Dear Dr. Sahely
I am pleased to submit the following missive to your blog – for your kind consideration.
In the accompanying article (please see below), PAHO Director, Dr. Carissa Etienne, recently issued a call for renewed emphasis on strengthening health systems. Undoubtedly, her call is prompted by the region’s ongoing challenges with epidemics of obesity, mental illnesses, new viruses and natural disasters which destabilize public health and hospital systems, and erode health progress.
The urgency of Dr. Etienne’s call is consistent with a principal take-home message of your recent blog “…. From Breakdown to Breakthrough“. You, like her, see the compelling need for walls of cynicism and inertia to be broken down for national and regional health agendas to advance.
“Our health is our wealth” which is safeguarded by a public health and hospital system built in the 1950’s in response to the calls for reform coming out of the 1935 Buckley’s Uprising. In the Federation, high life expectancy and low rates of child and maternal mortality, speak volumes about what has been and can be accomplished through people-power, political will, and rational investment.
The Federation’s health successes are illustrated by certain key indicators. They include clean air; universal access to potable water and nutritious food; universal education from early childhood to adulthood; effective sanitation, waste management and drainage; and well-trained core of motivated practitioners working in adequate (more or less) facilities. Hence, communicable diseases account for 4% of total deaths – a rate that is identical to that of wealthier countries. Although we are the smallest country in the Western Hemisphere, our health standards and overall quality of life are second to none.
There is considerable improvement and resilience work to be done. Like the richest countries, the Federation’s health profile is dominated by non-communicable conditions whose risk factors are overwhelmingly due to personal lifestyle choices, and lifestyle choices imposed on vulnerable and unsuspecting persons. The resulting organ failure burden is felt as relatively high rates of heart disease, stroke, cancer and complications of diabetes. These four conditions account for 66% of total deaths (approximately 360 per annum). When homicide is added, five conditions account for 75% of deaths.
High blood pressure, high blood sugar, high blood lipids, high blood levels of addictive substances, high levels of speed, high levels of inter-personal hostility, and high disregard for protected sex, are the major risk factors escalating the national burden of chronic disease to unsustainable proportions. The level of injuries, illnesses and disabilities plus the loud clamour for more sub-specialists and more high tech equipment, have caused a doubling of the hospital expenditure budget over five years.
However, no country can spend and treat its way out of chronic diseases, antimicrobial resistance, Climate Change, and new and reemerging infections. The USA spends 18% of its economy on healthcare, six percentage points above the next highest, but ranks 27th in the world in quality indicators.
People-centered strategic thinking and the making of hard but evidence-informed decisions trump throwing money at sickness care. Indeed, prevention is not only better than cure, but undeniably cheaper. Despite knowing this, some health system stewards persist in under-resourcing public health facilities and under-remunerating practitioners whose care outlook is devoted to keeping the population healthy and productive.
An investment emphasis on reactive/sickness care only benefits drug companies and practitioners whose income is based on a high volume of necessary and unnecessary diagnostic and surgical procedures. In the Federation’s hospitals, tax-payer subsidization of private wealth exists at a rate of 7 to 1. For every dollar the owner of the hospital collects, practitioners collect seven. Such is the extent of the resistance to change, intimidation and acquiesce (ham and turkey syndrome) that only a handful of brave administrators, doctors and nurses dare to push back against deeply entrenched profit-over-health mindsets. Push back is a major cause of increasing incidence of conflict involving providers and patients. Missing is the long-overdue and much-ruminated reform of matters pertaining to fee-for-service in the government’s hospital.
We can reorient the national health and hospital system to the values, principles and elements of equity, responsiveness, resilience, effectiveness, efficiency, customer service, and performance audit. Among the chief and immediately doable outcomes are the integration and corporatization of hospital operations across both islands, the inculcation of a culture of continuous quality improvement, high regard for worker wellness, and targeted investment in structural design and maintenance. The expected dividend (impact) include the highest possible levels of healthy life expectancy, high customer satisfaction scores, high levels of retention of good workers, and a high likelihood of favourable voter confidence.
Building on the past health gains, St. Kitts and Nevis can and shall go forward but only through a policy and operating environment where Servant Leadership, Continuous Quality Improvement, Evidence-Informed Decisions, and Respect for Human Dignity are not cliche but enforced. Such environment is achievable in one week but not in the current circumstances of leadership and management by intimidation, fear, favour, affection, and ill-will.
