Pandemic and Universal Health Coverage / HealthChoice

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welcome to this morning's webinar on pandemics and universal health coverage we are pleased to welcome participants on all platforms and are happy you could join us this morning this seminar is hosted by the research department of the eastern caribbean central bank as part of the bank's continued engagement during this difficult period the ongoing covet 19 pandemic has had severe impacts on the lives and livelihoods of people worldwide moreover it has exposed in the eccu and

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elsewhere gaps in health infrastructure health information systems and deficiencies in frameworks for design and implementation of public health policy these gaps and deficiencies have implications for the delivery of health services and the achievement of goal free of the sustainable development goals all three of the sdgs aims to improve access to healthcare to ensure healthy lives and promote well-being

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at all ages before the pandemic member countries of the eastern caribbean currency union were at varied stages of preparation of national health insurance initiatives aimed at ensuring universal health coverage consistent with commitments made in 2015 under the un-2030 agenda for sustainable development the disruptions in the delivery of health services brought about by covid19 and the fiscal burdens

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of increased resources to healthcare and social support systems will undoubtedly result in a reversal of some of the progress to date in the delivery of health services this webinar aims to highlight the impacts of the pandemic the implications for the design of public health policy and approaches to the delivery of universal health coverage a word about the panelists this morning we bring you free accomplished panelists

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first up will be dr stanley lauter who is currently a research fellow at the center for health economics at the university of the west indies center augustine he's a graduate of uwi central augustine university of cambridge york university and university of london he is a member of the caribbean commission of health and development established by pahu and caricom in 20 in 2005 with the objective of chatting aroma for

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health policy and programs in the caribbean he is co-editor of the very popular book caribbean economic development that many graduates of the university of the west indies would have utilized the first independent generation dr lauter special interests and publications are in universal health coverage health financing social health insurance chronic diseases and pharmacoeconomics he is well placed

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to assist us in discussing these issues this morning dr kester j ned is the founder chairman and ceo of the gpr network llc a global network of healthcare providers dr ned has devoted a significant portion of his career to the development of models for affordable healthcare by organizing companies and systems to deliver healthcare utilizing managed healthcare value-based

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principles and modern information technology he has served as president and founder of physician care network a medicare managed care network dr kester ned's career in medicine spans 45 years as a practicing neurologist in the united states and he has held faculty positions as an associate professor of neurology and head of the u.s sports concussion clinic at the university of miami

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dr anton cumberbatch is currently technical advisor to the center for health economics at uwi center augustine he has been a key member of the health economics team on national health insurance initiatives in saint vincent and the grenadines grenada and jamaica he continues to be an active contributor to health sector reform work at the health economics unit dr cumberbatch held the position of chief medical

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officer of trinidad and tobago over the period 2008-2011 and the post of county medical officer of health for the george east in trinidad over the period 1995 to 2008 and 1991 to 1992. dr cumberbatch has been dedicated to the improvement of public health in the caribbean and therefore has been intimately involved in health sector reform initiatives in his home country trinidad and tobago he was appointed chief executive officer

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designate of the national health insurance scheme in trinidad and tobago and head of the government counterpart team of consultants i am your humble servant tracy polius chief director policy at the eastern caribbean central bank and moderator for this morning's proceedings some notes on housekeeping each of our panelists will deliver a presentation for approximately 15 minutes dr lauter will speak to the health sector challenges that have emerged as a

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result of kovit 19 and the implications for health service delivery in the eccu he will be immediately followed by dr cumberbatch who will highlight the implications of the pandemic for public health policy and present some recommendations for addressing those challenges dr ned will speak to approaches to the development of models for affordable health care and national health insurance with emphasis to always eccu member countries

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the presentations will be followed by questions from the audience questions will be taken off by from from batches of three to five and the panelists will be given an opportunity to address them given the nature of this event the host will mute all microphones and participants will be allowed to unmute their microphones during that question and answer segment we immediately start this morning's proceedings by inviting dr

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lalter to commence his presentation thank you very much madam chairperson a panelist and participants a very optimistic good morning to everyone knowing that we are in a rather dismal period with a pandemic steering us and having to be confronted this is a joint presentation that will be done by myself and

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followed immediately by dr kombech i've borrowed a term that has been used by the governor of the eccb navigating because i do think that what we are entering into is how do we pilot our countries through this unprecedented crisis through this summer describing it as an existential threat some are describing it as an invisible enemy how do we pilot our country's

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chooses what is the role of universal health coverage in this process the presentation is organized along these lines immediately following this i'm going to show a couple slides which give us a quick idea what is the status of the epidemic what is some of the economic and social impacts without getting into too much detail on these because i do think that there's

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enough literature floating around which can give us a much fuller appreciation of these just to pull out some of the highlights for these is what i will be doing i look at some of the key lessons of experience in pulling out from kovil what does this mean for health sustainable development the chairperson has already mentioned the role of the sdgs developed by the u.n and adopted by all our countries

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but i also want to touch on what does this mean for the cultural framework of our countries our cultural values what does it mean for individual rights civil liberties freedom social responsibility and what is the crucial role of leadership in this process dr lalter can you speak up a little speak a little louder okay thank you very much tracy i will try so is this any better sure it's better

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okay thank you um the third part of the presentation will really look at some of the key aspects of universal health coverage three dimensions what we want to look at in terms of population coverage so that no one is left behind the crucial matter of quality of care and then health financing which will then float very easily into what dr ned will be looking at in terms of nhi in grenada and in the oecs countries

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the fourth part of the presentation is where dr cumberbatch comes in because he's going to look at the critical implications of the pandemics of universal coverage and how do small countries respond how do we adjust how do we confront how do we navigate these challenges and then we end up with a few pointers on coping with scoville and what our ex strategy may look like this is some very quick aspects about the epidemiological burden so that we

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can put all of this into perspective december 2019 seemed very long away from now but actually this is when it all started and initially in that province of wuhan it was felt that this was a very localized outbreak very soon because of globalization this spreads that now we are in august we are nearly 24 million cases around the world 814 thousand confirmed

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deaths in our continents the americas europe asia africa and this is only the confirmed version there may be other cases which have not been counted and which have not been confirmed what is still unknown because this is a very strange pandemic to some extent how it started what are the symptoms what's the treatment is a vaccine going to work is it going to work for a long period what is the extent of the length of

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immunity these are still unknowns which are the subject of the intensive treatment protocols and the um testing of the vaccines which have been undertaken who's affected well very early on it was felt that this was a disease or this was a condition that was only going to affect elderly persons and those with pre-existing conditions this has been proven to be wrong they are still

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the most vulnerable but now look at what's happening to frontline workers look at what's happening to persons in what may be called deprived communities what is social developments sorry determinants of health are very crucial look at what's happening with children what's happening with the younger population so this is a disease which is now crossing age barriers which is crossing income boundaries it is crossing geographic boundaries what has this led to in many countries the overwhelming of

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facilities of staff decisions have to be made on prioritization of patients who is going to get tested who's going to get treated who's going to get that ventilator and we expect soon when a vaccine comes on who is going to get priority for the vaccine to some extent and power who and the wh has brought this out it has led to a certain amount of deprioritization of other diseases for example some non-chronic

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non-communicable diseases hiv immunization for other diseases seem to have fallen by the wayside in some countries it has also brought about a certain amount of competition for the vaccine and i'll touch on this a bit later where you now have about 170 candidate vaccines which are being developed and it has also led to a certain amount of what we can call vaccine nationalism i should be first already countries like

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the us uk india have cornered the production facilities to say that we must get priority where's the role what's the role of the wh show what's the role of internationalism the role of small countries and all of this and who will get the vaccine first and all of us are being asked to share this responsibility of flattening the curve social determinants as we all know because this is what affects a lot of

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persons not everyone has formal jobs but everyone is well educated not everyone is well housed and where you have differences in all of these then you are going to have social differences and this is what is playing out very much in terms of who is affected more who's dying more from the disease how do we slow down the pandemic and this is a very popular graph that has been presented

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in several places how does an epidemic unfold and what's the impact on the population if you look at the dotted line dotted line really represents your health care system capacity what can you cope with the blue line showing the very steep curve at the top if you allow the disease to run a rampant without some kind of control if you allow it to run through the population then you have what is called uncontrolled transmission

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it floods the country overwhelm your health facilities how many persons die in that process uncountable if however you can control the disease to some extent and this is where social responsibility this is where regulations which is where personal controls and personal responsibility become very crucial if you can manage to do that then you can contain the disease to some

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extent within the capabilities of your health system but if you don't then you have the blue curve facing you how do we flatten the curve and then to some extent what we're finding is that there's no single curve we talk about the first phase we talk about second phase there may be a third phase so it's not just one single curve that we are looking at how do we flatten the curves infection rate fatality rate reproduction rate

