensuring that each step is simplified, smart and efficient, leading to improvement of patient outcomes.

The agenda in the field of sustainable development for the period by 2030 emphasizes that the spread of information and communication technologies, global interconnectedness, have great potential to accelerate human progress, bridge the digital gap and develop a knowledge society. In this case, we are talking about the Internet of Things, virtual care, remote monitoring, artificial intelligence, big data analytics, blockchain, smart wearable devices, platforms, tools that allow data exchange, storage and tools for remote data collection and exchange of relevant information in the global health ecosystem. WHO experts believe that, despite the significant progress made by some countries, many States still need institutional support for the development and consolidation of national electronic and / or digital healthcare strategies and the implementation of their action plans, which usually requires large resources and capabilities. It is believed that the Global Digital Health Strategy will improve and complement the work of existing and newly created digital health networks [17].

The vision of the Global Strategy is to improve the health of everyone, everywhere, by accelerating the development and implementation of suitable, affordable, scalable and sustainable solutions for digital health, focused on people, for the prevention, detection and response to epidemics and pandemics, the development of infrastructure and applications that allow countries to use health data to promote the health and well-being of the population [18].

The goal of the Global Strategy is to strengthen healthcare systems through the application of digital health technologies for consumers, healthcare professionals, healthcare providers and industry in the direction of empowering patients and achieving the Vision of Health for everyone. The strategy is developed in such a way as to meet the purpose and be used by all members of the state, including those with limited access to digital technologies, goods and services. In the context of this global strategy, digital health is understood as "area of knowledge and practice related to the development and use of digital technologies for health improvement" [19].

However, the Vision and Goal of WHO is one thing, and the realities in each individual country are another matter. The case of Abishev O., the Vice-Minister of Healthcare of the Republic of Kazakhstan, may be presented as an example. In 2020, he was accused of violating the law when signing a contract with a supplier regarding the AIS "Platform for Informatization and Provision of Interoperability of Healthcare Information Systems". According to the report on evaluation of tender bids, 44 companies requested the tender documentation, of which 19 foreign companies and 25 Kazakhstan companies. As a result, Ericsson Nikola Tesla (Croatia) was chosen as a supplier. The act of AIS commissioning was signed on January 14, 2019. The system showed itself as inoperable, despite numerous inspections by special state commissions [20].

The roadmap for the development of the infrastructure of healthcare organizations of the Republic of Kazakhstan for 2016-2019 provided for application of service model of implementation of healthcare informatization projects based on PPP, including innovative information and communication technologies and telemedicine; development of new initiatives in the framework of the State Program for Healthcare Development in the Republic of Kazakhstan. However, clanship and corruption impeded the implementation of state goals and objectives in the field of health digitalization by the planned deadlines.

Currently, the process of implementation of the Common Healthcare Information System (CHIS) is still underway in Kazakhstan, the purpose of which is establishment of state-of-the-art healthcare information structure that will fully correspond to the level of social, economic, technological and technical development of modern society.

According to McKinsey analysts [21], future healthcare ecosystems are likely to be determined by the needs of various groups of patients and the associated ways of effective treatment (including not only the care itself). The consumer-oriented nature of these ecosystems will increase the number of points of contact with healthcare in order to change patient behavior and improve outcomes. At one end of the spectrum, there will be healthcare ecosystems designed to meet the needs of healthy patients who have fewer medical problems, but often set personal health goals. These patients are most likely to experience the digital ecosystem ahead of others.The patient data and analytical information in such ecosystem are used in a very personalized and meaningful way, for example, via wearable devices. Only a small percentage of the points of contact will relate to traditional methods of treatment. At the other end of the spectrum, there will be healthcare ecosystems designed to meet the needs of patients suffering from multiple complex chronic conditions.

Summing up the above, we note that the modernization of the healthcare system management is a scientifically based set of documents, tools and actions of authorities aimed at improvement, including optimization, of structures and management bodies.

Digitalization is the key direction of modernization of healthcare management in recent years. Digitalization is designed to expand the concept of e-health to the use of digital technologies by consumers with a wider range of smart and connected devices. It also covers other types of application of digital technologies for health, such as the Internet of Things, advanced computing, big data analytics, artificial intelligence, including machine learning and robotics. The problem lies in the risks of imperfect management systems, as well as other threats, including risks of epidemiological security.

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