Health Care Systems Management Dissertation

Health Care Systems Management

As the society grew and evolved, its focus on healthcare increased and it has eventually come to a situation in which the life expectancy at birth doubled or even tripled. Macau is for instance the country with the highest life expectancy at birth with 84.36 years. It is followed by Andorra with 82.51 years, Japan with 82.12 years and Singapore with 81.98 years. At the other end sit Angola with 38.20 years, Zambia with 38.63 years, Lesotho with 40.38 years and Mozambique with 41.18 years (Central Intelligence Agency, 2010).

The past few decades have witnessed numerous processes of global change, one of the most important of them being the liberalization of markets and the globalization of not just economies, but cultures, technologies and societies. These values commenced to transcend boundaries and impacted the corresponding values in order global regions. But despite this process of globalization, differences remain obvious is various fields. One of the most relevant examples is offered by the healthcare sector. While the globally observable trend has been that of improving the living conditions for the populations and increasing the life expectancy, the means in which countries approached this goal vary.

A most relevant significance is noticeable — like many other elements — in terms of the western hemisphere vs. The eastern hemisphere. While the West has strived to improve the health of its citizens through technological innovations, the East has focused on making medical services more easily accessible for the entire population. Unfortunately enough however, the two alternatives proved rather exclusive and a notable example in this sense is offered by the case of Kuwait, where medical reform was conducted to increase the population’s access to medical services, but in the process, innovation and advancements were neglected.

The current research endeavor strives to assess the status of the Kuwaiti health care system and retrieve a relevant image of the situation. In order to accomplish this, it will construct a twofold approach. On the one hand, the basis of the research endeavor would be constituted by the analysis of the available literature in order to identify the situation as presented in secondary sources. On the other hand, an attempt will be made at assessing the situation through primary sources of information. Specifically, the analysis would be conducted through the lenses of the patient perceptions, as well as the medical staff perceptions over the status of the Kuwaiti health care system.

The assessment of the primary sources of information — patients and medical staffs — would be completed through a survey of the two categories of individuals. The selection of the research tools and techniques has been completed with the aid of the onion ring research methodology which revolves around the gradual answering of several questions, referring to elements such as the research philosophy, the research strategy, the research choice and so on.

Relative to the findings of the research process, these indicate elements such as technological limitations, training necessities or the required emphasis on prevention as well as treatment. In light of these findings, recommendations have been forwarded. They for instance include the offering of training to the staff members; the offering of better support for the educational system; the focus on disease prevention or the development and implementation of several strategic courses of action, originated from the private sector but with enhanced abilities to support managerial advancement in the public sector.

2. Research aims and objectives

The scope of the current research endeavor is that of objectively assessing the status of the Kuwaiti health care system and, in order to attain relevant findings, the research would consider the stand points of both patients as well as medical staffs. As the condition of the Kuwaiti health care system is overviewed, specific recommendations would be made. The very set of recommendations to be offered represents the practical significance of the current research endeavor, whereas the actual study represents the theoretical significance of the project.

At a more specific level, there are five sub-themes associated with the research project. They also represent the key questions of the study, and they are presented below:

Question 1: How can medical reporting errors be improved?

Question 2: How can performance management practices be improved?

Question 3: What is the patient perception over the provided services?

Question 4: What is the staff perception over the provided services?

Question 5: How does the media’s portrayal of the provision of healthcare in Kuwait impact the perception of staff and patients over the healthcare system?

In order to answer the above posed research questions, several smaller objectives are set. In this order of ideas, it is initially necessary to review the specialized literature in order to place the research questions in context. The literature review would constitute the starting point not only in the analysis, but also in the creation of the survey as it would create the background and would identify the issues to which attention should be paid. As the literature review is completed, the next sub-objective of the research endeavor is that of identifying the most adequate research methodology. As with most research elements, the researcher cannot simply adopt a specific technique, but this has to be selected in specific accordance with the research particularities.

The third objective is then that of combing the three research components — the information in the specialized literature, the sample and the research tools and techniques — in order to generate findings. This scope would be obtained through the processes generically called data analysis. The final objective of the paper is then the integration of all findings into a single, unified section restating the most important findings. In the aftermath of this process, a series of recommendations would be constructed and presented.

3. Literature review

3.1. The general context in Kuwait

Kuwait gained its independence in 1961, up until which point it had been ruled by the United Kingdom. In 1990, the country was invaded by Iraq and a resolution of the conflict was only possible the following year, after the intervention of the United Nations (promoted by the United States of America). The 1990s decade witnessed a deeply challenged Kuwait, struggling to rebuild the country as its infrastructure had been severely impacted by the armed conflicts.

The country’s location in the Middle East, bordered by the Persian Gulf, Iraq and Saudi Arabia means that the country is generally characterized by the problems of the region, such as relative high resistance to globalization as it is understood as Americanization or westernization, regional conflicts or high income inequalities. The geographic conditions in Kuwait are rather tough, with only 0.84 per cent of the entire land being arable. The weather is generally dry due to the dessert, with intense and hot summers and short and cool winters. The country’s main natural resources are petroleum, fish, shrimp and natural gas. Kuwait is facing several environmental issues due to both natural hazards as well as problems within the environment. In terms of natural hazards, these include sudden cloudbursts, heavy rains, sandstorms and dust storms. Relative to environmental concerns, these include “limited natural fresh water resources; some of world’s largest and most sophisticated desalination facilities provide much of the water; air and water pollution [and] desertification” (Central Intelligence Agency, 2010).

Officially entitled the State of Kuwait, the country is a constitutional emirate with its capital in the Kuwait City. The country is territorially divided into 6 administrative regions and the legal system is based on civil law, with strong Islamic influences. Kuwait has yet to adopt the jurisdiction of the International Court of Justice. The state representatives are elected by popular vote and the suffrage age is of 21; men in the limitary are not allowed to vote and the women’s right to vote has only been granted in 2005.

