ADDRESS - OBJECTIVES AND POLICY ISSUES OF HEALTH SECTOR REFORM

It is a watershed period, as the focus and enthusiasm which is building upon the foundation of the dedication of most members of the Ministry of Health, will shortly begin the revitalization of a St Lucia Health System under severe and unrelenting stress. It is a stress that each succeeding year becomes multiplied by raising expectations and hence demands of the St. Lucian public.

When our citizens particularly the younger, see shows such as E.R. on television their expectations of our own system jump 100 fold, after the fifth episode of this drama series.

Our proposed Health System Reform is an urgent requirement not as an end in itself but because the stress on the St Lucia Health System, while still under control, has been building to such an extent that meltdown will occur unless redesign, reform, re-organization is the chosen path of this Ministry.

I would like to put this another way for the benefit of all of us here particularly the major stakeholders in the Health System.

Health Sector Reform in the St. Lucian context is not a stand-alone proposition. (pause)

The health system does not stand on this side of the room with health sector reform on the other side.

The path of the St Lucia Health Sector in the future goes directly through Health Sector Reform and becomes one, and for the simple reason that the stress of inefficiencies on the system, will gradually cause the meltdown of our institutions and system over time.

Reform is therefore the prerequisite for a sustainable health system over time.

The question looms over us of "Why the reforms?" "Where is the stress in the system ?

As St. Lucia’s Minister of Health

I have seen where the reforms are required, the numerous reports we have on file show where the reform is required and most importantly the public know where the reform is required..

The obvious areas which directly impact on our citizens are;

The Accident and Emergency Service

This topic I specifically dealt with in the Budget Address in Parliament earlier in the year and noted that this was the perfect example of the "Smokescreen of order" which has characterized the reality of the Health Service in St. Lucia. This smokescreen, this facade being the sole concentration and focus of the previous political managers.

The factors of concern to us with regard to the Accident & Emergency Department are as follows:

The organization of accident and emergency services, especially the slow pace of service delivery and delays in attending to some urgent cases.

A reported lack of nurses with specialized training in casualty services

Limited skills and capacity of ambulance drivers to provide care for patients

Public perceptions that high standard of care is not always maintained and has declined over the past four to five years

The inefficiency, bureaucracy and inconvenience to the public of the outpatient clinic appointing system

Golden Hope Hospital

This institution is of particular concern to me. It is of concern not only because of the inadequacies of the system but also because of the frustration that must be felt by the dedicated staff who day in and day out have to care in almost total obscurity for the most unfortunate of our society.

The level of staffing is grossly inadequate for anything but purely custodial care.

Admissions have risen quite noticeable over the past three years.

All in all in this institution the work calls for strong reserves of dedication and perseverance from staff if they are not to become completely cynical about the conditions under which they are supposed to provide care.

Internally, within the Health Sector we ourselves are aware of certain declines.

One of our primary concerns is the excess of recurrent expenditure (much on salaries and wages) over capital expenditure the result of which is a significant decline in the quality and quantity of medical equipment and supplies utilized throughout the service.

Within a number of organizations many hospital staff find working conditions unsatisfactory and there is a danger of losing a number of skilled medical nursing and other staff to the private sector.

Bureaucratic, inflexible system of organization and service delivery lower efficiency levels.

Inefficient or ineffective use of staff, equipment, supplies and other resources means we get less for more.

Inadequate care and control of funds, fee collection, outstanding creditors, drugs, medical supplies is a recurrent problem.

The lack of a clear sense of direction for government hospitals and other services or a vision for their future development

Much of the above stem from under-managment or a lack of direction and control.

Even with the poor state of hospitals and inadequate funding there are improvements which could be made, but which are not happening because of this lack of direction and control.

The seven main reasons for under management are as follows:-

The decision-making authority of all managers is very limited compared with counterparts in the private sector. Senior managers, department heads and others in positions of responsibility have little control over budgets, staff or other resources. Although a Hospitals Board has been established it has few effective powers.

