Agile Governance

Modern military doctrine states that the higher command should clearly define the goal of an operation, but leave it to the leaders on the ground to make the tactical decision on how best to achieve that goal. The latter witness the evolution of the combat situation in real time and are much better equipped to respond to a changing battle field in a timely manner than a removed higher command. This leads to agility on the battle ground. What an agile actor can achieve, even without numerical and technical superiority, is clearly visible these days in the Ukraine.   

Agile governance, for lack of a better term, is not restricted to military doctrine, but similarly pertains to any other system operating in a rapidly changing environment in which decision-making is time sensitive. Any larger company operates within a hierarchy of delegated signing and budget authority – and the respective accountability that comes with being one who holds this authority.

Why should universal, public health care systems be an exception?

Canada – and some other countries – pride themselves to have universal public health care systems that are accessible to anybody. These health care systems are usually state run (directly by government or indirectly through a government mandated agency) and funded through tax dollars. Universal, public health care systems are large enterprises, not infrequently the largest single employment sector in a jurisdiction. Their total annual budgets often come close or reach into a two-digit billion-dollar amount.

Why, then, are these universal, public healthcare systems rarely governed like any large company with a hierarchical system of budget and signing authority – and the respective accountability? Why is there no agile governance in most if not all of these health care systems, but an outdated central command structure that has proven in history time and time again to be highly ineffective, not to say disastrous? And why are such universal public health care systems often legislated in a way that all their institutions are equal and organizationally at the same level, each a silo in itself?

Some might argue that various jurisdictions have attempted to break these silos by creating agencies tasked with coordination and planning across the entirety of the respective health system. While that might be technically correct, these coordinating agencies can plan and set standards until the cows come home, but nothing will change as long as they have no teeth. As long as they are excluded from the budgeting and funding process of the same silos they are meant to coordinate, we will see the same pattern repeat itself until eternity.

I don’t believe that governments in general scheme to set public health care systems up this way, but the result is the same: all decision-making power remains with government bureaucrats (elected or unelected) far removed from any insight into what is going on at the frontline. Too many initiatives and funding requests have to go up the chain to the political leadership for decision-making. This leads to a waste of energy and loss of precious time; result: the approval to launch the action comes too late.

If the Russian army with its central command structure is stuck against the numerical and technical inferior Ukrainian forces because of the latter’s agile governance structure, why do we believe we can improve our universal, public health care system without fundamentally changing its governance?

Agile governance within a hierarchical system of signing and budget authorities also requires to address two other fundamental deficiencies present in many universal public health care systems: the extremely complicated reporting relationships and the almost religious belief that decisions can and have to be made by consensus. Isn’t it common experience that the larger the group, the longer it will take to reach consensus and that consensus finding in diverse groups of more than half a dozen members is hardly ever possible within a timely manner? Why do we then still believe that consensus-based decision-making works in the large organization of a universal public health care system?

During COVID, I participated in a course on incident command. Incident commands are often put in place to react in a coordinated fashion to natural disasters such as large wild fires or flooding events, and have been put in place during COVID in health care systems at various levels. Among the issues discussed in that course, a couple of principles on governance structures are worth mentioning here: 1. one person can only report to one supervisor, and 2. a supervisor can reasonably manage only 3-7 direct reports (ideal is 5).

Now that COVID related incident commands have been dissolved, both of these governance principles are hardly ever adhered to anymore in universal public health care systems, even less so in those parts that are university affiliated. Usually universal public health care systems are organized in complex matrices with multiple dotted reporting lines often crossing several levels of the organization. It is not uncommon that a single leader wares many hats that create not only conflicts of interest for that individual, but also make the individual not infrequently reporting in one of the roles to somebody who they are supervising in another. Isn’t it a grand illusion to believe that such fuzzy governance structures can timely solve the many problems universal, public health care systems face?

The lack of a hierarchical system of budget and signing authority combined with relying on consensus decision making and extremely complex reporting structures paralyze decision making in universal, public health care systems and seriously hinder the timely implementation of solutions to the many problems they are challenged with. 

It seems therefore mandatory that universal, public health care systems move towards agile governance with a hierarchical system of budget and signing authority, simple reporting structures, and defined decision-making power (in the many cases a decision cannot be reached by consensus). Without this universal public health care systems will continue to fail not only the patients they are meant to serve, but also the taxpayers who fund them. Of course, such profound paradigm shifts would have ripple effects. It would be hard for health care workers including physicians and their leaders to observe from the side lines and enjoy the pastime of freely criticizing whatever happens. They would have to engage, accept the decision-making power at their level of agile governance – and the accountability that comes with it.  Are we ready to engage?