The Kuwaiti population totals up to 2,692,526 individuals, being as such the 140th largest population on the globe (the top was constructed by the Central Intelligence Agency and it integrates 238 countries). In terms of ethnicity, the majority (45 per cent) are Kuwaitis, followed by other Arabs with 35 per cent, South Asian with 9 per cent, Iranians with 4 per cent and other ethnicities with 7 per cent. The predominant religion is Muslim (85 per cent of the entire population) and it is followed by Christianity and Hinduism. The official language is Kuwaiti, but English is highly common. The literacy rate is of 93.3 per cent, with the average Kuwaiti expected to spend 13 years in school. The proportion of the national income spent on education if of 3.8 per cent.

The largest proportion of the individuals (70 per cent) is of ages between 15 and 64 and the total median age of the population is of 26.4 years. The life expectancy at birth is of 77.71 years, with 76.51 years for males and 78.96 years for females. The Kuwaiti population grows at an annual rate of 3.549 per cent; the net migration rate is of 16.01 migrants in 1,000 individuals and the large majority of the population (98 per cent) lives in urban areas. The infant mortality rate is of 8.97 deaths per 1,000 live births. This rate places Kuwait on the 160th position on the chart of the CIA. The adult prevalence rate of HIV / AIDS is of 0.1 per cent.

In terms of economy, Kuwait is a relatively open, small and wealthy economy. It relies extensively on oil exports — petroleum exports for instance account for 95 per cent of the total export revenues as well as for 95 per cent of the federal income. The Kuwaiti representatives have recently set the goal of increasing the oil production per day. Currently, Kuwait is facing the pressures of the internationalized economic crisis — which however, due to recent economic surpluses in Kuwait, affects the economy to a lower extent.

Simultaneously with the increase in oil production, the Kuwaiti authorities are also focusing on diversifying the economic activities in the sense of supporting non-oil related operations. “Kuwait has done little to diversify its economy, in part, because of this positive fiscal situation, and, in part, due to the poor business climate and the acrimonious relationship between the National Assembly and the executive branch, which has stymied most movement on economic reforms. Nonetheless, the government in 2009 passed an economic development plan that pledges to spend up to $140 billion in five years to diversify the economy away from oil, attract more investment, and boost private sector participation in the economy. Increasing government expenditures by so large an amount during the planned time frame may be difficult to accomplish” (Central Intelligence Agency, 2010).

In a more numeric format, the following economic variables are noteworthy:

Kuwait registers a gross domestic product of $142.1 billion, being as such the 59th largest economy of the globe

The GDP growth rate has been a negative one of 1.7 per cent

In a context in which the global income per capital is of $10,500, the Kuwaiti income per capita is of $52,800, making Kuwaitis the seventh wealthiest population on the globe

51.5 per cent of the GDP is generated by the services sector, 48.2 per cent is generated by the industry sector and only 0.3 per cent is generated by agricultural activities

The labor force is of 2.04 million individuals and the unemployment rate is of 2.2 per cent

The inflation rate is of 4 per cent

Exports account for $50.25 billion and imports account for $17.09 billion

The telecommunications industry in Kuwait is rather underdeveloped, with as few as 541,000 main telephone lines in use and less than 3 million mobile telephones in use. In terms of internet users, these do not exceed one million. There are seven airports and 4 heliports in Kuwait as well as 5,740 kilometers of roadways. From this standpoint, the country’s infrastructure is rather underdeveloped.

Relative to the status of crime in the society, Kuwait is currently facing severe problems of human trafficking. The country is a desirable destination for South Asian immigrants looking for a better life, but these are often abused upon arrival and employment. The Kuwaiti authorities have yet to efficiently address the problem. “Kuwait is a destination country for men and women who migrate legally from South and Southeast Asia for domestic or low-skilled labor, but are subjected to conditions of involuntary servitude by employers in Kuwait including conditions of physical and sexual abuse, non-payment of wages, confinement to the home, and withholding of passports to restrict their freedom of movement; Kuwait is reportedly a transit point for South and East Asian workers recruited for low-skilled work in Iraq; some of these workers are deceived as to the true location and nature of this work, and others are subjected to conditions of involuntary servitude in Iraq. […] Kuwaiti government has shown an inability to define trafficking and has demonstrated insufficient political will to address human trafficking adequately; much of the human trafficking found in Kuwait involves domestic workers in private residences and the government is reluctant to prosecute Kuwaiti citizens; the government has not enacted legislation targeting human trafficking nor established a permanent shelter for victims of trafficking” (Central Intelligence Agency, 2010).

3.2. The health care system in Kuwait

a) Brief history

Medical services in Kuwait are as old as the country itself, but the evolution of the medical system was only commenced starting in the early twentieth century. During the 1910s decade, the country was abundant in American missionaries, who offered medical services to the population. These missionaries represented the first and foremost medical trainers and they set the basis for the development of Kuwaiti health care. The involvement of the American missionaries was due to the fact that Shaykh Mubarak Al Sabah the Great — the ruler of Kuwait — had “invited doctors from the Arabian Mission of the Dutch Reformed Church in the United States to establish a clinic. By 1911 the group had organized a hospital for men and in 1919 a small hospital for women. In 1934 the thirty-four-bed Olcott Memorial Hospital opened. Between 1909 and 1946, Kuwait experienced gradual, albeit limited, improvement in health conditions. General mortality stood between twenty and twenty-five per 1,000 population and infant mortality between 100 and 125 per 1,000 live births” (Regional Health Systems Observatory EMRO).

