Whilst facilitating training in Tanzania last week, we spent time in an emergency centre where immense development and improvements has taken place. The development has been possible due to financial aid of an external donor. In addition the external donor has enabled international health care professionals to share their expertise whilst working within the unit on a rotation. Despite the fact that the donor program does not extend to the rest of the hospital, some of the practises has no doubt diffused beyond the emergency centre boundaries.
The ability to render better immediate emergency care and resuscitation has led to improved Emergency Centre (EC) resuscitation survival rates; resulting in more admissions into general hospital. Can the ICU and wards cope with the increased demand, as there has not been foreign aid and focus on their departmental development? How much stress is the improvement in the EC placing on the rest of the hospital?
In this blog I attempt to answer a few of my own questions including: can we afford to focus on only isolated parts of a hospital system? How much can we improve before the improvement cause bottleneck somewhere else, or before our improvement boomerangs back and cause problems in the “improved” department? Is it feasible to start with one part and once it is greatly improved move on, or do we start with a full system?
Within the global health arena the phenomenon of vertical versus horizontal development is extensively debated. The horizontal approach is focused on integrated health care for the greater community and all aspects of disease and disease prevention. In-Hospital this means a development program where all aspects of the facility is strengthened simultaneously.
Vertical development is focused on a specific target population and/or target disease. In Africa the trend has been for external donors to invest heavily in vertical improvement projects. Possible reasons includes the relative ease of investing in vertical health programs, measurable results, shorter timeframes to demonstrate improvement resulting in higher and faster return on investment, increasing the attractiveness.
On the flipside vertical development is criticised for weakening the local health infrastructure and creating dependency on foreign donors. There is a risk that if external funding is withdrawn the efforts and improvements may fall flat, raising questions on sustainability. Further criticism of vertical development programs includes that the focus on diseases like HIV/TB has been at the expense of other diseases, resulting in skewed development and luring resources away from further vital health care aspects. It is stated that vertical development is top-down approaches and the external funder may have preconceived ideas of the problem and how to best solve it disregarding local factors. I think that these comments are best judged on a case to case basis, what is clear though is that vertical development within an in-hospital setting can result in fragmented care and loss of communication or synergy between departments.
The WHO 2010 World Health Report estimates that 20-40% of all global health spending are wasted through inefficiency and poor governance. It’s believed that this percentage is much higher in Africa and the rest of the developing world. This poor governance counteracts the fact that horizontal development programs may be more cost effective over the longer term. In addition one should question the strength of African health systems and whether these systems can cope with the implementation of a full system approach. In some African countries the risk to invest in horizontal programs are unattractive due to high levels of corruption, political motivation and unrest.
Horizontal health system improvement is dependent on interrelated factors external to the health care which can analytically be allocated to different levels of the system (macro, meso, micro). All of the above makes vertical developments with quick wins sound so very appealing!
Taking a few lessons from global health; I think that the negative impact of a vertical development program would be more pronounced within the in-hospital setting due to the strong dependency of departments on each other and the patient flow; patients are served by more than one department at any given time during their patient journey. Any major change in service delivery from one department to another will have a dramatic impact on the patient and on the other departments.
In-hospital systems required synchronization from all the parts/departments and the contribution of one department is always strongly dependent on another department. The Emergency Centre is dependent on theater, ICU and ward capacity. The entire hospital is dependent on pharmacy and supply chain factors that are managed from pharmacy. The entire hospital is dependent on cleaners, porters and administrative services in order to render care. The advanced technical aspects of EC, ICU and theatre need up to date clinical engineering insights and availability of resources for calibration and servicing of advanced equipment.
We create boundaries in systems so that we can manage, understand and even manipulate it. These boundaries are arbitrary and every tiny part of the system is interrelated with other parts that might not be within the boundaries created. You cannot improve a full system by only focusing on a tiny aspect of it.
The crucial success factor in making the system work is not the individual parts or how brilliantly they perform independently. The make or break of a health system or an in-hospital system is the seamless transitions between the various subsystems. The patient should not even be aware that they are being served by various subsystems; they should experience it as one fully functional system. The old cliché applies that the strength of a chain is not determined by its strongest link, it is determined by the weakest link. As such the strength of an in-hospital service is not determined by the best equipped and advanced service provider, but the weakest.
Vertical development such as the approach that I have witnessed is a fantastic and worthwhile first step. The important part of the development is however the next step: evolving into a horizontal approach. Maybe an appropriate question would be how to decide when to transition successful vertical development into a more horizontal approach? Examples of such case studies exploring the transition in health care seem to be scarce and it would be interesting to know whether there are any success stories.
So to answer my questions: We need the parallel development of capacity integrating vertical projects into full horizontal system development. One of my concerns with horizontal development is the time frame before results are seen. Momentum is an important push to maintain development. As such a few select vertical projects with quick win strategies may be a great start, but it’s should never be the end of the process.