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treatment rate testing rate all of these have to be considered when we look at the epidemic economic dimensions and i think that the international organizations the imf the world ban they've had to change their assessments in january the assessment as to what the impact is going to look like and it was still felt that the world economy was going to grow by about three to four percent in march this would change a bit in june

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this is a change even more so that you find that now the imf is predicting that there will be five percent decline in global output as an average different countries are going to be affected differently on employment severe in fact a clock in this july 2020 document indicated that because of the loss of global output output of output in the latin american and caribbean countries

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we can very well look upon all the gains that we would have made from 2010 look at this as a lost decade in fact when you look at the sectors which have been affected then you can begin to see that all countries given the globalization of trade of travel of markets are affected but somehow who's growing the online businesses the take away play uh

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places and points are growing can everyone see the slides i mean i'm just getting a little note which tells me that we're still only seeing the first slide uh tracy chairperson can you just verify for me if the slides are running as i have them here or if it's full slash yes your slides are running now okay thank you all right

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for countries and the macroeconomic indicators what's happening to fiscal deficits fiscal balances debt balance of payments foreign exchange earnings foreign exchange reserves poverty all some of the macro aggregates which have been severely affected in fact the eccv governor is now speaking about what can be called a u-shaped recovery but i can also think about some other shapes which we can consider we can also

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consider a v we can also consider a j we can consider an l also no one wants to go in that direction we can we can consider a w shape hopefully it is the u shape but the depth and the length of that trough is what is going to be the important consideration social impact of the virus

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we are now speaking about the new normal emergency shutdown lockdown restrictions on schools church activities sports cultural events daily life visiting visiting elderly relatives persons want to go to funerals who may be caught abroad and can't return home i mean the social impact has been severe but more than that what it has meant is in terms of the stigma and discrimination of

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patients and also of health and frontline workers bear in mind that health and frontline workers more than one thousand have died even in the caribbean countries many of them have come down with the condition and they now have to be quarantined what's the extent of all protective safety net for the unemployed the poor countries have tried to put together packages to assist persons but for how long can these packages run

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and then that's for only persons in your database what about persons who are not on the database especially those working in the informal sector what about persons who may be what can be called undocumented persons with a certainty of hunger has to be matched with what we call the lottery of the virus so people go out and people do things quite contrary to what you may want to see happening in terms of the

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regulations and the lockdown there's a quick slide to give you an idea what's happening in oecs countries so far generally the cases have been kept into double digits and the mortality or the fatality has been kept in single digits mostly zeros guadeloupe martinique were very close neighbors uh some triple figures which you can look at and then other caribbean countries trinidad guyana

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bahamas suriname jamaica for example we're now running into four four figures in terms of the cumulative number of cases now in fact the language is changing not from so much to cumulative cases but active cases and a number of persons who have recovered so this is a very important distinction which we need to be making what does all of this mean how should we view health to a very large extent in many of our countries we saw health

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as an expenditure well really it is an investment his investment in human capital is investment in social capital because if we do not have a healthy environment then it means that other sectors as investments are going to crumble in fact it is health which gives us the freedom to achieve sustainable development on an individual level at a country level it is a foundation it is a freedom it is a flexibility which good health brings to the population

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now more and more we are realizing the importance of what is called public goods and public health goods and this is something which dr cumberbatch will touch more on in his presentation economic theory tells us as public goods generally are non-rival and non-excludable well think about public health goods surveillance disease control sanitation health education all of these are imperatives which must be in place if we are going to manage

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this as well as other pandemics which may be coming up international health regulations and dr khambatsh will again touch on some of this and this is a crucial aspect of our linkage with the international community in fact who has been very strong on this that if all countries were following all the considerations and all the capacities which are required in the international health regulations

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then probably we will not be at the stage where we are now in 2019 there was this assessment which was done showing how countries are trying to put together their response capability to deal with pandemics and in a way the global score 40 out of 100 meant altogether that national health security or preparedness to deal with pandemics is fundamentally weak around the world

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and no country is fully prepared for pandemics and epidemics every country has important gaps to fill and you can take a look at where some of the caribbean countries are located in terms of their scores strangely the us and the uk ranked number one and number two but i don't think that that is going to hold very much more more recently you have another index that has been coming around and this is one which has been prepared by oxford university

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what is called a government response tracker and we can take a look at those and see where countries are in terms of 17 indicators pertaining to health economic preparedness social preparedness and an overall preparedness index responsibilities for this state responsibilities for individuals this is a very crucial part of the whole process because we seem to think that

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government can manage all of this government on its own planet in absence of a vaccine in an absence in the absence of treatments which can be magic bullets solving the problem immediately is very much left to individual responsibility and we've defined this role of the state educate communicate to test trace the council to isolate the treaty to legislate to enforce the vaccinate and the role of individuals the role of individuals bring us a very

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crucial point about what does it mean for rights human rights civil liberties freedoms as against social responsibility you still have many persons who are not following the regulations in fact regulations are seen more as suggestions rather than obligations anti-massacres anti-vaxxers young who are invincible those who are denying the skeptics those who think that the conspiracy theory

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blame 5g they'll blame bill gates you know blame some other causes and then the fatalist among us to think that we must die of something battling this global emphademic or the fake news is a crucial part of this and this is where the right to private liberty now runs into the social responsibility dimension how do we balance this is what we're facing it is also a test of leadership political leadership medical

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leadership business civil society religious organizations social media leadership in the whole process because if we get this wrong if the leaders don't know the way show the way or go away then it makes a mess out of what social responsibility is going to look like okay a very quick look at the universal coverage and all of this is part of system what does this all mean battling the pandemic what does it mean for universal

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coverage well in a way universal coverage has a few critical dimensions it says that you should have barrier free access to a defense package of services delivered efficiency quality standards adequately financed based on equity and ability to pay it also requires a multi-sectoral approach so that you can address the social determinants three dimensions shown in this uh cube we can look at population

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coverage services which have covered financial protection on the third arm crucial in all of this in terms of we need to do the systematic evaluation we think that because we have a public health system there's coverage across the population this may not be so do we have adequate coverage across age differences gender income education social class disability language geographic distance if we can do that evaluation then we can begin to say that there's

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adequate coverage for health interventions for a total population but if we haven't done that then just claiming that we have a public health system does not meet the goal of total population coverage health quality we may have services being delivered but are they of adequate quality public sector private sector quality of our health professionals products supplies coming to the country medications

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facilities as a licensed pharmacies labs can any lab do dr covid test or do we have quality dimensions for these quality of health services all together and then the third dimension of this is really the financing side the financing side what are some of the crucial lessons coming out from consideration of health financing around the world we must have compulsory systems contributions must be fair in a way

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this graph gives us the critical insights into how we should organize our advancing systems contribute according to your ability but you get access to care or you utilize care according to your risk levels so equal incomes person my first dimension low risk high risk equal income so the contribution is the same and that's why the size of the arrows are the same on the contribution side

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but when it comes to utilization or accessing services then they access different levels because high risk will utilize more low risk lessons so the size of my arrows are different or if you look at the second half of the diagram equal risk persons but one is low income one is high income if you contribute according to your ability low income contribute a smaller amount smaller arrow high income contributed larger amount but because the equal risk when it comes

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to utilization they utilize approximately the same amount of services and that's why the size of the arrows are like that this is what you're looking for from each according to ability to contribute to each according to risk level your need for care if we can organize our systems on that basis which is what health insurance national health insurance tries to do then we can take us very close to

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universal health coverage across the caribbean and doctor combat will a touch on this much more across the caribbean we sometimes go away with the impression when you speak about universal coverage that government must provide everything and government must finance everything this is not so there's some critical functions and services for government to provide but because we also have strong and capable private health facilities how do we bring them on board and this

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is where the financing system this is where your i.t system and this is where your quality of care dimensions will be the critical linkages between what you want to do with the public system the private health system because no single system can manage all the problems of the health or the health of the population or cover the cost of all of these in the caribbean oecs countries this is where most

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countries are antigua for example has moved very far ahead since 1978 antigua has an operational medical benefit scheme it's now been reviewed for full coverage virgin islands has a universal coverage plan since 2016 martinique guadalupe of course they passed the french system and they have their plans in place other countries uh putting plans preparations have been undertaken for full nhi i want to draw a

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distinction don't only think that nhi means national health insurance national health insurance is a critical financial aspect but it is not the totality of universal health coverage what does all of this mean then managing the pandemic navigating pandemic navigating universal coverage in small countries and this is why i will turn it to dr kama batch to continue the presentation dr kamavatch

