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A seminal 1963 article has been credited for giving rise to the concept of health economics, and its establishment as a discipline. It focuses on issues that are related to scarcity in the allocation of health and health care. Amid growing concerns for health care and global health reform it has been recognized that health finances are finite, a view substantiated by Basch (1999), and that neither developed nor developing countries are immune to the scarcity of resources that plagues our health care system. Levine (2005) argues that the problems in health care systems have been hampered by chronic financing shortfalls, compounded by weak management and crippled by rigid budgeting. Against this backdrop the case of Bruce Hudson, Seven Seas Memorial Hospital is not so farfetched.
Robert et al. (2004), underwriters of many health policies in developing countries, put forward the argument that the elements of any form of systematic policy cycle, first seeks to define the problem, form a diagnosis to policy development, political decision making, implementation and evaluation. From the given case study it is clearly identified that the operating policies need to be revised, a decision needs to be made on how the new operating policies will be developed, how much political influence will be incorporated into it and how will these policies be evaluated.
With the ever increasing demand for improved efficiency in the health care sector there has been the ever increasing need to revise and change hospital structures. That has included the use of strategies such as mergers and downsizing, as modifications are made to cut down on expenditure. The difficulties of Bruce Hudson, in the given scenario, are not unlike the challenges that Hospital administrators face in developing countries. They grapple with limited finances and are often faced with the difficult decision of restructuring staff. Fulop et al. (2002) and Braithwaite et al. (2005) argue that in such cases as administrators seek to contain cost and cut down on over heads, there is increased emphasis on redefining job roles to ensure the delivery of health care in a more cost effective way. They go on to argue that there is very little evidence to suggest that restructuring actually improves efficiency or programme outcomes.
Hospital administrators face the difficult task of how to restructure and not affect quality. It is recognized that nurses are the largest component of the health care workforce and as a direct result they would be the largest operating expenditure. Attempts to cut back on labour costs could mean a cut back on the number of nurses operating within the facility. While the case study goes on to note that Mr. Hudson is not new to effectively running an operation with less than the current number of staff at Seven Seas Memorial Hospital, Kearin et al. (2006) cites in their work the view of Akien et al. (2002) who put forward the view that patient outcomes are linked to appropriate nurse-patient ratios and the proportion of registered nurses operating within the health care facility. As Di Frances (2002) indicated, the downside to downsizing is the fact that as a process it creates distrust and low morale among staff, not an environment to promote efficiency and greater work outcomes. While Mr. Hudson may want to expand roles and employ the use of organizational report cards to monitor performance, as a result of improving quality of care, retrenchment may not, according to the aforementioned arguments, be the best way of dealing with the problems or securing the future of Seven Seas Memorial. While with continued financial constraints it may inevitably come down to re-engineering or downsizing the work force, the potential negative impacts needed to be assiduously guarded against.
Having decided on the merits of delaying retrenchment as the first option to save cost, there is need to improve the flow of clients through the facility and by extension the clinics that serve the facility. This move allows for the program to care for more clients without actually lowering quality, hiring more providers, or increasing staff hours. The example of what obtained at a clinic in Guatemala providing maternal and child health services can be examined. They were able to improve client flow after a self-assessment by staff and a survey of clients. It was identified that 'clients used to wait, have a pre-visit discussion, return to the waiting room, see the provider, return to the waiting room, and then have a post-visit discussion,' a process that was not only time consuming but also made the operations inefficient. By improving the flow of clients to have them wait just once and receive all services in one visit with one provider allowed staff to process 33% more clients. That move allowed the facility to meet the needs of the clients more efficiently. In the given case study, there are six clinics attached to the health care facility. These clinics, as is often seen in many developing countries, serve the underprivileged and the underserved.
The Brundtland (1987) report describes sustainable development as development that will not impede the ability of future generations to meet their needs and enjoy a comparable or even better quality of life. Mowforth & Munt (2003:232) argue that sustainability "is considered a contested concept, a concept that is socially and politically constructed and reflects the interest and values of those involved". Regardless of the definition attached to it, or the constructs under which it operates there is a need to ensure that an innovative way to address the issue of providing a sustainable health service be employed in the situation involving the clinics. The structure and scope of the clinics can be revisited to ensure that they are most cost effective. The use of the concept of a mobile health clinic is such a way to cut cost, continue to provide the service and doing so in a cost effective manner. Mobile clinic services can be structured in such a way that the services continue to be provided for free on a walk-in or appointment basis, where the mobile travels to low-income or underserved communities twice per week. They are able to rotate and maximize staff use as well as continue to provide the service that the stationed clinic provided. The added benefit it that instead of six physical buildings two mobile facilities can be established.
Oriol et al. (2009) argues that the use of mobile health clinics provides 'an alternative into the healthcare system for the medically disenfranchised.' They go on to further define that group as those who are undernourished, underinsured and do not trust the healthcare system. For them mobile units serve the purpose of providing triage into mainstream healthcare for the underserved.
