Steering Committee Healthcare Reforms

On September 25, 2009 the Presidents of the subcommittees gathered to evaluate our work over the last four months. Did we do well? Over one hundred volunteers toiled tirelessly throughout the grueling summer months. Among our ranks we count doctors, nurses, patients, economists, lawyers, activists, and politicians. We have interviewed witnesses and experts, both domestic and foreign. We have produced almost 300 contributions and numerous other documents, all available through a ground-breaking Website that relies on advanced tools of social networking. Our indefatigable Secretariat compiled a draft Green Book with 400+ densely printed pages. Our Web Coordinator dedicates hours every day just to cope with the avalanche of new submissions.

What's next?

We have decided to give ourselves another three weeks in order to finish the first phase of our work on October 15. The Subcommittee for Financing and Purchasing will meet next week (on September 29) with foreign experts. The Subcommittees for Service Delivery, Pharmaceutics, and Patients' Rights intend to do the same.

Based on the two-day seminar with the ECDC and WHO, I have written this document, which will be debated in the next plenum of the Steering Committee. It is only my opinion and other members have indicated that they may have different ideas.

Steering Committee for the Advancement of the Health System in the Republic of Macedonia

The Public Phase

Based on: literature and the conclusions of the working groups in the ECDC workshop, August 26-27, 2009

Facts

1. Lack of resources, both financial and in manpower

2. Lack of media attention and interest

3. Cynicism and skepticism regarding the entire process on all levels, including stakeholders, politicians, and the public.

Goals

It is crucial to demonstrate unequivocally that the process is:

1. Not politicized, not some kind of cover for hidden political or commercial agendas of the participants or of its sponsors.

2. Is an exercise in truly participatory democracy where citizens, consumers, patients, and stakeholders not only have a voice, but also really influence decision-making.

Warning

If we do not involve the public in a meaningful way, we are likely to be accused of having run a deceitful sham (“paravan&#8221 in the first place.

The whole point of this drawn-out process was to listen to the people and demonstrate to the citizenry that it does have influence on decision-making and that its concerns are taken into account.

Suggested new Workflow of the Steering committee:

- Green Book (agenda; scenarios/solutions; process; legal)

- Public Consultations (meetings comprising randomly selected samples of citizens with stakeholder members of the Committee) using deliberative polling (see explanation and analysis of pros and cons below).

Throughout the public phase, we need to operate a toll-free phone number for citizen input.

Deliberative polling consists of the following phases (paraphrased from the New-York Times, see the full text below).

1. Selecting a commercial polling company (in a public tender). The country will be divided to zones (same as the electoral units).

2. Organizing surveys to identify the range of attitudes and demographics in each and every zone.

3. Inviting a randomly selected, representative sample of constituents from each zone to attend a long, two-day meeting. Thus, the total number of meetings between the citizens selected and the stakeholder members of the Committee will be equal to the total number of zones.

4. To facilitate discussion in these meetings, participants are sent balanced briefing materials (the Green Book and the Green Paper) about the issues to be discussed in advance, ahead of time.

5. When they first arrive at the deliberative poll, attendees answer a confidential questionnaire assessing their positions.

6. Participants are then divided up for small-group discussions. Trained moderators make sure that every voice is heard and that the group carefully and thoughtfully narrows in on its most pertinent and pressing policy questions.

7. This is followed by meetings with the stakeholders.

8. At the end of each day, participants are polled again using confidential questionnaires. This is intended to verify whether there has been any shift in the initial positions of the participants.

- Final Report of Public Consultations

- Reconciliation of Green Book with Final Report of Public Consultations

- White Book (review of the process; overview of the sector; operational recommendations for reform; draft laws; draft regulations; sources and uses of financing).

- Presentation to the Government for legislation.

Preparing to consult the Public

The European Center for Disease Control (ECDC) is now firmly aboard our process. Delegates from this newly-created EU organization as well from our long-time supporters, the World Health Organization (WHO), gave us a fascinating, thought-provoking, and highly beneficial workshop about public consultations: the way to organize them and pitfalls to avoid.

There is no universal formula, of course. Each country has its idiosyncratic values and conditions. Consequently, the five lecturers tried to avoid being prescriptive and stuck to mapping out the territory of citizen engagement. With the aid of examples from other polities - from Canada to Romania - they provoked the members of the Committee present, the youthful representatives of the NGO HERA, and the two journalists who participated into a review of activities past and future.

A SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of the Committee's operation hitherto cast its work in a new light by placing it in context: many countries have tried and failed to accomplish even the level of stakeholder involvement that we have. Further engagement of the wider public has to take into account the scarcity of resources, on the one hand, and the ever-present risk of engendering chaos rather than a structured and productive debate, on the other hand.

The members formed unusually lively workgroups, facilitated by the visitors. Rapporteurs summarized the proceedings of these mini-assemblies and reported them in full session. Some very practical insights emerged almost immediately:

1. The members of the Committee require additional time to submit material, which is often the outcome of inner consultations in the associations, organizations, and NGOs which they represent.

2. The compilation of the Green Book should be done by members of the various subcommittees, elected by their peers in a democratic and transparent way.

3. Only one phase of citizen engagement is recommended. This would combine a structured and protracted interaction with a representative sample of the population (in the form of focus groups, deliberative polling, citizen juries, or some other method) with electronic submissions (responses to questionnaires which will go out to NGOs and GPs; submissions via e-mail and the Web, etc.)

4. The media and public relations dimension of the entire process is sorely lacking. We have failed to engage the press and to interest them in the events and activities of the Committee. Our guests proposed a few ideas as to how to reverse this disconnect. Examples: to accompany thickset documents, like the Green Book, with a "thinner" flier or brochure (a "green paper"); to distribute the green paper as an insert in the daily printed press; and to seek media partnerships and sponsorships. We also discussed running a workshop specifically for the members of the media, perhaps in conjunction with the launch of the Green Book.