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thank you very much dr lalter good morning to everyone um i would want to take a look at that slide that dr lalter has put up the proposed pattern of provision and financing the caribbean but before i do that i would like to from a public health point of view because i'm a public health person remind the audience of some things the first thing is that this present pandemic

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was not an unexpected event debbie chupa who had been saying for the last 10 to 15 years as a public health professional i am aware of this that we are expecting infectious diseases new and emerging ones and the return of some of those that have been there before um and they've been putting it across the globe but it seemed that um their exhortations the countries were not

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really taken on board so this is not a unexpected event the other thing i would like to make a point as we're talking about pandemics and small island states and if you remember dr lalter making mention of the star wars presentation of a number of um epidemics that impacted upon us the h1n1 um the zika what and those things are small islands they come like a pandemic so we must remember

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that it is not just because they just described that this is a pandemic that the impact of an infectious disease outbreak can be very dramatic and can have far-reaching consequences for small island states especially states that are tourists depend on so that's the first point the other point i want to make is the question of universal health coverage one of the things we must remember in

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a health system structure and this is for a global point of view health system structure they are built upon a solid base of public health if you don't have a solid base of public health i it does not matter how many hospitals doctors nurses that you have and what technology you have what a pandemic shoes you it will overwhelm it and make all of it virtually useless because of the numbers

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of cases and this is a very important point we keep seeing it and for small island states this is actually a critical thing to understand we must make an investment with universal health coverage universal coverage for small island states does not start with clinical services i want to repeat that it does not start with clinical services nor does

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this end up with hospital services universal coverage starts at the base meaning safe water safe food safe borders and this is something the financial agencies need to understand we get it just so having said that i would now refer back to this slide where you see the proposed the health systems that we were talking what is deciding proposed part of health provision financing and services that

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one what you have there is on the left of the slide public health and health providers of public health agencies then the ambulatory outpatient inpatient what it says to you there that health systems are built on that kind of structure public health it's financed by uc taxes yes and nhi knew this is the critical

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foundation of any healthcare system so the universal courage starts with that and if you notice it is funded by taxation and if you get the coverage right then the baseline is correct the ambulatory part the outpatient which can be public or private or ngo the inpatient public or private and those two things are normally when you get the question of

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national insurance and you can get combinations of financing from public or private to cover that so the point is being made here that the financing of care and the spread of the universal coverage is very intelligent between government financing and also financing from social health insurance or national insurance and private sector financing next slide

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standing i think we need to go one step forward right for a small island steeps we have some issues with respect to how you approach these things one you will see that we are open and externally dependent we are resource constrained now that resource constraint because we do not have capacity of hospitals doctors we do not have depth of technology

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it means that our response to things like pandemics or challenges has to be early warning and prevention on early intervention we cannot tell ourselves like a big high a major country that we would have the hospital capacity or the technical capacity of all these labs and whatever else that they have including the ventilators to respond so therefore the

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collaboration of small island states together early warning early intervention is our solution the other thing that is very important is to ensure that the health staff the protective equipment that we may have because there's something that we need to understand about pandemics and infectious diseases the baseline equipment is fairly the same in terms of what we call pves this is a personal

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protective equipment so whatever you have as an infectious disease now what it means is this for our small island states we must make sure that all our healthcare professionals have the ability to respond with that type of training and also what people are now calling um the parallel health care system now even though you have to have the priority health care system which says you can have your partner let's get them

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dealing with infectious disease by the clinical services go on to some extent untouched by the infectious disease a small island state has a limitation of that because of the sheer numbers so therefore our staff even though that they may be working in the part of the the health care system that is not impacted by the immediate infectious disease they must be able to be able to cross over

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and assist by having them being trained in pves and all the other things that we need to do for infectious diseases the the there are some issues here with respect to the pps and the small island states i'm going to make a little controversial statement here as a small island state on small island states we may need to look into the future in terms of our research to see if it is possible

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that we can re and i'm careful with my words here re-sterilize ppe's that are supposed to be there for single use to have them function in a reusable form because is either that or we ourselves in the small island states make ppe's because what we have learned in these epidemics and these pandemics is that the resources that you are depending on from the larger countries

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will no longer come to you when you have a pandemic so we have to respond by developing our own ppe for our own cells not only just for the partnering for all infectious diseases and the question of re-sterilization and reuse as a new initiative needs to come on board next slide standing the essence of the thing is what we want to make sure that we also understand

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especially in this pandemic in the situation of the caribbean the pandemic is an acute infectious situation we have in the caribbean a chronic disease pandemic also going on in terms of diabetes and hypertension so what you're going to get is the impact of this acute infectious pandemic and we are seeing based on the reports that we're getting from the global response and the global impacts is that the

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infection this particular infectious disease has chronic disease implications in that people are having issues with mobility long after the acute infection has passed and we also now realize that the impact of this pandemic on chronic disease is deadly and disastrous what does it mean for the caribbean who has a chronic disease epidemic going on it means that when

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this acute epidemic is over we will see the impact of the epidemic on our chronic disease patients maybe for years to come what is the implication the implication is this and this is very universal health coverage the clinical impact can take place if we provide the services through universal coverage at the primary care level

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to control the diabetics and hypertensive because what what we know for this for this pandemic is that patients who have been properly controlled the diabetes the hypertension the obesity and prevention from strokes they get less mobility and mortality with the impact of the acute proven so what it is saying to us universal healthcare coverage at a clinical level

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re-impacting on our primary care services for all our diabetics hypertensives the people who have the the risk of strokes it's on obesity in children if we were to concentrate on that using our universal healthcare coverage at the primary care level it will have a very positive effect on the covered complications that will persist with us after the acute

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situation the other point i would make is the linkage across territories the way that we can handle this is by working collaboratively across territories very very important we must collaborate whether it is between the car for whether it is the curry come with us with the pahu and share the or best practices or early warnings

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and also for even the vaccinations to come using the revolving fund so collaboration is what is going to give us the protection borders and collaboration among ourselves but collaboration with the major countries my last little slide here my last statement is first to understand something i know that kovit 19 has shaken up the world but we have been down this road before maybe not with the kind of economic

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impact that is going on but we have survived many many types of infectious diseases challenges and one of the points that is being made and people seem not to um take it on board when the statement is saying well you have to learn to live with it they they go with 19. and it seems to be a shocking statement but if you look at what has happened in the past we have lived with polio we have lived with measles we have lived with yellow fever

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we have lived with tuberculosis we have lived hiv aids and we have lived all of these things and we have learned to do it with common sense and logic in a pandemic the behavior of the public is as important as the behavior with the doctors and the protocols and i with that statement i would like to tune it back over to dr larter the wrap of our presentation thank you very much dr kamaraj just two points in closing

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and the slides uh will be available to uh participants um firstly to borrow the words of the eccb governor we must adopt a growth mindset even as we tackle the crisis there's a health crisis an economic crisis a social crisis but we must have a growth mindset and emerge stronger and more resilient so we have to accept a certain level of risk as we adjust we move ahead we cannot lock down

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indefinitely so opening up with stringent disease control priorities and protocols is the key second major point in all of this is that we keep speaking about the new normal but let's be very clear this new normal does not mean that that's the end of the pandemic it's not a post-pandemic world we're looking at we have to look at the pandemic prone environment because

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the indications are there'll be further pandemics that we have to contend with 20th century the 21st century the 19th century we can go back in time um we haven't solved all of these problems yes this is a category 5 plus health disaster but it doesn't mean that that's the end of all disasters like this so pandemic prone environment and this is where the whole match of surveillance protection public health becomes very crucial

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our new normal in the caribbean then cannot just be going back to what we had before how do we be how do we become more socially equitable what do we do about our economies that become much more diverse rather than dependent upon one single sector how do we take on board the whole matter of environmental sustainability so when we begin to talk about the future this particular pandemic should give us the opportunity to

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really rethink what is this new normal in the future going to look like and how can we make it more equitable more diverse more sustainable from an environmental point of view managing all of these changes for the new normal will require what we call the leadership partnerships and more and more we will realize people have to be empowered knowledge capability that is what

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is going to lead us into the new normal and into the future which we will all want to be part of thank you very much for this very very um interesting and i i would say presentation that is filled with information for all of us to digest but before we move on to dr ned dr kambabachary is a very important issue which is that universal health coverage

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must start at the base and it must start with issues related to um security of our borders and food issues related to the quality and security of our food and this segues nicely into the next um digital dialogue that the eccb is going to hosts this digital dialogue is titled pandemic and food security and it will be held on thursday

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10 september 2020 at 8 00 pm during that dialogue the governor will convene a panel that includes the honorable saboteur caesar minister of agriculture in the government of saint vincent and the grenadines and that digital dialogue will tackle the issue of food security access to safe and nutritious food so i just thought that i would inform participants

