REVIEW OF HEALTH CARE SYSTEMS:
CARIBBEAN PERSPECTIVES ON THE
NEED FOR CHANGE
Stanley Lalta
University of the West Indies, Trinidad and Tobago
Presented at Health Care Conference Aruba 2017 (HCCA-17)
June 2-4, 2017
‘ALL IS NOT WELL IN PARADISE’
HEALTH CARE SYSTEMS LEADERS ARE UNDER
PRESSURE TO TACKLE MULTIPLE CHALLENGES
Responding to rising
costs
• Improving value for spending
• Adopting new drugs and technologies
• Creating value conscious consumers & providers
Delivering high
quality
Providing
How to balance cost,
• Managing tsunami of chronic disease
access
• Defining "right" level of care and coverage
quality, and access in a
• Reducing variations in clinical practice
• Adopting evidence-based care
• Defining role of private and public sectors
sustainable manner to achieve
health and social goals?
• Ensuring equity across the system
3
Universal Access to Health & Universal Health
Coverage (re: WHO, 2010; UN-SDG-3, 2015)
A. Requires that all residents have:i) Barrier-free (non-discriminatory) access
ii) To a defined package of comprehensive services (promotive;
preventive; curative; rehabilitative; palliative)
iii) Delivered efficiently
iv) With quality standards (inc. timeliness)
v) And adequately financed
vi) Based on equity and ability to pay
vii) So avoiding financial burden on the poor.
B. It also requires implementing policies/actions:i) with a multi-sectoral approach (public & private)
ii) addressing social determinants of health
iii) spearheaded by a strong national health authority.
Values:
Right to Health
 Equity
 Solidarity
Health Spending in Selected Caribbean Countries
Country
Population (c. 2016) Life Expectancy (yrs)
Tot. H. Exp. (THE) per cap. (US$)
THE%GDP
Aruba (15)
113,600
77
2000
8.0
BES (16)
24,000
81
5300
21.0
Curacao (16)
149,000
78
2100
?
St Maarten
41,500
?
?
?
Surinam
547,600
71
589
5.7
Barbados
292,000
75
1146
7.5
St Kitts/Nevis
52,000
76
771
5.1
T’dad & T’bgo
1,365,000
71
1136
5.9
Netherlands
17,000,000
82
5700
10.9
United States
321,000,000
79
9403
17.1
Singapore
5,500,000
83
2752
4.9
• SOURCES:- Pan American Health Organisation; World Bank; Country Presentations .
 Target THE to GDP should be about 7% with 6% from public sources
 Target Out of Pocket Spending Share should be less than 20% of THE.
CARIBBEAN HEALTH SYSTEMS:-THE FIVE (5) GAPS &
NEED FOR CHANGES
GAPS
FEATURES
NOTES
a)Health Financing
Resources
Demand for and Cost of Services
Outstripping Availability of Resources
Need to bridge gap—manage cost/demand and find
more resources
b)Equity in Access
Differential Access to Necessary Care
Need guaranteed access for all in defined benefit
package (available; timely; quality; enforceable)
c)Equity in Cost Sharing
High out of pocket payments esp. by
uninsured
Need contributions based on ability to pay and care
based on need
d)Efficiency &
Accountability
Weak national health information to
measure value for money spending
Need sector-wide health information system.
e)Patient Empowerment Inadequate self-management skills and Need for more empowered, knowledgeable
& Adherence
weak adherence to health guidelines
communities for self-management of health risks
a)
$
Health Financing Gap: Cost and Sustainability
• Aging Population
• Chronic Diseases
•Technology
• Inefficiencies
• Workers’ Demands
• Expectations
• Slow Growing Economy
• Demand from Other Sectors
• Less External Support
Demand for &
Cost of Health
Services
Availability of
Resources
Time Period
Burden of Disease: Types of Threats
• New /Re-emerging Infectious Diseases (New Microbes)
• Safety of Food, Water, Pharmaceuticals (Antibiotics;
Counterfeit Meds)
• Preventable Injuries and Violence
• Environmental Degradation and Climate Change
• Tsunami of Non-communicable Diseases (NCDs)
9
PUBLIC HEALTH—SMALL, OPEN, VULNERABLE SYSTEMS
• Dependent--trade; tourism; technology
• Limited resources –skilled personnel; health facilities; finance
• SO AIM TO KEEP PEOPLE HEALTHY i.e
-------maximize public/community health
-------manage avoidable and inevitable health costs
Disease surveillance and control-infectious and chronic
 Laws & Regulations –health professionals; goods; facilities
 Pharmaco-vigilance
 Inter-sectoral measures for health promotion-illness prevention
 Research and international collaboration
What Makes People Healthy or Unhealthy?