By the 1940s decade, the country was beginning to register the first significant revenues from oil exports. The state officials used the money to invest in the health care system and by 1949 they had opened the Amiri Hospital. The Kuwait Oil Company had also launched investments in health care and had primarily opened several smaller size medical care clinics. By 1950, the mortality rate had fallen to be somewhere between 17 and 23 per 1,000 individuals and the infant mortality rate had also decreased to 80 — 100 deaths per 1,000 live births.

During the 1950s decade, the Kuwaiti authorities developed and implemented a comprehensive plan to develop the medical system. The main scope was that of ensuring medical assistance for free to the entire Kuwaiti population. The free access to medical services was so increased that it even included veterinary services. The developments were possible with the aid of foreign medical staffs — especially Egyptian medical doctors — and the endeavor came to cost Kuwait one third of its entire national budget. The main critique brought to the reform was that it focused on treating the illnesses, rather than preventing them. Nevertheless, the reform did materialize in a series of positive outcomes. “The number of doctors grew from 362 in 1962 to 2,641 in 1988. The doctor-to-patient ratio improved from one to 1,200 to one to 600. Infant and child mortality rates dropped dramatically; in 1990 the infant mortality rate was fifteen per 1,000 live births. Life expectancy increased ten years in the postindependence years, putting Kuwait at a level comparable to most industrialized countries” (Regional Health Systems Observatory EMRO).

b) Organization

At the most generic level, the Kuwaiti heath care system is divided into two categories — the public health care system and the private health care system.

Figure 1: Kuwait national health system

Source: Regional Health Systems Observatory EMRO

The public health care system is organized into two tiers — the central Ministry of Health (MOH) and the regional health offices. The Ministry of Health is located in the City of Kuwait and it has seven specific functions, as follows: planning, resource allocation, financing and budgeting, regulation, monitoring, evaluation and delivery of health care services. The MOH is the third largest public employer, after the ministries of education and interior.

One of the most notable ministerial decrees was the one dividing the country’s public health care sector into six divisions — the City of Kuwait, Hawali, Ahmadi, Jahra, Farwania and Al Suabah. Each of the six regions is requested to complete the following four functions:

The implementation of medical action plans in accordance with the ministerial specifications in order to ensure the provision of medical services to the people in the respective region

The offering of various types and levels of medical care

The implementation of training programs for medical, technical and administrative staffs

The construction and implementation of a “comprehensive computerized system of health information in the area” (Regional Health Systems Observatory EMRO).

There are three categories of health care facilities — primary health centers, secondary health centers and specialized health centers. In terms of primary health centers, there are 782 of them and they offer “general practitioner services and childcare, family medicine, maternity care, diabetes patient care, dentistry, preventive medical care, nursing care and pharmaceuticals” (Regional Health Systems Observatory EMRO). The secondary health centers are formed from a general hospital, a health center and specialized clinics and dispensaries. The scope of the secondary care facilities is to provide the best possible care for the patients. Finally, in terms of specialized medical facilities, these are organized into the following ten categories: maternity care, pulmonary ailments, mental disorders, neurosurgery, burns treatment, allergies, cancer diagnosis and treatment, hearing disorders, organ transplants and physiotherapy and rehabilitation.

The private health care sector is characterized by modern institutions, both for profit as well as not for profit. The not for profit health care facilities are specifically represented by the medical facilities belonging to oil companies, such as the Ahmadi Hospital, the Texaco Hospital or the Kuwait National Petroleum Company (KNPC) hospital. The for profit sector is also thriving in Kuwait and the clinics are focused primarily on the treatment of illnesses, rather than their prevention. The actual number of private clinics is yet unknown, but the Ministry of Health is intensifying its efforts to ensure an even distribution of the facilities; today, they are concentrated in central and populated areas. “There are 5 private hospitals in Kuwait with a total bed capacity of 427. Total number of doctors in these hospitals is 254 and number of nurses 707. In 2004, total number of outpatient visits in private hospitals was 798,985 (compared to 1.75 million in public sector hospitals)” (Regional Health Systems Observatory EMRO). The medical care services provided by the private sector are generally perceived as higher quality as compared to the medical services offered by the public sector.

Typically, the healtcare system in Kuwait is under the control and supervision of the Ministry of Public Health, which provides almost 90% of the available health care services. According to state records, there are over 6,000 hospial beds in six general and 65 clinics; 157 dental clinics, and emergency services. The Ministry of Health has over 30,000 employees, of which 16% are doctors, nurses, and medical-technical staff (Al-Ansari).

c) Issues within the Kuwaiti health care system

A discussion of the issues observable at the level of the Kuwaiti health care system could commence with the recognition of various perceptions over the system. During the 1990s decade, about 60 per cent of the country’s population was made up from non-Kuwaiti expatriates. Their levels of satisfaction with the health care system were increased, whereas the perceptions of Kuwaiti individuals were limited. It should also be noted that non-Kuwaiti people would more often visit hospitals than Kuwaiti individuals, who would have to explain their absence to the employer and who as such strived to relieve their illnesses the best way they knew how. “Although the health services in Kuwait are free of charge for Kuwaiti nationals, some people might find it inconvenient to report for clinical examination during working hours since they would need to obtain permission for an absence from their work places” (Al-Awadhi, Olusi, Al-Saeid, Moussa, et.al., 461).

In addition, like much of the Arab culture, Kuwait is a land of social paradoxes. In Kuwait, there are vast symbols of wealth, modernization, and rapid urbanization. These often conflict with certain attitues and behaviors that have been part of the Bedoin culture for centuries. Modern healthcare has only a few decades of tradition for most Kuwaitis, and despite the social and demographic improvements for the majority of the population, there are still issues surrounding access to healthcare. Among these are the gender and ethnicity of the healthcare professional (e.g. men will rarely visit a female practioner; women are reluctant to share personal details with men). Social status, too, plays a big part in whether a Kuwaiti avails themselves to healthcare, and many report that even with purported “free” care, there still remains a perception that those with cash have easier access to the medical field (Meleis).

