Health governance: reponses to and effects of COVID-19

Abstract

Purpose

The purpose of the IJHG review is to present an overview of the content of papers included in the current issue.

Design/methodology/approach

NA.

Findings

NA.

Practical implications

The practical implications are that readers will be able to gain an overview of the current content and thus select areas of most interest to themselves.

Originality/value

The originality of the IJHG Review is that no other journal in the Emerald suite provides a review of this type.

Citation

MacVane Phipps, F. (2021), "Health governance: reponses to and effects of COVID-19", International Journal of Health Governance, Vol. 26 No. 1, pp. 8-12. https://doi.org/10.1108/IJHG-12-2020-0132

Introduction

As the COVID-19 pandemic continues to affect health care systems around the world, governance of health services is thrown into stark relief. Dealing with a health crisis that both affects large numbers of people and continues over an extensive period of time can serve to highlight what is working well and what is failing in any given system.

NCDs in a time of pandemic

This is particularly visible in areas where health systems are grappling with concurrent non-communicable disease (NCD) pandemics such as diabetes, cardiac disease, chronic respiratory illness and mental health disorders (Allen, 2017). NCDs have traditionally been attributed to poor lifestyle choices, but in re-examining levels and patterns of these illnesses, it is evident that political, economic and social trends are driving the rise and spread of NCD (Allen, 2017).

The effects of NCD become even more acute when combined with an infectious disease outbreak such as the current COVID-19 pandemic. Fatalities caused by the existing chronic disease may be overlooked while a patient is also suffering from an acute infectious disease (Collins et al., 2021). While the infectious disease may ultimately be the cause of death, a patient without comorbidities may have survived.

Collins et al. (2021) point to the fragmentation of health care and suggest that multi-level governance must be stepped up in order to address the patient as a complex whole with multiple health care needs. This becomes even more critical in low and middle-income countries (LMIC) where rates of communicable disease (CD) such as malaria, TB and HIV/AIDS are already high. In a pandemic, this critical eye needs to be developed in all health systems, especially where resources are not adequate to meet total healthcare requirements.

Rationing and triage as a pandemic response

This became a global problem at the start of COVID-19 as the pandemic exposed how under-resourced many health services were in terms of both personnel and essential equipment (TolchinHull and Kraschel, 2020). Because of the global nature of the crisis, many essential pieces of equipment such as PPE and ventilators became subject to speculation causing quickly rising prices; this only served to exacerbate the problem particularly in LMIC without the resources to outbid richer health care systems (Pinho, 2021). Lack of equipment also led to confusion in public health advice with the WHO originally advising against face coverings for the public and then as more non-medical masks became available, recommending that everyone wear masks in public settings.

A dearth of equipment exposed the existing problem of health care rationing and triage. In Portugal, this problem quickly became acute because of the already low level of equipment in a health service, which is under-funded compared to many of Portugal's European neighbours (Pinho, 2021). In order to take the ethical and practical burden of decision-making away from individual doctors, it became apparent that a structured pandemic treatment protocol would be necessary.

TolchinHull and Kraschel (2020) point out that the problem of resource allocation is compounded by systemic racism within health care. Non-White patients and those who are socioeconomically disadvantaged die in larger numbers than White middle and upper class patients. Socioeconomic disadvantage does not explain the racial disadvantage. These inequalities are exacerbated during a pandemic as the total death rate from all causes is higher.

Pinho (2021) points out that in times of scarcity health care rationing, which often happens with implicit understanding of unwritten rules, must become explicit and transparent. People have a moral right to understand why decisions are made about who is admitted to hospital and how resources such as ventilators are allocated.

Yale New Haven Hospital in Connecticut, USA, together with many other hospitals uses the “2017 Maryland framework for the allocation of scarce life-saving resources”. This deprioritizes patients who have less chance of one-year survival following discharge (TolchinHull and Kraschel, 2020). However this adversely affects ethnic minority and socioeconomically deprived patients who are more likely to be living with co-morbidities. As NCDs are understood today to be the product of particular political and social environments (Allen, 2017) health care rationing needs to take the whole person, their pre-existing, immediate and future health needs, in order to formulate a plan of care that is ethical and equitable. In terms of distribution of resources, several solutions have been proposed to make this a more equitable exercise including first come, first served (FCFS), health care lottery or prioritization of the most ill. There are arguments for and against all of these solutions. A more uutilitarian solution suggests that resources should be allocated first to any front line health workers because their recovery will allow more people to be cared for.

Compliance with science-based health advice during a pandemic

Health governance during a pandemic is about more than rationing care and equipment. In order to combat the virus, the general public must comply with scientifically validated advice on reducing transmission. This is just as important for those who are asymptomatic as, for instance in the USA, 80% of those infected with COVID-19 are asymptomatic (Emanuel et al., 2020). It is unclear how infectious such people are in terms of the spread of the disease.

Sumaedi et al. (2021) studied compliance during the pandemic in Indonesia, specifically focussing on the “stay at home” policy. They discovered that peer pressure, including social media influencers and perceptions of social control are more important determinants of whether people comply with policy than worries about their own susceptibility to, or the potential severity of, COVID-19. People also disclosed being more worried by financial threats than by health threats and so might choose to work during a pandemic despite risks if they perceived the risk to their finances being a more acute problem than being exposed to an infectious disease.

Pinho (2021) discusses Portugal's success in dealing with COVID-19 quickly. Within two days of the first death in the country, a state of emergency had been declared with all schools closed and citizens encouraged to stay at home. The high compliance of the Portuguese people enabled the success of this strategy.