Managerial accountability is extremely weak

Management structures are unsuitable, not well integrated and lines of responsibility are ambiguous, so that there are significant obstacles to well focused departmental management

Managerial systems for accounting, budgeting, planning, patient care, management information, quality assurance, stock control, revenue collection, etc are frequently inefficient and ineffective. They tend to be inflexible, bureaucratic, oriented towards central control rather than the needs of the citizens of St. Lucia. Many of the systems used in the hospital hamper good management rather than facilitate it. There has also been little attention to developing more appropriate management systems.

Skills and capacity need to be developed for all managers, especially in financial, human resource and general management

Initiative and leadership are lacking at most levels in our system.

The culture of management (as in most government services) emphasizes rules, regulations and taking action only when directed to do so, rather than encouraging and rewarding initiative or active responsibility.

Even Environmental Health has become a substantially different function from the public health services of the past, but this is not yet reflected in the organization, structure and management of this arm of the Ministry. There appears to be a strong case for a thorough review and restructuring of Environmental Health Services.

So, we are clearly aware of the dysfunctions within the system. We hold in our files a myriad of reports which have indicated the problems in very clear terms, the possible solutions also in very clear terms, but it is now incumbent upon my Ministry to define clear policy and implement defined plans for the restructuring of the system.

As we have made very clear, these plans will be formulated over the next few months based on intensive consultation with all the players in this field of endeavor.

At this point, we’ve addressed our objectives, the reasons for the reform, and the fact that we have the tools to initiate this reform, and we are aware that the political will is most definitely there from the Cabinet of Ministers and myself to ensure the success of this enterprise.

I would like to digress slightly at this point to address my concern as the Minister for the various stakeholders within the system directly responsible for the provision of health care.

The inefficiencies within the management structure , unavailability of resources, lack of clear direction all impact seriously upon morale, sense of direction, upon motivational levels of doctors, nurses, orderlies, medical technicians, administrative and ancillary staff.

Many are giving yeoman and humane service under these trying conditions and as important as addressing the concerns of the public, I am vehemently concerned about addressing the negative conditions that affect my people at the Ministry of Health.

I and the managers of the whole system have an important role to play in developing communication amongst these groups and in getting them to look at the holistic view rather than the short-term narrow view that in many ways have developed because of these adverse conditions under which they function.

I start with the premise therefore that there has been a management problem, a policy formulation problem within the Ministry that if tackled and changed then the enthusiasm, the dedication, the humanity of our people within the medical system will shine like a star, the brightest of stars in the night.

Others will address the specifics of the restructuring over the next few days and much will come out of our consultative process with the people of St Lucia over the next few months, but in terms of successfully carrying out its roles and responsibilities, we do know that the Ministry of Health will need to reinforce its base in policy making and planning, epidemiology, financial planning and control, quality assurance and clinical audit, human resource planning and management’ leadership, communications and public relations.

The emphasis on communications and public relations focuses on the need for the process of Health Sector Reform to be understood by all players.

As we meet here today and tomorrow we do so with guidelines and with some policy direction that has been formulated over the past months:

We look and will work towards a Health System with Universal coverage and access to a package of cost effective health services.

We will work towards the decentralization of authority to align with responsibility.

We look towards the integration of services with systems that encourage community based care and involve all providers in community based care and preventative care.

We look towards community participation in health care plan development and administration.

We look towards the separation of the provision of services from the financing of services.

Towards the development of a health information system to be simple, easy to measure appropriate outcomes.

Towards the establishment of accountability (clinical, managerial and financial) throughout the system.

We look towards the institutionalization of multidisciplinary health teams at all levels – primary, secondary and tertiary care.

Dr Nicholls, Dr Cumberbatch, I challenge you today to become effective catalysts in the formulation and implementation of St Lucia’s Health Sector Reform. As I said earlier, we are aware of the problems, I assure you that though the human resource element may be limited in terms of quantity, the enthusiasm, the dedication of persons in the health sector is there and therefore the challenge is to you.

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