Health is declared to be an essential human right. The right to access healthcare services implies that the authorities have to formulate viable strategies that will ensure each citizen is as healthy as possible. In typical conditions, this right would be promoted through the provision of quality medical therapies and health services such as safe working conditions, a healthy environment, nutritious food, potable water, sanitation services, adequate housing, and most importantly, affordable and accessible healthcare services.[1] In particular, health is defined by the World Health Organization to be the state of complete social, mental, and physical well-being, as opposed to the mere absence of infirmity or disease.[2]
In this light, health is regarded to be the most significant determinant of human life, and also an essential resource in routine life. Therefore, this implies that the different world governments are responsible for providing healthcare services to all citizens in equal measure without discrimination.
In essence, the access to healthcare services should not be something discretionary. Rather, services that improve the health of the masses should be provided regardless of economic, political, cultural, social, and geographic boundaries and affiliations. [3] What is worrying is that many people across the globe suffer a number of obstacles with regard to accessing health services, and most countries – especially the developing ones – face significant challenges in sustaining basic healthcare that is able to respond to the fundamental needs of patients. This calls on governments and health stakeholders and providers to formulate an efficient system of healthcare whose principal purpose is to promote the health status of the population. This healthcare system should be designated to provide health service within the prevailing health sectors, and particularly within healthcare organizations.[4] According to the WHO, healthcare service is a distinctively designed initiative that is intended to meet the health requirements of patients through the utilization of the available resources, skills, and knowledge.[5] In line with this description, the principal goal of health care service is to restore, provide, and maintain society health status through treating people with compassion, dignity, and respect. Similarly, it would be imperative to note that to be effective at improving the health status within a region, health determinants should be parallel to healthcare services (as shown in figure 1).
Figure 1: The Right to Health (WHO, 2000).
As an important human requirement, the right to health is maintained through ensuring the availability of the underlying health determinants (as indicated in figure 1) and along with ascertaining the provision of the actual healthcare services. On its part, the World Health Organization supports various strategies in the global arena, such as integrated health service, plans and strategies for reform, evidence-based plans, and the development of health policies. [6]
The nature of these initiatives can be tailored to different country settings, with the critical role of expanding health coverage so as to shape the provision of healthcare services. It is because of the importance of healthy populations, that WHO enshrines healthcare provision to be a basic human right, and that should be delivered in a quality, accessible, and acceptable manner so as to sustain customer service.
Literature Review
Customer Service
A number of researchers have attempted to deduce the relationship between the healthcare sector and customer service. In his 2009 article, Goodman explains that one of the fundamental and globally agreed aspects of business and the healthcare sector is customer service. In particular, healthcare providers and business enterprises should develop systems with the ability to determine the requirements and expectations of patients or customers. Often, health systems are identified with the quality of their service delivery. Such service delivery is the combination of inputs into productive services that cater for the health needs of individuals and communities at large.[7]
What is promising is that healthcare industries, especially in the recent past, have attempted to transform to the citizen centralized care model, which provides accessible and more effective service.
In this regard, managing the relationship between patients (customers) and their healthcare providers becomes a significant aspect of healthcare management.[8]
This association is essential towards establishing trust, mutual understanding, and the involvement of patients in the healthcare system, which, in turn, fosters patient satisfaction in the quality of services that they receive. In this light, Cheng and colleagues elucidate that it would be imperative for healthcare providers to comprehend the significance of patients within the health sector. Besides, healthcare managers should understand the innate requirements and behaviour of patients, and devise mechanisms to enable them effectively address the requirements that solidify the loyalty and satisfaction of patients.[9]
Over the past few years, many developed nations have been introducing effective tools within their health care systems and organizations to foster a healthy interaction between the providers of care services and patients. For instance, the Electronic Health Record System in the United States is efficient at promoting patient-physician relations. What is evident is that Customer Relationship Management (CRM) has an important duty in the business world, and specifically in the capacity of health care systems. CRM refers to a deliberate technique used to manage the association between health and business organizations.[10] The key aim of CRM is to ensure that the existing customers remain in the system, while concurrently attracting more customers so as to attain business sustainability. With regard to the health environment, the CRM technique adopted manages the crucial relationship between patients and healthcare managers, which undoubtedly leads to patient satisfaction.