In one study (Al-Kandari), there was a significant statistical difference in the perceied quality of care between nurses in the medical and surgical areas, specifically in the areas of accountability, medical knowledge, and span of control. Most of the nurses in the advanced units (e.g. specialized care or surgery) were considered competent and no perceived difference from other countries. However, the basic LPN or staff nurse was perceived as less well trained and professional.

In a report authored by Tony Blair, cautious optimism was the thesis in that more focus on quality of care and treatment should drastically improve the healtcare system by 2030. However, other medical scholars are concerned that it will take two decades to see the kind of improvement necessary to make the Kuwati system top-notch. Several recommendations were made to help enhance this plan: 1) restructuing and professionalizing the system; 2) promoting healtier life-styles and preventative care through behavior change; 3) use education to reduce tobacco and improve infrastructure for pre-disease screening. Finally, the Blair Report suggests a very aggressive and significant need for liason with hosptials and medical organizations worldwide in order to partner and improve the Kuwaiti system, the availability and training of Kuwaiti doctors and nurses, and the upgrading of the system so that individuals will not need to travel out of country for riskier procedures (Agency).

A particular element to consider is given by the role of perception in respect to reality. At a more specific level, the Kuwaiti perspectives can easily be infleunced by outer elements, such as the media. From this standpoint, the press has an increased ability to infleunce the patient and staff perceptions. The media as such promotes both sides of the story — on the one hand, the Kuwaiti medical system is one of the best in the region, easily comparable with the medical systems in Europe or the United States. On the other hand, the Kuwaiti medical system is massively broken and inefficient with only those who are have cash or are wealthy receiving adequate care. Regardless of the stands, fact remains that the Kuwaiti medical system remains in need of some consolidation and improvement, but criticized due to Kuwaiti cultural sensibilities or expatriate pressures and unreasonable demands for care in a host country. For example, a recent report stated: “[T]he state of the public healthcare system is a serious concern. Both men and women, urban and Bedouin, complained of the poor quality of healthcare service, especially when considering the country’s wealth. Participants were particularly critical of the inadequate number of hosptials; poor equipment maintenance; unqualified doctors; shortages in medicines and the necessity to purchase them from private pharmacies; and the approval of overseas treatment trips based on connections rather than a fair selection of patients. For most participants, it has become common practice to resort to expensive private clinics and hosptials. Several participants were also noticeably resentlful that the government was building hosptials in other countries while there was a perceived lack of public healthcare facilities in Kuwait” (National Democratic Institute for International Affairs).

In a similar manner, both scholarship and the media have shown that through religious and cultural prejudices, there are certain medical issues that are simply not part of “polite culture” — STDs, contraception, and even condom use. 41% of the retail pharmacists believed that the use of contraception was religiously objectionable, and that women who needed such things were irresponsible; 51% purported to be unaware of available contraception durgs, and 35% said that health providors in the country would not prescribe such drugs (Ball).

This is certainly an issue of perception from the outside world, who tend to see countries with this type of modesty, religious or not, to be backward and somewhat misogynistic. At almost every juncture, Kuwaiti’s perceive part of their healthcare problem to be due to inadequate training and competencies of the General Practiononer. This perception has bled into popular culture so much so that there is no an ongoing program to distingquish family practice and increase the competency level for new doctors and nurses. This program has been designed to increase core competencies, provide a greater span of training, additional sources of development, and, to engender public and media confidence, a very rigorous set of review courses after degree and internship as well as competency examinations (Al-Baho). In order to provide better medical services, though, many scholars believe that one of the more serious problems is the lack of, or inadequate medical libraries for students and professionals. The large majority of the medical libraries were not established until the 1980s and some are unable to provide current, cutting-edge, information. Research shows that not only are the collections relatively small, but the majority of library staff are neither trained librarians nor trained medical personnel.

The issue of supply and demand for professional nurses is another critical component of both the perception of healthcare and improvement that are needed. Unfortunatly, research shows that there is a decline in indigenous Kuwaiti nurses of about 3.5% annually since the 1990s. “There is a gap between the numbers of native and migrant nurses, which will be widerwith time.In 2006, native nurses constitute only 6.6% of the nursing workforce; this affects the quality of provided care owing to language, religions, and socio-cultural barriers between foreign nurses and patients…. Improvement in recruitment and retention of indigenous nurses and nursing students” is a critical iissue for the country (Al-Jarallah, Moussa, Hakeen, and Al-Khanfar).

4. Research methodology

4.1. The research methodology

At a broad level, the research methodology is composed from two specific directions: the analysis of the available literature — which has been completed throughout the previous section, and the direct interaction with the individuals, through a questionnaire. The analysis of the secondary research was conducted in order to create a starting point for the research project. Based on the findings, the survey was constructed in such a manner that it approached the most critical issues within the Kuwaiti health care system. The literature review was constructed through the gradual analysis of the available literature, composed from sources including books, journal articles or internet articles. Each of the sources is valuable as it is characterized by specific features. Books and specialized journal articles for instance are peer reviewed and as such highly reliable, but they tend to be outdated and not dealing with the newest topics. Internet and magazine articles on the other hand are seldom peer reviewed and might be biased by the personal insight of the editor, but they do discuss issues of novelty and of daily interest.

In terms of the second research tool — the survey — its selection was constructed in a gradual manner, through the response offered to several questions, including:

a) What is the research philosophy of the research?

b) What are the most appropriate approaches to the research?

c) What are the research strategies to be used?

d) What research choices have been made?

e) What is the time availability and how does this influence the research project and the research tools?

f) What techniques and procedures would be used in the data collection and analysis process?