The use of mobile phone technology to deliver care and advice during a pandemic

Another area of health governance during a pandemic can be altering the methods used to deliver care. Pai and Alathur (2021) suggest that more use could be made of mobile phone– based health care, including medical consultations over the phone rather than the current requirement in India that they must take place face-to-face. They suggest a more cohesive collaboration between medical and technical experts to develop phone apps that could make a real contribution to population health during the pandemic. As examples they point to test and trace apps and a cough sounds app used to evaluate cough sounds and advise whether medical consultation is advisable. One problem in the current pandemic may be the very wide range of symptoms reported which vary in intensity and presentation from one person to the next. These have been difficult for live doctors to assess and therefore the development of a medically agreed algorithm to be used in an app might not be available for some time into the future.

Is diabetes the canary in the mine?

In considering the multi-dimensional quality of disease in the world and how this affects treatment choices and outcomes during the current pandemic, a starting point is examining the care and treatment of patients with diabetes in the USA. The USA is unique among the developed nations in that it has no universal health care system. Patients pay for health care through complex insurance programmes, either funded by employers or self-funded, or they pay out of pocket. A limited number of Americans receive coverage through the government Medicare programme for the elderly and the Medicaid programme for the poor (Peter G. Peterson foundation (2020)).

Diabetes is a metabolic disease characterized by high blood sugar levels. Long- term diabetes, particularly if untreated can lead to blindness, stroke, cardiac disease and poor circulation in extremities leading to amputation (Egede et al., 2021). Diabetics are a high-risk group during the current COVID-19 pandemic. Because the USA lacks universal coverage, the care and treatment of diabetics is very uneven. People without insurance tend to delay treatment and recommended regular check ups. People with diabetes report a lower life satisfaction than a matched non-diabetic population. Egede et al. (2021) examined the insurance cover of people with diabetes before and after the Affordable Health Care Act (AKA “Obamacare”). The sample of participants in this survey were made up of 50% with private insurance, 40% with public insurance and 10% with No Insurance (Egede et al., 2021). Interestingly the ACHA did not significantly increase the rate of insurance among patients with diabetes. It did however alter the balance of public and private insurance. The Peter G. Peterson foundation (2020) states that healthcare in the USA is more expensive than anywhere else in the world. Such high cost does not equate to excellence in care as some significant markers such as maternal and neonatal mortality, life expectancy and unmanaged diabetes are much worse in the USA than in other developed countries. How diabetes is managed may be an accurate marker for the effectiveness of any health service, making diabetes the canary in the coal mine.

The introduction of quality initiatives in Scandinavian healthcare

One group of nations with much better health outcomes than the United States are the Scandinavian countries of Norway, Sweden and Denmark. The Scandinavian countries, with their Social Democratic models of government, have enjoyed universal health care cover for many years. This has resulted in excellent levels of care, available to all residents. However such care has been criticised as quite paternalistic with a “doctor knows best” philosophy employed in health care decision-making. Currently traditional state welfare systems are facing challenges, which may present ethical issues for health professionals (Dhalborg et al., 2021). Health professionals and healthcare managers acknowledge that problems exist at three levels: the political, or how decisions about healthcare are made by elected officials; the legislative level, or how such decisions are incorporated into law; and healthcare, or how healthcare practice is altered by changes in legislation.

New quality control systems have been introduced into Scandinavian health care causing a shift in focus from evidence-based care to quality-based care. While quality is presumed to mean the highest quality of care for patients, it also demands quality in terms of value for money.

Value for money and value to the patient may present as two opposing outlooks. In a social system where the good of all is the predominant philosophy, patients may accept care that does not exactly match their expectations because it provides the greatest good for the greatest number of people. When the perception of quality shifts to what is desired by the individual, then conflicts can arise. This shifting discourse in Scandinavian health Care has seen power move from the state to a New Public Management (NPM) model in line with health care systems in other Western democracies. This can cause conflict for patients as they learn to balance the new quality discourse with that of the traditional social model and move from a paternalistic model of care towards one where the patient plays a greater role in decision-making.

Quality improvements at East London NHS Foundation Trust

Another example of changing patterns of governance related to the introduction of quality control is at East London NHS Foundation Trust (ELFT)

ELFT is a major supplier of mental health and community services, with quality improvement (QI) at the heart of organizational policy. ELFT provides care to socially diverse and socio-economically deprived catchment area, and achieving sustainable change has proved challenging. The Trust has invested in new training and resources to foster staff motivation, to establish clear and realistic project goals and to promote inclusivity (O’Sullivan et al., 2021).

The Care Quality Commission (CQC), an independent regulator with a UK government contract to inspect and monitor standards in all health and social care provision, identified ELFT's commitment to QI as a factor in their “outstanding” rating. QI is primarily about improving outcomes and experiences for service users. At ELFT, managers and staff believe that their commitment to change empowers service users and staff and facilitates a beneficial flattening out of traditional power hierarchies. This has a positive effect on morale and staff cohesion. As in the new quality initiatives in the Scandinavian countries, quality at ELFT is not primarily about reducing costs, although it does expect changes to produce value for money through increased efficiency and productivity. How quality initiatives have been maintained during the COVID-19 pandemic and how introduction of a quality improvement philosophy has contributed to high standards of care at a time health services are under severe stress would be a very interesting topic of a future report.

The papers selected for this issue of IJHG have not all been about COVID-19, but they all have included some degree of reflection on how to change practice for the betterment of patient care. At no time is this more relevant than today when health services around the globe attempt to juggle increased patient loads, the unknown factors relating to a new disease and a shortage of resources including human resource.