Monday, March 30, 2015

المستشفيات الحكومية في الاردن: تحليل ومقارنة الكلفة


قطاع المستشفيات الحكومية قطاع كبير الحجم والتمويل. فقد بلغت سعة المستشفيات الحكومية التابعة لوزاره الصحة في جميع محافظات الاردن 4468 سرير في العام 2013 بحسب بيانات وزارة الصحة. وبلفت ميزانية هذه المستشفيات في نفس العام 394 مليون دينار مقسومة بين 283 مليون دينار نفقات تشغيليه و 111 مليون دينار كنفقات راسماليه . وشكلت ميزانية المستشفيات الحكومية 54% من ميزانية الصحة كاملة في 2013 والتي تشمل ايضا ميزانية الاجهزة والمعدات والعيادات الخارجية وخدمات صحية عامة و البحوث والتطوير. اي ان ميزانية المشتشفيات هي حصرا في نفقات المستشفيات.  في العام 2013 تم ادخال 347929  مريض الى مستشفيات وزارة الصحة حيث قضوا مليون ومائة الف ليله بمعدل 3.2 ليله لكل مريض بنسبة اشغال اسرة تساوي 68%. وعليه يكون معدل الكلفة لكل ليلة مبيت في المستشفيات الحكومية 256 دينار عند حساب النفقات التشغيليه فقط و 356 دينار عند حساب النفقات الاجمالية.


كيف تقارن هذه الكلفه في المستشفيات الحكومية مع مستشفيات القطاع الخاص؟ كمؤشر يمكن النظر الى ارقام مستشفيين في عمان الغربية مدرجين بسوق عمان المالي مما يسمح بتحليل ميزانياتهما. المستشفيان يعتبران من افضل _واغلى_ مستشفيات الاردن وموجودان في اغلى منطقة بالاردن. مجموع اسرتهما 420 سرير. وقد بلغ مجموع عوائدهما في عام 2013 32 مليون دينار وحققا ربحا بقيمة خمسة ملايين دينار.


على فرض ان نسبة اشغال الاسرة في المستشفيين الخاصين كانت اقل بعشرة بالمائة من نسبة الاشغال في المستشفيات الحكومية يتبين ان معدل ما دفعه المرضى في المستشفيين 336 دينار لكل ليله فيما تكون كلفة المستشفيين 284 دينار لكل ليلة. واذا افترضنا نسبة اشغال للاسرة في المستشفيين الخاصين مساوية لمعدل نسبة الاشغال في المستشفيات الحكومية ينخفض معدل ما دفعه المرضى في المستشفيين الى 303 دينار لكل ليله فيما تكون كلفة المستشفيين 255 دينار لكل ليلة. طبعا تشمل كلف المستشفييين الخاصين _المستندة الى ميزانيتهما_ استهلاك الاستثمارات الراسماليه  وبالتالي يمكن مقارنتها مع الكلفة الاجمالية في المستشفيات الحكومية.

اذن _و تقديرا_ فان معدل كلفة اغلى مستشفيات خاصة في الاردن لكل ليلة مريض اقل من معدل كلفة المستشفيات الحكومية ب 28% (356 دينار مقابل 255 دينار وهي كلفة المستشفى الخاص بدون الارباح). طبعا نتذكر انه _على الاغلب _ فان كلفة المستفيات الخاصة لا تشمل اجور اطباء الاختصاص والذين يتقاضون اجورهم خارج فاتورة المستشفى. وعليه لربما تكون معدل الكلفة الكاملة متقاربة بين المسشتفيات الخاصة والعامة. مع اننا نقارن مستشفيين خاصين من اغلى مسشتفيات الاردن مع معدل الكلفة في مستشفيات الحكومة في محافظات الاردن كافة.