There has been established precedence for the use of mobile clinics that provide the specific care that the community based clinics provided. Edgerley (2007), in a study looked at whether the use of a community mobile health van in an underserved population allowed for earlier access to prenatal care and increased the rate of adequate prenatal care, as compared to prenatal care initiated in community clinics. Their findings were able to confirm that the use of the mobile health van not only increased early access to adequate prenatal care in these communities but was able to reduce the barriers of accessing care; barriers such as the lack of insurance, inability to meet costs, transportation, language, and the need for an appointment. Their study successfully showed that the use of a community mobile health van to provide prenatal care may be one way of cutting down restricting community clinics and cutting on operating costs. That initiative is not isolated to just prenatal clinics but could be employed for clinics providing other types of services such as HIV treatment and testing.
A forty-foot primary health care clinic on wheels was used in Kentucky. Staffing was made up of a medical director, a social worker, a nurse practitioner and specialty physicians that are rotated, (www.hhnmag.com, 2006).
The question is, how cost effective is such a service as opposed to community based clinics. Oriol et al. (2009) calculated in their study the return on investment of mobile healthcare. In their findings they were able to elucidate a mobile clinic that had been serving the medically disenfranchised in Boston was able to have a return investment of thirty-six dollars ($36) for every one dollar ($1) invested into the programme. If such a venture were to be employed at Seven Seas Memorial hospital, not only would it save and recover cost on the six clinics that currently exist but it would get an opportunity to see returns on investment, while keeping the politicians satisfied.
One of the primary triggers to rising cost of health care, and by extension, hospital operating cost, is the rising health expenditures for costly new technologies. Jones (2005) argues that rising health care cost may be a natural reflection of economic growth. He goes on to postulate that 'as we get richer, one of the most valuable and productive opportunities for our spending is to purchase better health and longer lives.' Other factors such as aging populations and rising cost of health insurance that were directly influenced by the discovery and use of novel and expensive medical technologies. The inventions of MRIs and CAT scans as well as newer drugs meant that if hospitals are to remain competitive they had to spend money on the delivery of such services. Basch (1999) warns that there is a need in developing countries to ensure that if they are to be not only efficient, but also cost effective, there is the inherent need to keep cost down. As such it is not always possible to purchase every, or even most of the newer medical technological equipment that private facilities could offer in a market driven health care system.
The purchase and use of generic drugs can significantly reduce the cost of health care, as seen in the case of most parts of Africa, (Ford, 2010). This affords them an opportunity to circumvent the chasm that exist between the prices mandated by the pharmaceutical giants that develop the drugs in the industrialized world and the ability of developing countries, and by extension their people, to afford them. Further to that another way to combat cost would be to encourage programmes to buy supplies in bulk. There exist many procurement agents that allow health care facilities to merge their orders in an effort to qualify them for volume discounts from manufacturers, even as they ensure that the quality of the products. Further to that health care facilities that are facing budget constraints or that simply wish to be more cost effective in their operations can adjusting procurement to match demand. They are able to do this by monitoring use via a logistics management system. This system of operation will allow them to identify changes in demand and in the 'method mix' and as a result will prevent programmes and sectors from overstocking. Further to that health care facilities could seek to set up services in existing buildings and share facilities with other health services. Meeting rising demand efficiently
The market for costly medical equipment is limited in most developing countries, and many hospitals, especially public facilities are unable to afford them, (Ford, 2010). He goes on to note that the demand for high-cost medical equipment will continue to rise in developing countries, largely due in part to the need for patient monitoring and diagnostic equipment. He cautions that in many public facilities in the developing world, health care facilities may also lack the expertise to operate as well as maintain such equipment and so should limit such purchases. 'The lack of technical support from suppliers leads to chronic equipment failure'. In this case health care facilities, to make them more competitive with the facilities that can offer such specialized care should focus of being recognized for a particular product or brand.
There is a plethora of information on branding in the marketing literature. Branding is defined by the American Marketing Association (2005) as:
A name, term, sign symbol or design or a combination of these, intended to identify the goods or services of one seller or group of sellers and to differentiate them from those of competitors. `(p.28)
Kotler and Gertner (2002; 65) postulate that brands not only, `differentiate products and represent a promise of value but also incite beliefs, evoke emotions and prompt behaviours`. By branding his facility Mr. Hudson is able to incite confidence in clients of his facility's ability to deliver on that service for which it is known.
Muhammad Yunus, is cited as saying, 'poor people need health insurance, they deserve it and it can be done,' (Ford, 2010). That saw the birth of the concept of micro-insurance in South Asia, where the very poor are now able to purchase life insurance as well as healthcare insurance in return for a relatively small monthly payment.
The International Labour Organization (2005) postulate that countries need to continue to fight against social exclusion and poverty in health and can do so by shifting focus to social health insurance. They argue that apart from tax-funded health care as obtains for formal economy workers and their families, social health insurance is the other major concept when it comes to health protection. For them, social health insurance seeks to include informal economy workers and their families as well as the poor. What obtains is that affiliates of such a scheme are able to contribute according to their financial ability, rather than according to their current health condition. 'Financial resources are pooled and benefit all members of the system in case of illness.' A purely market-oriented approach to health insurance will exclude the poor and as a result would not work. Other countries are able to offer a more elaborate and detailed plan to deal with insurance and the provision of government funded coverage. Singaporeâ€¦.