In a recent review of published scientific literature, Cheung and Stephens establish that managing the relationship between patients and health managers is paramount to the delivery of quality health services that enhance patient satisfaction.[11]
An important role of health providers and the health sector at large is to preserve this association so as to remain resilient in the current highly competitive environment. In this era of increased need for health services, a number of boundaries have been identified to affect the delivery of healthcare. Such factors that influence patient (customer) satisfaction and cause undesirable health outcomes or insufficient delivery of services within healthcare circles are explained below:
Money Buys Health
A key obstacle to accessing quality healthcare services is are excessive costs involved. Even though access to healthcare services is important to human life and a recognized human right, individuals continue to shoulder high costs with regard to accessing healthcare. In this light, the government should implement a program that enables all its citizens to attain health care services irrespective of their economic status. While health is an important human right, over 150 million people across the world are currently suffering due to the inability to meet healthcare financial requirements. An additional, 100 million individuals are placed under poverty line due to the high expenses required to cater for treatments.[12]
v In most developing nations, healthcare services are exorbitantly costly. Therefore, many poor people lack the financial ability to access high-quality medical services and therapy.[13]
Many people work for long hours but are unable to attain access to healthcare services due to the continued growth in healthcare costs. In this light, the government should implement measures aimed at curbing the increase in healthcare costs. This could include providing insurance coverage, especially to poor citizens. The costs of care should also be effectively managed to ensure patients access the needed services within their medical coverage.
v A pilot study that focused on the United Kingdom, Canada, New Zealand, Australia, and the United States indicates that high-income citizens are more likely to access and sustain care and to be more satisfied with the quality of care services provided as opposed to those with low-income status.[14]
Similarly, low-income United States citizens were found to be dissatisfied and reported many problems with regard to obtaining health care services, as opposed to those from the other nations.
v In their article, Sutherland, Fisher, and Skinner explain that poor people in the United States (low-income earners) are often in need of care services and medical treatment, rather than the high-income families (see figure 2).[15]
Figure 2: The Association between Income and Annual Medicare Spending (adapted from Sutherland, Fisher, and Skinner, 2009).
v Sutherland and colleagues further explain that citizens who have a desirbale economic status also have good access to healthcare facilities, and there average spending on healthcare services is nearly $3,469. However, people with low financial status are less able to sustain care, and there average spending on health services was nearly 6 times that of the rich ($21,064). Besides, the death rate was found to be significantly higher among families with low income as opposed to those with high income.
v In their article, Sutherland and colleagues also cite another study that was conducted in Los Angeles and established that the predicted healthcare spending and medical treatment far exceed the monthly wages of citizens. In Los Angeles, healthcare spending per capita stands at $10,810, while that in Minneapolis is at $6,705. Similarly, 15 percent of Los Angeles residents are placed below or at the line of poverty, while the rate is nearly 10 percent in Minneapolis.[16]
v Magnussen, Ehiri, and Jolly elucidate that a significnat number of developed nations continue to experiment with implementing an operative approach in the health sector so as to realize the basic needs of the population regarding patient satisfaction and treatments.[17] In addition, a number of countries have allocated funds to subsidize care services and ensure every patient gains access to medical treatment and with the required services.[18]
The rallying call is for the health sector to reduce cost so as to facilitate service delivery to the right people and at the right time.[19]
What is evident is that a health provider who fosters efficient service delivery is able to obtain more customer satisfaction.
v Public health organizations should respond more efficiently and effectively to the demands of patients, especially for the families that are privileged. One study conducted in Florida found that customer service and healthcare is mostly provided in privately owned facilities and not public hospitals and primary healthcare centers (PHCC).[20] For this reason, individuals with low income are incapable of accessing good and quality health services.
v Conversely, lack of insurance coverage is identified as another economic barrier to the access to healthcare services. Insurance is helpful in financing the health expenditure of individuals and ensuring protection against the rising health services costs. In areas with high healthcare costs, many people suffer to sustain full insurance coverage. Thus, families with low income are denied access to the most essential and necessary care. What is evident is that the high costs of healthcare have made most citizens unable to afford entire healthcare expenses. Therefore, the controllers of healthcare costs, both in the United States and other nations should reduce the charges for medical care and increase insurance coverage, so as to sustain medical interventions and healthcare access for all people irrespective of their economic status.
In particular, the concept of health and the accompanying costs should be considered more largely due to the economic rationale. Healthcare payers should be able to access proper care and appropriate medical treatments. As indicated in the literature reviewed, people are not able to access treatments and care services due to the high costs involved in care. For this reason, reforms in public policy should target all the users of care services, to ensure they receive the basic health needs, except for the most expensive treatment modalities.
The Current Health Situation in Kurdistan Region
The systems of healthcare significantly vary from one nation to another. Each country’s system comprises of a complex range of factors and aspects that are guided by the underlying historical patterns. However, each system of health care represents the stipulations of the country in which it functions. Apparently, the general aim of each country is to attain high-quality of healthcare services and that are feasible for the whole population; this is reflected in the health system.