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about this as a related dialogue that the eccb and related engagement that the eccb will host this will be hosted by the governor on september 10th 2020 at 8pm we will now move on to the presentation by dr ned who will speak to us a little bit about approaches to universal coverage and access to health care affordable health

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care so without further ado we asked dr ned to start his presentation okay good morning everyone i'm gonna share the slides um at this point um so we can get started first could everyone see my slides i just okay okay and i'm able to advance right it's uh it's advancing properly okay yes okay thanks so good morning everyone uh let's uh i really appreciate the

53:53

opportunity to present to the eastern caribbean central bank research initiative and the listeners or the persons participating in the webinar so thanks all first i want to thank the unit at the university of the west indies for the tremendous work that they they have done in the caribbean in analyzing the healthcare systems and also the work they've done in grenada

54:25

uh in doing the initial research for the development of the national health insurance initiative certainly they've done this in other caribbean nations and we have worked alongside them in the past utilizing their data and the work they've done so we are fortunate in the caribbean to have such an organization to represent us in this field and thank you dr lantern company thank you so today i'm going to focus on the issue of

54:56

universal uh healthcare coverage in the context of the pandemic and also in the context of what we're doing in grenada to develop national health insurance a little disclaimer i just want to let everyone know that this is this is a model in progress and still being reviewed by the government of grenada and the people of grenada and a committee nhi committee that's working with us so so first i'll start by asking

55:29

this whole concept of universal care and universal access this age-old discussion is healthcare a right or healthcare a privilege we in the in the caribbean believe that healthcare is a right for some reason many developed nations including the united states believes health care is a privilege ah but when you think of something being a right a right must have certain

56:00

characteristics characteristics it must be first i call it the three a's it must be available must be accessible well you can have something available but some people can't get access to it so access and availability are two different issues and the third a is that it must be affordable so in a way we have to ask ourselves as caribbean nations is healthcare truly

56:29

a right based on this concept now uh i'm was particularly impressed with the presentations uh prior in addressing this whole issue of healthcare as an asset as compared to healthcare being a liability when we think of healthcare world over we view it as a cost it's a cost in our budget it's the cost for the government it's a cost for

57:03

people but we don't see many times we don't see healthcare as an asset as an economic driver as it is and so one of the challenges we have in the region is that a missing factor that drives healthcare as an asset is the stakeholder consolidation the stakeholder participation that's a clear missing factor

57:36

in this whole discussion of national health insurance and so as a result when we focus on the development of grenada's brand of healthcare or potential brand we look at it from the concept of stakeholder interest and participation one of the challenges we've seen in trying to bring forth a national health insurance initiative is that the stakeholders have very conflicting needs

58:09

and some of them are actually contrary to the others and that is a creates a sense of conflict and challenging so for example an insurance company's role is to get a run a healthy plan with a positive return for their investors while a physician or a hospital's role is to be able to be adequately compensated for what they do

58:39

and also to provide quality health care so on one hand you have a group that's trying to conserve resources and the other hand you have one group that's trying to spend resources so that makes it rather difficult and in in terms of those conflicts or how stakeholders view national health insurance or health coverage as a whole cheryl yeol said the best way to minimize disagreement is to make sure that all

59:12

the stakeholders are in the room what that really means is that if we have all the stakeholders joined together in some way you have something called the power of numbers when we look at the eastern caribbean as a whole each territory is doing their own are doing that they're doing their own healthcare systems when you look at banking as an institution

59:42

in the region the eastern and i have to applaud the organization that's which is sponsoring for facilitating this our nation organization of the eastern caribbean currency throughout the caribbean in a way that you have the power of numbers you have a strong currency as a result of collaboration and if we can do this in banking why shouldn't we do this in health care the challenge of globalization has made

01:00:16

healthcare a commodity when i say a commodity and most of us don't think healthcare as a commodity i said this once and a consumer of healthcare said to me we can't look at healthcare as a commodity healthcare is a profession healthcare is a service and i do agree with all of those descriptions but in today's world people are shopping for health care based on the following characteristics they're shopping for based on price

01:00:49

these are the characteristics of commodity commodities they shop shopping for healthcare based on how accessible it is what quality you have and certainly certain laws of economics are beginning to apply what we call the laws of supply and demand in the past in healthcare you could have a lot of service but yet the price goes up uh and in many cases when you have a lot in uh in terms of supplies

01:01:21

then uh then of course you have less demand and so the prices generally come down until recently those economic models weren't applicable in healthcare and in particular in systems in the caribbean that's based on columbia models we're not able to price health care according to real economic principles so clearly one of the stagnating factors of making health care a commodity in the region is to apply the principles of

01:01:54

worldwide economics of supply and demand that's an important driver of the service we have a demand for services in the caribbean but clearly we don't have a lot of the supply so issues that has made health care global in its reach so in fact if you look at television if you look at social media today there is a degree of transparency that's going on

01:02:26

in healthcare you go online and look up the statistics of a provider based on the comments of the patients they see you can look at forums and you could review a procedure as to how effective it is i mean all that information is available online and that's the world over so consumers in the caribbean have been educated and what quality healthcare is yet we've now advanced the healthcare delivery system to the extent that that type of quality could be

01:02:58

measured methods of payments for healthcare have not evolved in our region and the laws that govern healthcare financing have stagnated because healthcare policymakers have not really addressed those issues certainly there are some outside influence to keep the model as it currently is but we know clearly this whole issue of healthcare financing is not working if we want to ensure or cover

01:03:31

a population if you look at the caribbean between five and say 15 percent of the population in most nations have some form of health care coverage from at least from the private sector the bahamas the cayman islands and the bvi are certainly exceptions now there are other nations that are offering some of those service some of the french islands dutch islands have more comprehensive systems and they cover

01:04:01

pretty much all of the population but in the eastern caribbean we are still struggling with this concept of how to cover our population so the formation of the other concept that we are concerned about is the formation of these integrated healthcare networks that's needed to service uh this type of national health insurance systems and one of the challenges we have throughout the caribbean is that we lack this integration of

01:04:33

healthcare providers where we work together as a unit we could function independently but in the u.s and some other countries those are referred to as independent provider associations where providers contract under a common contract even though they provide care individually but that allows the linkage between entities so that you could parse and distribute care in a manner that could control costs so i'm going to speak a little bit about that

01:05:03

based on what we've tried to do in the modeling grenada but let's focus a little bit more on some of the challenges in the caribbean healthcare delivery system as we see it the first issue with national health insurance and the issue with with coverage or the issue with healthcare systems development has to do with having a way to pay for healthcare and national health insurance and universal healthcare is about funding healthcare

01:05:34

and funding it in its totality and what models we use to ensure that funding is allocated available and distributed in a proper way so that it effect to is effective in delivering the health care service at the point of care acquiring and maintaining technology becomes an issue if you don't have the appropriate financing as you know healthcare is growing at phenomenal rates in these days in terms of technology

01:06:08

certainly some of the economic drivers that consumers are concerned about and wanting and what they're asking for sometimes we as healthcare policymakers and and business leaders uh understand the need for primary care but when you have a catastrophic healthcare condition that you could potentially lose a family member that's high cost certainly at times those issues of prevention go out of the way and we focus on the high cost care

01:06:40

issues there are some philosophical constructs that we have to develop in our societies to decide where we focus on priorities when you look at how the insurance models are structured today in the caribbean they're all structured on specialty care catastrophic care and very few insurance companies offer services in primary health care in fact i look at some of the policy and the benefits they may offer one visit to two visits a year to the primary care who are generally

01:07:11

the gatekeepers and they really are the ones who focus on prevention there is not a strong motivation for insurance companies in the region participating in health care to focus on primary care and therefore that's left up to the governance another challenge we have is retaining professionals and specialists the caribbean today perhaps train more doctors per capita than any

01:07:42

nation in the world we have more medical schools in the region than we have elsewhere and we train doctors for all markets africa united states europe latin america but yet we have poorly developed health care system in fact in some cases we have a surplus of doctors primarily in the non-specialized areas the ability to acquire and uh produce medical products we were talking about

01:08:14

this issue a minute ago of what happened during the pandemic the nations that we generally rely on organizations like the cdc and others have not been there for us in the region the ppes in fact uh many countries had ppe's that were shipped to them were uh scounded by the u.s and other countries so that we weren't able to get what we needed we were in a bind getting ppes for our population and

01:08:45

testing and so forth and that still exists in some cases the whole idea of deciding when we should go overseas to care for care and of course it's high cost because we are purchasing those overseas care costs as individuals not as a group so we don't have the power of collective bargaining and the last point is the issue of training and uh provide after we train is providing employment one of the things we see is

