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    The development of the Libyan health system to improve the quality of the health services

    El-Fallah, Mohamed (2014) The development of the Libyan health system to improve the quality of the health services. Doctoral thesis (PhD), Manchester Metropolitan University.


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    Health Systems (HSs) are playing a more vital and influential role in people’s lives more than ever before. Unfortunately, however, they can also misuse their power, waste their potential, and do more harm than good. It is believed that most people in developing countries are not satisfied with the quality of health services provided to them and feel that something should be done. In Libya, evidence has shown that the HS is currently facing a considerable number of challenges. These include the increasingly common practices of paying personally for treatment in the private healthcare sector and/or travelling for Treatment Abroad (TA). The general population perceive the HS as inadequate, if not poor, and they are dissatisfied with all levels of health services, even though Libya has achieved some improvements in the quality of its health services and in the general health of the population over the past few decades. The Libyan HS is obviously based on the HS conceptual frameworks of the WHO, which may or may not be applicable to Libya, as the status of the HS and the quality of the healthcare it provides have not been fully assessed. Therefore, this comprehensive study is one of the first attempts to undertake this task with the aim of generating a reliable evidence-based framework as the basis of the reform and/or rehabilitation of the country’s national HS. The overall aim and intended outcomes of this study were: to provide a foundation for the development of a framework and evidence-base, based upon the perspectives of healthcare stakeholders; to inform policy-makers and healthcare providers in devising and developing policies and strategies to re-engineer/reform the HS at the national level; and to introduce and/or improve quality initiatives at the health facility level. Specifically, the following primary objectives were developed to address the above overall aim and intended outcomes of this study: 1. To assess patients’ perspectives on the quality of healthcare in Libya. 2. To analyse health stakeholders’ perceptions of the HS and the quality of healthcare in Libya. 3. To contribute to the development of knowledge about the HS and the quality of healthcare in Libya. A concurrent mixed-methods (quantitative and qualitative) approach was used: the quantitative method to identify patients’ perspectives on the quality of hospital care, and the qualitative method for exploring health stakeholders’ perceptions of the HS and the quality of healthcare. A specifically designed self-administered questionnaire for the purposes of this study was used to collect the quantitative data from 550 patients in public and private hospitals in Benghazi. The qualitative data was collected via semi-structured interviews with 40 individuals, 10 health experts and officials, 20 health professionals, and 10 hospital inpatients in Benghazi City. The quantitative data was analysed using descriptive inferential statistics and multivariate analysis with SPSS for Windows Version 19. Statistical significance was set at p < 0.05. The transcripts of the qualitative data were analysed manually using the framework approach and thematic analysis. xvii The findings suggest that the majority of the respondents experienced lengthening waiting times to access healthcare. Furthermore, the results reflect the large number of respondents who have travelled for treatment abroad (43.1%). The analysis revealed that patients were dissatisfied with many aspects of care provision in hospitals. The overall quality score of hospital care was generally low (50.16%); the scores for the private hospitals were higher (52.82%), while public hospitals scored 49.02%. Overall, patients are more concerned about the quality of technical services than the interpersonal aspects of services. The analysis suggests that the service itself had more influence on satisfaction than the characteristics that the patients themselves possessed. The Regression model was highly significant and explained 92% of the variation in satisfaction. Behavioural intention, perceived quality of the service, availability, responsiveness, patient safety and atmosphere all had strong effects on satisfaction with services across the two types of hospitals. The qualitative findings pointed to broad areas of obstacles and problems which affect the provision of high-quality and efficient healthcare, while the people’s choices about health services were influenced by the HS’s responsiveness. The findings demonstrated various constraints in equity, accessibility, availability, waiting times and the referral system, which all lead to poor responsiveness to patients’ needs. They also showed that the HS has misused its power and squandered its potential, as it is poorly structured, inefficiently organised and badly led. Broad areas of difficulties emerged such as polices, regulation and organisation, legislation, supervision and inspection, and the HIS, as well as various constraints regarding the HS’s financing and human and physical resources. Furthermore, cultural aspects and health awareness play both direct and indirect roles that negatively affect the quality of the provision of healthcare. The overall conclusion of this thesis is that the modern approaches and advances of the technical side of the Libyan HS have not been matched by developments in HS governance and managerial processes; beneath the surface, there lies a less developed HS of paternalism and bureaucracy. This unique situation produces a number of questions which require answers in order for Libya to evolve into the role of the twenty-first century country that the government and population desire. This study offers a dynamic model based on the findings, which gives a comprehensive view of a high-quality HS, incorporating its main components, structure, activities, and outcomes as well as the HS’s internal and external environmental factors, with an increase in the scope and participation of people and communities. Due to the convergence and similarities between HSs and their components, this model can be widely utilised, especially in developing countries.

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