Fixing Health: That vague health sector audit report
In early September, the Ministry of Health (MOH) released to the public 'Audit Report - Regional Health Authorities (RHA) Summary Report'. The report states that an internal audit was conducted within the four regional health authorities to "determine safety and functionality of the systems" and was in response to "several concerns raised about the status of public health facilities".
The complete audit has not yet been released to the public. This article is meant to be an unbiased review of what has been published so far and provide suggestions on a future course of action.
Jamaica requires improvements to our health service. A comprehensive and credible audit of the current system would be a step towards achieving that goal.
The purpose of an audit is to provide an independent review of the systems and processes being used by an organisation, as well as to provide an opinion on their practices. In the case of an executive summary, the main points within the body of the audit are expected to be outlined.
The report does not state a terms of reference. In the absence of the terms of reference, the findings and the recommendations in the report diminish in value.
WHO ARE THE AUDITORS?
The report does not name the auditors; instead, an "audit team" comprising internal auditors, health-facility maintenance, health and safety specialists and infection control are credited as having carried out the audit.
Best practice requires that the auditors be completely independent and able to determine the direction and method of their investigations.
It is customary that internal auditors report to a sub-committee of the board of directors or directly to the board of the entity. Other categories of staff report through senior management.
The inclusion of non-auditors in this audit process could have caused potential conflicts of interest, compromising the integrity of the report. Auditors should be sterile. In this case, the use of external auditors would have increased the perception of transparency and credibility. Perhaps the auditor general may be asked to assist with future audits of this nature and importance.
According to the report, the audit "focused" on: maternity, operating theatres, neonatal units, intensive care and accident and emergency. No mention is made about outpatient clinics, inpatient wards, primary health, management and governance structures or financial management. All of those areas are critical in assessing the "functionality and safety of the system".
Many aspects of health-care delivery are closely integrated and interdependent. For example, maternity outcomes in a hospital are closely related to the quality and availability of antenatal care delivered in a health centre. Successful surgical outcomes (for example, cancer) are closely related to the availability and accuracy of diagnostic tests. Both examples demonstrate that to properly understand and assess the safety and functionality of those services, an integrated and comprehensive approach should be used.
By only "focusing" on a few aspects of service, we are likely to have overlooked or underestimated the true state of affairs in our health sector.
The document mentions the use of formal and informal interviews and observations to inform the audit team. The Medical Association of Jamaica was not invited or consulted at any point of this audit process, it is possible that members of the association participated. It is hoped that there was no restriction on the scope of persons that could have been interviewed by the auditors. It is useful to remember that participation in a process helps to build consensus and increases the likelihood of its success.
Public concern has erupted at the ministry's decision to withhold the complete audit from the public. However, within what has been released, we can still infer a reasonable conclusion that is perhaps the most significant finding. Not a single facility is reported as being "adequately" supplied or managed. Therefore, it is not unreasonable to infer that all the institutions reviewed are affected in a similar way.
The problems are systemic and will have national implications. In other words, the findings are not localised to any one institution or region, which supports the widely held public view that our health services are in crisis. The document has not provided new details or findings to disprove reports of inadequate resources in the sector; in fact it has confirmed it.
Within the presentation of the Minister of Health on September 2, at The Jamaica Pegasus hotel, he outlined some achievements of the Ministry of Health as well as increases in expenditures of the ministry and the patient numbers served by the Regional Health Authorities.
The announcement of a "cabinet approved primary care renewal policy" highlights the government's commitment to primary care and is a principle supported by professional bodies as the best direction for Jamaica.
According to the report, the audit was requested by the minister of health, yet, only two of the four RHA "carried out audits on at least one health centre" - only the Western Regional Health Authority (WRHA) and Southern Regional Health Authority (SRHA) reportedly audited any of the almost 350 health centres.
Many persons bypass health centres in favour of attending hospital because they perceive that they will get better care there. This would have been a golden opportunity to study the health centres, and make recommendations that would support the thrust of the government.
The World Health Organization study of 2005 (WHO-CHOICE) reported that in 2005 the expenditure per patient in hospitals operating at 80 per cent capacity (excluding drugs and tests) was between J$1,742.37 and J$3,104.78, while per person health centre visit 2005 cost between J$366.97 and J$480.80.
No findings or recommendations are made on the financial management or governance of the related institutions or regions are mentioned in the summary. With recently announced budgetary increases for the health sector, it would have been prudent to determine if the relevant bodies are equipped to administer any increase in funds effectively, transparently and with accountability. As the country struggles to fund social services, we should ensure the prudent management of our funds.
During the Cliff Hughes hosted daytime radio programme on Power 106 FM on Thursday, September 3, the permanent secretary in the Ministry of Health confirmed that the document was in fact a summary of a review, and not an audit.
The report has achieved the admission of the MOH that our health sector is inadequate. We no longer have to disagree that there are problems and that they are generalised and not isolated in nature. The report could inadvertently create the basis for frank and open discussions on the way forward between stakeholders.
In the future, it is indeed likely that a comprehensive audit of the health sector will have to be done to objectively determine the true state of our health system. The findings of that future audit should then be referred to a politically neutral committee to deliberate on and oversee the implementation of those findings and recommendations.
An oversight committee with public and private members similar to the Economic Plan Oversight Committee should now be seriously considered by the Cabinet to assist in lending transparency, accountability and credibility to the process of health-sector reform in Jamaica.