Lack of involvement in policy making

An identified sub-theme concerned providers’ perceived lack of involvement in the policy development process. In their accounts they emphasised their feeling of exclusion from the processes that directly affected their daily work. Physicians were more emotional about having a chance to participate in the policy making, whereas pharmacists, were not as concerned with their involvement in consultation processes. Several physicians admitted there might be some processes - consultations through their professional association body for example - but most were not aware of when and how these processes had happened, and doubted if they actually existed. Several of the physicians expressed a very sceptical view, with one participant believing that most of the policies had been ‘invented’ by someone ‘who was never a practicing doctor’ (PCP5). Overall, there was a perceived lack of communication, which exacerbated the sense of a lack of involvement and a didactic approach:

“I don’t think anyone was ever invited to tell our problems…maybe the associations…we are only invited when they [Ministry and HIF] want to inform us of the new rules. Sometimes not even that, they simply send them in an e-mail as instructions.” (PCP7)

Providers believed that policies should not be developed without their participation, and were persuaded that officials and policy makers without practicing experience particularly in primary care could not develop appropriate policies:

“I don’t think anyone working in the Ministry and not in the primary health care should create a policy; one should have experience in the field.” (PCP6)

should we, even if we read and don’t agree with everything, we still have to sign them. Otherwise, I’d be out of work, and what patient would come to my private practice? So I accept everything.” (PCP3)

Although wanting to be part of the process, providers were not very articulate about how this involvement could be achieved. Only two providers, however, expressed their ideas on how they could be involved, mentioning online consultation and surveys:

“Well, maybe before sending out a plan of activities or measures, they could include us by making surveys on whether we agree on some issue or not….” (PCP6)

Among pharmacists, there were also several who did not feel they were consulted enough. One respondent shared an example of an initiative among small pharmacies to become a relevant voice at the negotiating table, which in her view, as depicted in the first quote below (Ph6), was not adequately recognised. Instead, as illustrated in the second quote, they felt that they simply had to deliver on the decisions, without being asked ‘if they can do it’ (Ph4):

“Large pharmacy chains like […] and […] are very strong, I don’t have such position…We [small pharmacies] got organized in the Joint Pharmacies of Macedonia, there were benefits for joint procurement, having one voice, but still the HIF does how they think, we didn’t get to change much…” (Ph6)

“We get letters or e-mails with decisions, what, how to do…there is no question in those mails if we can do it…I don’t even want to send reply back with a question, as they will see who is sending and maybe they will send me an inspection…” (Ph4)

Lack of involvement in the policy making was expressed also as not being consulted on the list of treatments made available to patients. As noted in the earlier sections, some

of the medicines typically prescribed at primary level were raised at higher level of care and could be prescribed only upon specialist recommendation. The purpose of such decisions was argued by policy makers to relate to controlling consumption of very expensive medicines (as exemplified in the quote by EI7 earlier (page 144), under the sub-theme of autonomy), but was interpreted by physicians as a lack of involvement, as they were not consulted on such decision.

“We are limited as [primary health] doctors to treat the patients in accordance with the knowledge we have acquired...if I know a patient is well off, I might suggest to buy the medicine out-of-pocket, if it’s better than the one on the insurance” (PCP7)

“I want to be treated as a professional. I am not here to take anything from them, I’m here to do my job, and I deserve to be part [of creation of policies].” (PCP16)

As reflected in this quote, and articulated by other physicians as well, after privatisation, there was a notion of divide - a sense of them and us - which was interpreted as widening with the introduction of the subsequent policy changes. As a prevailing perception among the providers, this detachment from the system was considered an important finding and interpreted under a separate sub-theme and is described in the next section. Based on their expressed perception of lack of involvement in policy making, providers were asked to reflect on possible ideas they might have shared if they were invited to participate in policy creation processes. From these discussions and across other parts of interviews, it was apparent that providers found it difficult to identify specific suggestions. So, although having strong feelings of being unrightfully distanced from the

involvement. There was, however, a belief among most of the providers – especially physicians – that, if given the chance to exert influence, they would either revert to the previous system or waive some of the restrictions and administrative burden imposed with the changes. The first of these propositions is consistent with the views expressed in section 5.2.1. The second suggested more of a concern around possible bureaucracy and process and did not appear to be related to the main concern about a lack of involvement for providers. However, one respondent did express a view as to how policies should be changed to improve providers’ position:

“…as there is a budget ceiling setting the limit we cannot exceed, there should be a lower limit [threshold] that we mustn’t go below as well. If somebody doesn’t spend the estimated amount of money, he [sic] should be rewarded. There should be rewards as there are sanctions.” (PCP3) It was also interesting to observe that elites, in particular policy makers did not consider it problematic that providers were only informed about policy decisions that they were asked to conform to. In policy makers’ accounts, providers were mostly mentioned as part of the implementation process, and policymaking was seen as the work of government institutions including themselves or institutions they represented. In this way, they appeared to implicitly delineate the responsibilities: policy makers – for policymaking, and providers – for implementation. Overall, the issue of involvement of diverse stakeholders in the policy making process was covered rather vaguely in their accounts. Policy makers were unanimous in acknowledging the necessity for involvement, but this appeared to be manifest more in a symbolic rather than actual way; only a few policy makers advocated or actually gave examples of provider involvement in policy development, mostly through providers’ associations.

Apart from the involvement in policy-making, participation of providers in development of clinical protocols and evidence-based guidelines was mentioned. Providers’ opinions were diversified and at one extreme were those who had no opinion on who should be involved in writing such protocols. In contrast, others considered their non-involvement to be a problematic limit to them expressing their professional knowledge and potential for providing best care to patients. In line with the latter, one policy maker respondent raised the issue, confirming lack of providers’ involvement, despite her view that it was critical to ensuring ownership and adherence to such standardized procedures: “This is exactly what I was talking about earlier. Before it [the guideline] is accepted and finalized by the [Health Insurance] Fund and the Ministry [of Health] as a public document, to make the draft available for discussion and review to the doctors in their Association or on their web site, so they can provide their input and express their thoughts about the guideline. In that case the guidelines will be more acceptable for all of them.” (EI6)

Other policy makers also considered evidence-based guidelines to be essential for containing costs and providing better quality of care, but as mentioned earlier, they have not made clear connection between guidelines development and providers’ involvement. Rather, in the view of the majority, this was the role of academia in collaboration with the Ministry of Health and Health Insurance Fund.

The issue of involvement of providers in policy making has not been explored with the patient group, for obvious reasons and the earlier discussed lack of knowledge within this group on policies and policy processes in which they were developed.

extent, ultimately providing a mixed message in arguing that provider involvement was important, but that delineation of responsibilities between policy making and implementation was also necessary. Crucially, it was apparent that elite stakeholders viewed providers as part of the latter in practice. The next section explores crucial consequences related to implementation for providers, manifest as a lack of support and a perception of detachment.