Healthcare is about people serving people. The people who are served are human beings – residents, tax-payers, voters, visitors. The people who serve are the healthcare providers – the real assets of the health and hospital system. Both deserve a “Breakthrough Movement” in healthcare to commence now because “Health is too big to fail”.
“Our lives begin to end the day we become silent on the things that matter.” – Martin Luther King, Jr.
Patrick Martin MD
Pediatrician
Certified Physician Executive
Basseterre, St. Kitts and Nevis
Tel: (869) 465-5348 (work)
Pediatrician
Certified Physician Executive
Basseterre, St. Kitts and Nevis
Tel: (869) 465-5348 (work)
I am not a saint, unless you think of a saint as a sinner who keeps on trying – Nelson Mandela
Etienne calls for increased investments, new research on how to make health systems effective, universal, and able to respond to epidemics and other threats
Washington, D.C., 16 November 2016 (PAHO/WHO) — One of the most critical lessons of the recent Ebola epidemic in West Africa was that weak health systems—those that cannot meet people’s health needs in normal times—cannot cope effectively with epidemics or other health emergencies, said the Director of Director of the Pan American Health Organization (PAHO), Dr. Carissa F. Etienne, at the 4th Global Symposium on Health Systems Research, in Vancouver, Canada.
To ensure that health systems can respond to future health emergencies, absorb shocks, and adapt to changing demands, countries need to take action and make the necessary investments to make their health systems strong and resilient.
“Preparedness requires more than emergency plans and simulation exercises,” said Etienne. “It means strengthening core aspects of health systems, from human resources and access to medicines, to health information systems and even legal measures to support public health action.”
Etienne’s remarks were made before an audience of more than 2,000 experts on health policy and health systems at the 4th Global Symposium on Health Systems Research, taking place this week in Vancouver. The symposium is cosponsored by Health Systems Global, PAHO, the World Health Organization, the Alliance for Health Policy and Systems Research, the Canadian Society for International Health, Canada’s International Development Research Centre, and the Canadian Institutes of Health Research.
Investing in health systems resilience is “considerably more cost-effective” than financing emergency response and is likely to better protect people’s health and well-being in both emergencies and normal times, said Etienne.
“Fragile health systems increase the vulnerability of populations to external risks that impact health and well-being, health protection, and ultimately social and economic development,” she said. “Again and again we see this, through epidemics of H1N1 influenza, chikungunya and Zika virus; through earthquakes in Chile and Ecuador; hurricanes in Haiti and the Bahamas; and through the effects of climate change on health.”
In September, health leaders from PAHO member countries endorsed a new framework for efforts to ensure that health systems are more resilient in future health emergencies. The “Resilient Health Systems” framework notes that more than 98 million people in the Americas were affected by disasters between 2004 and 2014, that the recent chikungunya epidemic sickened more than 1.6 million people, and the Zika epidemic had such a serious health impact that the World Health Organization declared it a “public health emergency of international concern.”
To ensure that health systems are prepared for such emergencies, the framework calls for integrated action and increased investments in disaster preparedness, risk reduction, and response; disease surveillance and outbreak management; and health system strengthening and universal health.
“We know that a fragmented approach is not enough,” said Etienne during a panel discussion on resilient health systems. “We need to address both traditional disaster and disease risks as well as longer-term internal and external risks that affect the ability of health systems to respond well in both normal times and during health emergencies.”
Research on strong health systems
To be effective, efforts to build strong, resilient health systems must be based on evidence from research in a range of areas. “Evidence generated must ensure that healthcare delivery systems of the future are of better quality, are universally accessible, and are more transparent, democratic, and responsive,” said Etienne.
A central goal of this research should be to identify what are the characteristics of resilience in health systems. The results could lead to the development of “stress tests” that can assess health systems’ response capacity and identify weaknesses that need to be addressed.
Getting started on this kind of research is especially urgent because the process of building resilient health systems will take time.
“Building health systems with the right attributes does not happen overnight. It requires long-term political, social, and economic stability and a broad commitment from countries to invest in health and development,” said Etienne. “We must work together to find solutions.”
PAHO, founded in 1902, is the oldest international public health organization in the world. It works with its member countries to improve the health and the quality of life of the people of the Americas. It also serves as the Regional Office for the Americas of WHO.