With regard to the Kurdistan region, it comprises 3 governorates – Dohuk, Sulaymaniya, and Erbil. Available statistics indicate that the Kurdistan region is home to 5.3 million people.[21] Kurdistan also accommodates diverse nationalities, including Turkmens, Arabs, Kurds, Assyrians, Chaldeans, and currently an increasing population of refugees from Syria. Over the previous few decades, the healthcare system in Kurdistan has encountered numerous challenges that hinder health promotion and prevent future progress in realizing its missions, strategic goals, and visions. These problems are largely rooted in war, marginalization, and negligence by the central government, displacement, inadequate budget allocations, political conflicts, and limited knowledge in the area of health.[22] What is evident is that Kurdistan region has a healthcare system that is unable to provide curative healthcare services and treatments.
The Kurdistan Regional Government (KRG) is charged with ensuring access to fundamental services of health care to all its population. However, the increase in the number of citizens, especially within the previous 7 years, as a result of war and conflicts in other regions of Iraq and the neighboring nations has led to a prodigious need for primary healthcare services. In this light, the United Nations High Commissioner for Refugees (UNHCR) in Kurdistan reported that the number of Syrian refugees in Kurdistan had increased to 219,579 by March 2014, and the number was expected to rise. In 2015, more internally displaced people (IDPs) and refugees shifted from central and southern Iraq to Kurdistan. With this increasing population, the KRG with the support of foreign agencies strives to ensure access to health services so as to protect life and promote health within refugee camps. However, the fact that the Kurdistan Regional Government is unable to meet the healthcare demands of the increased population cannot be disputed.[23]
As a rational government, KRG emphasizes the importance of healthcare access among all residents. For this reason, the government has attempted to increase the healthcare status of the population. Key initiatives have been driven towards making care more affordable and efficient for communities. Beginning in 2006, the Kurdistan Board of Investment has pumped over $927 million into the healthcare system of the region.[24] $732 million of this investment was from the licensing process projects of the board, while the remaining $195 million is as result of the foreign investments of the nation. Simply put, the Kurdistan government holds the health status of its people with dignity and has invested in many health projects aimed at developing the health standards of the region.
However, the healthcare system of Kurdistan remains disorganized and fragmented. It is apparent that one of the main factors that prevent advancements in the Kurdistan system of healthcare is limited knowledge in the area of health. All key entities, including KRG, the Directorate of Health (DOH), and the Ministry of Health face deficiencies regarding how to deliver the preferred care services within the area. For this cause, KRG has signed an agreement with the Royal College of Obstetricians and Gynecologists of Britain to develop healthcare service in the area and help in modernizing the system via the provision of quality education and globally accepted health standards.[25] The Kurdistan Ministry of Health quoted that this collaboration will help in improving the healthcare system and ensure better living standards for the citizens. Similarly, supported by MOH, the Kurdistan Ministry of Planning provides varied developmental plans. This approach is availed to support the education of health providers, health practitioners, and health specialists abroad, and to, in turn, contribute to improving the health standards of the region. The strategy incorporates valuable workshops, training courses, and seminars for health specialists in providing quality patient health.[26]
Recently, KRG has begun to invest in the private health sector, such as pharmaceutical plants, clinics, and hospitals so as to introduce operational health policies and ensure sufficient delivery of services that otherwise cannot be sustained within public health facilities. The minister for health recently explained that investing in the private sector is risky as it results in differentiation between the poor and the rich. However, the reason behind the strategy is to start from the basics, then subsequently the public sector will once again be able to provide quality services as there would be competition.[27]
At the same time, the Kurdistan Regional Government works on increasing public awareness on health issues through media platforms such as social networks, television commercials, social networks, and radios.[28]
In addition, a number of weekly programs have been presented to make citizens aware of the importance of health. The aim of the campaigns and programs is to increase awareness in society.
From the initiatives by the government, slight improvements have been recorded in the healthcare system over the last 10 years, especially in the private sectors. However, the region continues to suffer from relative weaknesses in many aspects especially regarding the delivery of healthcare services. Even though KRG has embraced many strategies to improve the health system, it is unfortunate that many of this strategies remain in the planning stages, without full implementation and/or monitoring. While planning is an important practice within the system of health care, initiatives cannot benefit the citizens without full implementation and continued supervision. In this light, the government should foster a more productive healthcare system that is able to improve the delivery of health services. It is evident that healthcare is among the most significant priorities in human life, and the quality of healthcare services should be considered the foundation in revitalizing Kurdistan’s system of healthcare. The rationale is that healthcare services should legitimate the requirements and expectations of patients, and increase the contribution of citizens within the economy of the Kurdistan region.