These six questions represent the core of the onion ring research methodology. The analogy between research and the onion indicates that just like the onion has layers, the research project is also constructed in layers and stages. In order to move on to the next layer, it is necessary to entirely remove the one on top of it; similarly, with research, in order to move on to the next stage of the process, it is necessary to complete the current effort (Oriesek, 2004). The following paragraphs answer the six generic questions in the context of the philosophies, approaches, strategies, choices and tools most appropriate in the study of the Kuwaiti health care system.

a) The philosophy of the research

Mark Saunders, Philip Lewis and Adrian Thornhill (2009) identify a total of ten research philosophies, namely: positivism, realism, interpretivism, objectivism, subjectivism, pragmatism, functionalism, interpretative, radical humanism and radical structuralism. Each of these philosophies is characterized by its own elements and these specific elements make one philosophy or the other more appropriate for a specific research endeavor. Just like with companies which cannot simply implement business models as presented by the literature, but they need to adjust them to the specifics of their company, researchers cannot just adopt any philosophy, but need to identify the one that best serves the purposes of their endeavor.

The positivist philosophy is characterized by the existence of an objective researcher who observes the phenomena and strives to form opinions. The scope is that of forming rules and theories of behavior based on the observations. The philosophy is often contested with the argument that not all phenomena can be explained by imposed rules (Oriesek, 2004). The objectivism approach is characterized by the efforts of the researcher to explain the observed phenomenon in the context of the social constructions which impact it or which are impacted by it. Subjectivism research however observes the phenomenon from the standpoint of the individual and strives to understand and explain how the individual impacts the phenomenon and how the phenomenon impacts the individual.

For purposes of objectivity, but also due to the highest degree of appropriateness with the objectives and construction of the study, the selected research philosophy is the positivist one. The researcher remains objective and the simple observer of the health care system in Kuwait. His scope is that of observing and documenting the context and constructing informed conclusions to explain the phenomenon.

b) The approach to the research

There are two types of approaches to a research project — inductive research and deductive research. Deductive research commences at a given theory and gradually assesses the elements of the phenomenon in order to test the validity of the theory. Inductive research on the other hand commences with the identification of the most important components of the phenomenon. It continues by observing their evolution and behavior within the context and it concludes with a formation of a theory regarding the behavior of the studied phenomenon. In regard to the study of the Kuwaiti health care system, the inductive research approach is considered as most appropriate and has as such been selected for integration in the analysis.

c) The strategy in the research

There are seven types of research strategies, as follows:

Experiment

Survey

Case study

Action research

Grounded theory

Ethnography, and Multi-method (Saunders, Lewis and Thornhill, 2009).

Each of the strategies is characterized by specific elements. The experiment is for instance characterized by the attempt to identify a causal link between the elements of a phenomenon. In other words, the experiment strives to identify the degree to which a change in one component generates a change in another component. The survey strategy is generally materialized in a questionnaire, through which the researcher collects vast information in an efficient manner. In the very words of the authors, “often obtained by using a questionnaire administered to a sample, these data are standardized, allowing easy comparison. In addition, the survey strategy is perceived as authoritative by people in general and is both comparatively easy to explain and to understand” (Saunders, Lewis and Thornhill, 2009, p. 144). These features make the survey useful, efficient and popular and they also constitute the reason as to why the strategy was selected for the current endeavor.

However they have not been selected, the rest of the strategies are noteworthy at least for future reference. The case study centers on the analysis of the situation from several sources and the integration of the findings within a case study analysis. In action research, the researcher takes a pro-active role and becomes directly involved in finding a solution to the raised issue. Throughout the analysis of the problem and the search for a solution, the phenomenon becomes researched.

In the case of grounded theory, much like the deductive approach, the researcher commences at a theory and strives to test its validity throughout the research process. The theory is constructed based on preliminary findings. The ethnography research strategy implies the full and complete integration of the researcher within the researched community and the first hand observation of the phenomenon. Finally, the multi-method strategy refers to the combined usage of two or more strategies.

d) The choice in the research

The choice of the research refers to the option of the researcher regarding the use of a single set of research tools and techniques vs. The use of a combination of research tools and techniques. In the analysis of the Kuwaiti health care system, the selection has been made in favor of a single method.

e) The time variable

According to the time variable, there are two types of research projects — cross sectional and longitudinal. Longitudinal research projects expand throughout a long period of time and revolve around the sustained analysis of the phenomenon during a prolonged time frame. Cross sectional studies are however limited in terms of time frames and they refer specifically to the concomitant analysis of several elements of the phenomenon during a restricted time frame. Given the nature of the current research, the cross sectional approach is to be implemented.

f) The techniques and procedures

Finally, the techniques and procedures refer to the materialization of the choices which have been made before. In other words, the analysis of the Kuwaiti health care system would be conducted through a questionnaire issued on a sample of 50 patients and 50 medical staff members. The answers would be processed, presented in tabular format and explained using common language.

4.2. The questionnaire

Question 1: Please state to which of the groups you belong:

a) Patient

b) Medical staff

Question 2: Please state your age

a) Up to 20

b) Between 20 and 40

c) Over 40

Question 3: Please state the income category to which you belong:

a) Below average

b) Average

c) Above average

Question 4: What is your level of satisfaction with the Kuwaiti public medical system?

a) Low

b) Medium

c) High

Question 5: What is your opinion regarding the medical staffs:

a) They do their best with what they have

b) They are inadequately skilled and trained

Question 6: Have you ever noticed an insufficiency of medical staffs?

a) Yes

b) No

Question 7: Do you consider that the public health care system is able to serve the needs of the population?

a) Yes, it is

b) No, it is not Question 8: What is your perception over the private health care system?

a) It is better but it can only be accessed by the wealthy individuals

b) It is redundant and unnecessary

Question 9: What is your opinion regarding the free medical system in Kuwait?

a) It is necessary and laudable as it offers basic care to the entire population

b) It compromises the quality of the health care services.

