Budget debates and the delivery of quality health care services.

It was in a DNO article titled "Delivery of quality health services in Dominica on a slippery slope" and published on the 27th June 2014 that I critiqued our leadership in health which brought on me the wrath of our rulers during the 2014 Budget debate. I must confess that I hardly pay attention to Budget debates in our parliament and consider them boring financial affairs, where well-dressed politicians pretend to debate financial issues of which they seem to know so little. I fail to comprehend the usefulness to ordinary citizens of a budget debate with little or no prior public input that never influences the automatic endorsement by the "ayes" in the majority. Why not just call it a Budget address, allocate one hour for precise delivery and move to implementation as quickly and efficiently as possible. This would definitely spare us the humiliation and embarrassment of witnessing the limited capacities and unbecoming behaviors of so called honorable men and women in Parliament and indeed save the nation some dollars.

I must admit that my interest in listening to the measures related to health care was dampened when the Budget debate was suddenly aborted for reasons that were never explained. However the health measures mentioned in the aborted debate and recent official public pronouncements on health care have done little to indicate that there has been any measurable improvement in the leadership approach to the future provision of quality health care services in the "Nature Isle".

I think the political directorate was either ill- advised or disregarded its technical advice in its approach to Dr Carissa Etienne's recommendations for a tax on unhealthy foods. The research shows that a broad strategy that includes increased health education, regulations to limit bad food choices in and around schools (example no bakes and Busta in schools), increased physical activity in the targeted population, strategies to decrease cost on healthy foods (example reducing costs on farming inputs), and a tax increase of 20% on the unhealthy habit is required for such a measure to influence behavioral practices that improve health outcomes. The tax is the easiest part and some studies suggest that in the absence of the other measures it could actually hurt those it was supposed to help.

Our politicians in power seem to have now understood that a hospital building is not a service, however they are further advised that according to Wikipedia.org " the phrase state of the art has been used since 1910, and has become both a common term in advertising and marketing, and a legally significant phrase …In advertising, the phrase is often used to convey that a product is made with the best possible technology, but it has been noted that "the term 'state of the art' requires little proof on the part of advertisers", as it is considered mere puffery".[1] . The current exaggerated emphasis on a "state of the art hospital" and the number of specialists being trained does not reflect the reality that a newly trained specialist will need time and experience to acquire the necessary skill set to provide optimum quality of care. Furthermore the training of a specialist is just one of the requirements in providing quality specialist services. Provisions will need to be made for other categories of health care workers, equipment, complimentary and support services, continuing education opportunities, adequate remuneration to list a few. The emphasis should also be on putting the personnel and systems in place that will ensure that those newly qualified specialists can indeed maximize their training and contribute fully to improved quality of health care.

I contend that we risk compromising our quality of care if we proceed with the "new" hospital as proposed (10.5 million dollars was allocated for this in the 2015 Budget) under the present management structure. At least three studies dating as far back as 1998 have recommended that a Hospital Board overseeing a more effective management structure would improve delivery of care at Princess Margaret Hospital. This recommendation should be dusted off and implemented. Though it has not been mentioned I would hope that there are plans to recruit or train Dominicans in Hospital Administration or Hospital Management. I recommend training two Dominicans in this field as a priority since it is universally accepted that the efficient management of health-care resources is one of the most important considerations in Health Care Financing. Another major challenge facing the country.

To date no objective evidence has been provided to justify the old compound at Goodwill as the best site for providing future secondary and tertiary health services. I think given the marked increased in trauma and accident cases and our susceptibility to natural disasters we should consider modernizing and diversifying our emergency services around the island with the main trauma and emergency centre at the Goodwill site. Our secondary and tertiary services could then be located at an appropriate site along the west coast. This would avoid concentration of services at one site in case of a disaster and allow for strengthening our training commitment with the two offshore medical schools thus encouraging closer cooperation and numerous future possibilities. (I understand land at Warner has been sold to All Saints Medical School for expansion.) Could this decision to build at Goodwill reflect the failure of the leadership in health to provide the health research or evidence that would convince the political directorate to rethink or is it a desperate politically motivated decision? I am unaware of any dialogue or consultation with relevant stakeholder input to support this decision.Now this is a topic for a useful inclusive national debate for the benefit of the present and future generations.

The continued failure to expeditiously upgrade the health services provided at Marigot (100,000 dollars allocated in this budget) is not only alarmingly negligent given its proximity to the airport, it also reflects the disarray and lack of leadership in our approach to primary care services. These are the same services that need to be improved and optimized to minimize disruption in patient care once work is commenced at Goodwill for the "new" hospital. Further evidence of the unsatisfactory state of affairs in our primary care system was demonstrated by our management of the recent visit of the US Naval Hospital ship. There were significant shortcomings in communication, preparation and organization for this event. The confusion was palpable. This resulted in our failure to maximize the opportunities provided by the ship to the detriment of those who needed it most. If nothing else this should indicate to the" leaders" in health the need for immediate national simulation exercises in disaster management. I suggest a complete evaluation and overhaul of our primary health care system is overdue. At a minimum an audit of the role and effective deployment of the medical doctors in this system after thirty plus years is required. Such an evaluation could be the place to start to address the gloomy forecast of the coming tsunami of the complications secondary to diabetes, hypertension, obesity, cancer, mental illnesses and trauma in our population predicted by a pioneer of primary health care Dr. Carissa Etienne.

In conclusion I exhort those in positions of leadership in health who cannot stop the slide in provision of quality health care services to quietly do the right thing.

May the spirits of my ancestors be pleased.

Dr Irving "Eipigh" Pascal MBBS. FRCS.