2. Marco teórico
2.1. La historia cultural y el estudio de las identidades
In the recent years, the global economy has seen some major disturbances. These changes have often impacted the ability of governments to provide basic health services for its
62 citizens. This study intend to compare relevant health outcomes and health expenditures for specific countries based on each country’s income classification. There are different ways of classifying countries based on economies. The most reliable international agencies for providing health statistical data are the World Health Organization (WHO) and the World Bank.
Table 3.1 Income groups (World Bank 2010)
Country GNI per Capita (2007-2011) Low Income Lower middle income Upper middle income High income Kyrgyz Republic 920 ⃝ Yemen 1,070 ⃝ Vietnam 1,260 ⃝ Sri Lanka 2,580 ⃝ Thailand 4,420 ⃝ Cuba 5,460 ⃝ UK 37,780 ⃝ Canada 45,560 ⃝
Meanwhile, in accordance with the World Bank list of economies, country income levels classified by gross national income (GNI) per capita. Low income countries have a GNI of $1,025 or less, lower middle income countries have a GNI of $1,026-4,035, upper middle income countries have a GNI of $4,036-12,476 and high income countries have a GNI of $12,476 or more (World Bank, 2012). The countries used and their classifications are listed in the table 3.1.
Using these country income classifications, that present the health outcomes from the WHO per country and relate these outcomes to general good practices in health reform. It will also compare and examine national incomes, economic factors, expenditure trends
63 and healthcare financing models for these countries and focus that information towards considering outsourcing for improvements in the delivery of the Yemeni healthcare model that will help healthcare reform for Yemen as a module for the LMIC. The study on the outsourcing experience in developing countries as per Siddiqi et al. (2006) revealed that most developing countries undertook contracting to improve effectiveness, efficiency and quality of health services have greater constrains on the legal framework and the necessary rules and procedures for outsourcing of health services. Moreover, Siddiqi et al. found that most ministries had limited capacity for cost and price analysis and transaction cost estimations were usually not done. However, recent reviews have suggested that contracting can influence access, equity, quality and efficiency of health services while promoting public health goals and creating an environment conducive to public–private collaboration (Liu, 2003).
Outsourcing projects have created a mixture of reactions from the public and other public interest groups concerning the low-income, the elderly and the disabled (Sangaralingam & Raman, 2003). Their concern is based on an increase in the operational costs of support services (Chan, 2000). Due to the lack of qualified skills in healthcare organizations in developing countries, outsourcing services has always been a valid option to consider given the promise of good return on investment. Moreover, Kshetri and Dholakia (2011) found that outsourcing such services has been shown to affect the bottom line. Nevertheless, other challenging issues and concerns also appear. An example is regarding personnel and having a qualified individual who monitors the contracted outsource vendor’s contract performance (Hazelwood et al., 2005). Another, is in regard to any issue of non-performance or under-performance and who will address those concerns. These overlooked aspects arise routinely when outsourcing (Roberts,
64 2001). Hurley (2001) emphasized that the retention of qualified people is key to success of an outsourcing project.
With strategic outsourcing solutions for healthcare providers it has been possible to increase efficiency, improve service and enhance the competitiveness. Healthcare outsourcing could provide access to specialized care as well as interpreter services (both day and night while allowing for time difference adjustments between the two countries involved in the outsourcing) which might otherwise be unavailable in individual hospitals (De Maria, 2006). In view of the fact, healthcare organization in the LMIC were secrecy of all kind of resources is a concern. As later identified in the study cost saving, access to best practices and leading technology among the top benefits of outscoring in LMIC. According to Hazelwood et al. (2005) the ownership of most healthcare organizations is 80% NP, government financed and managed by committees and not by an administration with no strategic planning and no cost driven decision making processes.
Due to lack of contract monitoring of the outsourcing contracts, the potential for great variation raises the risk of vendor service quality fluctuating below an acceptable level. For some services in a healthcare arena, the consequences of such variation might be limited and for others it could be severe (Foxx et al., 2009). In the example of a successful outsourcing venture, as demonstrated by Hazelwood et al. (2005), the hospital received measurable benefits from the services provided from India in the area of reading radiological results to be transcribed in patient’s charts.
There are several barriers to evaluate, such as the cost of hiring someone else to do the job and if it makes financial sense (Barthélemy & Adsit, 2003). The concern debated is; can the hospital justify the cost not to keep the service in-house? Does the outsourcing
65 vendor have the required experience to make outsourcing cost-effective for the hospital? Affected managers are another challenge of outsourcing (Roberts et al., 2013).
A most important alarming concern in the LMIC about changes in the environment is political instability or unrest in the vendor’s country of operations that would affect the continuity of care. In fact, Power and Bonifazi (2006) stress that the location of vendors is as important an issue as the location of the service to be provided because if there is political unrest in the service provider’s geographical location, the vendor’s business will be compromised. This, in turn, will directly affect how the business is conducted.