01:09:16

that we are also trained nurses but yet we can't keep nurses as soon as they train they get better wages so they travel to other nations and provide services we have a problem even in our countries in providing specialty trained nurse so we have lots of nurses that are involved in general services but not in specialized services like career care dialysis and so forth and nurses do have to specialize just as physicians

01:09:46

do so a little bit more about the challenges from a more administrative side in the caribbean healthcare delivery system we operate in the caribbean in silos we are all segregated and we've inherited this from the colonial model that colonial model maintains separate systems we are already small and we have a tiny population but yet we separate ourselves that also puts us

01:10:17

at a significant economic disadvantage so you separate the public from the private it creates conflict of interest and it also creates a situation where the uh persons that are seeking health care have are confused also it stratifies us in the society rich from poor it limits our ability to coordinate even within the private sector both to the private healthcare providers

01:10:50

and the insurance companies another issue is the funding mechanisms and the funding sources truly most health care is funded by the government and it's it's largely tax base very small percentage of health care budgets uh come from the private sector in fact when you take a country say as big as jamaica that has over three million population they have very limited private beds

01:11:20

in their system most of their beds and i believe someone i don't know the exact numbers someone said you know country is larger stuff have less than a thousand less than 500 beds a private bed most of the beds are up in public facilities the problem of health system strengthening is largely done by the government so you conflicted in supporting new technology new equipment because you have fixed budgets and there is no funding for for doing healthcare system

01:11:53

strengthening another issue that really poses some significant problems is the governance and administrative administration through ministries of health most ministries of health are not equipped with the technical uh training the technical personnel and systems to be able to manage a complex healthcare system and so uh what you have are the professionals that needs to be in those

01:12:25

systems driving the directions and the policies are not available the benefit systems in the caribbean is very fee for service or what we have is a healthcare payment model that's benefit-centric so when you have a benefit-centric and it's not a provider-centric and it's not a patient-centric what you have is that you use the benefit plan insurance companies to restrict care so what you try to do is to limit

01:12:57

what you pay for and therefore you get a confused health care provider system and you get a dissatisfied population because insurance companies use the benefit model to limit care and to control their profits clearly this is a model that we have in the caribbean and it's not working last point on this is non-standards uh we have very little standard-based care

01:13:26

very few facilities or systems in the caribbean are credited based on international standards so for example if you have a cardiovascular event you have chest pains there are models that says what happens after that if that patient has a cardiovascular issue we don't have those models except in few nations that we follow for getting a patient to carry a catheterization within a certain period of time or be provided a certain medication or stent

01:13:57

some of those issues so what you have is ongoing once you have an illness you are likely to either die from it or suffer uh long-term untoward outcomes so how do you develop a national health insurance system amidst all of these issues that i've just identified and have it become sustainable basically what we've seen in the entire caribbean in all attempts and i say some exceptions

01:14:31

to develop national health insurance it's really a band-aid model and one of the challenges that all of these nations who have utilized this type of banded model is they achieve some degree of universality but they have cost that's not contained there are no predictive modeling data sources to be able to track and look at where things are going policy issues legislative issues that

01:15:04

are not just developed once but are ongoing and modified according to what the system needs to keep it sustainable so on the policy side and i applaud again the university of the west indies for taking a lot of leadership we need a whole body of talent in this area in healthcare financing research in population health and many of the other aspects of health policy to be able to help guide these type of systems

01:15:33

of sustainability so we were privileged by to be given the contract by the government of grenada to facilitate and help develop the model of national health insurance and what we decided in so doing was not to present a band-aid structure but to develop a transformative model that offered this degree of sustainability these are some of the principles that we use that we currently apply first one is a top-down

01:16:05

model over a bottoms-up model of financing what we realize if we understand what capital is available and how we could bring all the capital that's been utilized in healthcare in the region or in grenada under one part whether it's controlled by other entities but we have all of that capital accounted for then we have a better way of modeling the system and distribute the capital so that the

01:16:35

bottom side of the delivery of the point of service receives what they need this model this method of modeling works well in a situation where you have rapid changes in your funding sources and your economic basis and clearly covet 19 is a perfect example of this where the tax base that you have in all of the countries have dwindled and so how do you in this type of environment continue to

01:17:05

implement national health insurance or how do you continue to sustain that model without having to fracture this model in a way that it's not sustainable and this is not the first time this is will occur we know that this is going to be an ongoing issue and certainly people call on government to solve those problems but we say these are problems that are not only for governments but it's for businesses it's for all concern

01:17:35

so the consolidation of the financing does give us the power of economies of scale so that we could respond in times of stress certainly you've done this in the banking industry in the eastern caribbean the issue of cost containment how do you maintain contain the cost and manage the rising healthcare costs by implementing models that allows you to track monitor uh these changing healthcare

01:18:06

cost models one of the things we've seen in most of the caribbean systems that have implemented national health insurance is that they have not included cost containment in their model and in the implementation as a result all of these institutions adjustable all of them are seeing tremendous cost overruns without any control mechanism another principle is that of shared risk we've seen this been an issue i

01:18:36

already talked about this whole stakeholder participation from our concepts in terms of developing it but we see an issue that if you share the risk across a population rather than a small group so for example the people who have insurance are generally the working class or the people who are wealthy that's a small group insurance is about spreading the risk across a broader population to allow for affordability national health insurance offers that but you don't only spread the risk with the across the population

01:19:09

but the financiers and also the consumers of health care so both for further growth and development in the health care system if you have national health insurance and you have a funding mechanism this is the way to grow and further develop your health care system clearly restructuring the governance is another basis we use because we believe that it will build confidence in the society that we are doing something fair

01:19:40

and it also would offer security that you have a sustainable system certainly governments change and and politics drives those decisions and we feel that we must have a neutral system that allows that irrespective of changing government that this type of model system does not change just because of government change and this is an important issue um and um really must applaud the government of grenada for giving us the ability to go in

01:20:11

and even work with the opposition to help develop what we are talking about accountability from a capital allocation perspective this is important also to keep the system fair and to avoid conflict of interest and that's a part of sustainability modern information technology and efficient uh administration today the administration of healthcare is fragmented at all level each entity is doing their own

01:20:43

administration in asylum and therefore not having a modern information system that links everybody together that consolidate the data in one place makes it very expensive 20 to 30 percent of health care the healthcare dollar goes into administrative in the caribbean it should be less than 12 to 15 percent our goal in grenada is to bring it to somewhere between eight and ten percent that's the admin cost and we're doing

01:21:14

this through consolidation we want to promote as a major part of our initiative and i know earlier speakers talked about this this whole concept of private public partnership while we depend on government we also want to rely reduce our reliance on government on us because of sustainability so when you have done downturn in the economy just which we have now we have other sources of capitalization that will help buffer the system this is very important now when you

01:21:46

think about stakeholders because of the culture and the social conscience that we have we hope and one of the slides went up to land in his um presentation talks about risk talks about economics talks about contribution and also talks about people that utilize the system obviously the poor would generally utilize the healthcare system more but they have less to contribute to it in a national health insurance system

01:22:17

you are your brother's keeper a concept that is driving this financing in grenada is that of when we look at what how how we actually pay for this our model calls for using the current dollars that are in the system and the current dollars that consumers are spending in grenada for 100 000 population 109 000 population they spend 90 million dollars in out-of-pocket expense

01:22:48

so if you take that and you divide it for every man woman and child clearly that's a premium in itself so why not take those dollars and spread it across the population to the taxation system so instead of a few people contributing contributing a large amount all persons contribute a small amount and then take the resources that you are currently using and add that to the system a challenge to make this fundamental change and we believe this is the transformative issue that we

01:23:20

face in getting through this system there is in all healthcare system in the region because of the colonial model a sense of bureaucracy so the key winning strategy that we see to achieve this kind of financial consolidation comes from a crop consolidation of the health care providers so that they're all working together consolidation of all the pairs including the government the insurance industry the employer groups

01:23:49

uh overseas coverage and so forth are individuals with travel insurance or people that live overseas and spend time in grenada all those are financing sources and of course the patient this we believe is the most powerful winning model for nhis success so the solution to the challenge of timely access to care making access affordable and managing the non-communicable diseases that is

01:24:22

eating up a major component of the capital is consolidation to increase the numbers of course covered so that we could spread the risk capitalization of the healthcare delivery system to a consolidation of capital consolidation of all of the providers into an organization where care could be delivered and patient could receive care in an orderly fashion through an accredited highly qualified

01:24:53

system introduction of cost containment methodologies develop a standard care coordination model where we know where to send which patients and for what purpose so that the patient doesn't go to the wrong place where you you sort of get a kind of duplication of service a big one for us is to consolidate the administration and utilizing the financial capital to develop health care system

01:25:23

so how is this done we believe the whole issue in health care is about value and value transcends just dollars and cents it has to do with the social responsibility as individuals as a government and as a region to actually find a way to get the best value for health care here's a thought that we all should consider right we tend to put value in material things