لا يختلف اثنان ان الخدمات التمريضية وخدمات النظافة في المستشفيات الخاصة افضل بمراحل منها في مستشفيات الحكومة. هذا مع ان معدل الكلفة متقارب جدا بين القطاعين. وقد يقول قائل _خاطئا_ ان السبب هو ان القطاع الخاص احسن دوما. هذا غير صحيح: الفرق الرئيسي هو ان مستشفيات القطاع الخاص تشتغل في ظل منافسة حقيقية فيما لا منافسة في قطاع المستشفيات الحكومي. فاي مستشفى خاص لا يقدم خدمات مقبولة سيخسر زبائنه المرضى لمستشفيات اخرى تقدم خدمة مقبولة. المستشفى الخاص يعمل لجلب الايرادات كل عام فيما في مستشفيات الحكومة الرواتب والنفقات مضمونة الدفع مطلع كل عام في ميزانية الحكومة. ولو كانت المستشفيات الخاصة بدون منافسة حقيقية فستسؤ خدماتها ايضا لا محالة.


الضروري في القطاع الصحي الحكومي هو _بداية_ معالجة النظرة الخاطئة والمستشرية (من قبل المرضى وطواقم المستشفيات على حد سواء) التي تعتقد ان الخدمة الصحية المقدمة مجانية. فالخدمة الصحية الحكومية ليست مجانية ابدا بل غالية الثمن يدفعها دافع الضرائب الاردني بمستويات تقارب ما تحصله المستفيات الخاصة شاملا ارباحها! وكون المريض لا يدفع لا يعني ان لا احد يدفع.


كذلك تبين هذه الارقام ان الحلول الناجعة لا تكون دوما بزيادة الانفاق. في حالة القطاع الصحي الاردني الممول جيدا،  الاولوية يجب ان تكون لمعالجة قلة الكفاءه والهدر في المسشتفيات الحكومية مع التفكير بحلول ابتكارية قد يكون منها تعريض المستشفيات الحكومة لضغوط المنافسة عبر اعطاء متلقي الخدمة الصحية فرصة اختيار المستشفيات التي يتعالجون بها وربط تمويل المستشفيات الحكومية مؤشرات اداء تنافسية.

Thursday, March 26, 2015

Jordan’s daily print newspapers: Under pressure

Jordan’s print newspapers are in a tough spot, with little hope for a turnaround for their classical business model.

The print newspaper industry in Jordan is under stress. Al Rai –Jordan’s largest daily newspaper- and ADDustour – one of Jordan’s oldest newspapers- both reported continued losses in 2014. Al Rai’s net loss widened by 153% in 2014, and reached 2.63 million JDs, up from 1 million JDs in 2013. For its part, ADDustour managed to reduce its loss in 2014 92% to stand at 322,000 JDs, down from 3.8 million in 2013. Cumulative losses have shattered Shareholders’ equity in Addustour which was a mere 49% of paid up capital by end of 2014. Addustour newspaper is currently facing a severe cash flow problem. 

The two newspapers suffer from declining revenues and pressured margins. The combined advertising revenues of the two newspapers steadily declined between 2010 and 2014. Total advertising revenues of the two newspapers reached 25.4 million JDs in 2010 and collapsed by 30% to 17.8 million JDs in 2013. 

Circulation revenues (from newspaper sales and subscriptions) are also in a steady decline. Total circulation revenues of the two newspapers were 2.48 million JDs in 2013 compared to 3.65 million JDs in 2010. A drop of 32%. Al Rai reported further drops in the first three quarters of 2014 while ADDustour detailed revenues for 2014 are not yet available.



The cases of Al Rai and ADDustour are indicative of the massive challenges facing traditional print media in Jordan at large. The drop in advertizing and circulation revenues is most probably caused by a combination of slower economic growth in the country as well as the increasing adoption of broadband Internet and smart phones in the country. Jordan’s fixed and mobile Internet account penetration (total subscriptions divided by total population) reached 25% in 2014. This suggests that some 40 to 50% of Jordanians are Internet users. These increasingly rely on the Internet for their news consumption. Online classified ads, social media and ecommerce also chip away at the utility of print advertising.