Conclusion
The current paper has offered a comprehensive reflection of the factors that impact healthcare service delivery in Kurdistan region from the perspective of public health organizations. Healthcare services in Kurdistan are provided within public health sectors and at a very low charge. However, the healthcare system of the region has significantly deteriorated and continues to tackle many problems as a result of political conflicts, wars, a limited financial budget, economic sanctions, overutilization of service, and an imbalance in the distribution of medical staff. The healthcare system of the region has not escaped from this problems. Even though the ministry of health has embraced various plans and projects, the strategy performs poorly due to ineffective management functions within hospitals. In this paper, different units of analysis have been reviewed to determine their perspectives and offer a deeper understanding of the problem. Most importantly, the study aimed to explain the experiences and concerns of the participants about the Kurdistan healthcare system at large. What is evident is that the Kurdistan system of healthcare is in a critical condition and needs to be reformed, especially in the area of management so as to deliver better customer service, which is an aspect of priority within the system of healthcare. However, management is a major determinant of healthcare reform with the aim of providing quality services and a true picture of hospitals to patients. Therefore, the Kurdistan healthcare system has to be reformed to improve on management. For instance, in the interview session patients emphasized strongly that poor leadership and management are the main factors that impede customer service delivery.
Healthcare management is a process that seeks to ensure smooth operation of the healthcare system and facilities, and eliminate elements that obstruct the efficiency of the healthcare system. Currently, many chances have emerged for people to become managers within the healthcare field. The prevailing environment and surrounding of healthcare organizations comprises many forces that call for extraordinary changes within healthcare facilities. These forces comprise increased customer watch, strengthened government pressure, changing demographics, and a rise in competition. Responding to such challenges requires efforts on the part of healthcare organizations to ensure they produce new values. In a sense, healthcare is an information-intensive process and pressure is rising for professional healthcare managers, especially is the era when health organizations are looking for new ways to enhance quality, reduce costs, and be able to operate in line with managed care requirements.
In general, management in healthcare is regarded to be a second level responsibility and is treated as a routine task. Managers within healthcare spheres are more concerned about medical care as opposed to managerial functions within the health organizations. As explained by Alwan, the healthcare system of Kurdistan comprises of a Biometric Model which necessitates health managers to be doctors as opposed to those with professional managerial skills.[29]
Nechirvan Barzani – the Kurdish Prime minister – once acknowledged that the healthcare system has performed poorly in the area of management.[30]
For this reason inadequacies in management have caused insufficient healthcare delivery which leads to lack of customer satisfaction across the entire region. However, it would be imperative for healthcare providers to maintain the rights of patients.
Recommendations
v First, the Kurdistan Ministry of Health should formulate an operational process of recruitment and selection across the region in a similar manner to that implemented by foreign countries. Healthcare managers should also raise a proposal to change the routine process that results in poor health providers within the region.
v With regard to doctors, the management should establish an adequate workforce through the selection of doctors who have graduated from leading universities located outside the region. Such doctors can bring their experiences and contribute to improving the healthcare system in the region.
v Health managers should embrace globally agreed healthcare policies and apply to their daily work. Similarly, they should research and determine functional rules that can assist health workers to perform better and shape the efficiency of healthcare organizations.
v The Ministry of Health should provide more training to healthcare leaders, especially the health managers. Similarly, the Ministry needs to formulate and implement a system of monitoring to continually evaluate the performance of healthcare managers after the training program.
v Doctors, health managers, and other workers within the healthcare sector should also be educated and trained in countries with effective healthcare models.
v Healthcare leaders should be trained more, especially in the area of management so that they comprehend the importance and application of key managerial techniques such as SWOT analysis and TQM.
v The overall management in healthcare organizations should conduct weekly meetings with other departments. The aim of such meetings would be to provide written weekly duties and motivate the staff.
v Equipment in the hospitals should also be supported by internationally leading firms in medical equipment and pharmaceuticals. The rationale is that if some of this internally recognized companies visit local hospitals, the hospitals will be motivated to acquire this equipment.
v Hospitals should provide an organized and smooth structure to assist patients, especially in cases of emergency.
v The mission of the management should be dedicated to improving the quality of care and promoting health delivery so as to enhance the satisfaction of patients.
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[25] Alwan, 2004,
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[27] Alwan, 2004 explains the mechanism through which investing in the private health sector can lead to improved services for all.
[28] KASO, 2009.
[29] Alwan, 2004.
[30] Rudaw, 2014.