01:25:54

and when you think of your health not just as an asset just like your car and your home in the caribbean today you require by law to have insurance in your car no one would give you a loan in a bank if you don't have an insurance on your house and most of us buy a policy for our death even to pay for a coffin to be buried so how about health care coverage do we value our health

01:26:26

less than we value our homes the coffins that we're going to pay for on a car that we drive that's a fundamental question that we have asked the grenadian society to in terms of representing this whole concept of national health insurance so uh this pales in comparison to what people spend on everyday activities so from a transformative model of consolidation we see value-based healthcare as the

01:26:58

basis for the national health insurance product that we develop in in grenada today and we hope that this kind of model could be developed in the eastern caribbean value is measured by outcome over cost so if you have a good outcome and you have low costs you have increased value a simple mathematical formula how do you develop value-based healthcare value-based healthcare is a kind is tied to a reimbursement model that's tied to

01:27:29

something called episodes of care this is unheard of in the region when you get sick and you have an episode and you go to the hospital and you get seen by multiple entities private the public we have to be able to cross that in a value-based proposition so when you have doctors working in the public system in a private system one person goes to the private system to get a cat scanner mri then they come back to the public system to have surgery we have to have a transparent system

01:28:00

that will allow patients to flow freely in that model and of standardized payment system that allows care to be delivered without this type of silo mentality that's how value-based happens system-based care take transplant take something like renal dialysis or cardiac care we have to develop system-based care where we are able to provide care in an interdisciplinary team approach

01:28:31

so that you have all of the qualified professionals working together so you're not running across town to get the lab and you're not going across town to get the prescription uh you need a system-based care because that also lowers the cost for the person's achieving care in some systems the person has to miss work three times in a week to be able to get the prescription see the doctor go to the lab go to therapy when they could go into one building and get all the care they need

01:29:02

we're talking about a system of population health so we look across the boat and we say how many people in the society has diabetes and how effective are we in our primary health care system in bringing down the hemoglobin a1c of the entire population averaging say nine or ten let's bring it down to seven that's what population health is if you think of persons with a hemoglobin a1c of between eight nine and above most of those individuals in 24 months

01:29:34

would have a major organ failure that ends up having a catastrophic consequences so a primary care physician just looking at a person's diet the homoglobin a1c as a measure of quality and a measure of outcome could impact on that person not getting to renal dialysis or getting a heart attack so you see prevention is very important so the ability to measure value based on costs and outcomes is critical in these value-based models

01:30:05

another major driver that we've implemented in the creator model or we've suggested is the model of managing healthcare or managed healthcare some people believe that managed healthcare means hmo our health maintenance organization yes the large degree does but there are many other aspects to manage health care that has some extremely positive health benefits one of those is the ability to cross-contain through managing care managing care

01:30:37

means the patient is referred into the right doctor the right facility receives the right products that's tested make sure they're placed on the right drugs and not based on a drug that has conflict with another drug that will cause a further complication it means that you have uh people in the health care system that are not just physicians but have the knowledge and ability to case manage care coordinate uh this is a whole new layer of care of professionals that we don't have

01:31:07

in the caribbean that's absolutely necessary the insurance companies today don't have those type of service providers that are absolutely necessary that's not available in the government system primary health care providers is a key keeper of course this whole issue of compensation and reimbursement based on value-based principles uh paying for healthcare on a poor head basis or paying it for healthcare and a poor diagnosis

01:31:37

on our episodes of care none of these models are available in the caribbean today a key component of managed healthcare is to prevent leakage leakage is an important principle in sustainability for healthcare it's very important to have this uh system so that you avoid leaking of dollars outside of your system and that's where if you have the management system and you have the primary care keepers that drives it

01:32:09

so what what must we accomplish we need a hybrid model that's consolidated through an independent provider association working with private public partnerships we need a care delivery system that we could upgrade with capabilities uh that allows for accreditation and meeting high standards we need to accord we need to consolidate the population under what we call a covert lies on the management strategy we need to pool the risk we have a model

01:32:42

that we created called stratified pool risk coverage spark and the other would be centralized administrative governance and governance so that we could control the cost of administration so quickly uh we are concerned about the model of patient-centric and patient uh provider-centric and patient-centered healthcare in this hybrid model

01:33:12

of care over a benefit-centric care we're organizing the physicians into an administrative model caller independent provider association where they they have some collective bargaining capabilities uh pricing models so that we could standardize the pricing across the board we could implement referral and authorization utilization review of our cost and see how uh whether there are excessive uh referrals into systems and patients are

01:33:45

getting procedures that are inappropriate or not getting appropriate procedures in this way you have a focus on primary health care and wellness secondary health care at another level and tertiary health care the model has three the provider-centric model has a component in the middle that we call the administrative core such as third-party administration the national healthcare uh system administration the

01:34:15

provider service administration and on either side you have access from a uh payer and then the providers uh so we're coming quickly to an end here the national health insurance model is focused on appropriately passing the legislation that matches these models and again we have we've done a tremendous amount of work on this already the governance structure all of those we've done working and then the stratified pool model i'll

01:34:46

talk a little bit about that and then i'll close um so on the capitalization side uh we believe that we have to combine capitalization to sustainability and we've defined as the model that we've defined i find in this model is a stratified model of coverage where it's layered the risk is pulled together but it's layered so the premiums are shared part by the government part by private payers packed

01:35:17

by employers and so forth but we have a single administration and a single provider network throughout the entire model and this is what it looks like first tier is a tax-based chair that's governed by the government taxes where all of primary care and all of the basic preventative and public health care public health services are covered for everyone in society and in the second tier would be more specialized care

01:35:47

there is where the insurance and the employer groups some of the unions could participate in providing some premiums uh that could manage payments at that level of course the third tier could be a catastrophic tier where reinsurance could be uh bought through a reinsurance company certainly the government could be participation in this often be handled by a combination of the private payers and the public uh system

01:36:18

what you have that's in this model that works is a single network of provider and a single administration so there is reduced cost in deciding who gets paid at what time so i'll conclude by saying raising capital and risk uh is about what this is about uh so the benefit for developing nation is to pre is to create a predictable premium and administrative model a benefit plans that's adjustable with

01:36:51

actuarial data analysis and that's adjustable to changes in the economy the risk spread across many pairs types including government and private sector so our pool of members are covered central administration central technology focus on benefits eligibility staff benefits provider and provider-centric and care centered

01:37:21

uh providing a model of management and governance that of offers security to the population and working with a network of providers that allow for consolid consolidation and collective body here's a launch pad we believe that this model is transformative given the complexity that we see moving from a colonial system to these more modern ways of funding health care it needs energy and we see the energy

01:37:54

as political economic and human capital and clearly the in order for a healthcare system to be transformed in a place like grenada it has to become a national concern of all grenadians i'll say for the eastern caribbean the same the biggest driving force behind this as i've said to the prime minister and others is something called political will the nations who have succeeded

01:38:25

in developing national health insurance have their start from the leaders of those nations having the political will to drive that's what it'll take to develop and implement national health insurance system in the caribbean thank you for this very informative presentation we will now we i now take the opportunity to thank all the presenters and we will now start the question

01:39:03

and answer segments uh the first question we have from [Music] um is from lydia elliot and it's a question from facebook she's acknowledging the importance of solid waste management and she is seeking some she is seeking some guidance in

01:39:43

particularly about in particular about retired persons and how do we help them manage their health issues in the context of um a universal health coverage model the second question we have from facebook um this question is asking how would a universal health coverage system treat persons of who who are low income

01:40:19

in other words persons who can't afford to pay how would the design of that system treat a low income person the third question is by delicia bonnie delicia is asking can you expand on currently established collaborations that support universal health coverage in the region we will start with those three three questions and we will move on to three more once the panel has addressed those panel did you get those three questions

01:40:56

yes sorry uh chairperson can you just give us the third one again please the third one can you expand on currently established collaborations that support universal health coverage in the region who's going first um would you like to take a stab um dr ned sure sure well first um

01:41:36

uh the issue about the design of national health insurance to cover the elderly and retired and those who are in low-income situation is critical and um a current model of healthcare has the government providing that what we call the safety net for those persons who can't afford in national health insurance while the

01:42:07

government provides this um this the idea of consolidating the dollars available from the persons could afford to pay with the government resources puts the entire country in a better situation there is a kind of amount of stakeholders a resistance from sometimes the people who have and could afford by saying look we don't we could support ourselves why can't the people

01:42:37

who can't afford why aren't they able to support themselves well one of the that's why in my uh original talk uh when i started i asked are we our brother's keeper and party responsibility in my opinion of government is to help balance this equation uh and legislators to help pass laws that will drive this resource allocation unfortunately

