What the Inquiry found
In May this year the Cabinet appointed a Commission of Inquiry to consider the proposed organizational structure of the merger between the Ministry of Health and the National Health Services.
Prominent lawyer and former Attorney General, Taulapapa Brenda Heather-Latu, chaired the Inquiry. Commission Members include Professor Fui Asofou So’o and Fa’amausili Dr. Matagialofi Lu’aiufi. The lawyers assisting the Commission were Sefo Junior Ainu’u, the Assistant Attorney General and Chief Public Solicitor, and Shalon Time, a State Solicitor.
The Commission’s terms of reference were:
• To review the structure that has been proposed for the merger of the Ministry of Health and the National Health Service;
• To consider the concerns raised by nurses;
• Consider and recommend options regarding the proposed organizational structure.
• Consult the representative for nurses, as well as representatives of the relevant
• government agencies presently engaged to bring the merger into effect;
This is the summary of findings by the Commission of Inquiry published verbatim:
1. The proposed structure ‘Taskforce Structure’ tabled before Cabinet on 9 March 2018, is unlikely to deliver the expected outcomes arising from the (re) merge of NHS and MOH decided by Cabinet in April 2017 in FK(17)13, insofar as the functions attributed to the three Deputy Director General positions in the proposed structure mix administrative and clinical functions to such an extent that there is a lack of clarity in respect of clinical and administrative and accountability, and the structure is overly complex;
2. As a result of its deliberations, the Commission has prepared and recommends an alternative structure called the ‘Commission Structure’ which is based on the two areas of critical governance in the Health sector consisting of:
a. Corporate Governance and Improvement; and
b. Clinical Governance, Public Health and Hospitals, from which the rest of the new health organization cascades down.
This recommended structure specifically separates the use and monitoring of all physical assets and resources under a single Corporate Governance and Improvement grouping called the ‘Corporate Governance’ pillar. A separate grouping is responsible for the delivery of health services to the public, (both hospital based clinical services and community based services), and provides the oversight for the many professional groups who provide all forms of medical and clinical care and treatment, as well as public health initiatives, all to be managed under a single ‘Clinical Governance’ pillar.
3. The ‘Commission Structure’ also includes the detachment of the professional monitoring of standards, as well as all public complaints which we propose are dealt with by an independent office from the Ministry called the Health Ombudsman (or Health Commission) which houses the qualified professionals who monitor professional standards, as well as an investigation unit for public complaints which reports to the Health Ombudsman/Health Commission, which in turn reports directly to the Minister of Health and Cabinet;
4. The Commission Structure also reintroduces a Health Advisory Board to support the work of the sector, and also proposes an avenue for seeking and receiving direct input from community representatives about the quality of the services being provided throughout the country and if approved will require an urgent review of Health legislation.
5. The Nurses’ complaints about the Taskforce Structure excluding recognition of their particular functions and responsibilities, is well founded, and we recommend the inclusion of an Executive Nursing and Midwifery role under ‘Clinical Governance’.
6. This Executive Nursing role should, in our view, be focused on how Nurses can provide the optimal support to health service delivery in every unit and health facility in the country, and focus on the interests of the whole health sector (instead of managing individual nurses), and provide positive input on broad issues such as: the strategic deployment of nursing staff across all clinical areas and across the hospitals and districts; career development and up skilling of all nurses; maintaining high professional standards, rather than exercising direct authority over nursing allocations, which in the Commission’s view must ultimately be decided by the DDG of Clinical Governance, and the Heads of Clinical Units, in consultation with the senior nurses in those Units.
7. The Executive Nursing role is designed to be collaborative and cooperative and should contribute positively to the proposed multidisciplinary ‘team’ culture for all frontline clinical services, personal qualities which should be identified as essential personal qualities of the senior Nurse/Midwife who will be eligible to fill this role.
8. In general, the diversion of core funding for health services to fund excessive administrative or bureaucratic processes and positions (including duplicated non-technical roles and a multiplicity of mid-management positions), is, we believe, a fundamental misuse of the extensive public resources and aid assistance allocated to the Health sector, which we consider should be sharply targeted and closely monitored to ensure all Health expenditure contributes to either, the effectiveness and efficiency of actual clinical and hospital services or public health programs, or the delivery of adequate health services beyond the Apia urban area, including MT2 Hospital at Tuasivi and all rural areas in Upolu and Savaii.
9. There is a fundamental lack of effective LEADERSHIP over and within the Health sector, which is now in a critical state of dysfunction and has been torn asunder by sector wide hostility, suspicion and conflict. This woeful state of affairs has been allowed to continue, and indeed flourish through a lack of attention and an unwillingness at the highest level to stamp out the destructive behavior and arrogant behavior of certain sector health leaders and their followers. The existing discord between senior officers within MOH and NHS was further elevated by the passage of the NHS Act 2014 which significantly altered the statutory balance between regulatory oversight and service delivery, resulting in the 2006 statutory framework (the product of an extensive World Bank funded project) being compromised and rendered unworkable.