I have spoken to members of the Committee after the event was over. We all feel more firmly grounded and with a renewed sense of direction. We have no answers, but now we seem to possess both the right questions and possible solutions. We need to meet and thrash out what we have learned. The workshop jolted us, put a mirror to our collective endeavor, and has made us attain that most precious of commodities in a complex undertaking such as ours: clarity.

The last 10 days have been a hectic period. All five subcommittees held their first and second meetings. Many members have submitted observations, ideas, and suggestions. To standardize this outpouring of input, the Secretariat has introduced a template: a form that contains "Three Steps to the Green Book": the current situation in Macedonia; possible solutions; and a space for comments - all three backed up by sources and bibliography.

We have a new Web Coordinator, Lidija. The entire eDocuments section has been revamped and now is updated in real time. You can find the latest correspondence, submissions, literature, and documents on our spiffy Website! The eLibrary has also grown handsomely. From now on, every month, we will post a collection of articles about healthcare reform throughout the world. The first such anthology is already online.

On July 21, we had the most unusual event, organized by the WHO. The members of the Plenum plus all the members of the Financing Subcommittee conversed, for three straight hours, via video-link, with one of the world's leading authorities on healthcare financing, Dr. Joseph ("Joe") Kutzin. Dr. Nora Markova, an WHO advisor who has helped design the matrix of activities of the various subcommittees, was present, too.

We covered a lot of ground with Dr. Kutzin: privatization; medical savings accounts; voucher systems; hospital management, purchasing, and contracting; earmarked (hypothecated) tax revenues; tax-based systems vs. social insurance systems; and a myriad other subjects. The whole event has been taped and will be distributed to the members on a DVD.

The second plenary session of the Steering Committee for the Advancement of Healthcare in Macedonia was held on June 30, 2009, in hotel Stonebridge. Attendance was full. We dispensed with some formalities to discuss at length the Agenda for the work of the five subcommittees of the Committee as it is laid out in the Matrix and graphically rendered. You can find the relevant documents on this Website.

Our process is so innovative that it takes everyone time to get adjusted. But now the members have finally begun to leverage the administrative tools at their disposal: various stakeholders have appointed voting members in all five of the subcommittees. Lively debate is going on, via e-mail and in person, regarding the Agenda, its scope and ambitions, and what we can expect as the final product and outcomes of the Steering Committee.

The International Community is beginning to notice our efforts. The WHO (World Health Organization) has been there for us from the very beginning with expertise, literature, and some logistical add-ons. The European Union and UNICEF made sure to be conspicuously present in every event, lending us much needed moral support. Now the Council of Europe and the World Bank (as well as its arm, the IFC) may join the fray.

The subcommittees - all five of them: Good Governance, Service Delivery, Financing, Pharmaceuticals, and Patients' Rights - will be starting their arduous work next week. They are slated to meet twice a month and by the end of September, if all goes well, will produce a Green Book. The first session of each and every subcommittee will be dedicated to learning the ropes: key issues to be tackled and solutions to be reviewed in view of experience from other countries and local conditions and peculiarities.

This week, we published an open invitation for Patient NGOs and advocacy groups to join the subcommittee for patients' groups. Interest is growing as the news is spreading that something truly unusual is happening in Macedonia. A foreign expert we met this morning even suggested that we brand and patent the process and spread the knowledge in other countries, even among EU members. It wasn't tongue in cheek: he meant it.

It's been a hectic week.

I spent Monday and Tuesday compiling the Agenda of the Steering Committee from the contributions of its members (together with WHO experts, the Program
Coordinator, and our volunteers: Bocconi healthcare management magister Nikola Grpceski and Lidija Rangelovska).

On Wednesday, the Forum of Chairmen of Subcommittees was formed and met to review the work procedures of the subcommittees in the first phase
(i.e., the preparation of the Green Book).

The Forum of Chairmen of the Subcommittees will convene once a month, one hour ahead of the Plenum to: (i) Share experiences and information among the
subcommittees (ii) Coordinate joint sessions of subcommittees.

Voting members can propose "standing (postojani) members". Nominated standing members will be accepted or rejected by a majority vote in the subcommittee in which they were nominated to become standing members.

Standing members will participate in all the meetings of the subcommittee in which they are standing members and will have the same rights and obligations as the voting members, except they will not have the right to vote.

Delegates delegated by voting members have the same rights and obligations as the voting members, including the right to vote.

Members, both voting and standing, can invite expert witnesses to sessions of their subcommittee. Invitations of expert witnesses are subject to approval, by a majority vote, of the voting members of the subcommittee in which the witness will testify.

Expert witnesses will be invited by subcommittees, through the Secretariat.

The plenum of the Steering Committee will convene on June 30 at 10 AM (in Hotel Stonebridge). We will review the Agenda, introduce changes, and adopt it. We will also set the frequency of the meetings of the subcommittees: once a week or twice a month. Then, it's work, work, work ... until we produce the Green Book and go with it to the public.

Download these files by clicking on the links or copy-pasting them to your browser window:

http://sc-healthreform.org.mk/blog/media/blogs/a/AGENDAFinancing.pdf

http://sc-healthreform.org.mk/blog/media/blogs/a/AGENDAGoodGovernance.pdf

http://sc-healthreform.org.mk/blog/media/blogs/a/AGENDAPatientsRights.pdf

http://sc-healthreform.org.mk/blog/media/blogs/a/AGENDAPharmaceuticals.pdf

http://sc-healthreform.org.mk/blog/media/blogs/a/AGENDAServiceDelivery.pdf

http://sc-healthreform.org.mk/blog/media/blogs/a/Matrica-Programa.doc