Question 10: Which of the following are of most importance in regard to medical services in the meaning that which should be improved with priority? Assign a grade from 1 to 6, with 1 being the most important and 6 being the least important.

a) Technological infrastructure

b) Staff training

c) Infrastructure (number of hospitals and clinics, their capacity and so on)

d) Disease prevention

e) Quality of medical services

f) Access to medical services

4.3. The research sample

The research sample is formed from two categories of respondents — patients and medical staffs. The combination of the two categories of respondents was necessary in order to identify both sides of the issue and assess the problems from two angles. This strategy ensures higher levels of objectivity as it reduces the chance of bias and balances out information.

It was initially considered to also include regular citizens in the survey. The questionnaire would have been distributed on the street and the objectivity of the findings would have been furthermore increased. Nevertheless, the third component of the sample was eventually renounced due to the tedious work it would have implied, the low levels of research efficiency as well as the fact that the findings could have been questionable and personally subjective, given the limited interaction of the respondents on the street with the medical system. In this order of ideas, the sample came to be formed only from medical patients and medical staff members, due to the two main advantages they present:

The patients and the staff members engage in continuous and sustained interactions with the medical system and are the ones best entitled to make comments and to form valid opinions. What they have to say is worthwhile considering as it is informed and experienced first hand.

Secondly, the patients and the staff members are highly concentrated within medical institutions and they are as such easily accessible. In order to reach them however, it was first necessary to obtain the approval from the institution managers. The approval was obtained, under the request that the findings of the study be also made available for the managerial teams at the respective medical institutions.

As a final specification, to further increase the objectivity and relevance of the findings, the answers were collected from staffs and patients at five medical institutions. This strategy was implemented based on the possibility of bias or certain conditions within one medical institutions and the possibility for these conditions to not reflect the overall situation within the Kuwaiti medical system. In light of these specifications, the sample is described as follows:

A total of 100 respondents, out of which 50 are medical patients and 50 are medical staffs

A total of five sources of respondents materialized in five medical institutions. 10 patients and 10 staff members were interviewed from each of the five medical institutions

The staff member respondents were as such selected to belong to both genders, to be culturally diverse (but mainly Kuwaiti), of both genders and to have at least five years of experience within the medical system and at least two years of expertise at their current position

The criteria to selecting the patients were less restrictive in the meaning that the respondents are of all ages and of all conditions, including everything from simple colds to chronic diseases. More emphasis was however placed on the opinions of chronic patients as their relationship with the medical system is more stable and as such their opinions are better informed

In terms of demographics, the large majority of respondents were of ages older than 40, followed by respondents of ages between 20 and 40 and the least large category of respondents younger than 20.

Finally, through the lenses of income, 50 of the respondents make below average income; 30 of them make average incomes and 20 make above the average incomes.

4.4. Limitations of the study

Just like any other research endeavor, the current process is met with some limitations. The first of them is given by the limited size of the research sample. Despite the strength of integrating two categories of respondents and as such increasing the relevance and the objectivity of the findings, the two samples are rather restricted. This virtually means that it might come to a situation in which not all of the responses retrieved from the sample members are able to faithfully reflect the opinions and perceptions of the entire Kuwaiti community.

The second limitation refers to the usage of a single tool of primary research — the questionnaire. It is often a common practice to combine two or more research tools in order to maximize their benefits and minimize their disadvantages; the process is generically referred to as triangulation. The limitation is however counter argued with the fact that the study findings are based on both primary as well as secondary research. The disadvantage is as such limited given that the questionnaire was constructed in accordance to the issues identified within the specialized literature.

5. Data analysis and findings

As the survey was issued, the responses were collected from both patients as well as medical staffs and they were processed. They were initially integrated in a tabular presentation, after which they are interpreted. The table below reveals the answers and the paragraphs below it reveal the explanations.

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

a b c a b a b a b

Patients (50)

Staffs (50)

Age:

Below 20

20-40

Over 40

Income:

Below average

Average

Above average

a) Satisfaction with the Kuwaiti public medical system

The satisfaction of the patients and staffs regarding the Kuwaiti medical system vary from one respondent to the other. A generalization cannot be made as the answers fluctuate across group of respondents. For instance, while the majority of above average income respondents argue that they are not satisfied with the public health care system, the majority of below average income respondents argue that they are mainly satisfied with the system. At a more specific level:

The majority of patients and staffs reveals medium levels of satisfaction regarding the conditions of the Kuwaiti public health care system

The relationship between satisfaction and age is a direct one in the meaning that as the individuals age, their satisfaction with the medical system increases. The younger individuals are less satisfied and the older individuals are better satisfied.

The relationship between satisfaction and income is an indirect one in the meaning that as income increases, the satisfaction with the public health care system decreases.

b) Perceptions of medical staff

A significantly large portion of the respondents indicate their beliefs according to which the staff members in the medical system try to do their best in the given circumstances. Higher demands from the staff members — who are perceived as insufficiently skilled and trained — are forwarded by the average and above average income categories of respondents.

c) Staff insufficiency

Staff insufficiencies have been observed generally by the respondents, confirming as such the initially raised question of nurses’ insufficiency, but also pointing out the generalization of the situation throughout the entire medical system. Less attention to this detail has been observed at the level of the younger respondents.

d) Ability of the health care system to serve the population’s needs

In terms of the public medical system’s ability to serve the needs of the entire Kuwaiti population, the majority of the respondents indicated that the Kuwaiti public system was indeed able to serve the needs of its population. Different answers were however observable at the level of the young respondents (up to 20 years) as well as at the level of the above average income individuals.

e) Perceptions over private health care

The majority of the respondents agreed with the superiority of the private sector over the public sector. They also indicated however that the higher prices of the private medical services raised an important barrier. An opposing view according to which the private medical sector was redundant and unnecessary was forwarded by the medical staffs.