 Why is young Peter in the hospital?
Because he has a bad infection in his leg and may need amputation.
 But why does he have an infection?
Because he has a deep wound on his leg and it got infected.
 But why does he have a wound on his leg?
Because he was playing in the junk yard next to his apartment building and there was some
sharp, jagged steel there that he fell on.
 But why was he playing in a junk yard?
Because his neighborhood is kind of run down. A lot of kids play there and there is no one to supervise them.
 But why does he live in that neighborhood?
Because his parents can't afford a nicer place to live.
 But why can't his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is only working part-time.
 But why is his Dad unemployed?
Because he doesn't have much education and he can't find a job.
But why ...?????????"
11
NCDs :-MAIN RISK FACTORS
Conditions
Risk Factors
Cardiovascular
Diabetes
Cancers
Respiratory
‘Unhealthy’ People-Economy
Smoking
xx
xx
xx
xx
xxx
Alcohol
xx
--
xx
--
xxx
Poor nutrition
xx
xx
xx
xx
xxx
Physical Inactivity
xx
xx
xx
--
xxx
Obesity
xx
xx
xx
xx
xxx
Raised b/pressure
xx
xx
--
--
xxx
Raised b/ glucose
xx
xx
xx
--
xxx
Raised b/lipids
xx
xx
--
--
xxx
The Shape of Progress..The Economist,
Dec. 2003
Obesity: A “War” We Are NOT Winning (CARPHA, 2016)
Adult overweight/obesity trends in the Caribbean
80
(%)
60
Male
Female
40
20
0
1970s
1980s
1990s
2000s
Prevalence of raised BP
(SBP ≥ 140 and/or DBP ≥ 90 mmHg or currently on medication for raised BP)
60
50
Female
Male
Total
30
20
10
Percentage with raised BP (SBP ≥ 140 and/or DBP ≥ 90 mmHg or currently on medication for raised BP)
Barbados
Cayman Islands
St. Lucia
Dominica
Trinidad & Tobago
Bahamas
St. Kitts
BVI
Grenada
0
Aruba
Percentage (%)
40
HARMFUL USE OF ALCOHOL
Alcohol burden also
Mental health,
injuries, violence, productivity
Source: STEPS surveys 2006-2013
120
Trends in Sugar Availability in 10 Selected Caribbean Countries, 2000-2009 (Grams
Sugar/Caput/Day)
110
gms sugar/caput/day
100
90
80
70
60
50
40
30
2000
2001
2002
2003
2004
2005
2006
2007
Sugar
Population Food Goal
Source: FAO Statistics 2009: www.fao.org
2008
2009
COMMUNITY and PERSONALISED STRATEGIES (eg in UK)
STRATEGY
ACTIONS
‘Hug’-Incentives
Incentives for healthy actions eg cash discounts to pregnant women who do not smoke; to
attend NCDs screening clinics
Vouchers/coupons to encourage purchase of healthy foods
Cash for involvement in sports
‘Nudge’
Use salt shakers with fewer holes or ‘on request’ in eating places
 Offer free entry to parks, gyms, swimming pools
Stress healthy behaviour to be with ‘in’ crowd eg. Healthy eating in social media
Show calorie-fat content of foods in eating places
‘Push’
Limits on ‘mega-sizing’ drinks and meals
 Restrict fast food outlets and ‘takeaways’ near schools
 Restrict sales of tobacco/alcohol to minors
‘Smack’
Legislate no smoking in public places or public ads-sponsorships
Apply higher taxes on ‘harmful’ foods, sweetened drinks, salted foods
Legislate food and drinks labeling requirements
Regulations on drinking and driving
b) Factors Affecting Barrier-free Access
•
•
•
•
•
•
•
•
•
Age
Gender
Language
Culture
Resident status
Disability
Disease/Illness (stigma and discrimination)
Geography/Transport (distance/cost from health facilities)
Financial capability
• Supply of services -driven by availability of skilled and other personnel,