01:43:08

um that has not happened in every case uh and i understand that there are some governments who have been successful in doing so in the region and i think the folks from the university could comment more on that now do you want me to answer the other question also in this context or should i have them respond to this and then i'll talk to the other ones you could do that we could have dr lausa do the other dr lalter dr kamavac in the interest of time

01:43:43

so dr lalter there was this question on whether they are established collaborations that support universal health coverage in the region regional collaboration has been paramount for many years for decades actually within the oecs you certainly have the work that has been done through the health desk at the oecs secretariat and secondly a major part of that is the work of the pool procurement of pharmaceuticals component

01:44:17

and it's not just pharmaceuticals but it's also a range of medical supplies so that's a collaboration which has been ongoing in the oecs countries for several years within curriculum and we can broaden from the oecs to the rest of the caribbean you do have what we call the caribbean cooperation for health initiative and within that structure you have a number of activities which have taken place i can broaden this to consider the

01:44:47

collaboration which took place among the caribbean countries at curriculum with chronic disease management that declaration in 2007 to stop the epidemic of chronic disease which has led to a number of initiatives in several countries establishment of national organizations what we see now with sugar-sweetened beverages with tobacco it's alcohol and a number of other products these are all aspects of the

01:45:18

collaboration for for coverage uh across the caribbean countries and broader than that we can look at the role of the pan-american health organization of an american health organization in training health systems strengthening laboratory strengthening which has been uh taking place also in respect of the procurement of vaccines and also essential medication training for example in the caribbean

01:45:50

countries training organized through the university of the west indies at the medical schools so then there are different aspects of universal health coverage that one can consider and in each one of these dimensions you can begin to see how regional collaboration has worked for some of the oscs countries one of the principal dimension one can look at is where do they send their patients to a very large extent from the ocs

01:46:21

countries for example we send patients to barbados so we send them to trinidad or we send them to jamaica for example these are critical points and critical entry points for looking at the tertiary or the specialist care aspect of how we're going to be managing our health issues much more can be done having cited these we are aware that much more can be done but certainly we do have the groundwork we do have some of the political will to get some of these things done it

01:46:53

is transforming these into the broader comprehensive framework that we have to be working on and that's what i always see as secretariat the carrick on secretariat become very crucial in coordination of these thank you very much dr lalter we'll go to the next three questions next question is from facebook as well i imagine it it is directed to dr ned and the question was like this how can we benefit from this health care

01:47:24

system that you've described in grenada another question from facebook brain drain we're doing three at a time dr ned bring during is a problem in the health sector how can this be rectified and the third question in this segment is from kellon fletcher how do you propose governments fund national health insurance especially with the impact from the pandemic and expected continuing lingering

01:48:00

economic malaise those are the three questions so i invite the panelists to address the three questions we could start with dr ned and then perhaps hear from dr cumberbatch so um i'll address the first um and uh parts of the second and third um so uh how do caribbean people benefit from this system uh well certainly what

01:48:32

we're doing what the university of the west indies doing is doing and what others in the region including some of the insurance companies and the governments we need to come to a point of collaboration where we could uh introduce what we call best practice i think that if we are able to and there are lots of other consultants and experts that we could bring to the table to solve problems and the covet 19 is a perfect example of

01:49:04

how what we needed to do to solve this this problem rather than fragment and and sort of do everything on our own this is the i think the real message of kovit 19 is saying to us is how do we come together to make sense of a challenge uh so i think the way that all uh citizens of the eastern caribbean and the caribbean in general to benefit is the leadership and the the stakeholders uh coming together in some kind of

01:49:35

organized way to consolidate the resources we have to make them work so that we have competitive advantage uh one of the biggest problems we have in the region is leakage of patients outside of our region when this happens our every dollar that we spend actually affects our currency and there's a huge economic um issue when people go out to the territory but at the same time if you don't have the quality of health care services

01:50:06

and your survival is necessary then you're going gonna leave so the leadership and the healthcare system must come up with some better models to be able to um provide a healthcare system where we all feel comfortable with the care that we need there the second point is the brain dream and that really uh ties in well with the with the first point i already alluded to the fact that we train a lot of physicians and nurses in the region and they leave to for what we call

01:50:37

greener pastures uh so we have to look at how we uh reimburse and fund health care professionals uh as one uh two the training that we provide them and the opportunities for a better lifestyle because if you overwork then you're underpaid obviously you're going to look to other opportunities and the whole economic development of the region i mean when you look at the economics of the caribbean i grew up in

01:51:07

it's totally different we are not um low income countries anymore we at least middle income and sometimes even higher so clearly just in general and i guess the dots could better speak to this um and the last point is the government funded healthcare insurance in these economic times the model we created we believe uh would allow a government to implement national health insurance even in a time of downturn uh

01:51:39

yes we have the ability to modify the payments to the doctors modify how much contribution the consumer makes uh in direct payments how much the government makes in government makes in payments and how much other funding sources for healthcare and think about this people traveling could pay something for healthcare and grenada because they may use resources other countries are doing that uh or in the caribbean um uh there are other

01:52:11

ways of actually funding healthcare someone talked about um solid waste uh important that we uh part of the contribution because solid waste does contribute to health challenges so how do we people that actually pollute the environment or use products where we have to heavily impact an environment and help affect health styles how do we extract dollars from those because those organizations are having financial benefit how do we use these models

01:52:42

or these opportunities to better fund healthcare so i think these are the ways that we could mitigate some of the issues of downturning economy the other area that we looking at there are a lot of developed nations who are helping countries like ours who are putting forth these kinds of initiatives that we are proposing because they are looking for these models for their own countries and they are willing to fund many of these initiatives

01:53:12

in grenada we are actually looking for grants and we have already received fundings from other organizations to help us and some of that money is free are there loans and other um opportunities there so again we we have to get the research people and the grant writing people on the ball so there are lots of ways that we could fund this it's just we have to become creative creative and we have to have the government and the political will of the people and the government behind us to be able to do this thank you dr ned are we now

01:53:49

yes um very interesting questions i want to get at the brilliant dream problem a bit and talk a little bit from a different perspective one of the issues in the caribbean is that the morbidity and the epidemical framework that we're working with the profile of the caribbean is that essentially a lot of our healthcare issues and chronic diseases etc really needs the participation of the community and not necessarily participation of the

01:54:22

doctor let me explain so i i just wanted to look at it from a different part and i'll also get to the brain drain point what we need in the caribbean is for people also to taking some self-responsibility for the diabetes hypertension overweight obesity and lack of exercise so doctors do not give you healthcare health status you have to work at it the doctors can help you the the dog the drugs can help you

01:54:53

but you yourself have to participate in healthy living to get the benefits especially in the caribbean that is very very important the other point i would make about the brain drain we live in the modern world technology what that means for a small island state is that your healthcare provider don't necessarily have to reside in your country technology allows you to access people all over the world

01:55:22

so if you need technological support advice even though people will be leaving but you can also link in the others in systematic ways throughout the world so yes we would like to keep our professionals here but they are also professionals from abroad who are linking with you online to help you solve your problems that's so i just want to make sure that we understand that we're not in a dire situation the other point i will talk about is the

01:55:54

question of how do we fund in the um in the one of the things that the hu has done throughout the caribbean is that we have been costing the present health care systems that we have the amount of money being paid by the population and the governments through the caribbean and the where is the tree under biegu grenada um seeing kids and et cetera et cetera and what we have found is that the amount of money that is

01:56:26

being spent right now by the public and the private sector is sufficient to have a health insurance coverage for every single citizen depending on what your benefit package is so let me just make that point again the amount of money that is being spent right now is sufficient to provide a national health insurance package of services for everybody so it is not a question of

01:56:56

if there is the money available in the in in the caribbean the money is there the other point i would also make is a whole assessment that came up and is relevant to us and the inefficient seasonal health system is recognized to be around between 20 and 40 percent so what that means is this and this is for a global figure in all over the world 20 or 40 percent of

01:57:27

their expenditure in health care systems are being done inefficiently so one of the key things you need to do is to look at measures to drive efficiencies and one way of doing that is by using modern information technology so there are savings to be made if we restructure and reorganize using modern information systems to get better outcomes given the present value of dollars that we are spending

01:57:58

so this is not beyond us the other last point i would make about the cost what we know in the caribbean for our epidemiological profile primary care prevention is a big winner what we need to stop doing indicative is spending money at the end of the health care cycle in hospitals where people are going with severe morbidity and ending up

01:58:28

with high mortality figures diabetes hypertension these things are preventable so if we front load the system by making sure our primary care systems are modernized running up-to-date and universal we will not have to spend that amount of money in the back end of the system which does not give you a good outcome doing dialysis changing your kidneys changing your coronary blood vessels changing your your your your joints