f) Perceptions of the free medical system

In terms of the free medical system, the generally accepted idea is that of a necessity for the free medical services, and the fiercest advocates of the idea are the respondents in the below average income category as well as the older individuals. The respondents in the above average income category strongly indicated that the free medical system severely compromises the quality of the health care services.

g) Improvements

When they were asked to assign importance coefficients to the elements which had to be improved first, the respondents indicated the following priority list:

1 — Access to medical services

2 — Quality of medical services

3 — Staff training

4 — Infrastructure

5 — Technological infrastructure

6 — Disease prevention

6. Concluding remarks

6.1. Summary of findings

The forces of globalization have driven change and innovation across the entire globe and they have managed to promote the evolutionary trend in human kind. One specific focus of the modern day societies is that of improving the quality of life through higher quality medical services. Yet, the means in which this goal is achieved varies from one country to another. As a general observation, the countries in the western hemisphere have strived to improve the health of their citizens through technological innovations and their integration in the medical system. The countries in the eastern hemisphere have however focused predominantly on increasing the access to medical services to as many citizens as possible. The second strategy has however compromised the quality of the health care system and has also become distanced from improvements through technology.

Given this scenario, the current research endeavor strived to assess the particularities of the health care system in Kuwait. The scope was that of identifying the dimensions of the health care reform, the obstacles it faces and the numerous problems of the system. The result would be a valid assessment of the system and the formation of solid recommendations to support the development of the Kuwaiti medical sector. The starting point of the project was constituted by the analysis of the available literature, which indicated the existence of a series of issues within the Kuwaiti medical sector. For instance, it was concluded that the medical sector, however easily accessible, performed at lower levels of quality. Additionally, it was often understaffed and the staffs were under trained. Overall, the Kuwaiti medical system is torn between offering medical services to as many people as possible and offering high quality services. This context reveals the impending need for change and developments.

The analysis of the specialized literature constituted the first research tool in the answering of the posed question. In the identification of the second research tool a processes of onion ring methodology was implemented. Six questions were posed relative to the philosophies, approaches, strategies, choices, time frames and techniques of the research and as they were gradually answered, the survey tool was identified as the most suitable method of researching the situation within the Kuwaiti medical sector.

The questionnaire was issued upon a sample of 100 individuals, out of which 50 were patients and 50 were medical staffs. The demographic characteristics of the respondents varied mainly in terms of age and income. The analysis of the questionnaire revealed the following:

The Kuwaiti population recognizes the necessity for free medical services but also recognizes the low quality of the medical act in the public institutions

The staffs are often insufficiently trained and even insufficient in numbers

The private medical care sector is a welcome addition to the public services but the access of the general population to private medicine is limited due to higher costs

The population indicated the following list of priorities to improve (in order of importance): access to medical services, quality of medical services, staff training, infrastructure, technological infrastructure and disease prevention.

6.2. Significance of the study

The current research endeavor is marked by a twofold significance. On the one hand, there is the theoretical significance revealed primarily by the restatement of the most important literary findings, as well as by the raising of questions for future research. On the other hand, there is the practical significance, through which recommendations are offered in the sense of improving the Kuwaiti health care system.

a) Theoretical significance

The theoretical significance can be divided into two categories. First of all, the research project is useful as it centralizes important information in the specialized literature and integrates it into a united source of information. This role is specifically played by the Literature review section, which is important due to two aspects:

It introduces the reader to the general situation of the Kuwaiti medical care system, and It offers the researchers a valid starting point in their own analysis of the Kuwaiti medical system.

Aside the literature review part however, support for future researches is also offered by the ability of the current study to raise several questions. While it would be traditionally expected for a research endeavor to answer questions, a good research project has to recognize its limitations and come to terms with the fact that it cannot answer all possible research questions. To better explain, while the research process advances, and as new sources of information and new data are uncovered, the topic widens and the single project cannot answer all of the newly identified topics and subtopics. They could however constitute research questions in future research projects.

Given this scenario, this current research endeavor raises the following questions:

1. What has been the evolution of medical care in Kuwait? What roles have the differences between the East and the West played in the development of the medical sector in Kuwait as well as in other Middle East countries?

2. What are the elements which impact the perceptions of patients and medical staffs regarding the quality of the medical service? Are there diverse elements which impact the perceptions of patients against other elements which impact the perception of staff members?

3. What managerial lessons from the business community can be extrapolated in support of the medical community? In this light of considerations, is it better for the leader of the health care institutions to be medical doctors or business men? Which characteristics are more important in the administration of hospitals — managerial skills or knowledge of the medical field?

b) Practical significance

Aside from the theoretical significance, the current research endeavor also strives to support the future development of the Kuwaiti medical system. It does so not only by pointing out its limitations, but also by proposing recommendations on how the identified problems could be solved. In this order of ideas, the following are noteworthy:

1. Lessons from the private sector

A noteworthy distinction is observed at the level of quality of the medical services. While the public services are extremely comprehensive and it would be generically assumed that a need for private medicine is not observable, the private sector is in fact thriving and this is due to differences in quality. In this order of ideas, despite the large size, specialization and access to the public sector, the population and the patients are also in need of higher quality services. Relative to the private sector, this could offer valuable lessons if the representatives of the public sector were to identify and implement the teachings.

One particular means in which this objective could be achieved refers to improvements in the managerial act. Resource allocation, planning and other managerial functions are often more successful within the private sector, where economic agents strive for profits and for wider market shares. The levels of competition force the players to continually develop and improve their operations. The adoption of the specific strategies at the level of public health care would improve the managerial systems and would eventually materialize in increased levels of operational efficiency as well as higher levels of patient and staff satisfactions. Some specific examples of managerial strategies worth considering include:

The offering of more training programs to the staff members. On the one hand, this strategy would lead to the formation of better trained and capable staff members which are better able to perform their tasks. On the other hand, training programs increase on the job satisfaction by creating a context in which the staffs register higher levels of job stability. The outcomes are those of increased organizational performance and higher levels of satisfaction for both staff as well as patients.