10.The use of the health sector as a ‘battlefield’ amongst senior health professionals, and the long standing conflict between Doctors and Nurses, is an abuse of their privileged position and a chronic waste of public resources at a time when the public still languish for long hours to see the few overworked doctors and nurses at TT Hospital in Apia (which is apparently a luxury if you live in Savaii where there is no registered Doctor available at any time), and in a system where there are still shortages of basic supplies, and is both disgraceful and symptomatic of managers who have misplaced their sense of responsibility, and misused their time and public resources to fuel conflict rather than focus on whether the public have access to efficient, clinically safe and humane care and treatment. Little kindness is evident from these stony faced, obstructive and aggressive senior members of the National Health Services workforce, some of whom, we are told, consider undertaking basic tasks in the wards demeaning and beneath their dignity, and shame the very professions to which they belong;
11. There has been a demonstrated lack of robust and practical monitoring by core agencies such as: Ministry of Finance ‘MOF’; Attorney General’s Office ‘AGO’ and the Public Service Association ‘PSC’, and a lack of such specialist oversight over this important sector, which has led to the growth of administrative roles and positions in both NHS and MOH; a change in operational coherence of the sector through the passage of a new Act in 2014, (which allowed NHS to effectively ‘opt out’ of the current sector structure), leaving MOH practically redundant with the passage of the new Act. MOH’s response to these events was primal and led to a proposal to Cabinet resulting in the total change of a national policy and sector structure when the Merge of NHS and MOH was approved by Cabinet in April 2017.
12. The approval of such a radical policy change from the Government’s 20 year reform agenda (i.e. to separate regulatory oversight from service delivery) strongly suggests a greater level of oversight and consistency is needed throughout the public service, to ensure the existing Government policies are either adhered to and considered (when significant policy changes are proposed by any Ministry or government agency), in order to ensure that the policy advice supplied by the core agencies to Cabinet on any matter is correct, robust, honest, consistent and supported by facts which then allow Cabinet to make informed, accurate and suitable decisions in every case. Seeking and receiving approval for a total sector regime change without adopting a considered or investigative process justifying such a radical policy shift, has exposed the weaknesses in the decision making process within the sector as well as across central government agencies. The apparent lack of ‘institutional’ memory and any understanding of the purposes behind broad Government policies, has further undermined the effectiveness of the Ministries concerned.
13. A lack of personal and professional discipline also played a significant part in the continuation of the dysfunction in the sector, where personal hostility and personal interest was allowed ‘free rein’ over policy and administrative decisions, thus misusing the public health system as simply a backdrop for personal agenda rather than a positive site for their committed and dedicated employment. The movement of nursing staff for no good clinical reason was cited as an example of the misuse of authority said often to be motivated by spite and not for the appropriate clinical reasons in a system which has allowed certain managers the freedom to act selfishly and aggressively (to continue or protect their own personal agenda), and is an sad indictment on the prevailing management culture in the sector.
14. A fundamental change in attitude of all Health sector workers is the Commission’s own prescription for the terminal condition which the sector is currently manifesting, an attitude of selfishness and mala fides (bad faith) which lies at the heart of the conflicts and disagreements which has paralyzed the service for many years. The Commission strongly recommends the conduct of a formal process of RECONCILIATION between the leaders of the warring occupational groups, and the need for a nationwide resetting of health sector goals where the best interests of patients and the needs of the public, dictate the form of health administration we have, (and not groups of privileged self- centered office bound jet setting combatants), whilst the vast majority of ill- treated underpaid staff continue to work hard and do the best with what they have, whilst ‘the war’ rages above and around them.15. The periodic threats to strike by both Doctors and Nurses have become an increasingly common feature of the sector’s industrial relations over the past few decades, and has become a threatening and bullying tactic which reflects a lack of acknowledgement from health sector leaders for the majority of health professionals who work hard with little respect and recognition yet who operate within a sector which receives more money and more resources than any other in the country, which perhaps suggests that it is in their hands to better utilize the funds they are already given rather than to further deplete the available budget for the work of all other sectors combined. This default setting where doctors or nurses threaten to leave their duties also does not befit the professions said to be ‘caring’ in nature and focused on the welfare of others. The ‘strike culture’ is however reflective of the degree of hostility within the sector and it suggests such action is considered the only possible avenue by those groups to convey dissatisfaction with management - a matter which also needs to be addressed and disabled as a matter of priority.16. The work of the Samoa Health Sector is crucial to the lives of the people in this country, who each deserve a health system which cares and treats them when needed, protects and offers them knowledge to avoid preventable diseases, and allows health professionals to perform their duties and functions without being unduly hampered by a lack of resources or respect.17.Fundamental, elemental and extensive change is needed in the sector immediately in order to save and protect people’s lives – there is no room for delay or prevarication – Samoa’s lives count.