01:59:00

that's not the way to do it you know we need to stop the mobility and mortality from occurring which can be done especially in a place like the caribbean where 24 7 365 we have good weather we have food that we can grow and eat we can exercise so i just wanted to make that point so to look at it from a different perspective thank you thank you dr kambabach we have

01:59:32

one more question from facebook given the small population of our states are there any specific challenges which can which can be anticipated from the implementation of national health insurance i would also like the panel to speak to uh measures to that measures that can be aimed at driving efficiency of the system um dr cumberbatch just spoke about that and maybe a little expansion might be

02:00:04

necessary this will be the two final questions for the session as it is already 12 so um we'd like to get some feedback from all the panelists as well as some summary um some closing statements you can begin with dr thank you very much jefferson um two specific questions let me give you the first one oh probably to to continue with the discussion started back up to converge on the efficiencies

02:00:41

some of the big areas for efficiency savings that we can look at in the caribbean put into how we manage overseas care where do we send patients to how do they get there what are the protocols how did we negotiate for the care that has been provided is there a way that the oecs countries for example can pool their overseas care requirements so then just as how you're pulling medications through the pps

02:01:14

can we do this also and get the economies of scale from this certainly sending people to the u.s to dominican republic panama cuba for example there are savings which can come from pooling those overseas care needs sharing services does it mean that every hospital we build in every country must have the full range of facilities can we as doctors come about say invest in telemedicine can we have moving

02:01:45

health professionals and specialists sure that we see as countries rather than each country having to have his whole its entire team of specialists so sharing services like this become a very important part the whole matter of length of stay for example in hospitals if you do not have adequate protocols then certainly what you're going to find all together is that people spend a longer time in hospitals

02:02:15

than they should be there let's look very closely what is causing long length of stay compared to what the norms should be and relates to that is the whole point which dr kumbach has been raising about strengths in primary care well if you look at a very big chunk of persons going to hospitals outpatient and emergency care a large number of these can also be treated in the primary care centers

02:02:46

why aren't we beefing up our primary care centers primary care centers are not there to only deal with antenatal care or immunization or a scrape or a cut they're there to provide a larger range of services so by beefing up our primary care services then that will cut down on the expensive treatments which may be provided or necessary in emergency care and the outpatient department so the number of the number of areas we can

02:03:16

look at where efficiency savings can be can be considered the first question pertaining to two small size small gdps for example in relation to the particular countries yes that is a consideration but how is it that you can have a private health insurance company operating in all of our countries and when their pool

02:03:48

is the same number of persons we're looking at even much smaller pools because they pick and choose persons in the formal sector for example how come private health insurance companies can be there what about a national company and what's the advantage of regional pooling again what's the advantage of having regional i.t systems in electronic systems which can provide the claims adjudication process all of these are factors which we need

02:04:18

to consider what's the advantage of having regional systems which pooled overseas care arrangements so small is not going to be the most critical constraint when it comes to putting resources together and already the oecs has been considering this already within curriculum there are considerations for the regional pooling of services for the regional for regional health insurance so there's

02:04:49

possibilities that we can consider in all of this dr komba batch can we hear from you nothing to add to what stanley said that i have concluded all his sound is statements and sentiments i am comfortable okay okay so finally yeah so the challenge uh in terms of size as i see it is that um who does what and one of the challenges we always have in the caribbean from a federated

02:05:30

standpoint is to decide uh because we as caribbean people are entrepreneurs and we all want to do it our way and the idea of relegating a service or product to one island or the other or one group or the other becomes an issue in some countries they have something called certificate of need and to avoid that what they do is they look at you have independent bodies saying you would only provide this kind of service

02:06:02

here or there so you regionalize it so you could consolidate i don't know if that's possible in the region because that's really difficult you know you are free states to do what you want but sometimes if you could collaborate i mean if you're gonna get an expensive technology like radiation therapy every island can't afford it so you know could you centralize it in certain caribbean islands where it becomes more and then the other question is how do you do it between the private and public the public sector may have it and only have access to a certain population of

02:06:33

patients and then the private sector has it and they really duplicate the service and neither one of them are providing have enough services to make it efficiently run and so how do you support technicians and all of those things so those this consolidation modeling i think is a major challenge in the design and development of these systems the next point i would say would be we have a very strong colonial model throughout the hospital the and i'm not

02:07:03

against the model by any means but when you look at how the employment situation is uh healthcare in order to prevent brain drain uh you have to promote and um uh you have to have a merit-based system rather than just a seniority based system so those are difficult things to do in a caribbean context and healthcare is much about merit because it's about the qualification the experience and the training of the

02:07:33

person in treating a particular disease not just because that person worked in the system for a long time so you have to you need the combination of both a seniority and a merit-based system and that's really challenging in small-sized nations where we are families we are close to each other and of course it's very difficult to um maneuver around those types of uh issues so i see those two issues as challenging but if we focus on how we

02:08:04

make the difference they could work thank you very much dr ned for this intervention uh we've come to the end of our session today um i don't know if any of the panels panelists have any final words we are about to close but if you have any burning words that you'd like to add well i'd like to say one thing and that is i want to really congratulate your organization for putting this type of initiative together first of all

02:08:53

you are a beacon and a great example of collaboration in the region and i trust that you know you all could offer a kind of leadership i'll continue to offer that kind of leadership in encouraging these type of collaboration that all of us have spoken about because now with kovid 19 this is a kind of life and death situation when you think about our countries uh being exposed to a condition such as this and the only real solution we have is

02:09:25

quarantine and closing our borders and now that we can't treat somebody with a covet 19 but you know you know when we if we have an outbreak that's uncontrollable and we don't have access to the resources to manage patients of course this could become cat's traffic and the fact that as dr lantano said we've seen so much other conditions in the region with the mosquito bone conditions and others that has contributed significantly to the problems in our nations it's

02:09:55

obvious that it's a wake-up call it's time for us to really organize and do something about healthcare in the region thanks thank you um [Music] dr ned i accept those kudos on behalf of the governor who leads and directs this um institution and who has insisted that we continue this engagement during this period i'm dr lalter you wanted to make an intervention yes madam chairperson since i started

02:10:27

the ball rolling i might as well stop it as we come to the close of the innings uh firstly to thank you and your team for putting together uh this panel discussion on this cruise show this very crucial situation that all of us are facing i think two comments on this firstly is that leadership becomes very very important we this is not going to be the dead snail of the oecs countries of the caribbean we've faced epidemics and pandemics

02:10:59

before in fact the hiv pandemic is still in our midst the ncds are still in our midst and so we are managing with these we have to learn to adjust leadership becomes very important but more and more our cultural values pertaining to personal freedoms civil liberties personal responsibility can we build on this feeling of health is important can we build on this feeling in the

02:11:31

population to now project that to other health issues ncds chronic diseases other infectious diseases so how do we use this empowerment situation and the opportunities for empowerment to create much more health conscious and healthier population that's part of sustainable development goals that's part of what universal health coverage is all

02:12:01

about and thirdly while we might you know want to uh become very pessimistic in this situation let's look at the countries which have faced this already and seem to be making headway what's happening to china where it all started in the first quarter of 2020 china's growth had fallen second quarter they're up again third quarter it may be up again the country has managed the crisis and it seemed to

02:12:33

be improving singapore hong kong and several other countries let's begin to be to really pick and learn the lessons of other countries which have managed this cuba our neighbor very close to us and so it is not it is not a totally pessimistic situation in every crisis there are opportunities for improvement thanks thank you thank you very much dr

02:13:05

lauter let me thank the panelists for what i consider a very exciting and intense conversation today very thought provoking you left us with a lot as policy make us to think about and to um think about how we could go about supporting um appropriate public policy frameworks public health policy frameworks in in the region so i thank you very much on behalf of the executive committee of the eastern caribbean central bank

02:13:35

for taking time out to participate in this exercise and for bringing us such valuable presentations and insights i also thank the team from the research department who were responsible for putting on this webinar today and for um organizing um the the seminar um led by chanel thompson the head of our technical unit um and zana bernard who is here with us today you're not seeing them but they've been very

02:14:06

involved in this whole process and we also have um our corporate relations department the lifeblood of of this whole um public relations engagement profile they have been very supportive and they are the ones who provide us with the necessary infrastructure and support to actually um conduct this um this webinar led by um director um shimelan kirby um we have

02:14:41

also marlon um marlon crafter crawford carina and and shana thank you very much colleagues and we also thank the the the public the participants who have who have been with us on zoom and on facebook we thank you for your participation with this would not have been possible without you thanks very much everybody have a good afternoon

02:15:26

you

Pandemic and Universal Health Coverage

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