medications and supplies, equipment and facilities (Re: ILO’s Access Deficit
Indicators)
EQUITY vs EQUALITY
ABSENCE OF UNFAIR AVOIDABLE DIFFERENCES
EQUALITY
EQUITY
21
c) Cost-Sharing:-Paying for Health Care at Individual Level
$
Subsidy needed
Cost of
needed
healthcare
Subsidy needed
Earnings &
capacity to pay
0
Age
EQUAL RISK
EQUAL INCOMES
Equity: Ideal Risk-Income Pooling and Access in Health
Contribution
Low Risk
$$
High Risk
$$
Low Income
$
High Income
$$$
Net Transfer
Utilisation
d) Inefficiency in Use and Spending
•
•
•
•
•
•
•
•
Too much emphasis on doctor-centred, hospital-based, curative services
Abuse of ER vs lower level appropriate facilities
Inappropriate average length of stay
Duplicative medical tests
Leakage and waste of medication/supplies
Over capacity in hospitals
Human Resources—wrong skills in wrong places
Too much use of fee for service payments to providers encouraging providerinduced demand (as compared to other payment methods eg. capitation, Case
Mix Groups)
* WHO estimates efficiency gains from the above could yield 20-40% more
funds for health
EFFICIENCY STRATEGIES
DEMAND MANAGEMENT
VALUE-BASED CARE/SUPPLY
FINANCING AND COST
CONTROL
More illness prevention
Evidence-based essential
package for all
Diversified funding sources—
public and private
Primary care-based
integrated care
Less hospitalization ..more early
detection and day surgery
Performance-based provider
payments
Empowered communities
Collaborative integrated publicprivate health services delivery
Shared purchasing of drugs,
supplies, contracted overseas
care
Selective co-payments
Targeted ICT solutions—
Prudential reserves and reelectronic records; telemedicine; insurance
e-health
CASE: INTEGRATED PHARMACEUTICAL MANAGEMENT
BURDEN OF DISEASE
ANALYSIS & FORECASTS
DRUG SELECTION &
PROTOCOLS
AUDIT & REVIEWS
QUALITY ASSURANCE,
TESTING, VIGILANCE
‘END TO END’
PHARMS.
MGT.
PROCUREMENT &
NEGOTIATIONS
TRANSPORT & STORAGE
PRESCRIBING, DISPENSING,
REIMBURSEMENT
REQUISITION & DISPATCH
e)ENHANCING INDIVIDUAL RESPONSIBILITY FOR HEALTH
• Knowledge and empowerment
• Mix of ‘hug’; ‘’nudge’; ‘push’; ‘smack’ strategies
• ICT tools and applications
• Cost-sharing according to ability to pay
• Patient feedback surveys
CONCLUDING COMMENTS
Findings
1.Need for health system changes:- gaps
in sustainability; access; cost-sharing;
efficiency and integration of patients
Suggestions
* Need systematic mapping and measurement of each of these
for evidence-based reforms.
2. Triple burden of disease based on range * Focus on social determinants of health and integrated
of threats—infectious; NCDs; trauma
medical-clinical measures eg ‘end to end’ management of NCDs.
3. Financial resources lagging behind costs * Need GUIDED PLURALISM i.e. rational mix of public-private
due to economic and social constraints
financing with dominant (NHI) public financing.
4. Sustainability requires focus on value
for money and empowered patients
* Need to spend wisely not widely esp. in small countries ..so
Primary care models, Integrated care, MIS-IT solutions critical.
5.Universal coverage requires constant
attention to EQUITY
* So emphasise ’from each according to ability (for
contributions) ….to each according to need (for health services)’.
Just because we are islands…
Does not mean we have to operate as islands