Increased attention to the allocation of resources as well as to other technical processes such as staffing or technological infrastructure. Efforts in these directions would materialize in enhanced abilities to meet pre-established organizational goals.

2. Improved education system

Another identified problem commences with the very education and preparation of the future medical staffs. This virtually means that the impending necessity is that of better preparing the medical school students as well as better training the medical staffs. At the level of the education, three developments are necessary. The first is that of improving the educational infrastructure in the meaning of integrating more advanced technologies in the educational process. The second recommendation is that of improving the educational act by integrating better trained and skilled teachers to train the students. And third, the last recommendation to improving the educational medical system is that of enhancing the capabilities of the libraries. The university libraries are often blamed for offering outdated information and not presenting students with the necessary support in identifying and understanding the required information. One specific means to improving the conditions of the libraries is to integrate technological developments such as more and better computers that can more efficiently access information. It is also important to train the assistants in libraries so that they are better able to offer support to the medical students. Health science libraries are highly technical and require skilled and specialized librarians. If training is needed elsewhere, then there should be a program to find biligual librarians with a specialization in medicine; or offer incentives to bring expatriates to Kuwait to rebuild the library system. It is also important to automate these collections and share information between libraries. Indeed, health science libraries must also be key in strengthening the level of competence and expertise at all levels of the medical paradigm (Al-Ansari).

3. Populous education

The current Kuwaiti medical system is often blamed for treating the ilness rather than addressing the cause and preventing the disease. This context is observable in several instances, not only just within the Kuwaiti medical system. The most relevant recommendation in this sense is the education of the population and their direction towards a healthier life style through proper alimentation and excercise. While the Kuwaiti population is not so prone to obseity and other modern day ilnesses, improvements in living conditions could occur to reduce the incidence of diseases.

At the very core of any plan to restructure a country’s health system, even a relatively small country, is the desire to ensure an enhanced and improved quality life for all citizens. The development must meet the needs of the presented without compromising the needs of the future (e.g. utlizing all resources now, etc.). This, of course, is the ecological model of sustainability.”Although the idea is simple, the task is substantial. It means meeting four objectives at the same time, in the world as a whole: social progress which recognizes the needs of everyone; effective protection of the environment; prudent use of natural resources; and maintenance of high and stable levels of economic growth and employment (Fabe).

References:

Agency, Kuwait News. “Blair’s “Kuwait Vision.” 15 March 2010. Zawya.com. .

Al-Ansari, H. And S. AL-Enezi. “Health Sciences Libraries in Kuwait.” Bulletin of the Medical Library Association 89.3 (2001): 287-93.

Al-Awadhi, Olusi, Al-Saeid, Moussa, et.al. “Incidence of Musculoskeletal Pain in Adult Kuwaitis.” Annals of Saudi Medicine 25.6 (2005): 459=62.

Al-Baho, A. “Resident’s Guide to the Curriculum for Training in Family Medicine.” December 2008. Kuwait Institute for Medical Specialization. .

Al-Jarallah, Moussa, Hakeen, and Al-Khanfar. “The Nursing Workkforce in Kuwait to the year 2020.” International Nursing Review 56.1 (2009): 65-72.

Al-Kandari, F. “Patient’s and Nurses’ Perceptions of the Quality of Care in Kuwait.” Journal of Advanced Nursing 27.5 (2003): 914-21.

AL-Zaid, A. “Kuwait Institute for Medical Specialization: Its Present Position and New Directions.” January 2002. Bulletin of the Kuwait Institue for Medical Specialization. .

Amwar, S. “A Factor Analytic Investigation of the Construct of Market Orientation.” International Journal of Management 25.1 (2008): 188+.

Ball, D., Marafie N., Abahussain E. “Awareness and Perceptions of Emergency Contraception Among Retail Pharmacits in Kuwait.” Pharmcology World Science 28.2 (2006): 101-6.

Casey, M. The History of Kuwait. New York: Greenwood, 2007.

Central Intelligence Agency, The World Factbook, 2010, https://www.cia.gov/library/publications/the-world-factbook/

Fabe, A. “Kuwait Healthcare System.” ThinkingLIbrary 2010: .

Gangal, N. “Healthcare Key Focus Area in Kuwait’s Development Plan.” 25 June 2010. Arabian Business.com. .

Group, Oxford Business. “Healthcare and Education.” The Report- Kuwait 2010. Oxford: Oxford University Press, 2010.

Health, Kuwaiti Ministry of. “Healthcare in Kuwait.” 2010. Kuwait-info.com. .

“Kuwait Health Initiative.” 2010. q8Health.org. .

Meleis, A. “The Health Care System of Kuwait: The Social Paradoxes.” Social Science and Medicine 13.2 (1979): 743-9.

National Democratic Institute for International Affairs. “Kuwait: Citizens’ Perceptions of Women.” February 2007. People’s Mirror – A Strategic Research Center. .

Oriesek, D.F., 2004, Maximizing corporate reputation through effective governance: a study of structures and behaviors, Universal Publishers

Regional Health Systems Observatory EMRO, Health system organization, http://gis.emro.who.int/HealthSystemObservatory/PDF/Kuwait/Health%20system%20organization.pdf

Sambidge, A. “Kuwait Eyes Healthcare Tie-Ups With Canada.” 24 January 2010. Arabian Business.com. .

Saunders, M., Lewis, P., Thornhill, A., 2007, Research methods for business students, 4th edition, Pearson Education

Shah, Shah, and Behbehani. “Ethnicity, Nationality and Health Care Accessibility in Kuwait.” Health Policy and Planning 11.3 (1996): 319-28.

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