Fixing health: Restructuring Jamaica's health sector for 2016
In recent weeks, the health sector in Jamaica has finally received the public interest and scrutiny it deserves. The call for, and subsequent release to the public of the "Health Audit" commissioned in 2015 by former health minister Dr. Fenton Ferguson has been the catalyst and the basis for current public discussions.
More public understanding of the history and development of our health services may assist us in better understanding current public discussions on health.
By the way, before I go any further, I would like to declare that I am currently employed to the South East Regional Health Authority as a Medical Officer.
Our health-care system has existed for more than 250 years. This was a period that included slavery, post emancipation, as well as the colonial and independence periods of our history. The delivery of health care in Jamaica, during that time, began with doctors attending to plantation owners, their families and slaves in an ad hoc manner, to a more organised health-care system with primary (community/preventative), secondary (hospital based) and tertiary-care services.
Since then, we have successfully implemented national vaccination programmes, antenatal, diagnostic and surgical services. The development of an organisational structure and management teams have also evolved, and Jamaica has been internationally acknowledged for achievements in health and medical research.
The ever-changing course of epidemiology: infectious diseases such as yaws and dysentery during slavery to lifestyle diseases such as hypertension and diabetes in the 21st century have required our health services to also adapt and evolve.
It is the inevitable cycle of change that must cause us to review our systems and adapt to new dynamics in health. The re-evaluation of our health sector should be compulsory by statute within a predefined time span - for example, every 10 years (earlier under specified circumstances) - with a framework for implementation. This will allow us to be more proactive and not reactive to changes, improvements and experiences in medical science. Unfortunately, it appears that Jamaica has not advanced as quickly as we perhaps could have.
BIRTH OF THE MINISTRY OF HEALTH
In 1974, an article in the discussion paper (Green Paper) titled 'The Health of the Nation' outlined several recommendations for our health sector. In summary, it proposed the centralisation of the Ministry of Health (MOH), both administrative and technical activities, while regional coordination of those policy directives would be implemented in the "field" by a local implementation mechanism.
This thinking propelled the process of consolidation of the Local and Central Boards of Health into what we now call the MOH. Subsequently, the Maintenance and Supplies Divisions were relocated from the ministries of Works and Finance, respectively, to the Ministry of Health (MOH). The unification process of the divisions of the MOH took place largely between 1976 and 1980. It is important to note that the Green Paper suggested that a high level of centralisation would lead to a "high degree of frustration and stagnation". The significant importance of the "field" and its ability to make locally based decisions in a timely and efficient manner was also highlighted.
The intention at that time was that the MOH would determine national policies, strategies, standards and norms, while the "field" would be responsible for co-ordination and implementation which was to be decentralised to geographic regions and eventually parishes.
While some elements of that proposal still exist, it is not the system of management we practise today.
It is important to remind ourselves that between the 1970s and 1990s Jamaica also experienced several 'internal shocks' of both a political and economic nature which are well documented and which had a significant impact on the Governments of the day. The research paper Primary Healthcare Jamaican Perspective (Davidson 1976) used local evidence to make the point that "Political ideology impacts public health policy and action".
BIRTH OF THE REGIONAL
The National Health Service Act of 1997 resulted in the formation and commission of four semi-autonomous Regional Health Authorities (RHA) - South East, Southern, North East, and Western (Health Authorities). The regions were determined by the geography, proximity to the population to be served, patterns of use, and transport flow (G. Briggs 1998).
Each RHA has its own corporate structure, budget, administrative and technical support.
At that time, the population of Jamaica was approximately 2.5 million, and the budget allocation to health was between four and five per cent of the gross domestic product (GDP).
The primary source of funding for the RHA is from the MOH, and more than 80 per cent of that amount is allocated for wages and salaries. Indeed, there has been very little change in either the administrative structure or the percentage of GDP to fund the health sector in Jamaica since 1998.
Population growth, migration (internal and external), increases in disease burdens and the chronic under funding of the health sector have placed the health system under severe strain.
The existence of bureaucracy within the regional health authorities and Ministry of Health has resulted in the delay of projects, programmes, financing and procurement of supplies. It has long been suspected that funding for projects may be available. However, slow turnaround in implementation has 6resulted in the stalling of projects and funding being redirected in some cases.
What has appeared to be a focus on administrative matters and reporting relationships, rather than on our patients, has undermined the work and potential success of Jamaica's health-care system. These anomalies must be corrected.
In the past, the chief medical officer (CMO), the chief technical advisor, reported directly to the minister of health. The minister of health is the ultimate decision maker in the MOH. However, this was changed and under the current structure the CMO reports to the chief accounting officer or permanent secretary (PS).
The role of the PS should be to ensure that the technical team's policies are supported administratively, financially and operationally. The reporting relationship that was once horizontal is now vertical, which now places administrative power above technical power.
Is it that non-medical concerns have superseded medical/technical advice?
Even at the local hospital level, the chief technical staff; matrons and senior medical officers report to the chief executive officer (CEO). In turn, the CEO reports to a committee of the board of the RHA. This is a departure from the existence of hospitals having their own Boards of Management.
In short, technical or clinical decisions are ultimately decided on by administrators who may or may not have technical knowledge or competence in health.
TREATED BY DOCTOR OR ACCOUNTANT?
If you are ill on a hospital bed, would you prefer that a doctor or an accountant treat you?
It is easy to be critical of the past, however, we must choose to learn from the past to ensure that we do not commit the same mistakes in the future. Since the inception of the RHAs, we have had an extended opportunity to rigorously analyse and critically evaluate the structure of our health care system. The benefits of improved technology and outsourcing practices to competent third-party providers have changed the management and operational landscapes forever.
At the same time, our disease profile (epidemiology) has also changed. Non-communicable diseases are an obvious danger to all of us. It is, therefore, timely and appropriate for the Cabinet to reconsider our RHAs in their current form as well as alternate structures for the efficient and cost effective delivery of quality affordable healthcare in Jamaica. An evidenced based, consultative, transparent, and credible approach to reform would be welcomed by stakeholders.
Reform of the healthcare system cannot be an isolated event. It is long overdue for sustainable solutions to finance our health services to be identified and implemented.
We must overcome the mental obstacle that health is a cost. It is, in fact, an investment in our future. This investment must be made by all parties - government, private sector, civil society and the general public.
The interest of our patients and the quality of life of all Jamaicans must be the central considerations of the reform of the health system. The pursuit of those objectives may lead to some job displacement, or even separation, but it is also true that we will ultimately save lives and live longer if we make better decisions.
The change we hope for can be implemented with a stroke of the pen or phased in over time. For example, the move from four RHAs to three, then two, and so on.
Whichever method of implementation is decided, we must act boldly. It is obvious from the health audit that our health-care system must now be urgently improved, and this can only be achieved through effective, managed change.
Replacing persons in leadership positions will not be sufficient to change the outcomes of the system. It is the hope of all health-care professionals to see our patients live long and productive lives. Let's hope our politicians also share these sentiments.