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Introduction

Many developing countries are responsible for the comprehensive health care of their citizens. These countries have very few private health organizations and therefore must rely on their own resources and those of donors to care for those in need. Because of this, developing countries and also countries with socialized medicine, can be viewed and analyzed as a "Integrated Delivery System (IDS)" and/or "Managed Care." These systems of health care must provide a continuum of health care across time and locations. 

To manage these systems requires a very comprehensive integrated information system.

Health Care expenditures are also generally not driven by market forces but rather by the individual agendas of politicians and donor countries. 

Governments

Government that are concerned with the efforts to expand coverage health care fear that it will cost more money and put further strain on an already hard-pressed governmental budget.

Governments should take more responsibility in “how” money is spent. By improving the efficiencies in the organization, health care coverage can be increased without increasing expenditures.. 

Although much is said of “how much money does the government invest in health care services,” most measurements only reference abstract indicators such as the “percent of total health system financed by tax revenue” or some other indicator that gives little indication of what this means to the individual client. These indicators say nothing about the ability of the lowest organizations to meet demand and to supply to the client what she or he needs. It says nothing about how much of that money actually goes to the care of the individual client. It is only by measuring the success of these individual organizations that directly deal with clients that effectiveness of government expenditures can be measured.

If the lowest level units are not successful in management, then no amount of government expenditures will be sufficient.

Donors

Donors have their own agenda. All donor organizations have (or should) Global objectives; although these objectives may not be very clear to the recipient organization. 

Donor organizations often fail to initiate their projects as an integrated, coherent whole with the national health system program. This has lead to duplication (Guatemala at one time had over 200 programs all doing what seem to be the same thing) and a complete waste of resources. Not only has it not provided for "overall" better care, in most cases, it has hindered national health systems from development.

Levels of Distribution of Funds

The theory held by most international donor organizations is that since most government's were so corrupt (probably correct) that the best way to help individuals was to give the money to Non-Governmental Organizations (NGO's) and let them do the work thus be-passing government bureaucracy completely.

Impact on Health Care Organization

• Cyclic
• Supply (funds) driven
• Priorities not set by organization
• Accounting procedures set by Donor
• Politically driven

One often hears "we only do it because that is what the donor wants." In many cases, the organization does not even fully understand why the donors require such processes.

Separation of “Project” from the overall operation of the “Organization” makes it extremely difficult to create team spirit and to do things for "the good of the organization."  For example – Each project manager wants to run his or her own project as his own even at the determent of the organization as a whole.

Funding may be predicated on the party in political power. 

Example
Organization hiring political "correct" personnel only to find that at the next "election," these people are a liability. 

Impact on Management

Funding organizations have made it very difficult for projects to be managed. Often donors demand the implementation of there own financial and information systems. It many cases however, this may be due to the fact that the organization does not have an effective system. 

Organization intrigue and turf wars are bane of any organization. Especially where organizations are project driven (funded projects), the director and his staff usually think of any asset not as a corporate strategic asset but rather as a personal one. It is the haves against the have-nots. 

The researchers that "have" engage in “Empire building.”

• Difficult to make changes
• No incentive for efficiency

NGO's Cost-Benefit Analysis

Unless a cost-benefit analysis is done, several things can happen:

• The Organization will receive less money than what it has to spend to do the project.

• The Organization will have to cut costs on the project and therefore will product sub-marginal research.

• The Organization will over-charge the donor, he will find out about it, and therefore will be less likely to give to the Organization money in the future. 

There are too many other competitors (NGO’s) to compare the results of that they get for their money.

Impact on Research

In many cases donors define the methods and indicators used in research. Standardization is not bad in itself, but when it inhibited creativeness than research will suffer. 

When it was found that there were three doctors and 3 nurses sitting at the table in a study ward doing nothing and having no patients, it was said to me they were doing that because they had no “subjects.” When asked why they couldn’t go somewhere else to work and help out it was then said that “they are being paid by that research grant and should not be assigned somewhere else.”

Recommendations

InHCc makes the recommendation that funding procedures be changed such that the efficient organizations be reward and the inefficient are removed from the market. It is our belief that funding should be based similar to the US DRG's, prospective payment systems. Donors have their agenda, and they should put these projects up for bid just as any other business.   

It is impossible for outside "experts" to present themselves into an environment without a clear understanding of the local needs. They will fail every time. It much better for these experts to offer strong technical support and have the local managers manage. 

Non-Governmental Organizations (NGO's)

Most NGO's lack a clear incentive to save money (product a profit/measured goal). Projects are generally rigidly budgeted that leaves little incentive for the NGO to improve on the processes. 

It is believed by InHCc that if NGO's had greater flexibility in managing their projects, with the possibility of making a profit/measured goal, more NGO's would be attached into the service area and efficiencies would increase. 

We are afraid that this one subject could grow larger than all the other pages together. InHCc feels this is one of the most important subjects in this Web Site. However, in order to do it justice, it is the attention of InHCc to leave this page until last. Sorry

What you see below will be our notes. 

Profit Incentive

NGO’s may be as much a “for profit” organization as any other…While it is true that the organization cannot distribute profits, there is nothing that prevents it from increasing the salaries of the owners...or of "paying" to subsidiaries the profit through increase charges.

Where donations are made to them based on a "budget", most NGO's lack a clear incentive to save money (operate more efficiently). Projects are generally rigidly budgeted that leaves little incentive for the NGO to improve on the processes and if they do not spend all the money given to them...then they may not get it the next time.

In many cases, if NGO's cannot get the money that they need to run their organization, they start cutting services. This often lead to poor services and a further decline in "sales". 

Issues may be the following:

• By creating "separate" NGO's it may be possible to raise more money because people would rather give to an organization that they relate...however, mergers of NGO's may enable the NGO to operate more efficiently.

Management

Consensus 

Reaching consensus in never easy in any organization, but it is more difficult in countries where there are different social standards. 

Human Resources 

Although in many organizations, employees may be highly trained, they are afraid to voice their opinion or to make decisions. Often they have the attitude that "don't make a decision or put out any suggestions or your supervisor may not like it."  

• Financial Resources

• Currency changes

• Cost of living increases

• Security

• National Policies

Although the idea of sharing information (the point of this web site) is may be very detritus to national policies to disclose such information.

A very big issue is the ability to compare countries, organizations, divisions, or projects among each other. There may be a real psychological or political problem with a country or organization knowing that they are “on bottom.”

An example of this is the publication of health statistics. A country that shows "bad" statistics may be "shamed," may be "looked down on" by other countries and it may caused political unrest due to the supposedly "non-caring" of the government [parentheses used because of the completely subjective nature of this information].  

Health Care Organizations may also need to have their "name and address" masked for complete privacy in order to guarantee their voluntary submission of data.

In general, it may very difficult to get organizations, of any kind, to share information. 

As in any decision, the chosen option should be based on the costs and benefits. Unless the benefits are clearly outlined and "sold" to these governments, this data will continue to be unable to research.  

Control of information

Data collection is expensive and the data collected in valuable. Developing countries should demand that the data collected in its country be make available to the country. It is understandable that researchers would want control of this collected data until a research project has been completed. Arrangements can be made. 

Advantage of Implementing a new system

Most organizations spend large amounts of money and time trying to protect their older systems and procedures. Because most developing countries, in general, have not made these large investments in older systems and technology, they have nothing to protect. This is a big advantage in implementing any new system. Developing countries can “leap ahead” of developed countries by not tying themselves down to their older technology

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