The two newspapers should devise clear strategies for a turnaround that sheds the old business model. Both must have clear online and mobile strategies that leverage their journalistic core to offer compelling online content on all platforms away from their currently quite traditional web pages. Print editions should be streamlined for maximum cost efficiency with an editorial focus on analyzing the news rather than breaking them (generally readers now see breaking news on TV or online not through print newspapers). Both would be best advised to develop compelling HR policies and bonus structures that encourage their journalists to exert all their efforts for the organization rather than run their own privately owned online news sites on the side. And both should realize, sooner rather than later, that print journalism will never return to its past glory days. The focus is about managing the decline in print while establishing a sustainable new business model online.

Tuesday, March 17, 2015

Government hospitals: Overpaid ?

Public hospitals “charge” tax payers as much as top private hospitals. Due to lack of competition, they are far less accountable.
  
I am an eye witness to this real story. A terminally ill cancer patient was admitted to a top rated private hospital in Amman. The room was sparkling clean, the furniture top notch and the nursing staff fully attentive, with round the clock attendance to the patient. The panel of specialist doctors decided that the patient cannot be treated and was in her final days, so they advised that she better be transferred to the top rated government hospital in Amman –where she was insured. 

At the government hospital, the family faced the massive contrast in nursing care between the private and government hospitals. Nurses at the government hospital never visited the room for regular checks, they came only when urged to come. They never administered the medicine: They insisted that each patient’s family companion should administer the medicine to their patient by themselves! Same applied to nasal feeding, and helping in personal hygiene of the patient. The family eventually had to hire a professional nurse, at their own expense, to help them since the nursing staff at the government hospital were quite useless.

Yet government hospitals are indeed very well funded. The Ministry of Health public hospitals across Jordan had 4468 beds in 2013. Their operational budget amounted to 283 million JDs and the budget for capital expenditure totaled 111 million JDs in 2013 resulting in the total budget for government hospitals reaching 394 million JDs.

In 2013, government hospitals admitted 347,929 patients who spent 1.1 million nights at the hospitals. The average stay per patient was 3.2 days and the utilization rate of hospital beds was 68%. The average operational cost of treating each patient at a government hospital thus amounted to 256 JDs per day (356 JDs per day when CAPEX budget is taken into account).

How does this compare to private hospital costs? Two private hospitals – publicly traded at the ASE – offer insights. One has 200 beds and the second has 220 beds. Both generated combined revenues of 32.2 million JDs in 2013, of which around 5 million JDs was operational profit. Conservatively, assuming a bed utilization rate 10% lower than average government hospitals (i.e. 61%), the two private hospitals charged 336 JDs per patient per night. Their costs stood at 284 JDs per patient per night. If we assume a similar bed utilization rate as that in Government hospitals, the revenues per patient per night drop to 303 JDs. And costs drop to 255 JDs per patient per night.


In summary, government hospitals across Jordan collected 356 JDs per patient per day in 2013. In the same year, profit seeking private hospitals in Amman charged 303 JDs per patient per night, 15% lower than government hospitals. Granted, specialist doctors in the private sector bill separately so the total in private hospitals would be the same or a bit higher than government hospitals.
The conclusions readily lend themselves:

-      Government health care is far from “free”. It is as expensive as care in state-of-the-art private hospitals in Amman.

-      If a private hospital’s nursing staff acted like the nursing staff in a government hospital, and had the same hygiene standards, a private hospital will go out of business. Because choice and competition exist for consumers of private health care services.

-      The main difference is not public sector management vs. private sector management. Rather the difference is lack of competition for government hospitals which makes them far less accountable than private ones. Patients in government hospitals do not have a choice, and the government hospital is guaranteed its operating budget every year regardless of its level of service. There is no risk of losing paying customers or going out of business. If private sector hospitals were monopolies, one can expect the same dismal result.

-      So long as the care providers think they are offering a free service to the patients, and so long as patients in government hospitals believe they are getting free health care, government hospitals will remain unaccountable and will not offer cost effective nor excellent care.

Health Policies in Jordan should change. They should aim at maintaining free health coverage to large swathes of the population, while holding the care providers accountable through some level of competition that makes their funding contingent on the level of service provided. Offering patients covered by public health coverage much needed choice – by offering them the option of choosing the hospital with a cap on expenses- would help massively as well.